NUR 113 Unit 2

After receiving a diagnosis of placenta previa, the client asks the nurse what this means. Which is an appropriate response?

"The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening." Implantation of the placenta in the lower uterine segment is the accepted definition of placenta previa. Premature separation of a normally implanted placenta is known as abruptio placentae; it occurs because the placenta is attached insecurely to the uterine wall. Premature aging of a placenta may not lead to placenta previa but will put the fetus in jeopardy.

*position*

(from moms perspective - where is the baby in relation to the mother?) right or left? feel for a smooth flat surface - that is the back) presenting part is the part of the fetus that is going to come out first! feel above the pubic bone and then the top of the uterus! -occiput (head) - O - also referred to as cephalic -mentum (face) - M -sacrum (buttocks) - S -acromion process (shoulder) - A position of the back of the babys head in relation to the pelvis -anterior - back of the head is at the front of moms pelvis -posterior - back of the babys head is facing moms back -transverse - side

stages of labor

*Stage 1* 0-10 cm dilation - *Latent* (0-5 cm cervical dilation) - *Active* (6-10 cm cervical dilation) -transition phase term no longer used *Stage 2* begins with complete dilation and ends with the delivery of the fetus - 10 cm (complete cervical dilation to delivery) *Stage 3* - begins after the delivery of baby to expulsion of placenta *stage 4* -1-4 hours after delivery

Rhogam is given when?

- Given at 28 weeks, & 72 hours post partum, IM. - Only needs to be given to Rh NEGATIVE mother

diabetes mellitus in pregnancy

-type I, II, and GDM experience the same issues through varying degrees -insulin resistance increases during the 2nd half of pregnancy -the body does not respond to insulin as well -if she is already taking insulin, her dose may increase by 3 or 4 times... they will need more as pregnancy progresses and this is NORMAL -diabetes increases the risk for HTN, polyhydramnios, preeclampsia/eclampsia, and difficult labors (large babies and dystocia) -every pregnant woman is tested around 24-28 weeks w/ a glucose tolerance test

stage 4 of labor

1-4 hr after delivery physiologic readjustment begins blood loss 250-500 mL hypotension, tachycardia contractions of uterus constrict vessels where placenta was attached, to decrease bleeding oxytocin *(20 units in 1000 mL LR)* over 20 minutes to an hour... 500-1000 ml/hr causes uterine to contract and decrease bleeding shaking, chills (because of hormones) they push on your belly to cause the uterus to contract so that a woman does not bleed too much PRIORITY is bleeding -administer oxytocin to help with uterine contractions (after the placenta is delivered) -assist physician as needed while perineal and/or vaginal repairs are being completed -fundal checks and VS Q 15 minutes for the first hour -fundus will likely be halfway between umbilicus and pubis during stage 4, especially while oxytocin is being administered -monitor for bladder distention, as this cause increased bleeding -*continuous trickle of blood from the vagina, with a firm uterus, may indicate a tear in the vagina that has not been located/repaired*

a nurse discovers a postpartum client with a boggy uterus that is displaced above and to the right ....

1. fundal massage 2. ambulate to bathroom 3. get the client bedpan rationale: the client is showing cardinal sign of uterine bladder distention or atony

When to perform: Amniocentesis for fetal lung maturity

32-39 weeks

when to perform: group b strep test

34-36 weeks

internal fetal monitoring

FSE (fetal scalp electrode) -applied during SVE; RN can perform -attached to fetal scalp -continuous direct monitoring of heart rate IUPC (intrauterine pressure catheter) -applied during SVE by physician -placed inside uterus, next to fetus, not attached -measures exact pressures inside uterus -can measure intensity of contractions in addition to frequency and duration

Causes of increased variability (> 25 bpm variation)

Fetal stimulation, mild transient hypoxemia, sympathomimetic drugs

Physiologic Changes Involution

Fourth trimester (after she delivers) -Immediately Midline -within 12 hrs her uterus will be above 1cm above umbilicus Contractions -Myometrium blood vessels -Oxytocin -Breastfeeding multipara (multiple babies) when they breastfeed the uterine cramping will be worse 6-wk after childbirth -autolysis (cells are shrinking down)

Focused Physical Assessment of the Mother

General appearance (activity level and response to activity, clean, well groomed, disheveled, behavior) Vital signs -Admission -Vaginal—q4h x 24 hrs then q 12 -Cesarean—q1h x 4 hrs, then q4 h x 24 hrs, then q 8 hrs

Which intervention would the nurse initiate when a fetal heart pattern signifying uteroplacental insufficiency occurs?

Helping the client turn to the side-lying position Assisting the client to turn to the side-lying position will improve uterine blood flow, and fetal oxygenation will increase. Inserting a urinary catheter is unnecessary; in addition, it requires a primary health care provider's prescription. Oxygen may be administered eventually if necessary, but this is not the first intervention. Encouraging the client to pant with her next contraction will not increase uterine blood flow or oxygen to the fetus.

thrombophlebitis

Increased Risk: -Obesity -Varicose veins -Previous DVT -Age > 35 -Smoking -Immobility -Cesarean birth -Multiparity Treatment: -bedrest -legs elevated -anticoagulants -moist heat -heparin and antibiotics prevention: get the client up as soon as possible!

Physiological changes-uterus

Involution of the Uterus -Placental area seals -Organ returns to pre-gestational size -Occurs by rapid uterine contraction -the uterus never returns to the exact prepregnancy state with each pregnancy the uterus gets bigger subinvolution of the uterus - (not clamping down for some reason) its softer, you might see some bleeding and you will have to report this to the MD Nursing Implications Palpation of the fundus: -Consistency - firm, soft/boggy? -Height - 12 hr after delivering 1cm above umbilicus *(it goes down 1 finger width ever 24 hr)* -Position (is it midline or deviated? ask mom when she emptied her bladder) Placental site -Endometrial regeneration: Vascular constriction & thrombosis reduce the placental site to an elevated nodule. -Lochia: Outer layer becomes necrotic and is cast-off—blood, fragments of decidua, WBCs, mucus, some bacteria Nursing Implications Assessment of lochia -Color (bright - fresh blood, dull/dark - older blood) -Amount (anything heavier than a pad/hr we must report that and start a pad count... check frequently) -Presence of clots

your pt is 10 cm dilated, 100% effaced but at -2 station

Labor down reposition let gravity help

Lochia

Lochia *Rubra*- bright red consisting of blood and decidual & trophoblast debris. After *3-4* days brown or pink Lochia *Serosa*- old blood, serum leukocytes, and tissue debris. Last *10-14 days.* Lightens in color and consistency Lochia *Alba*- leukocytes, decidua, epithelial cells, mucus, serum and bacteria. Continue *4-8 weeks* after birth

examples of rh incompatibility

Mother is Rh POSITIVE Father is Rh NEGATIVE = all good Mother is Rh NEGATIVE Father is Rh NEGATIVE = all good the body will not notice Mother is Rh NEGATIVE and newborn is Rh POSITIVE = not good give rhogam 72 hours after delivery Mother is Rh NEGATIVE and newborn is Rh NEGATIVE so she doesn't need rhogam Mom is A NEGATIVE newborn is B NEGATIVE - no problems for A and B and negative is good

Category I tracing

NORMAL They are strongly predictive of normal acid-base status Normal baseline (110-160 bpm), moderate variability, present or absent accelerations, no late or variable decelerations, may have early decelerations

Which oxytocic medication may help control uterine bleeding postdelivery and promote milk ejection?

Oxytocin Oxytocin is used to induce labor, control uterine bleeding after delivery, and promote milk ejection during lactation. Mifepristone is generally used to induce abortion. Dinoprostone induces labor but has no effect on milk ejection or uterine bleeding. Although ergot alkaloids control uterine bleeding after delivery, they do not cause milk ejection during lactation.

when to worry about Rh or not

Rh POSITIVE mom = no worry Rh NEGATIVE mom = maybe Rh NEGATIVE mom and Rh NEGATIVE dad = no worry (she is negative, he is negative so her body will not notice) Rh NEGATIVE mom and Rh POSITIVE dad = WORRY (she is negative, he is positive so her body may recognize as a foreign and attack)

Category III tracing

These are considered ABNORMAL. They predict abnormal acid-base status at the time of observation. They require prompt evaluation and intervention. Absent baseline FHR variability and any of the following... recurrent late decels, recurrent variable decels, bradycardia... also, sinusoidal pattern

FHT display

Upper pane is FHT and the lower pane is uterine activity (contractions) Fetal heart rate is displayed numerically in increments of 10 bpm and uterine pressure is displayed in mmHg The interval between the vertical red lines represent 1 min The baseline FHR is the average FHR over 10 minutes (rounded to the nearest 5 bpm

Physiological Changes-Bladder

Urinary Elimination -Loss of bladder tone & surrounding edema -Decreased ability to sense need to void -Diuresis of 3000 ml/day Nursing Implications -Assessment of voiding pattern -Stress incontinence (C/S) -Catherization -Providing increased fluids

VEAL CHOP

V- Variable C- Cord Comphression E- Early Decels H- Head Compression A- Accelerations O - OK L-Late Decels P - Placenta Insufficency

chorionic villus sampling (CVS)

a scraping from the placenta for genetic testing 10-12 weeks gestation performed trans-abdominally or trans-cervical risks: ROM, leakage of fluid, bleeding, infection, contamination w/ maternal tissues, Rh alloimmunization, fetal loss

Surfactant

a substance lining fetal lungs that allows for lung elasticity and is produced in large quantities in the later weeks of pregnancy

abortion/miscarriage

abortion - end of pregnancy prior to 20 weeks ... medical/therapeutic abortion done for mom or baby spontaneous abortion - miscarriage missed abortion - fetal demise it is important that all patients report all miscarriages and abortions due to the risk of the Rh alloimmunization ask privately and be sensitive

common causes for bleeding in pregnancy

abortion/miscarriage, ectopic pregnancy, cervical insufficiency, and molar pregnancy

admission to hospital

assessment of labor: and fetal well-being questions about labor, put baby on monitor, contraction pattern, what kind of symptoms she has been experiencing, vaginal exam if she is term review her history: medications, allergies, prior problems with pregnancy, gravida and para, chronic illness, has she had prenatal care confidential questions: support person waits to join the patient until this part is complete sti history, abortion history, domestic violence screening birth plan: pain management, other specific needs/requests

Monochorionic diamniotic

babies share ONE placenta but have their own sacs risk for twin-to-twin transfusion (when one fetus gets better blood flow) think... "they don't share very nicely" high risk, long-term fetal monitoring, the potential need for surgical procedure in utero

monochorionic monoamniotic

both babies share ONE placenta and ONE amnionic sac high risk; long-term fetal monitoring d/t cord entanglement most dangerous!

Which woman experience afterpains more than others?

breastfeeding, multipara, over distention

previa

bright red painless bleeding

cesarean section (c/s)

c/s birth through the abdomen in the US 2013, 32.8% of deliveries were by c/s indications for c/s -cephalopelvic disproportion (CPD), complete previa, abruption, active genital herpes, umbilical cord prolapse, failure to progress in labor, non-reassuring FHR (late decelerations that we cannot fix or absent variability), prior classical (up and down cut) c/s typically a transverse skin and uterine incision a vertical uterine incision is done for speed VBAC (vaginal birth after cesarean) epidural or spinal typically; general in the case of an emergency if the uterus ruptures, the mom will bleed and send less blood flow to the baby and we will very quickly move to a c/s if needed it is VERY important to know that even though we see a side to side incision it is important to look at the documentation to verify if they had a transverse or classical c/s if she had a classical (up and down cut) she will ALWAYS be a c/s there is NO chance for VBAC if she has had a transverse c/s (side to side) she can possibly have a vaginal delivery in the future

assisted delivery

can assist if she is pushing ineffectively or if she has been pushing for a long time and is exhausted vacuum -application of suction to the fetal head to aid in the delivery -cephalohematomas and brain injuries can occur forceps -surgical instrument used to assist in the delivery of the fetal head -can cause facial bruising/laceration on newborn, cephalohematoma with hyperbilirubinemia may occur -maternal lacerations of vaginal sidewalls

Stage two of labor

complete dilation through delivery of the baby contractions continue to be 60-90 seconds in length, occurring every 2 minutes laboring down ... letting the body do the work (not common for women without an epidural) pushing - when the baby is in the + station raise the head of the bed and let gravity do the work sometimes we can do a vaginal exam while she is pushing and we can push down and instruct the client where the right area to push is DO NOT push before 10 cm dilation - only with contractions episiotomy (man made by the physician and they will stitch later) or laceration

a woman's WBC 17,000; she's afebrile and has no s/s of infection... what nursing actions? a. continue routine assessment, b. call the client's physician, c. encourage increased amounts of fluid, d. order a repeat WBC lab stat, e. repeat vital signs every 2 hr

continue routine assessment and encouraged increased amounts of fluid

Variable deceleration interventions

cord compression first thing... turn mom! reposition and try and get baby off the cord assist in delivery if appropriate

stage 3 of labor

delivery of placenta

dilation vs effacement

dilation - opening of the cervix (0-10 cm) measured through a vaginal exam effacement - thinning of the cervix (0-100%) 0% effaced = none of it is gone 50% effaced = half the length of the cervix is gone the cervix thins out and gets shorter

your pt reports that she is feeling the urge to push. her last vaginal exam was 2 hours ago. what would you do?

do a vaginal exam if she is not complete yet, get her to wait! do some breathing, tell her not to push! "you cannot push yet your cervix is not fully dilated and if you push you will cause it to swell"

medical tx for hyperemesis

doxylamine succinate (unisom) pyridoxine hydrochloride (vitamin b6)

fetal anemia

due to restricted blood flow, it is a common outcome, it means that nutritional concerns should be addressed immediately after birth for fetuses exposed to meth oxygenation is not as good as we need so the woman needs to manage through bloodwork and possibly even a vitamin with extra iron

why is it important to report all abortions and miscarriages?

due to risk of rh alloimmunization

amniotic fluid

during the 2nd half of pregnancy the fetus begins to swallow and inspire amniotic fluid and urinate

Fetal lung maturity tests

fluid is collected through amnio or pooling fluid from the vagina surfactant (a substance lining fetal lungs that allows for lung elasticity and is produced in large quantities in the later weeks of pregnancy) made up of lecithin and sphingomyelin (L/S ratio needs to be at least 2 to be considered mature... we are looking for 2 parts lecithin and 1 part sphingomyelin)

early deceleration interventions

head compression check dilation because you might be close to delivery, push if appropriate or alert physician of dilation

heparin during pregnancy

heparin is safe during pregnancy

signs of fetal anemia

hypoxia you can see on the fetal heart monitor and look for absent or minimal variability

Remember this for the test

ice packs 4 times a day sitz bath twice a day peripads how often? spray bottle after ANY void both c/s and vaginals need to be escorted to the bathroom two times and dangle before getting up

chorioamnionitis

inflammation of the chorion and amnion

ABO incompatibility

is less common and less dangerous risk for moms with type O blood pregnant with fetuses with type A, B, or AB fetus with type O blood is not at risk women are exposed to anti-a and anti-b antibodies through foods eaten and exposure to various bacteria those antibodies can pose a risk for fetuses of blood types A, B, and AB there is no treatment but monitor the newborn for anemia and hyperbilirubinemia note: it is possible to have both ABO incompatibility and Rh incompatibility at the same time remember an Rh+ person can receive Rh- blood BUT an Rh- person CANNOT receive Rh+ blood.

high risk pregnancy HIV

it is important that pt are tested for HIV because she can pass it to the baby if she knows she has HIV then she can take her antiviral medications therefore the risk for passing it on to the baby is decreased the virus enters the body through blood, blood products or other bodily fluids such as semen, vaginal fluid, and breast milk HIV screening is required for all pregnant women in NC. if the mom refuses testing then her newborn will be tested without her consent newborns should be tested as soon as possible after delivery and initiate treatment if the test is positive

signs of labor

lightening (head lowering in the pelvis) contractions (women actually have practice contractions throughout pregnancy) cervical changes (a woman is not truly in labor until we see progressive cervical changes) bloody show (bleeding and mucus at the same time) ROM (rupture of membranes) GI upset (n/v/diarrhea) true vs false labor

when water breaks

look for s/s of infection and also prolapsed cord

ectopic pregnancy medical treatment

methotrexate (stops cell growth) surgical removal of the affected tube (fertility remains)

Causes of Overdistention of the Uterus

occurs in multipara multiple gestations polyhydramnios retained placenta macrosomia (big) babies (expect that we might need to administer oxytocin to help the uterus shrink back down)

5 P's of Labor and Delivery

passageway (pelvis) passenger (baby) position (that baby is in) powers (physiological forces - hormones and muscles) psyche (moms mental state)

late deceleration interventions

placenta insufficiency - causes: mom might not be feeding the placenta very well, the placenta is really old, hypotension, tachysystole, supine position first: turn mom on her side to decrease pressure on the vena cava and to allow for adequate blood flow to the uterus another thing that can happen is hypotension due to epidural causing less blood flow to the uterus - correct the blood pressure problem! w/ fluid bolus sometimes late decels happen if the women have too many contractions with no resting period - tachysystole - the baby is getting less oxygen than it needs... you might want to slow down contractions (w/ terbutaline or stopping/turning down the Pitocin) need o2, change position, apply o2, fluid bolus, treat hypotension

stage 3 of labor

placental separation placental delivery within 30 minutes moms side that was attached to the uterus - Duncan the glossy side with the umbilical cord is baby's side - Schultz

retained placental fragments

prevention: careful inspection of the placenta and teach warning sign of change in lochia treatment: ultrasound and removal by D&C

lacerations and hematomas

prevention: gushing of bright red blood, steady flow treatment: repair and vaginal packing

PPH nursing diagnosis

risk for shock

If the mom is Rh NEGATIVE

she will be tested for antibodies to determine alloimmunization (indirect Coombs test) we will give her (no matter what the result of the Coombs test) a dose of Rhogam at 28 weeks (every pregnancy) if the indirect Coombs test is positive, the fetus will be CLOSELY monitored NST and BPP for fetal well being ultrasound and doppler studies to assess the fetus for issues such as ascites, increased fetal heart size, and polyhydramnios PUBS (percutaneous umbilical blood sampling) can be done to assess for fetal anemia. Blood transfusions can be given PRN Mother will receive a dose of Rhogam after delivery within 72 hrs if the newborn is Rh positive

oxytocin practice math questions

supply: 20 units/1000 mL LR order: infuse at 3 mu/min 1. convert to milliunits. 20 x 1000 = 20,000 milliunits 2. 3 mu/min x 60 min/hr = 180 mu/hr 3. D/H x V = mL/hr -> (180 mu/hr / 20,000 mu) x 1,000 mL = 9 mL/hr supply: 10 units/500 mL LR order: infuse at 5mu/min 1. convert: 10 x 1,000 = 10,000 milliunits/500 mL 2. 5 mu/min x 60 min/hr = 300 mu/hr 3. 300 mu/hr / 10,000 mu x 500 mL = 15 mL/hr

stage 2 of labor

the baby is delivered

passageway

the birth passage size of pelvis type of pelvis (gynecoid and anthropoid are favorable for vaginal deliveries but they can all work!) the ability of the cervix to dilate and efface

passenger (the fetus)

the fetal head is made up of 5 plates that allows for the baby to mold and shape to fit through the pelvis fetal attitude is relation of the fetal parts to one another - flexion of head, arms, and legs fetal lie is the relation of fetal spine to the maternal spine (longitudinal or vertical... transverse, horizontal, or oblique) fetal presentation (the part that enters the pelvic inlet first through the birth canal) is the presenting part -cephalic (head first. presenting part: occipital back of head/skull) -breech (buttocks, feet, or both first. presenting part: sacrum) -shoulder (shoulder first. presenting part: scapula) fetal station 0 (at the ischial spine) = fetus is "engaged" fetal position where the babies presenting part is located in the pelvis

stages of labor: stage one

the onset of true labor until completely dilated (0-10cm) *LATENT PHASE* - "early labor" *dilated 0-5cm* -beginning of regular contractions -mild, 40 seconds duration, frequency every 10-30 minutes -gradually increasing to frequency every 5-7 minutes, duration of 45-60 seconds -pt should be encouraged to rest because this is a really long period *ACTIVE PHASE* -cervix dilates from 6-10cm -increased anxiety, relying on a support person -contraction frequency Q 3-5 min *TRANSITION PHASE* - term not used in the textbook ... *may see in the women laboring w/o epidurals* -last few centimeters -restless, changing positions, fearful -contractions are 60-90 seconds in length and occur Q 2 min -may begin to feel rectal pressure as the fetal head descends -increased bloody show, hyperventilation (make sure pt is breathing appropriately), may give up on birth plan

induction of labor

typically 39+ weeks unless otherwise medically indicated *methods* amniotomy or AROM cervical ripening -cervidil/dinoprostone - can be easily removed, can be used for VBAC ... the best thing about cervidil is that we can pull it out -cytotec/misoprostol cannot be removed, contraindicated for VBAC ... the pill dissolves inside the vagina. this causes uterine contractions so we can use it to induce labor OR after delivery to prevent PPH stripping membranes - release prostaglandins and breaks the bag/membrane from the inside wall of the uterus mechanical dilation - insert catheter inside the cervix and blow up the balloon inside the cervix will allow it to open up to at least 3-4 cm dilated oxytocin infusion - increase oxytocin about q 20-30 mins and monitor FHR and contraction pattern. half-life is 10-12 minutes side effects of IV oxytocin: can cause water intoxication (fluid volume overload) and can cause too many contractions.

active and transition pain management

walking and position changes moaning, swaying, and rocking touch, massage, relaxation techniques breathing techniques watch for cues from the patient IV pain medications *(avoid at 7cm or greater)* side effect can be some respiratory depression (fetal) it is fine in utero but when the baby is born, they can have some respiratory depression do a cervical exam before administering IV pain medication to avoid giving at 7 or 8 cm dilated epidural anesthesia *(we must know her PLATELETS count is before administering epidural ... normal 150-400)* if a woman has PLT under 100,000 anesthesiologists might not administer the epidural

a client has had a c/s *3* days ago

*three* centimeters *below* the level of the umbilicus

Postpartum Hemorrhage p. 510

-Most common cause of maternal death -Can occur early or late (early within the first 24hr... late occurs after 24 hour period) -Failure of blood to clot or too many clots, may indicate a more serious condition risk for shock

Fetal Heart Tracing (FHT) includes what two things?

1. Fetal Heart Rate (FHR): can be measured externally w/ a Doppler (Toco) and internally with a fetal scalp electrode (FSE) 2. Tocodynamometer (Toco): is measured externally with a Toco belt OR internally with a intrauterine pressure catheter (IUPC) -Toco shows frequency of contractions (external) -The IUPC frequency AND strength of contracting if internal.

When to perform: Chorionic villus sampling

10-12 weeks

L/S ratio

2:1 or higher less than 2:1 indicates high risk of hyaline membrane disease or Infant respiratory distress (HMD/IRDS) RECOMMEND SURFACTANT THERAPY

BUBBLE HE

B reasts U terus B ladder B owel L ochia/Lacerations E pisiotomy/Edema H emorrhoids/Homan E motions

Physiological changes - breast

Breast -Formation of milk on day 3-4 -Breasts become fuller, larger, firmer -Engorgement Nursing Implications -Teach proper care of breast depending on choice to breast or bottle feed

PROM assessment

COAT color odor amount time

Which laboratory test is conducted during the initial prenatal visit? Select all that apply. One, some, or all responses may be correct. 1-hour glucose tolerance test 3-hour glucose tolerance test Cervical culture for Neisseria gonorrhoeae Chest x-ray for a positive tuberculosis skin test (TST) Group beta streptococcus (GBS) vaginal and anal cultures

Cervical culture for Neisseria gonorrhoeae During the initial prenatal visit, a cervical culture for N. gonorrhoeae is obtained. A 1-hour glucose tolerance test is completed at 24 to 28 weeks of gestation. A 3-hour glucose tolerance test is completed if a pregnant client fails the 1-hour glucose tolerance test. A chest x-ray is required after 20 weeks of gestation if the client has a positive TST. Vaginal and anal cultures for GBS are obtained at 35 to 37 weeks of gestation.

Discharge Planning Postpartum

Group Classes Individual Instruction Returning for follow-up infant/maternal Discharge instruction on infant /self care

Changes in the vagina-perineum

Healing of Perineum -Decreased estrogen and progesterone r/t rugae thinning vaginal mucosa -Edema, tenderness, ecchymosis (caused by pressure) resolves -Suturing of lacerations (some might be dissolvable some might not) Nursing Implications -Assessment of healing -Measures to promote healing (sitz bath 2x a day, spray bottle with every void) -Examine lacerations or episiotomies side-lying position

external fetal monitoring

EFM/US transducer -US transducer is placed over the fetal back -baseline 110-160 (average over 10 minutes, rounded to 5 bpm) -tachycardia, bradycardia -variability (absent, minimal, moderate, marked) indicates oxygenation -acceleration (15 bpm x 15 seconds) -decelerations (variable, early, late) toco -place just below the fundus -external monitor can show frequency and duration of contractions -intensity must be assessed by palpation

molar pregnancy increases risk for ....

cancer careful follow up after molar pregnancy necessary

Mifepristone

abortion pill

Sinusodial pattern

associated with severe fetal anemia or hypoxemia and acidosis. FHR is visually smooth wave-like pattern with a frequency of 3-5/min that persists for greater than or equal to 20 minutes. Immediate evaluation is necessary and immediate delivery may be indicated.

Methergine (Methylergonovine)

can drop the blood pressure! the client NEEDS a blood pressure of at least 140/90

hyperemesis puts woman at risk for

dehydration, fluid & lyte imbalance, muscle wasting, protein & vitamin deficiencies

on admission to the postpartum room 3hr after delivery the client has a temp of 99.5 F - why?

she is dehydrated!

Glucose tolerance test is performed

on every pregnant woman at 24-28 weeks

vaginal birth after cesarean (VBAC)

there is a risk for uterine rupture during labor 0.2-1.5% considered the safest option when compared related to c/s (major surgery) faster recovery for mom with fewer complications less risk of newborn respiratory distress specific consent form stating risks

When to perform: amniocentesis for genetic testing

16 weeks

Biophysical Profile (BPP)

usually only done if the NST is nonreactive includes a real time ultrasound looking for fetal movement (breathing, body/limbs, fetal tone- flexion of extremities, and amniotic fluid volume) and a NST a BPP of 8 or greater is considered normal a score of 2 is given for normal findings while a score of 0 for abnormal.

Attachment

•Assess for behaviors that facilitate and indicate mother-infant bonding (they are interested, want to learn, sign up for classes) •Assess for behaviors that impair and indicate a lack of mother-infant bonding (ignoring infant, not feeding, not seeing to the infants needs)

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 16 weeks' gestation because of which factor? 1. The appearance of the fetal external genitalia 2. The beginning of differentiation in the fetal groin 3. The fetal testes are descended into the scrotal sac 4. The internal differences in males and females become apparent

1 Rationale: Between weeks 16 and 20, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Differentiation of the external genitalia occurs at the end of the ninth week. Testes begin to descend into the scrotal sac at the end of the 38th week. Internal differences in the male and female occur at the end of the seventh week. Test-Taking Strategy: Focus on the subject, sex of the fetus. Remember that the sex of the fetus can be recognizable visually on ultrasound by the appearance of the external genitalia by gestational weeks 16 and 20.

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? 1. "It connects the pulmonary artery to the aorta." 2. "It is an opening between the right and left atria." 3. "It connects the umbilical vein to the inferior vena cava." 4. "It connects the umbilical artery to the inferior vena cava."

3 Rationale: The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery. Test-Taking Strategy: Focus on the subject, the description of the ductus venosus. Note the relationship of the word venosus in the question and vein in the correct option.

Fundal Height (Box 21-3)

A. Fundal height is measured to evaluate the gestational age of the fetus. B. During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals fetal age in weeks ± 2 cm (Fig. 21-1). C. At 16 weeks, the fundus can be found approximately halfway between the symphysis pubis and the umbilicus. D. At 20 to 22 weeks, the fundus is approximately at the location of the umbilicus. E. At 36 weeks, the fundus is at the xiphoid process.

Causes of decreased variability (< 5 bmp variation)

Hypoxemia/acidosis, fetal sleep cycles, drugs (magnesium, narcotics), prematurity, arrhythmias, fetal tachycardia, preexisting neurologic abnormality, congenital anomalies. Interventions for decreased variability and rationales: -Observation - may be transient (i.e., associated with fetal sleep cycle) -Review hx - may be related to drugs or known anomaly -Position change, O2, fluids - may help if hypoxia is suspected -Stop Pitocin, tocolytic - may help if associated with tachysystole -Perform scalp stimulation - may provide reassurance if acceleration results

acceleration

a visually apparent abrupt increase (onset to peak in less than 30 seconds) in the FHR from the most recently calculated baseline. Duration of acceleration: the time from the initial change in FHR to the return on the baseline FHR. At 32 wks+: an acceleration has an acme of 15 bpm or more above baseline and a duration of 15 seconds or more but less than 2 minutes. Before 32 wks: an acceleration has an acme of 10 bpm or more above baseline with a duration of 10 seconds or more but less than 2 minutes. Prolonged acceleration lass longer than 2 minutes (but no more than 10 minutes) If the acceleration lasts longer than 10 minutes, it is considered a baseline change. The presence of acceleration is the basis of the nonstress test (NST)... two accelerations in a twenty minute span along with moderate variability is said to form a Reactive NST.

Contraction Stress Test (CST)

also known as the oxytocin challenge test evaluates the oxygenation and perfusion of the fetus when exposed to contractions contractions decrease the blood/O2 which causes a decrease in FHR if the FHR decelerates w/ contractions then it might not be able to tolerate contractions negative CST has NO decelerations with 3 contractions over 10 minutes positive CST shows repetitive, persistent late decelerations with contractions. contractions can be spontaneous or induced (oxytocin or nipple stimulation)

Dichorionic Diamniotic

each baby has their own placenta and sac this is the lowest risk!

polyhydramnios

excess fluid fetal anomalies cause increased fluid maternal discomfort, prolapsed cord

amniocentesis

fluid is collected for genetic testing (16 weeks and beyond) and to determine fetal lung maturity (32-39 weeks). NPO not necessary (some physicians might prefer it) Ultrasound is used to identify fetal/placental placement and to locate pockets of fluid. a needle is inserted to withdraw fluid post procedure: assess maternal VS and FHR. monitor for s/s labor, ROM, and/or infection administering Rhogam to a woman who is Rh negative is standard practice after an amniocentesis

biggest difference between placenta previa and abruption

previa is painless bleeding and abruption is very painful (may or may not have bright red bleeding)

preterm labor is diagnosed as

regular contractions along with a change in cervical effacement and/or dilation preterm birth is between 20-36 weeks

stage 4 of labor

the first 1-4 hours after delivery of the placenta (recovery)

abruption

the placenta separates/detaches from the uterine wall before it is supposed to PAINFUL vaginal bleeding or might have no bleeding at all. *complete abruption is an emergency* the placenta has completely detached from the uterus causing the mom to have massive bleeding and the baby only has what little oxygen/blood that is already with the placenta. central- separates centrally so blood is trapped confirmed by ultrasound abruption should be suspected if the woman experiences a sudden onset of intense, localized, uterine pain with or without vaginal bleeding. complications: severe blood loss, DIC, perinatal mortality (fetal), fetal anemia/hypoxia, preterm delivery and associated risks, c-section assess/treatment: monitor blood loss, VS, FHR, contraction/abruption pattern (may see a "continuous" contraction... consistent waves w/ no break between contractions and this occurs because the uterus is squeezing and releasing and its trying to force everything out!)

PROM prolapsed cord

this is an emergency and going for a stat c-section

interventions to correct late decelerations

turn pt of the left lateral side (relive vena caval compression, increase cardiac output) fluid bolus; lower head (reverse hypotension, increase cardiac output & placental perfusion) vasopressor (ephedrine... useful with maternal hypotension i.e., after epidural bolus) O2 (controversial, but may increase O2 delivery to fetus) stop oxytocin (may increase resting time between contractions) tocolytic (terbutaline... may be useful with tachysystole or tetanic contraction) perform exam (rigid abdomen, excess bleeding may indicate abruption) perform operative delivery (if pattern persists despite above and delivery not imminent).

multiple gestation

twins, triplets, etc more due to fertility treatments fraternal (dizygotic) 2 separate ova identical (monozygotic) occur from 1 ova increased risk for: miscarriage, preterm labor, c-section, preeclampsia, PROM monitored more closely, more frequent office visits

After a speculum examination in the first trimester of pregnancy, the nurse states that the client's cervix is bluish purple, which is known as the Chadwick sign. Which explanation of this sign would the nurse provide?

"It is caused by increased blood flow to the uterus during pregnancy." Stating that the Chadwick sign is caused by increased blood flow to the uterus during pregnancy underscores the normalcy of Chadwick sign and provides a simple explanation of the cause; women often need reassurance that the physical changes associated with pregnancy are expected. Stating that the Chadwick sign helps confirm pregnancy answers part of the question, but fails to explain why it occurs. The Chadwick sign is a probable sign of pregnancy; it is not seen in nonpregnant women. There is no free blood circulating in the uterus during pregnancy.Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.

infection (TORCHS)

*some of these tests are done routinely but some are only done if there are s/s abnormalities* Toxoplasmosis - associated with cat feces or can also get it if you eat raw or undercooked meat... KNOW that when a pregnant woman comes to you instruct to cook meats thoroughly and do not clean the cat litter box Other: HIV, hepatitis, etc... the liver produces red blood cells and removes toxins from the body Rubella - test for immunity... if she does not and she gets exposed that puts the baby at risk... know that you cannot administer rubella vaccine during pregnancy as it is a live virus BUT you can administer after delivery Cytomegalovirus Herpes simplex virus Syphilis - can cause second-trimester pregnancy loss and stillbirth. some babies can be born with syphilis group b strep - done at 34-36 weeks ... swabbed and commonly found in the vagina. this does not bother mom but could bother the baby... treated during labor with antibiotics

Which intervention would the nurse anticipate when caring for a postpartum mother who is AB negative, had a negative Coombs test, and delivered a neonate whose blood group is B positive?

Administering Rho(D) immune globulin intramuscularly to the mother within 72 hours of delivery Rh sensitization occurs in an Rh-negative mother who has given birth to an Rh-positive neonate. Rh sensitization in the mother can result in erythroblastosis fetalis during a second pregnancy. To reduce the risk of Rh sensitization, the Rh-negative mother should receive Rho(D) immune globulin intramuscularly within 72 hours of the delivery. Intravenous infusion of Rho(D) immune globulin is usually reserved for emergency situations, such as a threatened abortion. Rh sensitization does not occur in an Rh-positive neonate, so Rho(D) immune globulin should not be administered to the neonate.

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean section

Answer: 1 Rationale: Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by 3 contractions of at least 40 seconds' duration in a 10-minute period. Options 2, 3, and 4 are incorrect interpretations. Test-Taking Strategy: Note that options 2, 3, and 4 are comparable or alike in that they indicate an abnormal test result finding.

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? 1. "It promotes the fertilized ovum's chances of survival." 2. "It promotes the fertilized ovum's exposure to estrogen and progesterone." 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 4. "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."

Answer: 3 Rationale: The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. Luteinizing hormone and follicle-stimulating hormone are excreted by the anterior pituitary gland. The survival of the fertilized ovum does not depend on it staying in the fallopian tube for 3 days. Test-Taking Strategy: Note the strategic word, best, and use knowledge of the anatomy and physiology of the female reproductive system. Remember that fertilization occurs in the fallopian tube and the fertilized ovum remains in the fallopian tube for about 3 days. This promotes its normal implantation.

Which sign would immediately alert the nurse that the postpartum client 6 hours after delivery is hemorrhaging?

Continuous trickling of blood Trickling of blood indicates continuous bleeding. The pulse will increase, not decrease, with hemorrhage. Blood pressure will decrease, not increase, with hemorrhage. Persistent muscle twitching is not a sign of hemorrhage.

Ectopic pregnancy

fertilized egg implants in a site other than the endometrial lining of the uterus typically implants in the ampulla of the fallopian tube usually presents around 6-8 weeks causes: PID, STIs, surgery, endometriosis, IUD, DES exposure around 9% of maternal deaths are because of ectopic pregnancy the embryo outgrows the tube - the tube ruptures - internal bleeding occurs SUDDEN onset of pain - sharp and ONE SIDED syncope monitor pain and monitor bleeding (physical assessment, ultrasound, IVF, blood transfusions, medical tx methotrexate stops cell growth and prevents rupture of tube surgical intervention - laparoscopic tube removal is removal of the affected tube... fertility is maintained

hyperemesis gravidarum

excessive vomiting risk for malnourishment increased hcg levels might play a part risk for dehydration, fluid & lyte imbalance, muscle wasting, protein & vitamin deficiencies suggestions for managing n/v during pregnancy: small frequent meals, minimize odors, eat dry and starchy foods i.e., crackers upon awakening in the morning, vitamin B6 might help some women and may be prescribed by a doctor sometimes typical dietary changes do not work so... treat NPO, IVF, replace electrolytes medication is doxylamine succinate (Unisom) and pyridoxine hydrochloride (vitamin B6) promethazine, metoclopramide, ondansetron, TPN, dobbhoff with intermittent feeds some woman can continue their day-to-day routines but some might not be able to perform typical daily activities

Which vaccine would the nurse identify as being safe to administer during pregnancy?

Inactive influenza The inactive influenza and diphtheria, tetanus, pertussis (dTAP) immunizations can be safely administered during the first trimester of pregnancy, although dTAP is recommended at 27 to 36 weeks' gestation to provide immunity to the mother and infant. The inactivated influenza vaccine may be given because it is a killed virus vaccine and will not have a teratogenic effect. Rubella (measles) and rubeola (German measles) vaccines are both live viruses that should never be administered during pregnancy because they can have teratogenic effects. Varicella (chicken pox) immunization is not given because it may cause birth defects in the fetus.

fetal station

Location of the presenting part in relation to the mid pelvis or ischial spines expressed as cm above or below the spines station 0 is engaged station -2 is 2 cm above the ischial spines station +2 is 2 cm below the ischial spines

prolonged deceleration

Prolonged deceleration: visually apparent decrease in the FHR below the baseline Deceleration is 15 bpm or more, lasting 2 min or more but less than 10 min from onset to return to baseline. Typical causes of prolonged deceleration Cord compression (i.e., cord prolapse), profound maternal hypotension, maternal hypoxemia, tetanic uterine contractions, prolonged head compression, and amniotic fluid embolism. *Interventions to correct prolonged decelerations:* · Change maternal position - repositioning may relieve cord compression · O2 - controversial but may increase O2 delivery to the fetus · Stop oxytocin - may be useful with tachysystole or tetanic contraction · Perform exam - may reveal cord prolapse or ability to expedite delivery · Assessment of maternal status - may reveal hypoxemia, hypotension, or placental abruption · Expeditious delivery - necessary if unable to rapidly resolve decel within about 6 minutes

Category II tracing

These tracings are considered INDETERMINATE. They do not predict abnormal acid-base status. *Baseline rate* (bradycardia not accompanied by absent baseline variability. Tachycardia) *baseline FHR variability* (minimal baseline variability, absent baseline variability not accompanied by recurrent decelerations, marked baseline variability) *accelerations* (absence of induced accelerations after fetal stimulation) *periodic/episodic decelerations* (recurrent variable decelerations accompanied by minimal or moderate baseline variability, prolonged deceleration greater than or equal to but less than 10 mins, recurrent late decelerations with moderate variability, and variable decelerations with other characteristics such as slow return to baseline ... "overshoots" or "shoulders")

Cervix

-Soft to firm -Ectocervix poss lacerations, bruised -Cervical os closes. Never return to pre-pregnancy appearances. It goes from slit to stellar. -Lactation can delay mucus production *nothing goes in the vagina for 6 weeks!!! no sex, no tampons*

Nursing Diagnosis

*Acute Pain* r/t: Uterine ctx, laceration repair, hemorrhoids, incisional pain, perineum trauma, nipple soreness, breast engorgement Interventions: Pain medications Comfort measures get the client up as early as possible! early ambulation :) *Risk for complications* r/t: Perineal/inc pain, decreased peristalsis,, inactivity, abdominal relaxation, pain medications, Interventions: Cold/hot packs, sitz baths, early ambulation, stool softeners. TCBD, *Risk for impaired urinary elimination* r/t: Loss of bladder tone & sensation after birth Interventions: Assist in voiding q 2 hrs Palpate bladder tone *Risk for infection* r/t: Denuded uterine surface, surgical incision, laceration repair, cracked nipples Interventions: Uterine assessment Monitor lochia Assess pain level and location Teach proper infant latching, Provide breast care teaching *Imbalanced nutrition* r/t: less than body requirements Lack of knowledge about postpartum needs Provide teach on proper nutritional intake *Disturbed sleep pattern or Fatigue* r/t: Exhaustion from childbirth, rooming-in with newborn Interventions: Teach exercise progression at d/c, provide respite care for mother. Assign support persons to assist with daily tasks. Take naps during day

Puerperal Infection

-Another leading cause of maternal death -Local infection can easily spread to the peritoneum (peritonitis) or bloodstream (septicemia) temp > 100.4F (need elevated temp 2x) treated with IV antibiotics and may need to isolate infant or discontinue breastfeeding more info: -Bacteria infects the uterus and surrounding areas after a woman gives birth. -AKA Postpartum infection -*Endometritis* most common post partum infection follows vaginal delivery (infection of the wall of the uterus)

Postpartum Complications

-Collaboratively works with the Interdisciplinary health care team -Lengthens hospital stay and increases cost. -Women may die as a result of a complication -Devastation to family unit & disciplinary

Focused Health History of the Mother

-Health History: preexisting disease/illness, allergies -Family Profile: support persons, other children -Pregnancy History: para and gravida status, prenatal care, complications of pregnancy -Labor and Birth History: type of birth, problems during birth, presence/degree of lacerations, type of incision -Infant Data: sex, birth weight, gestational age, feeding preference, pediatrician -Lab Data: HGB/HCT on admission and the first day after delivery, blood type (infant's type if the mother is Rh-), GBS and whether treated if positive, HBsAg/RPR/HIV/Rubella status, vaccination status (Flu, MMR, Varicella, Tdap) overtreating group b strep could cause ototoxicity in the mother rubella is given at discharge because it is a live virus (if the rubella titer is positive mom is immune! if it's negative, she needs the immunization) wait 28 days and you can breastfeed after the rubella virus

Cesarean Birth- Differences p. 447

-Involution of the Uterus, Healing of Endometrium (Same as vaginal delivery) Urinary Elimination, Bowel Elimination - related to abd surgery and anesthesia -NPO (they given clears until bowel sounds) after birth until Bowel Sounds present -Assess incision (REEDA) (reasons for c/s: Cephalopelvic disproportion, breech, failure to progress in labor, active genital herpes, fetal intolerance of labor, prolapse cord, prior classical c section, macrosomia baby) don't forget a c/s is just like any other surgery! they get an incentive spirometer - they will not have episiotomy - no hot or cold packs or antiseptic sprays.. but they both might have pooling of blood when they have been laying around so don't be surprised if there is a gush of blood upon standing

Nursing Assessment of the Mother

-Pain: presence, scale, type, location, relief measures, comfort measures, relief response Afterbirth pains -Nutrition: type of diet (house/regular diet) -Hygiene: self-care or assisted, peri-care, bath or shower -Activity: OOB with assistance or independently, degree of ambulation, response to activity -Braden skin risk assessment -DVT risk assessment, interventions -Fall risk assessment -IV site

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply. 1. "The ductus arteriosus allows blood to bypass the fetal lungs." 2. "One vein carries oxygenated blood from the placenta to the fetus." 3. "The normal fetal heart beat range is 160 to 180 beats per minute in pregnancy." 4. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 5. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."

1, 2, 4 Rationale: The ductus arteriosus is a unique fetal circulation structure that allows blood to bypass the nonfunctioning fetal lungs. Oxygenated blood is transported to the fetus by one umbilical vein. The normal fetal heart beat range is considered to be 110 to 160 beats per minute. Two arteries carry deoxygenated blood and waste 632 products from the fetus, and one umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries. Test-Taking Strategy: Focus on the subject, fetal circulation. Recall that three umbilical vessels are within the umbilical cord (two arteries and one vein) and that the vein carries oxygenated blood and the arteries carry deoxygenated blood. Also recalling the normal fetal heart beat will assist in answering correctly.

So What is the nursing Implication? p/462 box18.1

1. Women receiving oxytocin will have decreased flow until the medication wears off. 2. Lochia is decreased with cesarean births. 3. Lochia flow increases with breastfeeding and ambulation 4. *Continued bleeding suggests retained placental fragments. retained placenta (low-grade fever, blots, continuous bleeding, malodorous)* 5.Continued lochia serosa or alba > 3-4 wks may indicate *endometritis* infection of the lining of the uterus 6. *Continuous* bright red bleeding with a *firm* uterus may be r/t vaginal or uterine tear.

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? 1. "I will record the number of movements or kicks." 2. "I need to lie flat on my back to perform the procedure." 3. "If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours." 4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

198. Answer: 2 Rationale: The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify the primary health care provider (PHCP) if she feels fewer than 10 kicks over two consecutive 2-hour intervals or as instructed by the PHCP. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. If you are unfamiliar with this procedure, recalling that the risk of vena cava (supine hypotensive) syndrome exists when the client lies on her back will direct you to the correct option.

Stages of labor

1st: dilating stage 3 phases: Latent (0-3cm) Active (4-7cm) Traditional (8-10cm w/ urge to push) 2nd stage: delivery 3rd: placental delivery 4th: recovery- primary goal to prevent hemorrhage from uterine atony, 1st void within 1 hour and then q2-3 hrs, Rhogam

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. 1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus

Answer: 1, 2, 3, 4 Rationale: The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus. Test-Taking Strategy: Focus on the subject, the characteristics of amniotic fluid. Visualizing the location of the amniotic fluid will assist in answering this question.

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Positive pregnancy test 5. Fetal heart rate detected by a nonelectronic device 6. Outline of fetus via radiography or ultrasonography

Answer: 1, 2, 3, 4 Rationale: The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (rebounding of 669 the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography. Test-Taking Strategy: Focusing on the subject, probable signs of pregnancy, will assist in answering this question. Remember that detection of the fetal heart rate and an outline of the fetus via radiography or ultrasonography are positive signs of pregnancy.

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? 1. "Your type of pelvis has a narrow pubic arch." 2. "Your type of pelvis is the most favorable for labor and birth." 3. "Your type of pelvis is a wide pelvis, but it has a short diameter." 4. "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

Answer: 2 Rationale: A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate. Test-Taking Strategy: Focus on the subject, female pelvis types. Recalling that the gynecoid pelvis is the normal female pelvis will direct you to the correct option.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

Answer: 2 Rationale: Accurate use of Näegele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months and add 7 days to the first day of the last menstrual period, and then add 1 year to that date: first day of the last menstrual period, October 19, 2020; subtract 3 months, July 19, 2020; add 7 days, July 26, 2020; add 1 year, July 26, 2021. Test-Taking Strategy: Focus on the subject and use knowledge regarding Näegele's rule to answer this question. This rule requires addition and subtraction, so read all options carefully, noting the dates and years in the options, before selecting an answer.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately." 2. "The vaginal discharge may be bothersome, but is a normal occurrence." 3. "Report to the emergency department at the maternity center immediately." 4. "Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours."

Answer: 2 Rationale: Leukorrhea begins during the first trimester. Many clients notice a thin, colorless, or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently. Test-Taking Strategy: Eliminate options 1 and 3 first because they are comparable or alike, indicating that the client requires medical attention. From the remaining options, recalling that this manifestation is a normal physiological occurrence or that tampons should be avoided will assist in directing you to the correct option.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate? 1. "Have you ever had surgery?" 2. "Do you plan to have any other children?" 3. "Do either of you have diabetes mellitus?" 4. "Do either of you have problems with high blood pressure?"

Answer: 2 Rationale: Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility, because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options 1, 3, and 4 are unrelated to this procedure. Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the subject, sterilization procedure. Note the relationship between the word sterilization and the words plan to have any other children in the correct option

A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? 1. "How often do you have sexual relations?" 2. "Please share with me more about your concerns." 3. "You are still young and have nothing to be concerned about." 4. "You should not have a decline in testosterone until you are in your 80s."

Answer: 2 Rationale: The nurse needs to establish trust when discussing sexual relationships with men. The nurse should open the conversation with broad statements to determine the true nature of the client's concerns. The frequency of intercourse is not a relevant first question to establish trust. Testosterone declines with the aging process. Test-Taking Strategy: Note the strategic word, best. Determine whether further assessment or validation is needed. In this case, more information is needed to determine the nature of the client's concerns. Keeping these concepts in mind and using therapeutic communication techniques will assist in directing you to the correct option.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. 6. The area of the injection needs to be covered with a sterile gauze for 1 week.

Answer: 2, 3, 4, 5 Rationale: Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization or as specified by the obstetrician because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze. Test-Taking Strategy: Focus on the subject, client instructions regarding the rubella vaccine. Recalling that the rubella vaccine is a live virus vaccine will assist in selecting options 2 and 5. Next, recalling the route of administration and the contraindications associated with its use will assist in selecting options 3 and 4.

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. Strict bed rest is required after the procedure. 2. Hospitalization is necessary for 24 hours after the procedure. 3. An informed consent needs to be signed before the procedure. 4. A fever is expected after the procedure because of the trauma to the abdomen.

Answer: 3 Rationale: Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest, but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in the obstetrician's office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure. Test-Taking Strategy: Focus on the subject, nursing implications related to amniocentesis. Recalling that this procedure is invasive will direct you to the correct option.

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate? 1. Contact the primary health care provider. 2. Instruct the client to maintain bed rest for the remainder of the pregnancy. 3. Inform the client that these contractions are common and may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a preterm labor condition.

Answer: 3 Rationale: Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, there is no reason to notify the primary health care provider. This client is not in preterm labor and, therefore, does not need to be placed on bed rest or be admitted to the hospital to be monitored. Test-Taking Strategy: Options 1 and 4 are comparable or alike and can be eliminated first. From the remaining options, knowing that Braxton Hicks contractions are common and normal and can occur throughout pregnancy will assist in directing you to the correct option.

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding? 1. The client is measuring large for gestational age. 2. The client is measuring small for gestational age. 3. The client is measuring normal for gestational age. 4. More evidence is needed to determine size for gestational age

Answer: 3 Rationale: During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm. Therefore, if the client is at 28 weeks' gestation, a fundal height of 30 cm would indicate that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process. Test-Taking Strategy: Focus on the subject, the location of fundal height. Remember that during the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Notify the obstetrician (OB). 4. Tell the client that the fetal heart rate is normal.

Answer: 3 Rationale: The FHR depends on gestational age and ranges from 160 to 170 beats per minute in the first trimester but slows with fetal growth to 110 to 160 beats per minute. If the FHR is less than 110 beats per minute or more than 160 beats per minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the OB. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the OB needs to be notified. Test-Taking Strategy: Focus on the data in the question and note the strategic word, priority. Then, note if an abnormality exists. Also note the FHR and that the client is at 38 weeks of gestation. Remember that the normal FHR is 110 to 160 beats per minute.

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. 1. It cushions and protects the baby. 2. It maintains the temperature of the baby. 3. It is the way the baby gets food and oxygen. 4. It prevents all antibodies and viruses from passing to the baby. 5. It provides an exchange of nutrients and waste products between the mother and developing fetus.

Answer: 3, 5 Rationale: The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta. Test-Taking Strategy: Focus on the subject, the purpose of the placenta. Remember that the placenta provides oxygen and nutrients.

Physiological Changes-Perfusion

Blood loss -Vaginal birth—300-500 mL -Cesarean—500-1000 mL -1 gram drop in HGB for every 250 mL -Increased blood return to heart from non pregnant uterus -High levels of fibrinogen—risk for thrombus formation -Increased WBCs to 30,000/mm3 -Varicosities of the legs and anus should resolve in Post partum period Nursing interventions •Assess repeat HGB (we might give blood if its less than 8) •Administer iron or blood transfusion •Cardiac OP is increased 60-80% •Reduced pulse rate from increased stroke volume (50s-70s is normal) •Orthostatic hypotension •Assess DVT risk, take preventive measures •Expect slight increase in temp first 24 hours. Temps > 100.4 F call physician

Changes in GI & Bowel

Bowel Elimination -Constipation -Residual effects of progesterone decreases peristalsis -Relaxation of abdominal muscles -Perineal/incisional pain -Side effects of pain meds -Rectal Protrusions -Hemorrhoids -Third and 4th degree through anal sphincter Nursing Implications -Assess bowel function -Administer stool softeners -Comfort measures for rectal protrusions Expectations -Hungry -Incontinent of Flatus

breast and nipple care

Breastfeeding mothers -Encourage infant to breastfeed -Use warm compresses or warm shower -Teach effective latching, breastfeeding techniques -Lactation consult -Lanolin to nipples Bottle-feeding mothers -avoid nipple stimulation -use cold compresses Both mothers -Wear a good supporting bra -Wash breast daily with clear water, avoiding soap -Use gauze or breast pads for leakage

When discussing dietary needs during pregnancy, a client tells the nurse that milk causes her to be constipated at times. Which would the nurse teach the client?

Increase high-fiber foods and water intake and continue drinking milk. Unless lactose intolerance is present, the client could continue drinking milk and adjust her diet through increased intake of high-fiber foods, increased fluids, and activity to help ease constipation. Substituting cheeses for milk and replacing fat-free or low-fat milk with whole milk would not ease constipation. Mega doses of vitamins can be harmful, and prenatal vitamins are not a substitute for milk. For the client who cannot drink milk, other calcium-rich foods are available, as are calcium supplements.

trauma during pregnancy

LIFE SAVING MEASURES FOR MOM FIRST (you cant bake a cake if the oven isnt working) uterine displacement (tilt her to the left to optimize blood flow to the uterus) deliver if necessary (might allow for better life saving measures for the mother or if the mother is not in immediate danger but the fetus is) if mom and fetus are stable, continue to monitor for 4 hours

Which action would the nurse immediately perform 30 minutes after birth on a postpartum client who has excessive lochia and a relaxed uterus?

Massage the uterus. massaging the uterus will induce uterine contraction and cause expulsion of clots; frequent massage should be continued to keep the uterus firm and inhibit bleeding. Pulse and blood pressure should be monitored but may not change significantly unless large amounts of blood are lost. If bleeding continues after the fundus is massaged, the health care practitioner should be notified. Placing the client in the Trendelenburg position is appropriate if the client is in shock, but the data do not indicate shock.

Compare: NST, CST, BPP

NST: noninvasive test, fetus with adequate O2 and intact nervous system will have accelerations. reactive = 15x15 CST: evaluates oxygenation and perfusion status of the fetus, ctx can be induced or spontaneous. negative = no decelerations with 3 ctx over 10 mins. positive = repetitive late decelerations with ctx.... normal is negative BPP: done is NST is nonreactive. real time ultrasound to look for fetal movement (breathing, body/limbs, fetal tone, and amniotic fluid volume) score of 2 is given to normal findings. 8 to 10 is a normal score. normal findings indicate the fetus is not hypoxemic

´Deficient Knowledge (specify) r/t absence or deficiency of cognitive information related to postpartal care and/or care of a newborn

On Admission: -Orientation to unit -Activity/ADLs -Nutrition/Diet -Medications -Hand Hygiene When Baby Arrives: -ID/HUGS tags -Safety -Bulb syringe -Crib supplies -Flowsheet—feeding, voids, stools -Cord care Infant Feeding: -Bottle or Breast Discharge: -Medications -Follow ups -Warning signs

A woman, 34 weeks gestation, comes to OBED w/ reports of vaginal bleeding... what questions should we ask her?

What questions would you ask?: are you having any pain? do you have any problems with your placenta that you know of? are you bleeding? and tell me about that bleeding! how many pads have you been through? is baby moving for you? has this happened to you before? What assessment?: put baby on the monitor, check FHR to monitor status and oxygenation, maternal VS but do not do a vaginal exam! Say the patient has no pain. She woke up with bleeding and this has never happened to her before... what do you suspect?: Placenta previa because she is experiencing bleeding with no pain. Plan: continue to monitor bleeding through peripads, chuck pads, what type of blood is it? what does it look like? weigh the pads!

violence during pregnancy

can increase the result in preterm labor or loss of pregnancy screening questionnaire during prenatal visits identify and offer assistance are you with a partner who threatens or physically hurts you? are you with a spouse or partner who emotionally hurts you? Within the past year has anyone hit, slapped, kicked, or otherwise hurt you? Has anyone forced you to have sexual activities that made you uncomfortable? are you afraid of your partner or anyone listed above?

Stage 1 of labor

cervix dilates from 0-10 cm 3 phases: latent (early labor), active, and transition Goal is cervix dilation effacement due to contractions

Cervical insufficiency

cervix is less than 2cm in length painless dilation of the cervix and they can find this with ultrasound it can be congenital/structural defect ... sometimes she's just born that way! sometimes it is an acquired factor (surgery, abortions, trauma to the cervix, etc.) cerclage - our "fix" to insufficiently. its a very thick stitch in her cervix to keep it closed. this is done around 11 or 12 weeks of gestation. they will cut the suture out around 36 weeks and let her labor on her own it is often one cause of late miscarriage progesterone supplements prepare the uterus for pregnancy and decreases contractions - given PO, IM, or vaginal which is given throughout her pregnancy

signs and symptoms of preterm labor

change in type of vaginal discharge increase in amount of vaginal discharge pelvic or lower abd pressure constant low, dull backache mild abd cramps w or w/out diarrhea regular or frequent contractions or uterine tightening - often painless ruptured membranes

Variability

fluctuations in the FHR of 2 cycles/min or greater... it is the most important indicator of fetal oxygenation status! Moderate variability is considered normal for a term fetus... caused by interplay between the sympathetic and parasympathetic nervous systems... clinically, comments on variability should be based on the last 10-20 minutes of fetal tracing. Visually quantitated as the amplitude of peak-to-trough in bpm Absent: amplitude range is undetectable Minimal: amplitude range is detectable but 5 bpm or fewer Moderate (normal): amplitude range of 6-25 bpm Marked: amplitude range greater than 25 bpm

prevention of preterm labor

for moms with a hx of preterm labor/births or short cervical lengths may be prescribed progesterone

placenta previa

implantation of the placenta over the cervical opening or in the lower region of the uterus complete previa - definitely c section partial previa - most likely c section placenta previa can be a manageable condition confirmed by ultrasound if pt has episodes of bleeding we need to anticipate a c-section and high blood loss anticipate high blood loss... the baby might be deprived of blood number one sign is PAINLESS bright red bleeding! complications: bleeding - worry about blood and oxygen to the baby and mom. c-section ... preterm delivery assess/monitor: blood loss (weigh pads), monitor VS, FHR, and ctx, labs (h&h, type & cross) ... no vaginal exams if unsure of the reason for vaginal bleeding!!! your finger can puncture the placenta IVF and/or blood transfusions

Preterm labor

increases the risk for infant mortality and respiratory distress syndrome (RDS) preterm newborns have immature organs and systems and are not prepared for life outside the uterus preterm labor - prior to 37 weeks gestation if the pt reports ctx tell them to stop what they are doing - hydrate and rest and continue to monitor - call MD if ctx do not go away labor = contractions that are regular, get stronger and closer together causing cervical dilation and effacement treatment: -something to stop contractions (tocolysis) which suppresses uterine contractions -IVF; hydration -nifedipine (calcium channel blocker), oral -indomethacin (NSAID), oral or suppository -terbutaline (used less frequently d/t side effects... tachycardia), oral or SQ -magnesium sulfate as a neuroprotective for the fetus ... decreases brain bleeds and is a very strong muscle relaxer... WILL STOP CTXs -betamethasone (steroid injection w/ mom still pregnant and is used to help the babys lungs develop

variable deceleration

is a visually apparent abrupt decrease in FHR An abrupt FHR decrease: defined from the beginning of the deceleration to the beginning of the FHR nadir of < 30 seconds. The decrease in FHR is calculation from the onset to the nadir (lowest point) of the deceleration. When variable decelerations are associated with uterine contractions, their onset, depth, and duration commonly vary with successive uterine contractions. Decels are classically caused by cord compression. Can also be caused by rapid vagal stimulation (head compression). Occurrence after ROM may be associated with cord prolapse. When associated with diminished or absent FHR variability, decels may indicate hypoxemia or acidosis. *Interventions to correct variable decelerations and rationales:* Change maternal position - repositioning may relieve cord compression O2 - controversial but may increase O2 delivery to fetus Stop oxytocin - may decrease contractions causing cord compression Tocolytic (terbutaline) - may be useful with tachysystole or tetanic contraction Perform exam - may reveal cord prolapse or ability to expedite delivery Amnioinfusion - shown to decrease severe variables and cesarean rate

oligohydramnios

less than normal fluid usually related to kidney problem skeletal abnormalities, respiratory difficulties, and fetal intolerance of labor can occur

Rh alloimmunization

moms blood type and dads blood type can impact the baby an Rh- mom if she is exposed to an Rh+ person the baby has a 50% chance of being positive or negative... In general, the mother's blood does not mix with the fetus but it can occur. If mom is exposed to a + blood type, she will go after it and attack it like it is a foreign body. FIRST child generally not affected because mom has not yet been exposed - subsequent children are at risk A dose of Rhogam at 28 weeks for all pregnant women (each pregnancy) and 72 hours after delivery if the baby is Rh+

Nonstres test

noninvasive - over 20-30 minutes or longer if fetus is in a sleep cycle monitors fetal well being a fetus with adequate oxygenation and intact nervous system will have accelerations in heartbeat with movement categorized in two ways: reactive and nonreactive reactive is normal - at least 2 accelerations (of *15bpm over 15 secs*) in a 20 minute period ... fetus is mature enough to achieve this at 32 weeks but at 28 weeks accelerations of 10x10 would be considered reactive too. nonreactive is not normal and should be evaluated further - if the criteria above is not met in a 20 minute window a BPP should be performed. NST is usually repeated once or twice weekly for the remainder of pregnancy

surgery during pregnancy

nothing elective shield from radiation SCDs post-op... pregnant women are at increased risk for DVTs wedge pt so that uterus is displaced and allows for adequate blood flow to the uterus/placenta. monitor FHR before/during/after depending on gestational age use spinal or epidural anesthesia if possible monitor vs and blood loss

A woman 28 weeks gestation comes to the obstetric triage area reporting leakage of fluid from her vagina... What questions would you ask?

onset and amount of leakage? do you feel anything abnormal down there? has your baby been moving? what kind of assessments... SVE - wait for the physician ... while waiting we can put the baby on the FHM and we can also obtain moms history and her VS

molar pregnancy

placenta will have grape-like clusters loss of pregnancy for many women potential for cancer if a woman has a molar pregnancy, her bleeding will look like prune juice grape looking clusters assess uterine size (larger than expected for gestational age) hyperemesis know that most molar pregnancies end in miscarriage evacuation of mole and curettage of uterus to remove all fragments instruct the need for close and careful follow up due to the risk for cancer

heart disease in pregnancy

pregnancy causes increased cardiac output impacts co-morbidities woman with heart disease might have a difficult time adapting to these changes in cardiac output... consider those with AMA (advanced maternal age) pt should be monitored by their specialist heparin is safe during pregnancy diuretics and antiarrhythmics can cross the placenta but are not teratogenic some conditions might require minimal exertion during labor/birth. use of vacuums or forceps are sometimes used to limit the amount of effort the women has to put into pushing.

Rupture of membranes (ROM)

premature rupture of membranes - occurs prior to the onset of labor pprom - preterm premature rupture of membranes is a rupture that occurs before labor begins and prior to 37 weeks gestation prolonged ROM - membranes rupture for greater than 24 hours prior to delivery DIAGNOSIS: sterile speculum exam by a physician that looks for fluid pooling in the vagina, tests the fluid with nitrazine/litmus paper... turns blue if the membranes rupture (fern pattern under a microscope) SVE is avoided in preterm pregnancies because it increases the risk of infection but can be performed for a term pregnancy PROM assessment (COAT - color, odor, amount, time) fluid should be clear (not meconium stained) monitor for s/s of labor, infection (chorioamnionitis) ... if term SVE for dilation and presence of cord treatment for PROM - move towards delivery. if ruptured longer than 18 hours begin IV antibiotics and consider augmentation of labor if preterm IV antibiotics then oral... also betamethasone to promote fetal lung maturity ... IV mag sulfate (neuroprotective) and inpatient monitoring until labor occurs... deliver at 34-37 weeks

uterine atony

soft uterus prevention: routine palpation of the fundus treatment: fundal massage, oxytocin or methylergonovine, misoprostol

advanced pattern recognition

some FHT patterns are beyond the scope of NICHD guidelines... *Wandering baseline (or agonal pattern)* -Unusual pattern that is not clearly defined. Can represent hypoxemia and acidosis or a fetus that has already suffered a neurologic insult for any number of reasons. This often precedes terminal bradycardia and fetal demise. Management depends on the situation and often expedited or emergent delivery is warranted. *Lambda pattern* -Consists of acceleration followed by deceleration then a return to baseline. Probably caused by partial cord compression. Decel too shallow to be considered a variable, though the physiology is the same. Not associated with fetal hypoxia or acidosis. Clinically important to distinguish from late deceleration *Checkmark pattern* -This pattern appears as a saw tooth on fetal tracing. It is often indicative of profound neurological damage that has already occurred to the fetus. The necessity of immediate intervention is unclear. *Fetal arrhythmias* -Various arrhythmias may be observed both during labor and during antepartum fetal evaluations. Some arrhythmias are: tachyarrhythmias, PACs and PVCs, atrial flutter and/or fibrillation, SVT, bradyarrhythmias, heart block (1st degree, 2nd degree, and 3rd degree) *Maternal heart rate with fetal demise* -Maternal HR can often be confused with the fetal HR. It is important to compare the maternal pulse and compare it to the fetal tracing when first placing the toco. When the mother is febrile the maternal HR can be in the range of a normal fetal HR. Both an external Doppler can falsely record the FHR as well as the internal FSE when there is a fetal demise

Bleeding during pregnancy

some bleeding is considered normal if a woman reports he is bleeding she must be seen as it is difficult to assess the amount of blood and characteristics over the phone count pads and weight them, monitor VS, monitor for shock, assess heart tones, administer IVF (LR), physical assessment and interview - what happened and has this happened before? common causes for bleeding are: abortion/miscarriage, ectopic pregnancy, cervical insufficiency, and molar pregnancy

Fetal tachycardia & bradycardia

tachycardia (baseline FHR greater than 160 bpm) bradycardia (baseline FHR less than 110 bpm) Typical causes of tachycardia: maternal fever, chorioamnionitis, fetal sepsis, drugs, fetal hypoxemia, tachyarrhythmias, fetal heart failure, severe fetal anemia/hydrops, maternal hypothyroidism Typical causes of bradycardia: hypoxemia, drugs, maternal hypotension, hypothermia, maternal hypoglycemia, fetal bradyarrhythmias, congenital heart block, umbilical cord compression, amniotic fluid embolism, normal variation (greater than or equal to 100) Average FHR baseline is 110-160 bpm Interventions to correct bradycardia and rationales: -Turn pt to left lateral side - relieve vena caval cord compression and increase cardiac output -Fluid bolus and lower head - reverse hypotension and increase CO and placental perfusion -Vasopressor (ephedrine) - useful with maternal hypotension (i.e., after an epidural bolus -O2 - controversial but may increase O2 deliver to the fetus -Stop oxytocin - may increase resting time between contractions -Tocolytic - may be useful with tachysystole or tetanic contraction -Perform exam - rigid abdomen and excess bleeding may indicate abruption -Review hx - any evidence of congenital heart block in the fetus? -Perform operative delivery - if pattern persists despite above and delivery not imminent Interventions to correct tachycardia and rationales: -Check maternal temperature - may need antipyretics -O2 - controversial, but may increase O2 delivery to fetus -Evaluate maternal hx - sympathomimetic drugs, maternal hyperthyroidism, etc. -Assess uterus - may establish diagnosis of chorioamnionitis needing antibiotics -Evaluate for arrhythmias - fetus may have atrial flutter/fibrillation or svt -Evaluate rest of FHT - look for nonreassuring signs (absent variability, late decels) which may warrant expedited delivery

Variability

tells us about oxygenation *absent variability* - amplitude is undetectable. there are now significant movements up or down! this would indicate *hypoxia*... note that it would look almost like a flatline interventions: O2 mask 10L of oxygen *minimal variability* - amplitude of 5bmp or less (ex: HR bounces back and forth between 145 and 150) this indicates a *sleep cycle*, early gestation, *hypoxia*, tachycardia. There is not a lot of movement in the FHR line. *moderate variability* - this is what we want to see!! the amplitude of 6-25 bpm and indicates *adequate oxygenation*. BPM between 135-155 ... movement in the baseline *marked variability* - amplitude of greater than 25 bpm and indicated hypoxia, fetal stimulation, and stimulant meds... ex: 145-180 bpm

late decelerations

visually apparent, usually symmetrical, gradual decrease and return of the FHR associated with a uterine contraction. A gradual FHR decrease that is defined from the onset to the FHR nadir of greater than or equal to 30 seconds. The decrease in FHR is calculated from the onset to the nadir of the decel. The decel is delayed in timing, with the nadir occurring after the peak of contraction. Mostly, the onset, nadir, and recover of the decel occur after the beginning, peak, and ending of the contraction. This is typically caused by uteroplacental insufficiency (UPI) which involves uterine perfusion, uterine tone, or placental function. Some causes are immediately reversible and some are not. Always associated with relative hypoxia but not necessarily hypoxemia or acidosis. *Immediately reversible causes of late deceleration* -Maternal hypotension and uterine hyperactivity *Causes of late deceleration that may or may not be reversible* -Maternal hypertensive disorders, IUGR, maternal diabetes, cardiac disease, chorioamnionitis, maternal anemia, Rh Isoimmunization, and maternal tobacco use *Causes of late deceleration that are typically not reversible* -Placental abruption/infarction and placenta previa

early deceleration

visually apparent, usually symmetrical, gradual decrease and return of the FHR associated with uterine contraction. A gradual FHR decrease that is defined from the onset to the FHR nadir of greater than or equal to 30 seconds. The decrease in FHR is calculated from the onset to the nadir of deceleration. The nadir of the decelerations occurs at the same time as the peak of the contraction In most cases the onset, nadir, and recovery of the deceleration are coincident with the beginning, peak, and ending of the contraction. Classically cause by head compression and vasovagal response Early decels are never associated with hypoxemia or acidosis Appearance of early decels in labor (<5 cm dilation) may indicate cephalopelvic disproportion (CPD)

contractions

when measured externally with a Toco, only shows how frequent contractions are... when measured internally with IUPC we can see how strong they are as well as how frequent. Uterine contractions: the number of contractions in a 10 minute window, averaged over 30 minutes. Contraction frequency alone is a partial assessment of uterine activity. Duration, intensity, relaxation time between contractions are all important in clinical practice

A young woman appearing to be in her 20s enters the ED. She is holding her abdomen and crying. What questions do you want to ask her?

when was your LMP? was the onset of pain sudden? sharp? one-sided? are you bleeding? describe... is there any possibility you are pregnant? know that you would not expect to see grape like clusters or prune juice bleeding as that is associated with molar pregnancies what would we suspect? ectopic pregnancy