2500 - Unit 2
hemolysis, elevated liver enzymes, low platelets
What does HELLP stand for?
Preterm Premature Rupture of Membranes
What does PPROM stand for?
premature rupture of membranes
What does PROM stand for?
rupture of membranes
What does ROM stand for?
to prevent pushing
Why would the nurse in the active stage of labor encourage the pt to pant with pursed lips
"I know you must be very upset and angry about your daughter's pregnancy, but because she's still an adolescent herself, she'll need your guidance in making nutritional and health choices that will be good for the baby and for herself."
A 14-year-old client and her parents have presented at the obstetrician's office in the second trimester; the teen had been hiding the pregnancy. The nurse is helping them develop a plan of care. What is the best thing the nurse can say to the clearly angry parents?
Assess deep tendon reflexes
A client with preeclampsia is receiving magnesium sulfate to suppress or control seizures. Which nursing intervention should a nurse perform to determine the effectiveness of therapy?
calcium gluconate
A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?
"knife-like" abdominal pain with vaginal bleeding
A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess?
fetal hypoxia
A nurse is caring for an antenatal client diagnosed with umbilical cord prolapse. For which condition should the nurse monitor the fetus?
breech presentation
A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation?
"Hold your baby as long as you like. Please let me know what I can do to help you."
A pregnant woman gives birth to a term fetus who has died in utero. She requests time after the birth to hold her baby. What is the best response by the nurse?
HELLP Syndrome
A variant of pre/eclampsia. Life-threatening. threatening.
Gestational Hypertension
Blood pressure of 140/90 or higher identified after 20 weeks gestation, without protein in the higher identified after 20 weeks gestation, without protein in the urine. Resolves within 12 weeks postpartum. urine. Resolves within 12 weeks postpartum
an Rh- mother with an Rh+ fetus
Hemolytic disease of the newborn can result from
rises slightly
How does the basal body temperature change during ovulation?
Chronic Hypertension
Hypertension that exists prior to pregnancy or develops before 20 weeks gestation. pregnancy or develops before 20 weeks gestation
Preeclampsia
Hypertension with protein in the urine. Develops after 20 weeks gestation. Develops after 20 weeks gestation
Eclampsia
Onset of seizure activity in women with preeclampsia. preeclampsia
Preterm Labor (PTL)
Regular uterine contractions + cervical effacement and dilation + <38 weeks
PPROM
Rupture of membranes at membranes at <38wks and before onset of true labor
PROM
Rupture of membranes before membranes before onset of true labor
false
T/F: you can deliver vaginally during a case of placenta previa
elevated liver enzymes
The nurse is reviewing the laboratory test results of a pregnant client. Which finding would alert the nurse to the development of HELLP syndrome?
a 35-year-old, 21-week G3P2 client with blood pressure of 160/110 mm Hg, blurred vision, and whose last blood pressure was 143/99 mm Hg and urine dipstick showed a +2 proteinuria
The nurse is transcribing messages from the answering service. Which phone message should the nurse return first?
abruption placentae
The placenta breaks away or abrupts from the uterine wall before the baby is born.
>140/90 mm hg after 20 weeks gestation
blood pressure for mild preeclampsia
>160/110 mm hg
blood pressure for severe preeclampsia or eclampsia
ultrasound
how is placenta previa diagnosed
• Elevated BP • Oliguria • Visual disturbances • Pulmonary edema • Headache • Right upper quadrant pain (liver) • Low platelets • Elevated liver enzymes
if a pt has no protein in the urine, but has these symptoms, it qualifies for a diagnosis of preeclampsia
Amnioinfusion
introduction of a solution into the amniotic sac; an isotonic solution is most commonly used to relieve fetal distress
• Notify physician ASAP • Maintain airway, oxygenation, IV access • Seizure precautions and patient safety • Start Magnesium loading dose, Ativan can be used for recurrent convulsions if Mag isn't working • Monitor vital signs, Deep Tendon Reflexes (DTR) and check for clonus. • Quiet environment low light to prevent cerebral disturbances • Monitor labs • Monitor for progression to HELLP
list some interventions for eclamptic seizures
- Maternal hypertension - Maternal trauma - Smoking - Cocaine use - Advanced maternal age - Scarred uterus or uterine fibroid - PROM >24 hrs, especially with infection - Amniocentesis
list the risk factors for abruption placentae
- first time pregnancies - pregnant teens - women over 40 - hx of high blood pressure - hx of preeclampsia - mother or sister with preeclampsia - hx of obesity - carrying more than one baby - hx of diabetes, kidney disease, lupus, or rheumatoid arthritis
list the risk factors for preeclampsia
- Sudden or severe abdominal pain - Light, moderate, or severe vaginal bleeding - Uterus that hurts or is sore - Uterus may feel hard or rigid - Contractions - Symptoms of shock include N/V; restless; weak; disoriented; fast, shallow breathing - Abnormal FHR
list the s/s for abruption placentae
• Increasing edema, especially of the hands and face( if on bed rest observe for sacral edema) • Worsening headache • Epigastric pain • Visual disturbances • Decreasing urinary output • Nausea/vomiting • Bleeding gums • Disorientation • Generalized complaints of not feeling well
list the s/s of worsening preeclampsia
1.8 - 2.6
normal magnesium levels
Severe headache, generalized edema, RUQ or epigastric pain, visual disturbances, cerebral hemorrhage, renal failure HELLP
s/s of eclampsia
Depression or absence of DTR's Oliguria Confusion, change in LOC Respiratory depression Circulatory collapse Respiratory paralysis
s/s of magnesium sulfate toxicity
Mild facial or hand edema, weight gain
s/s of mild preeclampsia
HYPERREFLEXIA Headache, oliguria, blurred vision, scotomata (blind spots), pulmonary edema, Thrombocytopenia (platelet count <100,000 platelets/mm3) Cerebral disturbances, Epigastric or RUQ pain HELLP
s/s of severe preeclampsia
placenta previa
the abnormal implantation of the placenta in the lower portion of the uterus the placenta is on top of the cervix, blocking the baby
colposcopy
visual examination of the vagina and cervix using a colposcope that magnifies the tissues
2+ or 3+
what are normal reflexes graded at
Unknown Causes Placenta Abnormalities Umbilical Cord Abnormalities Cord Accident PIH Diabetes Infection Isoimmune hemolytic disease Congenital Anomalies
what are possible causes of IUFD
Mg Sulfate, nifedipine, terbutaline, indomethacin
what are some examples of tocolytics
- Crosses placenta - Monitor Serum levelsMonitor Serum levels - Monitor respirations - Assess Reflexes - Strict I&O; Monitor specific hourly output! - give close fetal monitoring - monitor newborn for signs of MgSo4 toxicity
what are some nursing considerations for MgSo4
Unilateral lower abdominal pain, bleeding may or may not be visible
what are the s/s of ectopic pregnancy
surgery or methotrexate
what are the treatments for an ectopic pregnancy
insulin requirements will increase during pregnancy and decrease after delivery
what changes in insulin requirements will occur for a pregnant mother with type 1 diabetes?
red, wrinkled skin, lanugo, and hypotonic muscles
what characteristics are most commonly seen in a preterm infant?
increase protein in the diet
what diet change should a woman with preeclampsia make?
Intrauterine fetal death
what does IUFD stand for
ceftriaxone IM with doxycycline PO for 7 days
what is a common medication regimen to treat gonorrhea
calcium gluconate
what is the antidote for magnesium sulfate
infection
what is the most common complication of a prolonged rupture of membranes
platelet count, serum creatinine, and liver chemistries
what labs will they draw to determine preeclampsia
left
what maternal side increases uterine blood flow to the fetus
300 mg/24 hr or greater than 1+ to 2+ protein on a random dipstick urine sample
what will the protein levels look like for a woman with mild preeclampsia
>500mg/24 hr or greater than 3+ on a random dipstick urine sample
what will the protein levels look like for a woman with severe preeclampsia
before 34 weeks
when can you administer tocolytics for preterm labor
at the fourth intercostal space at the left midclavicular line
where do you assess an apical pulse on a newborn infant
high magnesium levels
why would a gravida patient have diminished or absent reflexes
CNS irritation/ severe preeclampsia
why would a gravida pt have hyperreflexia
helps the baby's lungs mature
why would they administer betamethasone to a PTL mom
