4802 OB Exam 3

Management of of Severe Preeclampsia

*Depends on the severity and the gestational age 1. Conservative management includes: -Steroids (betamethasone for the fetal lung development of surfactant) -Careful nursing assessments (BP, lung fields, etc) -EFM (electronic fetal monitoring for fetal well-being) -Patient teaching -Seizure precautions (limit ambulation, bed in the lowest position with 3/4 rails up, patient education) -Medications (HTN medications, magnesium sulfate) 2. Induction -The only "cure" for preeclampsia/eclampsia is to deliver the baby and the placenta

What does home management of prolonged premature rupture of membranes look like?

*Especially in the mid-2nd trimester. 1. The mother takes an antibiotic PO 2. She takes her temperature at least four times a day. 3. She stays a couple days in the hospital to get IV antibiotics and be monitored and then, switches to PO antibiotics to go home.

Maternal Complications for mothers with diabetes during pregnancy

*Similar complications for both mothers with and without vascular complications: -Increased risk for Pre E -Increased risk for eclampsia -Increased risk for C/S (large babies) -Hydramnious -Infection -DKA -Hypo/hyperglycemia

Eclampsia

*The onset of seizure activity or coma in a patient with no previous history. -1/3 of seizures occur in pregnancy -1/3 occur in labor -1/3 occur within 72 hours of delivery

Hypertensive Disorders in Pregnancy

- Affects 6-8% of pregnancies -HTN occurs more frequently in African Americans and American Indians. -More frequent in older and younger patients -The rate is rising consistently

Fetal complications in mothers with vascular disease and without good glucose control during pregnancy

- Intrauterine growth restriction (IUGR) -Fetal distress -Respiratory distress: This is common for all babies with diabetic mothers because high fetal insulin production slows the production of surfactant (common for mothers with and without vascular complications) -Stillbirth (we used to deliver diabetic mother at 36 wks because the risk of stillbirth increases dramatically in the last 4wks) -Spontaneous abortion (SAB)

What percentage of pregnancies are estimated to end in spontaneous abortion (SAB)?

-10 to 20% of all confirmed pregnancies end in SAB. (These mothers knew they were pregnant. They had a positive pregnancy test)

What is a missed abortion?

-A pregnancy in which there is fetal demise but no uterine activity to expel the products of conception; -Recurrent SAB: 3 or more consecutive pregnancy losses.

Treatment of Superficial thrombophlebitis

-Anti-inflammatory meds (NSAIDS) -Rest with leg elevated -Elastic hose Nursing assessments -Teaching -Pulses -Pain management

What is the treatment for threatened spontaneous abortion (SAB)?

-Bedrest (reduces the pressure of the pelvis) -Pelvic rest (nothing in the vagina) -Pain meds if needed (for cramping) -Possible ultrasound (US)- check pregnancy status -Emotional support/teaching (whenever possible)

Macrosomia

-Big baby -Usually related to or caused by gestational diabetes. -Sometimes the baby's size prevents the baby from being delivered vaginally and a C-section is needed.

Mastitis

-Breast infection most common in nursing mothers. -Effects up to 30% of mothers, usually 2 to 8 weeks after delivery or whenever nursing frequency declines. -Staph and strep most common organisms. - Untreated mastitis can result in a breast abscess. *Anyone can get mastitis, but it is most common in breast feeding mothers. 33% of nursing mothers will have a case of mastitis. Only 1% on non-nursing mothers will develop mastitis. -SX: Fever, thickened area in the breast where there is usually a clot, the patient may also have enlarged lymph nodes in the axillary region.

Postpartum Infections Treatment

-Broad spectrum antibiotics -Hydration -Rest (upright position) -Pain management -Emotional support *Providers will usually treat fever with ABX during labor and most likely after delivery as well. The FHR increases when the mother develops a fever. *Resting in an upright position allows any infected drainage to come out of the vagina instead of moving up into the tubes. *Provide emotional support and patient teaching

What puts pregnant women at a higher risk for forming clots?

-Coagulation factors are higher in a pregnant woman. This makes her 10-20% more at risk for a clot than a non-pregnant woman. -Early ambulation is one of the best ways to prevent clot formation. Also make sure the patient doesn't have her legs in the stirrups for a long period of time (it puts pressure on the popliteal area increasing the incidence of a clot)

What is the definition of preterm birth?

-Delivery prior to the completion of the week 37 -This can result in maturity problems -Prematurity is the #1 cause of neonatal mortality. It accounts for 35% of infant deaths and neurological disabilities in the United States

Post delivery treatment: Eclampsia

-Eclampsia patients need to stay on magnesium sulfate longer than preeclamptic patients -After giving birth eclamptic patients may still have a seizure, so they should be on seizure precautions.

What causes hydramnious in diabetic pregnancies?

-Excess circulating glucose travels through the placenta to the fetus, but the fetus can only produce so much insulin before the fetus essentially becomes diabetic itself. As a result, the fetus produces more urine (polyuria) which is one of the S&S of diabetes. This results in excess amniotic fluid.

Signs and Symptoms of Postpartum Infections

-Fever (after 24 hours) -Chills -Nausea -Pelvic and/or abd pain -Foul smelling, profuse lochia *Fever is 100.4 F or higher, but in postpartum women, it only counts 24 hours after giving birth because before that it could be related to dehydration or fatigue. If the mother develops a fever with that first 24 hours, increase fluids to ensure that dehydration isn't the cause and check their lab work.

How does glucose get to the fetus during pregnancy?

-Glucose levels in fetus proportionate to levels in mother -Transported across placenta through carrier mediated diffusion (essentially, it takes energy from the mother to transport the glucose across the placenta) -Main fuel used by fetus

Blood pressure medications given during pregnancy

-Hydralazine (Apressoline) -Labetalol (Trandate) -Nifedipine (Procardia) -Aldomet (Methyldopa)

What type of fluids are usually given for hemorrhagic shock?

-IVF: Ringer's Lactate or Normal Saline with or without pitocin. Run it wide-open initially. -Mom is typed/cross-matched. Try to stay two units ahead of transfusions (as you use two units of blood, order two more units of blood)

Chronic hypertension during pregnancy

-Impacts 1-5% of all pregnancies Risk factors: -Advanced maternal age (AMA) -African American -Obesity *Pregnant women with a history of chronic HTN are considered high risk or low risk depending on how well their BP is controlled and whether or not they have any other risk factors

How do you reduce the risk of preeclampsia if you are already a high risk?

-Low dose ASA (aspirin therapy) for high risk mothers from 12-28 weeks gestation. High risk mothers include: -Previous pregnancy with the diagnosis of Pre E -Multifetal gestation -Chronic hypertension -Preexisting diabetes -Renal disease -Autoimmune disease

Fetal complications in mothers without vascular disease and without good glucose control during pregnancy

-Macrosomia -Shoulder dystocia -Increased C-section (C/S) risk -Slows surfactant production -Hydramnious (high levels of glucose to the fetus causes polyuria [think diabetic fetus] leads to too much amniotic fluid) -Birth defects (i.e. Sacral agenesis)

What is prolonged, premature rupture of membranes?

-Membranes ruptured more than 24 hours before birth. -Ideally, once the membranes have ruptured, you want the baby to be born within 24 hrs, but this is not always the case. -Previous HX of PPROM increases risk. ~50% PPROM can be held about a week until birth. -Less than 10% of fluid leaks will heal.

Post delivery treatment: HEELP syndrome

-More severe tha preeclampsia -Takes about 72-96 hours to resolve -It often gets worse (within the first 12 hours) before it gets better. -They tend to remain on magnesium sulfate longer than preeclamptic patients

Risk factors for gestational diabetes mellitus (GDM)

-Noncaucasion -Over 25 years old -Obese -Family history -History of big babies, SABs, stillborn babies, or baby with congenital defects.

What can cause hemorrhagic shock

-PPH -Inverted uterus -Tears/lacerations -Retained placenta Undiagnosied bleeding disorders

Risk factors for mastitis.

-Plugged milk ducts -Abrupt stop to BF -External pressure on breast -Smoking -Anemia -Stress -Fatigue -Possibly pacifier or bottle use

What are the symptoms of a threaten spontaneous abortion (SAB)?

-Spotting -Cramping -No cervix (cx) dilation -No products of conception (POC) passed *The SAB is threatened until proven otherwise (don't use this terminology with the mother) *The CX is more fragile in the beginning of the pregnancy. *During this time, pelvic rest is necessary (no sexual intercourse, etc)

Signs and Symptoms of Thrombophlebitis: Deep Vein

-Tenderness -Swelling -Unilateral leg pain -Doppler flow studies needed to confirm diagnosis

Management of exogenous insulin during pregnancy

-Therapy usually maintained by multiple injection therapy (MIT) -Combination of short and intermediate acting insulin -Sliding scale to cover blood sugars -Glucose - 100/30 (for calculating sliding scale: glucose level minus 100 divided by 30. This formula may be different depending on the patient and the perinatologist. -Insulin pump is option for some patients. *Exogenous insulin has to be adjusted depending on the trimester (1st trimester, the mom doesn't need a lot and the 2nd/3rd trimester, she will need a lot more). Most of the time, they take 3 scheduled doses a day and then add the sliding scale as needed.

What are the signs and symptoms of molar pregnancy?

-They are very definitive (clear cut): spotting, may have dark brown color discharge, excessive N/V (overabundance of placenta produces way too much HCG), feeling of pelvic fullness, size greater than date, rapidly elevated BP (HTN is highly correlated with placental tissue)

Shoulder Dystocia

-This occurs when one or both of the baby's shoulders get stuck during child birth -Sometimes the McRoberts maneuver is needed to unstick the shoulder and allow for vaginal delivery.

Nursing care for placental abruptions

-Treated similar to trauma patient -Fetal monitoring -Steroids for baby -Possible C/S -Emotional support/teaching

Post delivery treatment: Preeclampsia

-Usually resolves within 48 hours -Mom remains on magnesium sulfate 12-24 hours -Vascular changes lead to diuresis

What is the definition of preterm labor?

-Uterine contractions (UC) with cervix (CX) changes between 20 and 37 weeks. -This means uterine contractions every five minutes for 30 minutes or 8 uterine contractions in an hour. -Preterm labor may result in preterm birth.

What is a threatened abortion?

-Vaginal bleeding -Cervix is closed -Products of conception have not passed

What is a complete abortion?

-Vaginal bleeding -Cervix is open -All products of conception have passed

What is an inevitable abortion?

-Vaginal bleeding -Cervix is open -Products of conception have not passed, but no way to save pregnancy

What is an incomplete abortion?

-Vaginal bleeding -Cervix is open -There is partial passage of products of conception

Signs and symptoms of Superficial thrombophlebitis

-Warmth -Redness -Tenderness -Hardened area over vein -May have positive Homan's sign

Labs that should be monitored with the pregnant diabetic patient.

1. 24 hour urine- to get a baseline glucose, urinc acid, and creatinine clearance level (renal function) 2. UA and culture- asymptomatic bacteriuria is more common with diabetic patients. 3. HbA1C- Ideally, between 5 and 6, but less than 6.5 (the cut off is 7). Mothers with an A1C>7 are more likely to have complications. 4. Glucose monitoring- usually fasting glucose in the morning, just before eating, two hours after eating, and just before bed.

Risk factors for early hemorrhagic disorders

1. Advanced Maternal Age (AMA): Advanced maternal age is any woman that is pregnant at 35 or older. 2. Smoking: causes vascular issues 3. Previous Preterm birth: Having a previous PTB increases the chances of having another PTB. 4. Infections: Certain infections increase the risk of breeding (chlamydia and gonorrhea) 5. Maternal drug use: Cocaine increases the risk of SAB. 6. Patients may have none of these risk factors: Sometimes we don't know why this happens.

What are the risk factors for placenta previa?

1. Advanced maternal age, 2. multiparity, 3. previous uterine surgery (i.e. C-section), 4. multiple gestations (fewer unused portions of the uterus), 5. smoking (causes unusable areas of the uterus due to ischemia), and 6. cocaine use (causes unusable areas of the uterus due to ischemia). *1/250,000 pregnancies are affected by a previa in book (usually it's about 1/400,000)

What are the risk factors for preeclampsia?

1. Age 2. First pregnancy/new partner (more common for Pre E to develop) 3. Maternal medical conditions (Diabetes makes you more at risk) -Renal disease -Molar pregnancy -Diabetes -Chronic hypertension 4. Multiple gestation (Multiple fetuses means bigger placenta which puts the patient at a higher risk for Pre E) *Family history also increases the risk.

What are risk factors for molar pregnancies?

1. Age extremes (old and young) 2. Fertility drugs 3. Diet low in carotene 4. Asian

High Risk Pregnancy: Maternal Risk Factors

1. Age extremes: Young moms and moms over 35 2. Inadequate prenatal care: No labs, care, etc 3. Unmarried status: No support 4. Non-white race 5. Low education status: Don't understand what is necessary for a healthy pregnancy

Assessment of early bleeding

1. Amount and type of bleeding 2. Pain level 3. Previous pregnancy history: Does the patient have a HX of PTL or PTB? 4 Emotional status: Emotionally distraught? in the mind-set to learn or provide information? 5. Labs /tests -Serial beta HCG: HCG they is supposed to double -Ultrasound: fetal well-being

Lab tests for placental abruption/trauma

1. Apt (blood in amniotic fluid) 2. CBC 3. Klinhaur-Betke (fetal blood in maternal system)

Clinical presentations of Severe Preeclampsia

1. BP > 160/90 2. MAP > 105 3. Protein > 2+ -on dipstick -2 grams in 24 hour urine 4. Worsening maternal symptoms (more headaches, higher BP, more edema, etc.) 5. Worsening fetal symptoms (signs that the fetus is experiencing reduced perfusion)

Labor Management and Post Birth Follow-up Gestational Diabetes Mellitus (GMD)

1. Blood sugars every 2 hours 2. May need insulin drip *Levels return to normal quickly after delivery 3. Suggest repeat 1 hour screen 6 to 12 weeks after delivery **Infants have increased risk of type 2 diabetes, childhood obesity

Nursing care for eclamptic seizures

1. Call for help 2. Have oxygen and suctioning ready for after the seizure 3. Prevent the patient from injuring herself during the seizure 4. Monitor the baby for fetal well-being 5. If severe, the patient may need a bolus of magnesium sulfate or Ativan. 6. Explain to the patient what happened 7. Worst case scenario, the baby might need to be delivered via C-section

What is chronic hypertension versus gestational hypertension?

1. Chronic HT means that they already had HTN when they became pregnant. 2. Gestational HTN is HTN as a result of the pregnancy. This diagnosis occurs after 20 weeks gestation, has no other symptoms (just high BP). * Both conditions are usually manageable resulting in good maternal and fetal outcomes.

What types of placenta previa are there?

1. Complete 2. Partial 3. Marginal 4. Low lying

What are the two types of placental abruptions?

1. Concealed abruption 2. Visible abruption

High Risk Pregnancy: Newborn Risk Factors

1. Congenital abnormalities: especially with diabetic moms, moms that drink, or moms that smoke 2. Preterm/LBW 3. SIDS: Occurs more frequently with high risk pregnancies 4. Respiratory distress syndrome 5. Maternal complications 6. Racial/ethnicity

Management of an incompetent cervix

1. Conservative -Bedrest (Bedrest will help take the pressure off of the cervix.) -Hydration (Good hydration prevents contractions) 2. Medical -Tocolysis (medications that relax the uterus and decrease the instances of contractions or pushing the POC down) -Cerclage (Cerclage is the is of sutures or synthetic tape to reinforce the cervix during pregnancy) 3. Nursing Care -Emotional support/teaching (Especially important for a woman that has had multiple losses) -monitoring

Management/ Patient teaching for mild Pre E

1. Daily wts 2. BP 3. Urine dip stick (both in the office and at home) 4. Kick counts (fetal well-being -at least 10/hour) 5. Activity restriction (bed rest is not usually warranted) 6. Follow up visits 2 to 3 times per week 7. Regular diet (plenty of protein and fluids) 8. Medications (as necessary to control blood pressure-i.e. methyldopa/Aldomet)

How does the vasospasm and concurrent increase in blood pressure impact the renal system?

1. Decreased GFR (glomerular filtration rate) -Retained BUN, -Creatinine, -uric acid, Na, H2O -Lost protein, especially albumin (holes in the glomerulus allow the protein to leak into the urine) 2. Eventual oliguria (can't urinate) 3.Decreased colloid osmotic pressure leads to edema (the presence of protein is the intravascular system plays a role in retaining intravascular fluid) 4. Intravascular shifts lead to hemoconcentration (higher concentrations of cells/H&H and lower fluid concentration [dehydration]; blood is more viscous)

How is gestational diabetes mellitus treated?

1. Diet/lifestyle modifications are the first line of treatment: -Calorie intake 1500-2200 2. Medications: -Insulin vs glyburide or metformin -20% will need meds *Sometimes mothers need to be hospitalized to teach them how to manage their pregnancies.

Nursing Goals in High Risk pregnancy

1. Early identification: Find it and treat it early 2. Appropriate interventions: Treat the patients as needed (medication, frequent check-ups, etc.) 3. Referrals: To whatever level of care the patient needs -Basic care (family doctor) -Specialty care (specialist/ perinatologist) -Subspecialty care (high level NICU/ICU)

Reasons for induction in previously preeclamptic patient

1. Eclampsia 2. Uncontrollable hypertension 3. Pulmonary edema 4. Placental abruption (significant pulmonary edema can cause placental abruption and hemorrhage) 5. DIC (disseminated intravascular coagulation-an emergency in pregnant women as it can lead to organ dysfunction and bleeding because of depletion of platelets and coagulation factors with the ongoing activation of blood clotting [deposition of fibrin]) 6. Category 3 fetal strip (Category 3 fetal heart tracing is predictive of an abnormal fetal acid-base status, meaning that the fetus is not getting enough oxygen) 7. Fetal gestation of less than 24 weeks (fetus unlikely to survive and it is dangerous for the mother to continue with the pregnancy) 8. Fetal demise

What are the labs that are used to determine whether or not a woman is at risk for preterm labor (PTL)?

1. Fetal fibrinectin 2. Cervical length US (<2.5cm esp. with UC indicates PTL) 3. Cultures for STDs: -Chlamydia, Gonorrhea, Trichomonas, and bacterial vaginosis -~10% of moms with PTL have an STI 4. UTIs (increase chances of PTL ~50%) 5. Dental screening -Periodontal disease has shown to increase the risk of PTL.

What is conservative management of preterm labor (PTL)?

1. Hydration- Treatment depends on the gestational age and the severity of the symptoms 2. Home monitoring- bed rest used to be the treatment of choice, but there is no evidence that it prolongs gestation. Additionally, there are financial, social and physical (DVT) concerns associated with prolonged immobility

Fetal complications that are associated with gestational diabetes mellitus (GMD) with a mother with vascular disease

1. IUGR 2. Fetal distress 3. Still birth 4. Hydramnios 5. SAB 6. Post delivery glucose control: infants born to mothers with gestational diabetes tends to have their blood sugars bottom out shortly after birth. Feeding these babies ASAP is important and blood sugars should be taken at least every 4 hours via heel stick (sometimes more frequently)

What are three things that preeclampsia can do?

1. It can stay the same. The blood pressure may be high, but it is manageable. 2. The preeclampsia can lead to eclampsia, where the mother has seizure activity 3. In severe cases, it can lead to HEELP syndrome

How does the vasospasm and concurrent increase in blood pressure impact the Fetus?

1. Lack of perfusion leads to intrauterine growth restriction (IUGR). This is common with the vasospasms that occur with preeclampsia. 2. The placenta is supposed to last about 40 weeks. However, with constant exposure to vasospasm, the placenta can become ischemic in some areas. This leads to infarcts and calcium deposits, giving the placenta an "old" appearance.

How does the vasospasm and concurrent increase in blood pressure impact the liver?

1. Liver function is decreased 2. Elevated liver enzymes **The liver filters 40-605 of the blood in the body at any given time. The constant pounding that is caused by high blood pressure damages the liver, which decreases it function and increases the number of liver enzymes.

What is included in the interview assessment for a preeclamptic patient?

1. Medical history: HX of BP problems, medications taken, prenatal care, etc. 2. Family history: Anyone in the family have high BP or HX of preeclampsia/eclampsi? 3. Social history: Drug HX, Smoking HX, Alcohol HX, social support

What does hospital management of prolonged premature rupture of membranes look like?

1. Medications: If it is a viable pregnancy, IV antibiotics for about 3 days, about 1 week of PO antibiotics, and a stay in the hospital. 2. Labs 3. Fetal monitoring: NST-not constant monitoring.

Nursing care for patients on Magnesium Sulfate (MgSO4)

1. Monitor urinary output because it is excreted through the kidneys (via bedside commode or Foley catheter- should be 30mL/hr. to show that kidneys are functioning properly) 2. Mag decreases DTR so a lack of deep tendon reflexes suggest mag toxicity (remove mag) 3. Monitor pulse Ox, BP, RR, for SOB, LOC, Temp., blurry vision, headache 4. Keep the patient in a controlled (dark, non-stimulating) environment when possible

What are the definitions of postpartum hemorrhage?

1. Most common way to DX postpartum hemorrhage is an estimation of blood loss -More than 500mL for a vaginal delivery and more than 1000mL for a C-section is considered a postpartum hemorrhage. *The problem with this method is that blood loss is often underestimated and therefore it is inaccurate but most commonly used method. 2. A more specific method is to evaluate a patients H&H levels (before and after delivery). If there is a 10% or more change, that is considered a postpartum hemorrhage. 3. The last method is if the patient is symptomatic enough (i.e dizzy or light-headed enough) to need a blood transfusion, they have likely experienced a postpartum hemorrhage.

Labor Management pregestational diabetes mellitus (PGDM)

1. Patient induced by estimated due date (EDC/EDD) if no spontaneous labor 2. May have regular insulin drip 3. Glucose levels every 1 to 2 hours to regulate drip 4. After delivery insulin needs drop quickly - no more placenta

What are two examples of late pregnancy bleeding disorders?

1. Placenta Previa 2. Placental Abruption (Also called Abruptio )placentae

Plan of care for pregestational diabetes mellitus during pregnancy?

1. Preconceptional counseling 2. Prepregnancy and early pregnancy glucose control is the single most important predictor of pregnancy outcome. *The better the glucose control, the better the fetal outcomes will be. The higher the glucose levels are during pregnancy, the greater the risk is for congenital defects.

What are the risk factors for incompetent cervix (cervical insufficiency)?

1. Previous cervical trauma/procedures: Colposcopy or Leep procedure (electrosurgical excision of abnormal cells on the cervix) can weaken the cervix. 2. Multiple gestations: More babies in the uterus means more pressure on the cervix. 3. History of very short labors: If the mother has a HX of very short labors, it could mean that she is dilating very quickly or she has an incompetent cervix. 4. DES use during pregnancy: DES was a hormone used 30-45 years ago for mothers that were recurrent SABs to help them stay pregnant. It worked but for the mothers of girls, it caused the girls to have abnormal reproductive tracts, increasing the girl's risk of having an incompetent cervix.

Causes of Thrombophlebitis

1. Primarily venous stasis 2. Hypercoagulation 3. State of pregnancy Other risk factors: -C-section -History of blood clots -Obesity -Advanced maternal age (AMA) -Smoking

Risk factors for ectopic pregnancies

1. Scarred Fallopian Tubes: Prevents the egg from travelling down the Fallopian tubes to the uterus. 2. STIs: Some STIs can cause scarring in the Fallopian tubes (especially gonorrhea or chlamydia). 3. Previous tubal ligation or IUD: Prevents the egg from descending. After ten years, the tips of the tubes could reattach and allow sperm to ascend the tubes and fertilize the egg, but the egg still may not past. 4. Previous ectopic: This may indicate a problem with the tubes, themselves 5. Smoking: The more the mother smokes, the higher her risk for ectopic pregnancy * Pregnancy with IUD is very rare, but if it does happen, the uterus is inhospitable, making the risk of ectopic pregnancy higher.

Fetal assessments for the mother with pregestational diabetes mellitus (PGDM)

1. Serial ultrasound (US): usually done at least monthly for the first 28 wks and at least weekly after that. 2. Alpha feta protein (AFP): Helps with the diagnosis of any neural tube defects. 3. Doppler flow studies: Helps show perfusion status. 4. Non-stress test (NST) 1 to 2 times weekly after 28 weeks: Shows fetal well-being (may also use biophysical profiles-BPP) 5. Kick counts: 10 movements an hour

Early hemorrhagic disorders

1. Spontaneous Abortions (SAB) 2. Ectopic Pregnancy 3. Molar Pregnancy 4Incompetent Cervix

What medications are used in preterm labor (PTL)?

1. Terbutaline (Brethine): It has cardiac and respiratory effects. Terbutaline to stop or slow down PTL is an off-label use (normally used for asthma). SE: elevated pulse (hold dose if HR>120), headache, and palpitations. Long term use: can cause severe pulmonary edema and hyperglycemia. Typical SQ, 0.25 mg, q 20 min for 3 doses (check pulse every time). 2. Beta 2 adenergic 3. MgSO4 4. Calcium channel blockers: Nifedipine slows UC by blocking calcium. SE: hypotension, tachycardia, and headache. 5. Prostaglandin synthetase inhibitors: Indomethacin or Indocin stop the inflammatory response that can cause UC, but it can cause premature closure of the ductus arteriosus, so it isn't used after week 34 or for more than 48 hrs.

Clinical presentations of Preeclampsia

1. This is a pregnancy disorder that occurs after 20 weeks gestation 2. Elevated blood pressure; usually greater than 30/15 3. Proteinuria 4. Although it is not considered diagnostic criteria anymore, edema is also commonly seen with preeclampsia. 5. Hormones take several weeks to go back to normal which is why it can be diagnoses after giving birth, but most of the time it is diagnosed during pregnancy.

Types of Spontaneous Abortion (SAB) before 20 weeks

1. Threatened (abortion is possible) 2. Inevitable (fetal demise; CX dilated, but not expelled) 3. Incomplete (partial loss of POC in first 20 wks) 4. Complete (SAB before 20th wk) 5. Missed (fetal demise; not uterine activity to POC; recurrent SAB-3 or more consecutive losses) 6. Septic (caused by uterine infection including endometritis)

Signs & Symptoms of Ectopic Pregnancy

1. Varied: They are vague, and therefore difficult to diagnose. 2. Positive pregnancy test 3. Low abdominal pain: She tends to have diffuse lower abdominal pain that tends to settle on one side and become sharper or more colicky/spasmy. The ultrasound will not show evidence of an embryo in the uterus. A very careful vaginal exam can be done by the provider (don't want to rupture it) 4. Spotting 5. Shoulder pain: Ruptured pregnancy fills the abdomen with blood and causes irritation to the diaphragm which causes referred shoulder pain. 6. Cullen's sign: discoloration in the belly (bruising, edema, etc. around umbilicus) that is suggestive of bleeding in the belly. The pain of a ruptured ectopic is horrendous. The mother can lose a lot of blood very quickly.

Pathophysiology of HEELP Syndrome

1. Vasospasm that leads to endothelial damage 2. Damage to the endothelial lining of the blood vessels leads to leaky vessels 3. The body tries to compensate by plugging up the damage with platelets, but uses the platelets faster than they can be replaced. 4. The holes and plugs lead to irregularly shaped vessel lining which damages the RBCs as they try to pass through the vessels 5. Damage to the RBCs causes hemolysis and the formation of Burr cells (irregularly shaped cells)

What is the dosage for Magnesium Sulfate (MgSO4)?

40g in 1000mL IVF (D5 1/5 NS) -4-6g load, then 2-3 g/hr -The therapeutic blood level is usually between 4-7mEq/L (4-6hrs) ***Must check the patients blood pressure every 15 minutes while they are on mag.

What is a blighted ovum?

A blighted ovum is a condition in which a gestational sac forms without an embryo. This is usually realized during the first weeks of pregnancy during an ultrasound. The mother may have N/V and a positive pregnancy test, but there is no POC growing and there is no fetal heartrate. Most of the time, a D & C is needed. Might be caused by: TORCH viruses: syphilizes, varicella-zoster, toxoplasmosis, Rubella, Cytomegalovirus, and Herpes.

What is ferning?

A fluid sample is taken when ruptured membranes are suspected. The fluid is placed on a slide, allowed to dry, and inspected under a microscope. The appearance of fern-like structures under the microscope are indicative of amniotic fluid.

What is an late postpartum hemorrhage (PPH)?

A late postpartum hemorrhage is anything that occurs 24 hours after birth and up to 6 weeks after birth. This is most commonly caused by subinvolution, or failure of the uterus to return back to normal size. -The patient may notice a continued large amount of lochia rubra that lasts more than 2 weeks. -The uterus doesn't return to the pelvis in the amount of time that it should. -The uterus may still feel boggy -There may be no known cause or it may be caused by uterine infection or retained placenta fragments. -This is treated by medications (most specifically methergine-PO/IM, which causes the uterus to contract. Cannot be given IV). **Methergine increases blood pressure so it cannot be given to a patient that has preeclampsia. (it could cause a stroke)

Molar pregnancy/ Hydatidiform mole:

A non-viable pregnancy caused due to the growth of an abnormal fertilized egg or overgrowth of trophoblasts, the cells which normally develops into placenta within the uterus. (1-3% of pregnancies) 1. Trophoblastic disease 2. Complete 3. Partial

What is a nonadherent placenta?

A nonadherent placenta is one that may be difficult to remove, but it is not ingrown into the uterine muscle (can be removed manually or with a D&C). The placenta may tear as it releases during stage 3 of labor or pieces may be left behind during manual removal. The body knows that it should be gone, so it keeps bleeding to get rid of it because the placenta side of the uterus can't clamp down the way it needs to.

What is a partial mole?

A normal egg is fertilized by two separate sperm (the zona reaction doesn't form quickly enough and a second sperm gets in). This results in too many chromosomes for a normal fetus.

Postpartum Infections

A postpartum infection can occur any time in the 28 days following a birth. Early onset infections are frequently caused by group beta strep (GBS). Later onset infections are more commonly caused by chlamydia. Endometritis occurs in 1-3% of patients with a vaginal birth and up to 35% of patients with a C-section (especially if the patient labored, ruptured her membranes, and then had to have a C-section). ***Infection post normal spontaneous vaginal delivery (NSVD) usually affects the placenta site. Infection post C-section can become systemic.

A nurse in the prenatal clinic is assessing a woman at 34 weeks' gestation. The client's blood pressure is 166/100 mm Hg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mm Hg. What is the priority nursing action? A. Arranging transportation to the hospital B. Obtaining a prescription for an antihypertensive C. Rechecking the blood pressure within 30 minutes D. Obtaining a prescription for acetaminophen to relieve the headache

A. Arranging transportation to the hospital Hypertensive crisis is defined as systolic BP greater than 160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia

A client with preeclampsia is admitted to the high risk prenatal unit because her blood pressure is progressively increasing. The nurse reviews the practitioner's orders. What orders does the nurse expect? Select all that apply. A. Daily weight B. Side-lying bed rest C. 2-gram-sodium diet D. Deep tendon reflexes E. Glucose tolerance test

A. Daily weight B. Side-lying bed rest D. Deep tendon reflexes

Which statement concerning the complication of maternal diabetes is the most accurate? A. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy. B. Hydramnious occurs approximately twice as often in diabetic pregnancies than in nondiabetic pregnancies C. Infections occur about as often and are considered about as serious in both diabetic and nondiabetic pregnancies. D. Even mild-to-moderate hypoglycemic episodes can have significant effects on fetal well-being.

A. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy. Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times more often in diabetic pregnancies. Infections are more common and more serious in pregnant women with diabetes. Mild-to-moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being.

A breastfeeding mother experiences redness and pain in the left breast, a temperature of 100.8° F (38.2° C), chills, and malaise. What condition does the nurse suspect? A. Mastitis B. Engorgement C. Blocked milk duct D. Inadequate milk production

A. Mastitis

Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. A. Monitoring deep tendon reflexes B. Assessing urine output every 8 hours C. Maintaining a dark, quiet environment D. Using a pump to regulate the medication E. Having calcium gluconate available at the bedside F. Notifying the care provider if the respiratory rate is slower than 20 breaths/min

A. Monitoring deep tendon reflexes (q.2HRS) C. Maintaining a dark, quiet environment D. Using a pump to regulate the medication E. Having calcium gluconate available at the bedside

With regard to hemorrhagic complications that may present during pregnancy, nurses should know that: A. an incompetent cervix usually is not diagnosed until the woman has lost one or two pregnancies. B. The incidence of ectopic pregnancy is declining as a result of improved diagnostic techniques. C. One ectopic pregnancy does not affect a woman's fertility or her likelihood of having a normal pregnancy the next time. D. Gestational trophoblastic neoplasm (GTN) is one of the persistently incurable gynecologic malignancies.

A. an incompetent cervix usually is not diagnosed until the woman has lost one or two pregnancies.

What is a Battledore Placenta?

Abnormal cord insertion. The cord is implanted into the placenta itself, but it is way over to the edge instead of the middle. It is easier to pull off (this is why the cord should not be yanked to remove the placenta after delivery. It can lead to severe bleeding)

Risk factors for placental abruption

Advanced maternal age, a patient that has had a previous abruption is at higher risk, a patient who is hypertensive, a patient who has had trauma (i.e. car accident or a battered woman), a patient with substance abuse problems (specifically smoking and cocaine use)

When is gestational diabetes mellitus diagnosed?

After 20 weeks

What is an early postpartum hemorrhage (PPH)?

An early postpartum hemorrhage may be a slow, steady tricky (difficult to spot) or it may be a sudden gush of blood (this usually happens when a large clot comes out and a rush of blood follows).

What does AC stand for?

Ante cibum = Before meals

What is the leading cause of maternal mortality?

Antepartum hemorrhage is the leading cause of maternal mortality.

What is a septic abortion?

Any abortion, spontaneous or induced, that is complicated by uterine infection, including endometritis. This term is primarily used for women that are less than 20 weeks pregnant. Women greater than or equal to 20 weeks are described as having intraamniotic infection.

Risk factors for postpartum hemorrhage (PPH)

Any factor that causes the uterus to be distended, like multiple births, polyhydramnios, or grandmultiparity can contribute to postpartum hemorrhage. -Mothers with really long labors or really short labors are at risk -Any assisted birth (vacuum or forceps) -Patients who were induced (especially over several days) because their pitocin receptors are already saturated and won't respond to more pitocin. *Long-term inductions will usually get pitocin during the day and then they will turn it off at night so that the pitocin receptors will clear and they can start over the next day. *Between 50%-70% of postpartum hemorrhage are caused by uterine atony, about 10% are caused by retained placental tissue (important to look at the placenta after birth to insure that it is intact and no pieces are left in the uterus, about 19% are caused by underlying trauma, and about 1% are caused by previously undiagnosed uterine problems or bleeding disorders. *If you have had a postpartum hemorrhage with one pregnancy, you are at a higher risk of bleeding with a subsequent pregnancy.

High Risk Pregnancy

Any pregnancy in which the life or health of the mother or baby is endangered by a disorder either coincidental with the pregnancy or unique to the pregnancy. This includes biophysical, psychosocial, sociodemographic and environmental factors.

A pregnant woman at 29 weeks of gestation has been diagnosed with preterm labor. Her labor is being controlled with tocolytic medications. She asks when she might be able to go home. Which response by the nurse is most accurate? A. "After the baby is born." B. "When we can stabilize your preterm labor and arrange home health visits." C. "Whenever your physician says that it is okay." D. "It depends on what kind of insurance coverage you have."

B. "When we can stabilize your preterm labor and arrange home health visits." This client's preterm labor is being controlled with tocolytics. Once she is stable, home care may be a viable option for this type of client. Care of a client with preterm labor is multidisciplinary and multifactorial; the goal is to prevent delivery. In many cases, this goal may be achieved at home. Managed care may dictate an earlier hospital discharge or a shift from hospital to home care. Insurance coverage may be one factor in client care, but ultimately, client safety remains the most important factor.

A nurse is obtaining the health history from a client with a DX of ruptured tubal pregnancy. At what point in the pregnancy does the nurse expect the client to state that the low abdominal pain and vaginal bleeding started? A. At the end of the first trimester. B. Around the sixth week of pregnancy. C. Midway through the second trimester. D. When the first menstrual period was missed.

B. Around the sixth week of pregnancy. At week 6, the pregnancy is about 2cm and the tube is stretched causing pain.

A client at 38 wks gestation is admitted with the DX of placenta previa. What is the priority nursing care at this time? A. Withholding oral intake. B. Assessing for hemorrhage. C. Avoiding extraneous stimuli. D. Encouraging supervised ambulation.

B. Assessing for hemorrhage.

The postpartum nurse has just received report on four clients. Which client should the nurse care for first? A. Client who vaginally delivered a 7-lb baby 1 hour ago B. Client who vaginally delivered a 9-lb baby 1 hour ago C. Client who vaginally delivered a preterm baby 4 hours ago D. Client who had a planned cesarean delivery of an 8-lb baby 2 hours ago

B. Client who vaginally delivered a 9-lb baby 1 hour ago

The exact cause of preterm labor is unknown but believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Which type of infections have been linked to preterm birth? (Select All That Apply) A. Viral B. Periodontal C. Cervical D. Urinary tract E. Breast

B. Periodontal C. Cervical D. Urinary tract Infections that increase the risk of preterm labor and birth are bacterial and include cervical, urinary tract, periodontal, and other bacterial infections. Therefore, early, continual, and comprehensive participation by the client in her prenatal care is important. Recent evidence has shown a link between periodontal infections and preterm labor. Researchers recommend regular dental care before and during pregnancy, oral assessment as a routine part of prenatal care, and scrupulous oral hygiene to prevent periodontal infections

With regard to preeclampsia and eclampsia, nurses should be aware that: A. Preeclampsia is a condition of the first trimester; eclampsia is a condition of the second and third trimesters B. Preeclampsia results in decreased function in such organs as the placenta, kidneys, liver, and brain C. The causes of preeclampsia and eclampsia are well documented D. Severe preeclampsia is defined as preeclampsia plus proteinuria

B. Preeclampsia results in decreased function in such organs as the placenta, kidneys, liver, and brain

Clinical presentation of mild preeclampsia

BP > 140/90 MAP >105 Protein > 1+: -30 mg/dl -300 mg in 24 hour urine

What is hypertensive crisis during pregnancy/delivery?

BP consistently >160/110

When do early bleeding disorders occur?

Before 20 weeks gestation.

During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. Which statement by the client reassures the nurse that teaching has been effective? A. "I will need to eat 600 more calories per day because am pregnant." B. "I can continue with the same diet as before pregnancy as long as it is well balanced." C. "Diet and insulin needs change during pregnancy." D. "I will plan my diet based on the results of urine glucose testing."

C. "Diet and insulin needs change during pregnancy." Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the third trimester, insulin needs may double or even quadruple. The diet is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. Energy needs are usually calculated on the basis of 30 to 35 calories per kilogram of ideal body weight. Dietary management during a diabetic pregnancy must be based on blood, not urine, glucose changes.

To manage her diabetes appropriately and to ensure a good fetal outcome, how would the pregnant woman with diabetes alter her diet? A. Eat six small equal meals per day. B. Reduce the carbohydrates in her diet. C. Eat her meals and snacks on a fixed schedule. D. Increase her consumption of protein.

C. Eat her meals and snacks on a fixed schedule. Having a fixed meal schedule will provide the woman and the fetus with a steady blood sugar level, provide a good balance with insulin administration, and help prevent complications. Having a fixed meal schedule is more important than the equal division of food intake. Approximately 45% of the food eaten should be in the form of carbohydrates.

Signs of a threatened abortion are noted in a woman at 8 weeks gestation. What is an appropriate management approach for this type of abortion? A. Prepare the woman for a dilation and curettage (D&C). B. Place the woman on bed rest for at least 1 week and reevaluate. C. Prepare the woman for an ultrasound and bloodwork. D. Comfort the woman by telling her that if she loses this baby, she may attempt to get pregnant again in about a month.

C. Prepare the woman for an ultrasound and bloodwork.

Which preexisting factor is known to increase the risk of GDM? A. Underweight before pregnancy B. Maternal age younger than 25 years C. Previous birth of large infant D. Previous diagnosis of type 2 diabetes mellitus

C. Previous birth of large infant A previous birth of a large infant suggests GDM. Obesity (body mass index [BMI] of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years is not generally at risk for GDM. The person with type 2 diabetes mellitus already has diabetes and thus will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy.

A nurse is assessing a client with a tentative diagnosis of a Hydatidiform mole. Which clinical finding should the nurse anticipate? A. Hypotension B. Decreased FHR. C. Unusual uterine enlargement. D. Painless, heavy vaginal bleeding.

C. Unusual uterine enlargement.

Sacral agenesis

Caudal regression syndrome, or sacral agenesis (or hypoplasia of the sacrum), is a rare birth defect. It is a congenital disorder in which the fetal development of the lower spine—the caudal partition of the spine—is abnormal. It occurs at a rate of approximately one per 60,000 live births.

Incompetent Cervix Cerclage

Cerclage is called a "purse-strings" suture. It goes around the cervix and you pull it together tightly like a draw string. The cervix is already too short or if the amniotic fluid bag is coming out, they call that funneling. If this is the case, sometimes you can put the patient in the Trendelenburg position and it takes pressure off of the cervix, allowing the amniotic sac to slide back into the uterus and allowing the cervix to get a cerclage.

A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1-2 minutes, dark red vaginal bleeding, and a tense, painful abdomen. The nurse suspects the onset of: A. Eclamptic seizure. B. Rupture of the uterus. C. Placenta previa. D. Abruptio placentae

D. Abruptio placentae

A nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. For what complication associated with this problem should the nurse monitor this client? A. Stroke B. Pulmonary edema C. Impending seizures D. Hypovolemic shock

D. Hypovolemic shock

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. Which finding indicates that preterm labor is occurring? A. Estriol is not found in maternal saliva. B. Irregular, mild uterine contractions are occurring every 12 to 15 minutes. C. Fetal fibronectin is present in vaginal secretions. D. The cervix is effacing and dilated to 2 cm.

D. The cervix is effacing and dilated to 2 cm. Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor such as cervical changes.

How does the vasospasm and concurrent increase in blood pressure cause hepatic edema?

Damage to the blood vessels in the liver leads to increased swelling in the liver. This causes an increase in liver enzymes and decreased liver function. S&S: Epigastric or right upper quadrant (RUQ) pain. It could feel like really bad heart burn. WARNING: The liver is encapsulated. If it swells too much, the capsule could rupture. IF the patient isn't already in the hospital, they could hemorrhage to death.

How is placental abruption treated?

Depends on severity of abruption, GA, fetal status GA=gestational age of the baby. Fetal status means how well the baby is tolerating the abruption. Example: If you have a mother with a 30-40% abruption, you may have some time and the baby might be able to tolerate it well, but more than that might cause the baby to struggle.

What is the most common endocrine disorder during pregnancy?

Diabetes during pregnancy

Insulin production in the 2nd/3rd trimester

Diabetogenic effect - insulin resistance -During the 2nd and 3rd trimesters, the placenta becomes active and it increases its production of human placenta lactogen (similar to growth hormone). There are elevated levels of prolactin, cortisol and glycogen. Even though adequate levels of insulin are produced, glucose is not moving into the cells (insulin resistance). Therefore, there is an increase in circulating glucose that the baby can access.

How is HEELP syndrome diagnosed?

Diagnosis of HEELP syndrome is based on changes in the patients lab work. 1. H-Hemolysis: RBCs are damaged (torn or abnormally shaped-Burr cells) as a result of constant insult of high blood pressure. 2. EL- elevated liver enzymes is due to the damage to the liver caused by high BP. 3. LP- you will see dramatic drops in the platelet counts 40,000-50,000 (normal is ~146,000-429,000 in the third trimester). This is because the body uses platelets faster than it can replace them to repair damage caused by the high BP. * Incidence is about 5% *Symptoms: Increased including increased bleeding

Early Spontaneous Abortion (SAB)

Early SABS are usually caused by Chromosomal abnormalities and occur before 12 wks.

What is uterine atony?

Failure of the uterus to "cramp down" and tighten after delivery - This most commonly causes postpartume hemorrhaging (PPH)

True or False: Macrosomia is more common in mamas with vascular complications from their diabetes.

False

True or false: A molar pregnancy occurs when a single sperm fertilizes two different eggs.

False. 2 sperm one egg, or an egg without a nucleus is fertilized.

True or false: Preconceptual counseling is a vital component in treatment of the patient with gestation diabetes mellitus (GDM).

False. Gestational diabetes is diagnosed between weeks 24-28. Women who are chronically diabetic should receive preconceptual counseling.

True or false: Once a patient experiences spontaneous rupture of membranes (SROM) it is necessary to be delivered within 24 hours.

False. If the patient is term (40 weeks), we would prefer that she deliver within 24 hours to prevent complications (decels and infection). However, this is not always the case.

True or false: Glucose moves across the placenta by carrier mediated osmosis while insulin moves across directly by diffusion.

False. Insulin (both exogenous and endogenous insulin from the mother) doesn't move through the placenta. Fetuses begin to make their own insulin between gestational weeks 10-12.

True or false: Diabetics in pregnancy are classified as type 1 or type 2.

False. It is a condition during pregnancy in which the body doesn't produce enough insulin. It is directly related to the pregnancy.

True or false: Cocaine is a common cause of placenta previa.

False. It is more associated with abruption than previa. -However, cocaine could possible cause there to be areas of ischemia in the uterus, which might result in limited places for the embryo to attach. This could theoretically result in placenta previa.

True or false: A D and C is performed to treat an ectopic pregnancy.

False. It is used to treat an SAB

True or False: A Hgb A1C of <20 is acceptable in a pregnant diabetic.

False. It should be close to 6 (<6.5)

True or False: Lowering the patient's salt intake helps to lower the preeclamptic patient's blood pressure.

False. Lowering salt doesn't seem to impact patient's blood pressure. However, it is recommended that they eat a diet high in protein and maintain good hydration.

True or false: The terms preterm birth (PTB) and low birth weight (LBW) are interchangeable.

False. PTB can lead to LBW, but a full-term birth can also result in a LBW.

True or false: Placenta previa can be diagnosed in the first trimester with an ultrasound.

False. Previa can't be diagnosed in the first trimester with an ultrasound. It is too small to tell. As the uterus gets bigger it stretches and the placenta moves higher.

True or false: Placenta previa is more common in primips.

False. Primips are first time pregnancies. Placenta previa is more likely when the mother has had more pregnancies.

True or false: The goal is to prevent all preterm births.

False. Sometimes it is necessary to induce early for the safety of the fetus and/or for the mother's safety.

True or false: Placenta abruption is defined as painless vaginal bleeding with no uterine tenderness.

False. That is the definition of placenta previa. Placental abruption causes severe pain

True or false: A molar pregnancy increases the patient's risk for cervical cancer.

False. Uterine cancer (GTN-gestational trophoblastic neoplasm)

Which fetal assessment is more limited, gestational diabetes mellitus or pregestational diabetes mellitus?

Gestational diabetes mellitus (GDM): 1. Kick counts 2. Ultrasound every 34-6 weeks 3. Non-stress test (NST) weekly after 36 weeks

What does molar pregnancy put you at higher risk for?

Gestational trophoblastic neoplasm (GTN). It is more common in complete moles. It occurs in about 1/40,000 molar pregnancies. It is also the most curable form of gynecological cancer (if discovered early)

What is HEELP Syndrome?

H - hemolysis EL - elevated liver enzymes LP - low platelets

Signs & Symptoms of placental abruption

Hallmark symptoms are sudden onset abdominal pain, tender, tight uterus and vaginal bleeding. -Abruptions can occur during labor. It causes the resting tones between contractions to stay high so the uterus never completely relaxes (it's painful). -They are graded on percentage of detachment: 10% may be asymptomatic, but an 80% abruption is treated as a trauma. -They are also termed as "visible" or "concealed" -Once the abruption occurs, you are going to see much closer and stronger contractions (resting tone disappears essentially). The contractions don't match the stage of labor.

Insulin production in the 1st trimester

Higher insulin production which leads to lower circulating glucose levels. -Hormones in the first trimester (wks 0-12) stimulate insulin levels, so insulin tends to be higher in the 1st trimester. This moves more glucose into storage and reduces the levels of circulating glucose. The mother may have N/V which may also decrease her intake (appetite changes occur in first trimester as well).

Treatment/ Nursing care for placenta previa

Home care and Hospital care Mother may be able to go home but needs good teaching: kick counts, needs to be able to get to hospital quickly, no heavy lifting, pelvic rest, hydrating, iron rich food/supplement, modified bed rest, usually kept in hospital after that 2nd bleed. She is kept on monitor with bathroom privileges, she has a pad count. ***That final bleed is considered an emergency (blood is dripping onto the floor

What does HS stand for?

Hora Somni = At bedtime

What is the primary blood pressure medication given to a pregnant patient is hypertensive crisis?

Hydralazine (Apressoline) -Magnesium sulfate is primarily given to prevent seizures, but it has a blood pressure lowering effect as well. However, if the patient's blood pressure remains high, an IV blood pressure medication like hydralazine can be given over 2-5 minutes IV push (5mg at a time every 20 mins.). To give the medication at a slower rate, it is recommended that the drug be diluted with NS. **Bring blood pressure down slowly helps prevent a sudden drop that could dangerously reduce placental perfusion

Hypertensive crisis during pregnancy is defined as

Hypertensive crisis includes hypertensive urgency and emergency; the American College of Obstetricians and Gynecologists describes a hypertensive emergency in pregnancy as persistent (lasting 15 min or more), acute-onset, severe hypertension, defined as systolic BP greater than 160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia.

Hemorrhagic Shock

If the circulating fluid gets low enough, it leads to organ system failure and eventually death. The body tries to protect the brain and the heart at all costs. *In a postpartum hemorrhage with hemorrhagic shock, the last resort treatment is a hysterectomy if the patient is stable enough to tolerate it.

How is preterm labor managed in the hospital?

If the preterm labor cant be managed at home (UC won't stop and there is a change in the cervix), hospitalization should be considered-at least initially and IV fluids are usually the number one choice: 1. Tocolysis -Suppress uterine activity -Long term use is not recommended (just use long enough to administer steroids if possible) 2. Hydration 3. Steroids Betamethasone (to increase the surfactant production of the fetus) 4. Transfer to level 3 center 5. NICU consult 6. Fetal monitoring 7. Ultrasound

What is the antidote for magnesium toxicity?

If the respiration rate of a patient on magnesium sulfate is less than or equal to 10 breaths per minute, the may have mag toxicity. The antidote is calcium gluconate (~1g IV over 3 minutes -slowly or you will stop their heart)

Why are vital signs a late sign of shock in a postpartum patient?

In a postpartum patient, VS are a very late sign of Shock! This is because the body has such an increased fluid volume that the VS don't change quickly. The mother can lose a lot of blood before there is a blood pressure change. Urinary output is going to be the best indicator of organ perfusion (30mL/hr)

What is McRobert's Maneuver?

In the McRoberts maneuver, the woman's legs are hyperflexed on her abdomen. This maneuver causes the sacrum to straighten, and the pelvis and symphysis pubis to rotate toward the mother's head. The angle of pelvic inclination is decreased, which frees the shoulder. Suprapubic pressure can then be applied over the anterior shoulder in an attempt to dislodge the shoulder.

Thrombophlebitis

Inflammation or partial obstruction of a vessel 3 types: -Superficial -Deep -Embolus

Procedure to remove cerclage

Insert speculum and use surgical scissors to snip the suture (the knot) and pull it out. *Frequently, once the suture is pulled, the mother goes into labor quickly, so you don't want to pull it too early (prevent preterm labor). Some mothers want to leave it in for the duration of the pregnancy and c-section is scheduled.

What are interventions for hemorrhagic shock?

Interventions: IV fluids (IVF), make sure that your patient is typed and crossed or typed and screened depending on how much they are bleeding and how much the provider orders (might need a transfusion), you want to put a Foley in so that you can get a good measure of the urinary output (tells us about the organ perfusion), give the patient O2 via mask (8-10L), and if the patient can't be stabilized quickly, they might need to be transferred to the ICU. *Always check to see if the fundus is firm. If it is, the hemorrhage could be caused by a laceration or tear that hasn't been previously noted. *Stay with the patient and call for help.

What does a molar pregnancy look like?

It has a cluster/grape-like formation that looks like a snow storm (vesicles)

What does litmus paper/nitrazine paper test for?

It is a paper that tests vaginal secretions for amniotic fluid.

What is Fetal fibrinectin?

It is a protein that acts like a glue during pregnancy. It attaches the amniotic sac to the lining of the uterus. -It is usually present in vaginal discharge at the beginning of the pregnancy and it can be detected at the end of the pregnancy as well (It should not be present between weeks 22-34 or it suggests preterm labor) * only 1% of moms that have a negative test will deliver within 7 days. False positives are more common. This test should be performed prior to a vaginal exam to prevent contamination of the sample.

What does Magnesium Sulfate (MgSO4) do for a preeclamptic patient?

It is a smooth muscle relaxant that interferes with the release of acetylcholine to decrease CNS irritability. In other words, it helps to prevent seizures caused by vasospasm. It is a vasodilator which helps to decrease blood pressure, but it is not given for BP. It's given to prevent seizures.

Symptoms of placenta previa

It's not usually just spotting. The mother usually is bleeding enough to have to put on a pad, but no pain. Typical bleeding pattern: (Anecdotal) 1st time mother that comes in bleeding is usually late 2nd trimester (26-28 wks). May have a little cramping, but not severe. 1st bleed is usually handled with Tocolytics, they are monitored and can go home after. The 2nd bleed is usually 2-4 wks later. The cervix is getting softer closer to the end of the pregnancy and there's more bleeding. Mom is given fluids and Tocolytics again and usually stays in hospital. Blow out bleed occurs ~34-36 wks and she usually has to deliver.

What is a true knot?

Knot in the umbilical cord: the tighter, the more problematic (can cause a fetal demise because the placenta becomes ischemic)

Late Spontaneous Abortion (SAB)

Late SABS usually occur between 12-20 wks and are usually related to maternal issues. i.e. gestational diabetes, gestational HTN, maternal drug use, or maternal infection.

Aspirin therapy during pregnancy

Low-dose aspirin has been found to reduce preeclampsia and adverse outcomes in selected high-risk women. ACOG recommends that consideration be given to initiating daily low-dose (81 mg/day) aspirin therapy between 12 and 28 weeks of gestation for the prevention of preeclampsia. It is recommended that only women considered to be at high risk for developing preeclampsia take the low-dose aspirin. This includes women with the following risk factors: history of preeclampsia, especially if accompanied by an adverse outcome; multifetal gestation; chronic hypertension; preexisting diabetes (type 1 or type 2); renal disease; and autoimmune disease (e.g., systemic lupus erythematosus, antiphospholipid syndrome).

What is the primary drug of choice for preeclampsia?

Magnesium Sulfate (MgSO4)

Glucose testing goals for the diabetic pregnant patient

Maintain fasting glucose levels between 70 and 95 mg/dL and the 2 hour PP (post prandial=after eating) levels should be less than 120 mg/dL

Treatment options for ectopic pregnancy

Medical: -Ultrasound (transvaginal): to get the exact location of the pregnancy. -Beta HCG: to get the exact date of the pregnancy. -Methotrexate: stops cells from growing (cancer drug) Surgical: The surgical option is the removal of all or part of the tube. If the patient does not want to become pregnant again, she can opt to have both tubes removed. -Salpingostomy: The surgical unblocking of a blocked fallopian tube. Patient teaching is the same as any abdominal surgery. The partial or complete removal of a tube doesn't mean that the patient is infertile. It does take away some of her fertility level.

What are tocolytic agents?

Medicines that are given to women in preterm labor to prolong the pregnancy at least 48 hours (allowing for the administration of antenatal corticosteroids, magnesium sulfate, or buy a bit more time for maternal transport to a tertiary care facility). Tocolytics have been shown to improve infant morbidity and mortality rates.

Dilation and curettage (D&C)

Metal rods are inserted into the vagina (cervix) one at a time to open it large enough to fit it the suction catheter. The catheter is used to suction out the rest of the POC. Most of the time the mother is put to sleep. It is uncomfortable and noisy. This is done in the OR and she goes to the recovery room to wake up from anesthesia. *12 weeks or more because dilation of the cervix is more difficult. Prostaglandins or laminaria (match-stick sized seaweed that is put into the cervix, absorbs moisture, and causes the cervix to open)

Methotrexate use

Methotrexate is a cancer drug that targets the fastest growing cells in the body. In pregnancy this is the ectopic pregnancy. The mother receives an injection of the methotrexate and her HCG levels are monitored very closely. A downward trend lets us know that the medications are working. Sometimes it requires a second dose, but the patient can't have more than 2 doses. Once there is a downward trend, HCG levels are monitored weekly until they return to normal (<5mIU/mL). This can take 4-12 weeks. This is not invasive but only works in specific situations. At least 50% of the time, the mother won't be a candidate for this. 1. Hemodynamic stability and no evidence of ectopic rupture 2. Gestational sac ≤ 4 cm if no cardiac activity; Gestational sac ≤ 3.5 cm if cardiac activity is present 3. Reliable patient, able to follow up for appointments and laboratory studies 4. Beta-human chorionic gonadotropin (beta-hCG level) ≤ 5 mIU/mL.

Nursing assessment for patients with preeclampsia

Mom: 1. Interview 2. Physical exam -Weight (sudden WT gain could be fluid retention and can be 4-5lbs) -BP (2 BPs that are high 2-4 hours apart; make sure the right cuff is used) -Edema (could be caused by damaged vessels_ -Fundoscopy -DTR's/clonus (Deep tendon reflexes will be stronger with preeclampsia) 3. Symptom analysis (blurry vision, headache, chest pain, abdominal pain)) 4. Labs (H&H, platelets, liver enzymes, BUN, Creatinine, uric acid, 24 hour urine collection -for protein) Fetus: -FHT (fetal heart tones) -BPP (biophysical profile -fetal well-being) -US (ultrasound) -Doppler flow (checking blood flow in vessels to and from the placenta/ to and from the fetus)

Thrombophlebitis: Deep Vein

More commonly seen in patients that have a previous history of a clot. The patient may also experience a low-grade fever that will spike and lead to chills. The location of the pain depends on the specific location of the clot, so it is necessary to talk with the patient to find out where it hurts the most. A doppler flow study is going to give you the specific diagnosis. About 50% of DVT can be diagnosed by symptom analysis, but the doppler flow will give the final confirmation.

When do most early spontaneous abortions (SAB) occur?

Most early SAB's occur before 8 weeks gestation often before the mother knows she's pregnant. This may seem like a heavier than normal period, but it is actually a miscarriage.

What is a recurrent spontaneous abortion (RSA)?

Mother who has 3 or more consecutive SABs and needs more testing to determine why. *RSA usually means that the mother has something else going on that is preventing her from carrying a pregnancy to term. She may have diabetes, hormonal problems, thyroid issues, lupus, etc.

If a patient comes in with bleeding that is more than spotting, should you do an internal exam without an ultrasound?

No. Don't risk disturbing the placenta. It could be placenta previa and lead to hemorrhaging if it is disturbed.

What are normal H&H levels for women?

Normal hematocrit levels for women are 38-46% Normal Hemoglobin levels for women are 12-16g/dL

When is a cerclage usually removed?

Once cerclage is placed, the goal is to maintain the pregnancy as long as possible. It is usually snipped at about 36/37 weeks to allow normal labor to occur.

What is an incompetent cervix (cervical insufficiency)?

Passive, painless cervical dilation in the 2nd trimester. If there is a mother that is consistently having late (14-16 wks) pregnancy losses we need to consider the possibility that it is a cervical problem (incompetent cervix. The patient may not have any other symptoms (sometimes there is spotting, the patient may feel fullness or pressure, but it rarely hurts.)

Why is it recommended that pregnant women get a dental exam and their teeth cleaned early on in their pregnancy?

Periodontal disease has shown to increase the risk of PTL.

Nursing interventions for postpartum hemorrhage (PPH)

Pitocin can be injected into the IV bag and be allowed to drip in (10, 20 or even up to 40 units of pitocin depending on how much fluid is left it the IV bag. -Keep a pad count or some way to estimate the blood loss. -Always check the fundal status first and begin massage immediately if the fundus is boggy. -IV pitocin is the first line medication for postpartum hemorrhage -Methergine is the second line medication for postpartum hemorrhage. However, it causes vasoconstriction so if the patient already has high blood pressure, it can cause the patient to have a stroke. *It is the nurse's responsibility to be aware of the patient's blood pressure, so if the provider calls for methergine and you know the BP is high, you have to tell the provider. -The third line drug is a prostaglandin, like hemabate (Carboprost Tromethamine), which can be given rectally or as an injection. It has side effects: diarrhea, fever, etc, so they don't like to use it unless they have to. -Empty bladder -O2 -Keep patient calm -Notify the provider

What is placenta previa?

Placenta implants over or near the cervical opening

Placenta increta

Placenta increta: the placenta grows into the uterine muscle and has to be surgically removed. It can't be removed manually.

Placenta percreta

Placenta percreta: the placenta grows all the way through the uterine wall and into the abdominal cavity. It can attach to the colon, ovaries, or stomach (any abdominal organ). The only way to take care of it is with a total hysterectomy.

In a normal pregnancy what impacts maternal metabolism?

Placental hormones help adjust maternal metabolism. In a normal pregnancy, carbohydrate metabolism is impacted by the different maternal hormones and many of these hormones are related to the placenta. They act at different times during the pregancy.

How does the placenta impact preeclampsia?

Poor remodeling of the uteroplacental spiral arteries is linked to early-onset preeclampsia and several other major obstetrical syndromes, including fetal growth restriction, placental abruption, and spontaneous preterm premature rupture of membranes. -Specifically the spiral arteries are normally flexible, but with Pre E, these arteries in the placenta are straighter and not stretchy. This leads to vasospasm and not vasodilation, which increases BP

What does PP stand for?

Postprandial = after eating

Diabetes during pregnancy statistics

Pregestational diabetes mellitus (PGDM) -Occurs in approximately 2% of pregnancies Gestational diabetes mellitus (GDM) -Occurs in approximately 4% to 7 % of pregnancies

What kids of pressure on the breast can contribute to mastitis?

Pressure on the breast can include things like underwire bras and even things like a purse strap or diaper strap. Pacifier and bottle use can change the way that a baby sucks, which can interfere with the baby completely emptying the breast. Abrupt stopping of breastfeeding can leave a stasis of milk in the breast that leads to mastitis.

What is PPROM?

Preterm Premature Rupture of Membranes before the onset of labor occurs and before 37 weeks gestation (3-5% of births; implicated in ~35% of preterm births).

Fetal complications that are associated with gestational diabetes mellitus (GMD) with a mother without vascular disease

Pretty much the same as pregestational diabetes mellitus (PGDM)" 1. Macrosomia 2. Shoulder dystocia 3. Increased C/S risk 4. Slows surfactant production 5. Hydramnious

Health teaching postpartum depression

Remember that every patient should be screened for postpartum depression. It is important with patient teaching and family teaching to talk to them about the differences between postpartum depression and the baby blues. The baby blues has a transient nature (get better within about 2 weeks). Anytime the mother has prolonged symptoms of depression, it could be postpartum depression. Warning signs: ideation of hurting herself or the baby. Not something that means that they are bad people or doing something wrong. It is just something that needs to be treated.

Nursing Role: Chronic hypertension during pregnancy

Remember that hypertensive disorders in pregnancy are very complicated and can be dangerous. Nurses are often on the front line to identify patients, complete assessments and teach patients what they need to know to care for themselves.

What are the two most common causes of hemorrhagic disorders during pregnancy?

Ruptured ectopic pregnancies and placental abruptions are the 2 most common causes.

Signs and symptoms and treatment of mastitis

S and Sx - unilateral Thickened area Fever/local heat Pain Engorgement Nipple discharge Axillary adenopathy Treatment Antibiotics Empty breast Pain management Emotional support SX: Fever, thickened area in the breast where there is usually a clot, the patient may also have enlarged lymph nodes in the axillary region.

Superficial thrombophlebitis

Superficial thrombophlebitis is more common than DVT. It is seen with mothers that have preexisting varicosities. The SX are usually noted on the 2nd or 3rd postpartum day (listed below). Nursing assessments are important to catch changes early and you can evaluate improvement. The patient needs to understand what the problem is and why the specific treatment is used. Treatments for superficial thrombophlebitis are not as drastic as the ones for DVT.

Symptoms and treatment of complete spontaneous abortion (SAB)

Symptoms: -All POC passed -May pass intact in bag -Cervix closes -Pain improves Treatment: -Emotional support/teaching *The body is able to get rid of the pregnancy completely. This can happen in pieces or in can happen completely. Fetus on the left was about the size of a quarter.

Symptoms and treatment of Incomplete spontaneous abortion (SAB)

Symptoms: -Bleeding and cramping severe -Cervix dilates -Most of POC is passed (The body is trying to expel the POC, but can't get it all out.) Treatment: -D and C -Pain management (Tylenol and/or Percocet for pain management.) -Emotional support/teaching (Can be very stressful and/or emotional)

Symptoms and treatment of Inevitable spontaneous abortion (SAB)

Symptoms: -Bleeding and cramping worsen -Cervix begins to dilate -Minimal if any POC passed Treatment: -Depends on maternal status -Emotional support/teaching *Might wait to see if the mother will pass the POC on her own. If not, she may need a D&C.

Symptoms and treatment of a missed spontaneous abortion (SAB) or blighted ovum

Symptoms: -Initially none -POC stops growing -Pregnancy symptoms subside Treatment: -May eventually have complete SAB -May need D and C -Emotional support/teaching

What happens to insulin production in the 2nd and 3rd trimester?

The amount of insulin produced by the mother substantially increases (sometimes five times as much as normal) to reduce the chances of complications due to hyperglycemia. -Need to assess A1C to ensure that glucose levels are under control -It is important to teach the patient about what changes are expected and should be monitored because of her diabetic status.

How does the vasospasm and concurrent increase in blood pressure cause cerebral edema?

The blood vessels in the brain are damaged which leads to increased leaking of fluid into the extravascular spaces of the brain. This causes swelling or edema in the brain. There is only so much swelling that the brain can accommodate for. One pressure becomes too great, the patient will start to have seizures. The administration of magnesium sulfate is to prevent this from occurring as a result of eclampsia.

What is placental abruption?

The detachment of all of part of the placenta from the decidua basalis after 20 weeks gestation. It most often occurs in the 3rd trimester, but it can happen any time after 20 weeks.

What is a concealed abruption?

The edges of the placenta are still intact, but there is bleeding occurring underneath. In this case you won't have a lot of active bleeding, but you will have a lot of pain and pressure. This will also cause decompensation in the baby.

What is a complete placenta previa?

The entire cervix is covered by the placenta (requires C-section)

What causes preeclampsia?

The exact causes are unknown. The most common theory is that it stems from the placenta. Studies have been done to see the impact of aspirin therapy and diet changes on preeclampsia.

What is a complete mole?

The most common. An abnormal egg (no nucleus) is fertilized by a normal sperm (not enough chromosomes) so you can't form a fetus and end up with an overgrowth of placental tissue.

Septic abortions

The mother is infected. She has a fever, she has a lot of pain, the lochia smells really bad, etc. This happened a lot more frequently when therapeutic abortions' were illegal or difficult to get. (Teenagers had to have parental consent, so many of these infections were caused by back- woods abortions/ "Coat-hanger Abortions")

Why have the number of postpartum hemorrhages declined?

The number of postpartum hemorrhages have declined do to aggressive management in the 3rd stage of labor (delivery of the placenta: -Giving pitocin immediately after the placenta releases and in some cases while the placenta is still in place -Immediate fundal massage

Treatment of Thrombophlebitis: Deep Vein

The nursing care is more intense because the patient will most likely be on bed rest and be taking an anticoagulant like heparin (need someone to double check the heparin drip calculations). Follow the hospital protocols as well. Teach the patient not to rub the area. it could dislodge the clot and lead to a pulmonary embolism. -Requires anticoagulant therapy -Bedrest -Assist with ADLs -Don't rub area or flex knee sharply - Measure leg -Elastic hose

Placenta accreta

The placenta grows deeply into the uterine wall

What is a marginal placenta previa?

The placenta is at the edge of the cervix *can sometimes deliver vaginally. It depends on the gestational age of the baby and the general health of the mother.

What is a partial placenta previa?

The placenta is blocking at least half of the cervix (requires C-section)

What is a low lying placenta previa?

The placenta is not touching the cervix, but it is very close to it or at the edge of the cervix (proximal to it) *can sometimes deliver vaginally. It depends on the gestational age of the baby and the general health of the mother.

What is the only cure of preeclampsia?

The termination of the pregnancy (giving birth and passing the placenta) or SAB.

What is a visible abruption?

The whole side of the placenta is loose and you have bleeding from the portion underneath. There is more significant vaginal bleeding with this.

What is the American College of Gynecologists' recommendation for diagnosing gestational diabetes?

They recommend the 2 step method: 1. Between wks 24 & 28, the non-fasting mother is given a 50g load of glucose drink and the blood sugar is checked after one hour. Below 140 is normal. 2. If the blood sugar level is over 140 after one hour, the mother must do the 3 hour glucose test. For this test, she must fast, the fasting blood glucose level is drawn, she is given 100g glucola, and the blood sugar is then drawn at 1hr, 2hrs, and 3hrs. If any 2 of those labs are abnormal, she is diagnosed with GDM *Mothers with other risk factors may be screened earlier.

What is an inverted uterus?

This doesn't happen frequently, but you can push a uterus inside-out. It is most commonly caused by pulling on a cord that is firmly attached or trying to manually remove an attached/ adhered placenta. *This is why you shouldn't pull on the cord until you know that the placenta is releasing (the cord will lengthen)

What is human chorionic somatomammotropin (hCS) or human placental lactogen (hPL)?

This substance is similar to a growth hormone and stimulates maternal metabolism to supply needed nutrients for fetal growth. hCS increases the resistance to insulin, facilitates glucose transport across the placental membrane, and stimulates breast development to prepare for lactation.

What are the three types of accretas?

Three types of Accretas, where the uterine wall has been invaded by the placenta: 1. Placenta accreta 2. Placenta increta 3. Placenta percreta

True of false: Even mild diabetes during pregnancy can lead to complications and increased perinatal mortality and morbidity.

True

True or false: A complete SAB results in all POC passed, a closed cx and minimal bleeding.

True

True or false: A fetus with macrosomia has increase risk for fractured clavicles and spleen or liver damage.

True

True or false: Gestational diabetes blood glucose levels are usually more strict that regular diabetic levels

True

True or false: Gestational diabetes mellitus (GDM) increases the risk for developing diabetes mellitus later in life.

True

True or false: Most hemorrhagic disorders are considered medical emergencies.

True

True or false: Patients often mistake preterm labor (PTL) symptoms for normal discomforts of pregnancy.

True

True or false: Placenta previas are classified as total/complete, partial, marginal and low lying.

True

True or false: Pregestational diabetes mellitus (PGDM) can be type 1 or type 2.

True

True or false: Symptoms of a threatened SAB include spotting and mild cramping.

True

True or false: Ruptured ectopic pregnancies are one of the top two causes of maternal mortality.

True, the other is an abruption

True or false: A symptom of a ruptured ectopic is shoulder pain.

True. Bleeding causes irritation to the diaphragm, which causes referred pain to the shoulder.

True or false: Maternal insulin production varies by gestational age with the highest levels of insulin production in the first trimester.

True. Glucose levels in the pregnant woman change depending on trimester. They typically get worse as the pregnancy progresses.

True or false: Ruptured ectopic is the leading cause of maternal mortality in the 1st trimester.

True. It is very easy for a rupture to cause the mother to bleed out very quickly, so unless she is in or close to a medical facility, she could bleed to death. Usually, if the pregnancy ruptures, the fertilized egg just dies. Occasionally, the fertilized egg attaches itself and becomes an abdominal pregnancy. In most cases, it attaches to the bowel (there are lots of nutrients/fluid in the bowel). It is not common and it requires a C-section. Most of the time the pregnancy reabsorbs because it doesn't have enough nutrients to survive.

True or False: Most preeclamptic patients recover quickly after delivery.

True. Most improve within a day or two, but Pre E can be diagnosed after delivery (the blood pressure keeps going up during delivery) ** it's important to keep an eye on the mother even post-partum.

True or false: Diabetes is associated with preeclampsia.

True. Preeclampsia is associated with gestational diabetes so it is important to monitor the patient's blood pressure in addition to glucose levels. *The earlier you can get the mother's baseline blood pressure the better. -Because the eyes are a good indicator of vascular damage that is taking place in the body, monitor for papilledema (swelling of the optic nerve as it enters the back of the eye due to raised intracranial pressure).

True or false: With patients that have had prolonged premature rupture of membranes, they should try to maintain bedrest with bathroom privileges whenever possible.

True. The more that she is upright, the more fluid she will leak.

True or false: Infants born between 23-25 weeks have less than a 50% chance of recovery without a severe disability.

True. The odds improve with gestational age.

True or false: At least another 10% end before the pregnancy is confirmed.

True. These mothers did not realize that they were pregnant. They may have been late, but never had a positive test.

What is an ectopic pregnancy?

Tubal pregnancy, when a fertilized egg develops outside the uterus (usually in the fallopian tube). High risk for rupture and death.

Insulin production post delivery

Typically, insulin production returns to normal 7-10 days after delivery of the baby and expulsion of the placenta.

How does the vasospasm and concurrent increase in blood pressure impact peripheral and pulmonary edema?

Vasospasm causes high blood pressure, which causes damage to blood vessels. As a result, these vessels increase in their permeability. This leads to leaks of the main source of colloid osmotic pressure (albumin). This allows for more liquid to lead from the vessels into the extravascular spaces. Increased leaking causes increases peripheral and pulmonary edema. *You will often see increased swelling around the eyes (periorbital edema), feet, hands, and pulmonary edema (so listen to the patient's lungs- if mom isn't oxygenating/perfusing, neither is baby)

What is Velamentous Insertion?

Vessels are in the bag not the placenta -This is one of the worse. Also called "vasoprevia" In a normal placenta, the cord is attached right in the middle of the placenta. -In a velamentous insertion, the cord is going to split on the fetal side and it splinters off into separate blood vessels that run through the membrane to the placenta. The vessels are in the bag and not in the center of the placenta (pictured left) **The potential problem is that if there is a ROM, the vessels could break because they are not protected by the Wharton's jelly. This can cause very excessive bleeding, very quickly (often don't know until it is too late)

How is a molar pregnancy treated?

With a D&C

After treatment for a molar pregnancy, is extensive follow-up needed?

Yes. The patient is told not to get pregnant again for at least a year so that the HCG levels can continuously be monitored. HCG is checked twice a week for several weeks, then weekly, then every other week, and then monthly to make sure that the HCG levels return to normal (<5mIU/mL). An increase in HCG could mean onset of gestational trophoblastic neoplasm (GTN).

The nurse has taught a postpartum patient about postpartum blues. Which statement given by the patient indicates effective teaching? a. "I might feel like laughing one minute and crying the next." b. "I should call the support line only if I hear voices." c. "I should notify my primary health care provider (PHP) immediately if I am depressed." d. "I need to take medication to treat anxiety and sadness."

a. "I might feel like laughing one minute and crying the next." Rationale Mood swings are a common symptom of postpartum blues. The patient may have continuous mood swings and may feel like laughing one minute and crying the next. The patient can call the support line whenever she feels depressed or anxious. The patient should consult the PHP if the symptoms persist for more than 2 weeks. Postpartum blues are usually self-limiting and require no medication.

The nurse is assessing a pregnant patient and finds that the patient has inflammation around the teeth and bleeding of the gums. What should the nurse tell the patient after the assessment? a. "You might be at risk for preterm labor." b. "Your baby might have spina bifida." c. "You may be at risk of having a miscarriage." d. "Your baby might have delayed tooth eruption."

a. "You might be at risk for preterm labor." Rationale According to research, the patients who have periodontal diseases like gingivitis, inflammation around the teeth, and bleeding of gums may have an increased risk of preterm labor. Down syndrome and hypothyroidism would cause a delay in tooth eruption in the infant. Periodontal diseases would not cause miscarriage, because it does not affect fetal development. Spina bifida results from a deficiency of folate, not from maternal periodontal diseases.

What does the nurse regularly monitor in a patient with cocaine addiction to prevent its associated complications? a. Blood pressure b. Blood glucose levels c. Blood uric acid levels d. White blood cell counts

a. Blood pressure Rationale Cocaine impairs cardiac functioning and causes cardiovascular disorders, such as tachycardia and hypertension. Therefore, to prevent these complications the nurse should regularly monitor blood pressure and heart rate of the patient. Cocaine does not affect the pancreas and insulin levels, so it is not mandatory to regularly monitor blood glucose levels. Cocaine also does not affect hyperuricemia and leucopenia. Therefore, the nurse need not assess the blood uric acid levels and white blood cell count.

The nurse observes that intravenous (IV) administration of magnesium sulfate has resulted in magnesium toxicity in a pregnant patient with preeclampsia. The nurse immediately discontinues the infusion and reports to the primary health care provider (PHP). For which drug does the nurse obtain a prescription from the PHP? a. Calcium gluconate b. Nifedipine (Adalat) c. Hydralazine (Apresoline) d. Labetalol hydrochloride (Normodyne)

a. Calcium gluconate Rationale The nurse needs to obtain a prescription for calcium gluconate because it acts as an antidote to magnesium toxicity. Nifedipine (Adalat) and labetalol hydrochloride (Normodyne) are antihypertensive medications, which are prescribed for gestational hypertension or severe preeclampsia. Hydralazine (Apresoline) is also an antihypertensive medication used for treating hypertension intrapartum.

Which hypertensive disorders can occur during pregnancy? Select all that apply. a. Chronic hypertension b. Preeclampsia-eclampsia c. Hyperemesis gravidarum d. Gestational hypertension e. Gestational trophoblastic disease

a. Chronic hypertension b. Preeclampsia-eclampsia d. Gestational hypertension Rationale Chronic hypertension refers to hypertension that developed in the pregnant patient before 20 weeks of gestation. Preeclampsia refers to hypertension and proteinuria that develop after 20 weeks of gestation. Eclampsia is the onset of seizure activity in a pregnant patient with preeclampsia. Gestational hypertension is the onset of hypertension after 20 weeks' gestation. Gestational trophoblastic disease and hyperemesis gravidarum are not hypertensive disorders. Gestational trophoblastic disease refers to a disorder without a viable fetus that is caused by abnormal fertilization. Hyperemesis gravidarum is excessive vomiting during pregnancy that may result in weight loss and electrolyte imbalance.

During the assessment of a postpartum patient, the nurse finds the patient has endometritis. Which medication should be administered in the treatment plan for this patient? a. Clindamycin (Cleocin) b. Misoprostol (Cytotec) c. Ergonovine (Ergotrate) d. Methylergonovine (Methergine)

a. Clindamycin (Cleocin) Rationale Endometritis is a common postpartum infection. It usually begins as a localized infection at the placental site and spreads to the entire endometrium. Endometritis is usually managed by giving the patient a broad-spectrum antibiotic drug, like Clindamycin (Cleocin). Therefore clindamycin (Cleocin) should be involved in the treatment plan for management of endometritis. Misoprostol (Cytotec), ergonovine (Ergotrate), and methylergonovine (Methergine) are uterotonic drugs used to manage postpartum hemorrhage (PPH) caused by uterine atony.

The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms should the nurse expect to observe? Select all that apply. a. Decreased urinary output and irritability b. Transient headache and +1 proteinuria c. Ankle clonus and epigastric pain d. Platelet count of less than 100,000/mm3 and visual problems e. Seizure activity and hypotension

a. Decreased urinary output and irritability c. Ankle clonus and epigastric pain d. Platelet count of less than 100,000/mm3 and visual problems Rationale Decreased urinary output and irritability are signs of severe eclampsia. Ankle clonus and epigastric pain are signs of severe eclampsia. Platelet count of less than 100,000/mm3 and visual problems are signs of severe preeclampsia. A transient headache and +1 proteinuria are signs of preeclampsia and should be monitored. Seizure activity and hyperreflexia are signs of eclampsia.

The nurse is assessing environmental factors that could cause fetal damage in a pregnant patient. Which questions should the nurse ask the patient? Select all that apply. a. Do you smoke habitually or occasionally? b. Do you undergo radiation tests frequently? c. How many times do you exercise in a week? d. Do you take any medications for any condition? e. Does your partner take alcohol or any substance?

a. Do you smoke habitually or occasionally? b. Do you undergo radiation tests frequently? Rationale Cigarette smoke is an environmental factor that can cause fetal damage. Smoking during pregnancy increases the risk for low birth weight and miscarriage. Radiation is a detrimental environmental factor that can cause fetal damage. Repeated scans during pregnancy may expose the fetus to radiation for a longer time. Some medications can cross the placental barrier and affect the fetus; therefore it is prudent for the nurse to ask the patient about medication use during the pregnancy period. However, this question relates to environmental factors, and the use of medications is not considered an environmental factor. This is a biophysical risk, not an environmental risk. Exercise is not a risk factor. Alcohol intake of the mother can adversely affect the health of the fetus, so the mother should be advised to avoid alcohol intake. However, paternal alcohol intake does not cause fetal damage.

The nurse is assessing a pregnant patient and finds that the patient has had spinal surgery. What does the nurse interpret from the assessment? a. Epidural anesthesia is contraindicated in the patient. b. Cesarean birth should be recommended for the patient. c. The patient may have higher chances of preterm delivery. d. The patient may have right lower quadrant pain during pregnancy.

a. Epidural anesthesia is contraindicated in the patient. Rationale From the assessment the nurse determines that the patient has a history of spinal surgery, and epidural anesthesia can lead to severe complications in such patients. A history of spinal surgery does not cause preterm delivery or cesarean birth. If the patient has had uterine surgery or extensive repair of the pelvic floor, then cesarean birth would be recommended. Unlike appendicitis, spinal surgery does not cause right lower quadrant pain during pregnancy.

Which intrapartal factors can contribute to a postpartum infection? Select all that apply. a. Hematomas b. Prolonged labor c. Diabetes mellitus d. Epidural analgesia e. Immunosuppression

a. Hematomas b. Prolonged labor d. Epidural analgesia Rationale Hematomas, prolonged labor, and epidural analgesia are intrapartal factors that can contribute to a postpartum infection. Diabetes mellitus and immunosuppression are preconception factors that can contribute to postpartum infection.

An 8-month-pregnant patient presents with preeclampsia. Which clinical findings in the patient indicate that the disease has progressed to HELLP syndrome? Select all that apply. a. Hepatic dysfunction b. Elevated liver enzymes c. Vaginal bleeding d. Low platelet count e. Chronic hypertension

a. Hepatic dysfunction b. Elevated liver enzymes d. Low platelet count Rationale Hepatic dysfunction in a patient with preeclampsia indicates that the disease has progressed to HELLP syndrome. It can result in both endothelial damage and fibrin deposits in the liver. Hepatic tissue damage results in elevated liver enzymes. Narrowed blood vessels damage the red blood cells (RBCs) and they become hemolyzed, resulting in a decreased RBC and platelet count. Vaginal bleeding is sometimes seen in patients with severe gestational hypertension or those who are at risk for miscarriage. Chronic hypertension is a condition in which patients develop hypertension before the pregnancy. It is not related to HELLP syndrome.

A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the health care provider, anticipating an order for what? a. Hydralazine b. Magnesium sulfate bolus c. Diazepam d. Calcium gluconate

a. Hydralazine Rationale Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus)or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The patient is not currently displaying any signs or symptoms of magnesium toxicity.

Which obstetric or medical complications should the nurse be alert for while providing care to a pregnant patient with diabetes mellitus? Select all that apply. a. Hydramnios b. Preeclampsia c. Hypoglycemia d. Monilial vaginitis e. Brachial plexus palsy

a. Hydramnios b. Preeclampsia c. Hypoglycemia d. Monilial vaginitis Rationale A pregnant patient with diabetes mellitus is at risk for hypertension, which may result in preeclampsia. Hypoglycemia may occur because of an increase in insulin levels in the first trimester of pregnancy. Hydramnios may occur in the third trimester of pregnancy because of hyperglycemia. Monilial vaginitis is a vaginal infection that is seen in women with diabetes during pregnancy. This results from an alteration in the normal resistance of the body to infection. Brachial plexus palsy may be seen in the child born to a woman with diabetes as a result of a difficult vaginal birth.

Which postpartum conditions are considered medical emergencies that require immediate treatment? a. Inversion of the uterus and hypovolemic shock b. Hypotonic uterus and coagulopathies c. Subinvolution of the uterus and idiopathic thrombocytopenic purpura (ITP) d. Uterine atony and disseminated intravascular coagulation (DIC)

a. Inversion of the uterus and hypovolemic shock Rationale Inversion of the uterus and hypovolemic shock are considered medical emergencies. A hypotonic uterus can be managed with massage and oxytocin. Coagulopathies should be identified before birth and treated accordingly. Although subinvolution of the uterus and ITP are serious conditions, they do not always require immediate treatment. ITP can be safely managed with corticosteroids or intravenous immunoglobulin. DIC and uterine atony are very serious obstetric complications; however, uterine inversion is a medical emergency requiring immediate intervention.

Which condition is a fetus at risk for if the mother has poor glycemic control later in pregnancy? a. Macrosomia b. Hydramnios c. Ketoacidosis d. Preeclampsia

a. Macrosomia Rationale Poor glycemic control later in pregnancy increases the risk for fetal macrosomia, or an infant with a birth weight of more than 4000 to 4500 g, or greater than the 90thpercentile. Hydramnios may occur in the third trimester of pregnancy because of hyperglycemia. Ketoacidosis occurs during the second and third trimesters if the maternal metabolism is stressed by illness or infection. Preeclampsia is seen in women with nephropathy and hypertension in addition to diabetes.

The nurse is reviewing the medical record of a pregnant patient with diabetes mellitus and notices the patient has poor glycemic control throughout the early weeks of pregnancy. What does the nurse infer that the patient may be at risk for? a. Miscarriage b. Ketoacidosis c. Polyhydramnios d. Fetal macrosomia

a. Miscarriage Rationale Metabolic changes in the early weeks of pregnancy change the insulin and glucose levels in the body. This may result in poor glycemic control and may increase the chance of miscarriage. Polyhydramnios may occur in the third trimester of pregnancy because of hyperglycemia. There is an increased chance of fetal macrosomia if there is poor glycemic control in the later weeks of pregnancy. Ketoacidosis occurs during the second and third trimesters if the maternal metabolism is stressed by illness or infection.

What would make a patient seek immediate medical attention during pregnancy? a. No fetal movement after the sixth month of pregnancy b. Fetal movement occurs at the fifth month of pregnancy c. Mild uterine contractions after the fifth month of pregnancy d. Increased size of breasts from the third month of pregnancy

a. No fetal movement after the sixth month of pregnancy Rationale Fetal movement occurs after the fifth month of pregnancy. The mother can usually feel the movement of the fetus. If no fetal movement occurs even after the sixth month of pregnancy, then the patient should seek immediate medical attention to fi nd out if the fetus is still alive. Ultrasonography is performed to detect fetal movement. If the fetal movements are felt by the fifth month of pregnancy, it indicates that the fetus is healthy and no medical attention is required. Breast size increases normally by the third month of pregnancy because of the release of human chorionic somatomammotropin (hCS), a protein hormone. Mild uterine contractions are common and result from increasing concentration of estrogen during pregnancy; no immediate medical attention is required.

Which risk factors are associated with postpartum hemorrhage? Select all that apply. a. Obesity b. Maternal age c. Chorioamnionitis d. Cervical laceration e. Placental abruption

a. Obesity c. Chorioamnionitis e. Placental abruption Rationale The risk factors associated with postpartum hemorrhage include obesity, chorioamnionitis, and placental abruption. Maternal age and cervical lacerations are not associated with postpartum hemorrhage.

The nurse is caring for a postpartum patient. The nurse finds that the patient has continuous discharge of lochia serosa even 3 weeks after delivery. Which manifestations would indicate the presence of endometritis in the patient? Select all that apply. a. Offensive odor of lochia b. Persistence of lochia rubra c. Recurred bleeding after 7 to 14 days d. Fever, pain, and abdominal tenderness e. Excessive bright red-colored lochia rubra f. Gush of dark colored lochia upon standing

a. Offensive odor of lochia d. Fever, pain, and abdominal tenderness Rationale A continued fl ow of lochia serosa or lochia alba 3 to 4 weeks after birth may indicate endometritis. Normal lochia smells like that of normal menstrual flow. An offensive odor of lochia indicates an infection, which may be due to endometritis. In addition, patients with endometritis have fever, pain, and tenderness in the abdomen, which particularly indicate infection and inflammation of the endometrium. Presence of retained fragments of placenta or other membranes can result in continued lochia rubra early in the postpartum period. Bleeding may recur 7 to 14 days after childbirth, which is associated with the healing placental site and does not indicate endometritis. A gush of lochia is seen when a woman lying in bed stands up or when the uterus is massaged. This gush of lochia would be dark in color if it is composed of pooled blood and then reduces to a bright red lochia. This should not be mistaken with hemorrhage or endometritis. Excessive and continuous discharge of bright red colored lochia rubra indicates a vaginal or cervical tear.

A postpartum patient has uterine atony. What medication does the nurse expect the primary health care provider to prescribe to the patient? a. Oxytocin (Pitocin) b. Misoprostol (Cytotec) c. Ergonovine (Ergotrate) d. Methylergonovine (Methergine)

a. Oxytocin (Pitocin) Rationale Continuous intravenous (IV) infusion of 10 to 40 units of oxytocin (Pitocin) added to1000 mL of lactated Ringer's or normal saline solution is a primary intervention in the management of postpartum bleeding. Drugs like misoprostol (Cytotec), ergonovine (Ergotrate), and methylergonovine (Methergine) are prescribed only if the patient is not responding to oxytocin (Pitocin).

The nurse is caring for a patient with uterine atony. The nurse massages the patient's uterine fundus. The uterus remains boggy even after the blood clots are expelled. What medication would be most beneficial for the patient? a. Oxytocin (Pitocin) b. Adrenaline (Epinephrine) c. Ibuprofen (Motrin) d. Magnesium sulfate

a. Oxytocin (Pitocin) Rationale Oxytocin is the most common drug ordered to increase the uterine tone and control uterine atony. A patient who is allergic to duck eggs can develop a hypersensitivity reaction to the rubella vaccine, and adrenaline is given to such patients. Nonopioid analgesics such as ibuprofen are used for pain management in postpartum breastfeeding women because they do not reduce maternal or infant alertness. Magnesium sulfate is used to treat preeclampsia.

Which are characteristics of postpartum venous thrombosis? Select all that apply. a. Pain b. Warmth c. Redness d. Chest pain e. Calf tenderness

a. Pain b. Warmth c. Redness Rationale The characteristics of postpartum venous thrombosis include pain, redness, and warmth in the affected extremity. Chest pain occurs with an acute pulmonary embolism. Calf tenderness is associated with a deep vein thrombosis.

Which condition is seen in a pregnant patient if uterine artery Doppler measurements in the second trimester of pregnancy are abnormal? a. Preeclampsia b. HELLP syndrome c. Molar pregnancy d. Gestational hypertension

a. Preeclampsia Rationale Preeclampsia is a condition in which patients develop hypertension and proteinuria after 20 weeks' gestation. It can be diagnosed if uterine artery Doppler measurements in the second trimester of pregnancy are abnormal. HELLP syndrome is characterized by hemolysis (H), elevated liver enzymes (EL), and low platelet count (LP) in a patient with preeclampsia. Molar pregnancy refers to the growth of the placental trophoblast due to abnormal fertilization. Gestational hypertension is a condition in which hypertension develops in a patient after 20 weeks of gestation.

Which factor is known to increase the risk of gestational diabetes mellitus? a. Previous birth of large infant b. Maternal age younger than 25 c. Underweight before pregnancy d. Previous diagnosis of type 2 diabetes mellitus

a. Previous birth of large infant Rationale Previous birth of a large infant suggests gestational diabetes mellitus. A woman younger than 25 is not at risk for gestational diabetes mellitus. Obesity (greater than90 kg or 198 lb) creates a higher risk for gestational diabetes. The person with type 2diabetes mellitus already has diabetes and will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy.

A pregnant patient in the first trimester reports spotting of blood with the cervical os closed and mild uterine cramping. What does the nurse need to assess? Select all that apply. a. Progesterone levels b. Transvaginal ultrasounds c. Human chorionic gonadotropin (hCG) measurement d. Blood pressure e. Kleihauer-Betke (KB) test reports

a. Progesterone levels b. Transvaginal ultrasounds c. Human chorionic gonadotropin (hCG) measurement Rationale The spotting of blood with the cervical os closed and mild uterine cramping in the first trimester indicates a threatened miscarriage. Therefore the nurse needs to assess progesterone levels, transvaginal ultrasounds, and measurement of hCG to determine whether the fetus is alive and within the uterus. Blood pressure measurements do not help determine the fetal status. KB assay is prescribed to identify fetal-to-maternal bleeding, usually after a trauma.

What is the most significant finding in a urinalysis for a patient with preeclampsia? a. Protein b. Ketones c. Glucose d. Leukocytes

a. Protein Rationale Protein is a significant finding in a urinalysis for a patient diagnosed with preeclampsia. Normally protein should not be present in the urine. It is reflective of glomerular damage caused by hypertension in preeclampsia. Ketones are reflective of nutritional status. Glucose in the urine primarily occurs in the presence of elevated blood glucose. Leukocytes are present when there is inflammation or infection of urinary tract system.

Which clinical reports does the nurse evaluate to identify ectopic pregnancy in a patient? Select all that apply. a. Quantitative human chorionic gonadotropin (β-hCG) levels b. Transvaginal ultrasound c. Progesterone level d. Thyroid test reports e. Kleihauer-Betke (KB) test

a. Quantitative human chorionic gonadotropin (β-hCG) levels b. Transvaginal ultrasound c. Progesterone level Rationale An ectopic pregnancy is indicated when β-hCG levels are >1500 milli-international units/mL but no intrauterine pregnancy is seen on the transvaginal ultrasound. A transvaginal ultrasound is repeated to verify if the pregnancy is inside the uterus. A progesterone level <5 ng/mL indicates ectopic pregnancy. Thyroid test reports need to be evaluated in case the patient has hyperemesis gravidarum, as hyperthyroidism is associated with this disorder. The KB test is used to determine transplacental hemorrhage.

The nurse is assessing a group of pregnant women at a community health center. Which patients would be at highest risk for pregnancy-related complications? a. The patient with uncontrolled diabetes mellitus b. The patient who is of African-American descent c. The patient who is between 30 and 33 years old d. The patient with a history of alcohol consumption

a. The patient with uncontrolled diabetes mellitus Rationale Patients with uncontrolled diabetes are at a higher risk for complications associated with pregnancy. If the pregnant mother develops uncontrolled hyperglycemia, this may produce hyperglycemia in the fetus. This in turn stimulates fetal hyperinsulinemia and islet cell hyperplasia. Hyperinsulinemia prevents fetal lung maturation and places the neonate at an increased risk for respiratory distress. African-American patient shave an increased chance of having dizygotic twins. They are not associated with an increased risk for pregnancy-related complications. Patients within the age group of30 to 33 years are not at risk for complications associated with pregnancy. Alcohol consumption during pregnancy leads to respiratory complications and fetal alcohol syndrome. However, patients with a history of alcohol consumption do not usually have pregnancy-related complications.

The nurse is providing follow-up care to a patient who is 2½ weeks postpartum. Based on the involution process, which finding does the nurse expect to see when assessing the patient? a. The uterus will not be abdominally palpable. b. The uterus will have returned to its nonpregnant location. c. The uterus will be located halfway between the umbilicus and the symphysis pubis. d. The uterus will be at about the same size as it was at 20 weeks gestation.

a. The uterus will not be abdominally palpable. Rationale After 2 weeks postpartum, the uterus should not be abdominally palpable. It will have returned to its nonpregnant location by 6 weeks postpartum, not two and a half. The uterus is located halfway between the umbilicus and the symphysis pubis by the sixth postpartum day, not by 2½ weeks. The uterus is about the same size as it was at 20weeks gestation by 24 hours after birth, not 2½ weeks.

The nurse is reviewing the lab reports of a patient who is 10 weeks pregnant and has a family history of diabetes mellitus. The nurse finds that the patient's 1-hour glucose tolerance test is normal. What does the nurse advise the patient? a. "Increase food intake." b. "Repeat the test at 28 weeks." c. "Undergo a renal function test." d. "Undergo a 3-hour glucose test."

b. "Repeat the test at 28 weeks." Rationale The pregnant patient has a family history of diabetes and may be at a high risk for developing gestational diabetes. Because the initial 1-hour glucose tolerance test results are normal, the patient should be advised to repeat the test again at 28 weeks of pregnancy. The patient has normal blood sugar levels and is therefore unlikely to have renal complications. The patient does not need to undergo a renal function test. The laboratory reports do not indicate that the patient has any nutritional deficiencies and does not indicate a need for the patient to increase her food intake. A 3-hourglucose test is conducted only for pregnant patients whose 1-hour glucose tolerance test is positive.

A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits what? a. A sleepy, sedated affect b. A respiratory rate of 10 breaths/min c. Deep tendon reflexes of 2+ d. Absent ankle clonus

b. A respiratory rate of 10 breaths/min Rationale A respiratory rate of 10 breaths/min indicates that the patient is experiencing respiratory depression (bradypnea) from magnesium toxicity. Because magnesium sulfate is a central nervous system (CNS) depressant, the woman will most likely become sedated when the infusion is initiated. Deep tendon reflexes of 2+ are a normal finding. Absent ankle clonus is a normal finding.

The nurse is monitoring a postpartum patient for signs of hemorrhage. Which observation would indicate excessive blood loss? a. A body temperature of 100.4º F b. An increase in pulse from 88 to 102 beats/min c. An increase in respiratory rate from 18 to 22 breaths/min d. A blood pressure change from 130/88 to 120/80 mm Hg

b. An increase in pulse from 88 to 102 beats/min Rationale During the postpartum period, maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to increase the supply of blood. A body temperature of 100.4° F is a normal finding. A respiratory rate of 22 breaths/min indicates that the patient has no internal bleeding. A blood pressure of 120/80 mmHg does not indicate that the patient has hemorrhage.

A 28-year-old multipara delivered a 9-pound, 3-ounce baby girl an hour ago after a 22-hour labor with a forceps-assisted birth. As the patient is holding her daughter, she keeps shifting position and is becoming increasingly irritable and annoyed with everyone in the room. What action should the nurse initially take? a. Massage the fundus. b. Check her perineum. c. Assess her vital signs. d. Check the tone of her fundus.

b. Check her perineum. Rationale The patient is exhibiting increasing anxiety, which can signal the presence of postpartum hemorrhage. Risk factors for postpartum hemorrhage include a large fetus, prolonged labor, and a forceps-assisted birth. Because vital signs change late, the fastest way to see the amount of current hemorrhage is to check the perineum. The fundus would be massaged and additional nursing and medical interventions would be instituted.

A woman delivered twin babies at the thirty-sixth week of her first pregnancy. How does the nurse record gravidity and parity of the patient? a. Gravida 1, para 0 b. Gravida 1, para 1 c. Gravida 2, para 1 d. Gravida 2, para 2

b. Gravida 1, para 1 Rationale Gravidity indicates the total number of pregnancies that the woman has had, including the present one. Parity indicates the number of pregnancies that have reached 20weeks of gestation. Because the woman had twins at 36 weeks in her first pregnancy, the nurse should record this information as gravida 1, para 1. If the woman had been pregnant for the first time (primigravida) and had not carried a pregnancy to 20 weeks, then it would be documented as gravida 1, para 0. The nurse should document it as gravida 2, para 1 if the woman has one living child and is pregnant with the second one. If the woman gave birth at 36 weeks during her third pregnancy, then it is documented as gravida 3, para 2.

A patient diagnosed with placenta accreta has uncontrolled bleeding, despite medications. What is the best choice for treatment in this situation? a. Massage the uterus. b. Perform a hysterectomy. c. Replace blood components as needed. d. Apply traction on the umbilical cord.

b. Perform a hysterectomy. Rationale Placenta accreta is an obstetric complication in which the placenta adheres to and penetrates the myometrium. The patient with placenta accreta is at risk of hemorrhage during childbirth. If bleeding is not stopped after the administration of medication to the patient, a hysterectomy must be performed to prevent further complications. Replacement of blood components is not useful because the patient has uncontrolled bleeding. Massaging the uterus and applying traction to the umbilical cord are helpful to expel the placenta but are not useful when the placenta is adhered to the uterus.

Which is an important nursing intervention when a patient has an incomplete miscarriage with heavy bleeding? a. Initiate expectant management at once. b. Prepare the patient for dilation and curettage. c. Administer the prescribed oxytocin (Pitocin). d. Obtain a prescription for ergonovine (Methergine).

b. Prepare the patient for dilation and curettage. Rationale In the case of an incomplete miscarriage, sometimes there is heavy bleeding and excessive cramping and some part of fetal tissue remains in the uterus. Therefore the nurse needs to prepare the patient for dilation and curettage for the removal of the fetal tissue. Expectant management is initiated if the pregnancy continues after a threatened miscarriage. Oxytocin (Pitocin) is administered to prevent hemorrhage after evacuation of the uterus. Ergonovine (Methergine) is administered to contract the uterus.

A postpartum patient complains of a headache. What could be the reasons for the headache in the patient? Select all that apply. a. Orthostatic hypotension b. Stress of childbirth in the patient c. Postpartum-onset preeclampsia d. Leakage of the cerebrospinal fluid e. Presence of varices and hemorrhoids

b. Stress of childbirth in the patient c. Postpartum-onset preeclampsia d. Leakage of the cerebrospinal fluid Rationale Persistent headache in postpartum patients need to be evaluated further. However, the stress and physical fatigue of childbirth may cause the patient to experience headaches. Postpartum-onset preeclampsia, characterized by high blood pressure and the presence of proteins in the urine, may also cause headaches. Epidural or spinal anesthesia involves the placement of the needle into the spinal space. This may lead to leakage of cerebrospinal fluid into the extradural space, resulting in a headache. Orthostatic hypotension may cause dizziness, but it does not cause headache. The presence of varices and hemorrhoids may cause discomfort and pain, but these do not cause headache.

What are thromboembolic conditions that are of concern during the postpartum period? Select all that apply. a. Amniotic fluid embolism (AFE). b. Superficial venous thrombosis. c. Deep vein thrombosis. d. Pulmonary embolism. e. Disseminate intravascular coagulation (DIC).

b. Superficial venous thrombosis. c. Deep vein thrombosis. d. Pulmonary embolism. Rationale An AFE occurs during the intrapartum period when amniotic fluid containing particles of debris enters the maternal circulation. Although AFE is rare, the mortality rate is as high as 80%. A superficial venous thrombosis includes involvement of the superficial saphenous venous system. With deep vein thrombosis, the involvement varies but can extend from the foot to the iliofemoral region. A pulmonary embolism is a complication of deep vein thrombosis occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs. DIC is an imbalance between the body's clotting and fibrinolytic systems. It is a pathologic form of clotting that consumes large amounts of clotting factors.

The nurse helps a postpartum patient ambulate around the patient's bed. What complication is the nurse trying to prevent? a. Bladder distention b. Thromboembolism c. Orthostatic hypotension d. Postpartum hemorrhage

b. Thromboembolism Rationale Thromboembolism is a postpartum complication caused by hormonal imbalances, stress of childbirth, and long periods of immobility. This complication can be prevented by encouraging early ambulation. Ambulation does not help relieve bladder distention, orthostatic hypotension, or postpartum hemorrhage. The first priority in bladder distention is to help her to the bathroom or onto a bedpan if she is unable to ambulate. Orthostatic hypotension can be managed by asking the patient to change positions slowly. Postpartum hemorrhage has multiple causes and is not managed by ambulation.

While reviewing the reports of a pregnant patient in the third trimester ,the nurse finds that the patient has been referred for transvaginal and transabdominal ultrasound scanning. What is the most likely reason for referring the patient for both tests? a. To determine genetic abnormalities b. To determine the risk of preterm labor c. To assess development of the embryo d. To determine the risk of ectopic pregnancy

b. To determine the risk of preterm labor Rationale Premature labor occurs when the mother's body starts preparing for childbirth too early in her pregnancy. In some instances, during the second and third trimesters, transvaginal ultrasound scan may be used along with transabdominal scanning to evaluate the preterm labor. To detect genetic abnormalities in the fetus, chorionic villus sampling (CVS) is used in the first trimester and amniocentesis is used in the second and third trimesters. Ultrasound scan is usually not used to detect genetic abnormalities in the fetus. Transvaginal ultrasound scan is used in the first trimester of pregnancy to detect ectopic pregnancies and monitor development of the embryo.

What instruction does the nurse provide to a pregnant patient with mild preeclampsia? a. "You need to be hospitalized for fetal evaluation." b. "Nonstress testing can be done once every month." c. "Fetal movement counts need to be evaluated daily." d. "Take complete bed rest during the entire pregnancy."

c. "Fetal movement counts need to be evaluated daily." Rationale Preeclampsia can affect the fetus and may cause fetal growth restrictions, decreased amniotic fluid volume, abnormal fetal oxygenation, low birth weight, and preterm birth. Therefore the fetal movements need to be evaluated daily. Patients with mild preeclampsia can be managed at home effectively and need not be hospitalized. Nonstress testing is performed once or twice per week to determine fetal well-being. Patients need to restrict activity, but complete bed rest is not advised because it may cause cardiovascular deconditioning, muscle atrophy, and psychological stress.

Which statement made by the nursing student about the management of molar pregnancy indicates effective learning? a. "Methotrexate therapy is prescribed to abort molar pregnancy." b. "Expectant management is initiated as per the amount of bleeding." c. "Suction curettage is the safest way of terminating molar pregnancy." d. "Induction of labor with oxytocic agents is one of the treatment options."

c. "Suction curettage is the safest way of terminating molar pregnancy." Rationale In molar pregnancy, the avascular transparent vesicles in the uterus may cause uterine distention. Therefore suction curettage is used for rapid and effective evacuation of the hydatidiform mole. Methotrexate therapy is prescribed to dissolve an ectopic pregnancy. Expectant management is initiated in case of a normal fetus and not molar pregnancy. Induction of labor with oxytocic agents is not a safe method, because it has a risk of embolization of trophoblastic tissue.

A woman who is 32 weeks pregnant is informed by the nurse that a danger sign of pregnancy could be what? a. Constipation b. Heart palpitations c. Alteration in the pattern of fetal movement d. Edema in the ankles and feet at the end of the day

c. Alteration in the pattern of fetal movement Rationale An alteration in the pattern or amount of fetal movement may indicate fetal jeopardy. Constipation is a normal discomfort of pregnancy that occurs in the second and third trimesters. Heart palpitations are a normal change related to pregnancy. This is most likely to occur during the second and third trimesters. As the pregnancy progresses, edema in the ankles and feet at the end of the day is not uncommon.

Which is an important nursing intervention for a patient with pregestational diabetes mellitus during the first trimester? a. Encourage oral fluid intake. b. Increase the insulin dosage. c. Assess blood glucose levels. d. Prevent nausea and vomiting.

c. Assess blood glucose levels. Rationale During the first trimester of pregnancy, the maternal glucose levels reduce and the insulin response to glucose is enhanced. The nurse should assess the blood glucose levels in the patient and increase the dose accordingly. The nurse does not increase the insulin dose without determining the glucose levels, because it may result in hypoglycemia. Nausea and vomiting is normal in early pregnancy, which may necessitate a reduction in the insulin dose. Increasing fluids will not help prevent hypoglycemia in the patient.

The nurse assesses a postpartum patient and finds that the patient has lochia rubra with a firm fundus at the level of the umbilicus. Which is the most important nursing intervention in this situation? a. Administer prostaglandins. b. Administer oxytocin. c. Document the findings and continue to monitor. d. Massage the fundus every 15 minutes.

c. Document the findings and continue to monitor. Rationale Lochia rubra and a firm fundus are normal findings in a postpartum patient. Because the assessment findings do not indicate a postpartum complication, the nurse should document the findings and continue to monitor. Because the patient has a firm fundus, she does not have postpartum hemorrhage, so prostaglandins and oxytocin should not be administered. Because the fundus is firm, massage is not needed to help the fundus contract.

What risk factors does the nurse assess in a patient during preconception care? Select all that apply. a. Gingivitis b. Sleep disorder c. Exposure to toxic chemicals d. Down syndrome and cystic fibrosis e. Hypertension, diabetes, and anemia

c. Exposure to toxic chemicals d. Down syndrome and cystic fibrosis e. Hypertension, diabetes, and anemia Rationale The nurse should assess patients for risk factors, such as toxic chemicals exposure, Down syndrome, cystic fibrosis, hypertension, diabetes, and anemia, during preconception care to minimize fetal malformations and miscarriage. Sleep disorders and gingivitis do not cause fetal malformation and miscarriage. However, advising the patient to avoid consuming coffee and to listen to soft music can treat sleep disorders. Gingivitis can be prevented by advising the patient to maintain proper oral hygiene and to take vitamin C supplements. These do not cause major risks to the fetus and patient.

The nurse is reinforcing discharge instructions to a postpartum patient after a cesarean birth. The patient reports leaking urine every time she sneezes or coughs. Which exercises should the nurse teach to the patient? a. Sit-ups b. Abdominal exercises c. Kegel exercises d. Pelvic tilt exercises

c. Kegel exercises Rationale Kegel exercises consist of the voluntary contraction and relaxation of the pubococcygeal muscle, similar to trying to start and stop the fl ow of urine. This strengthens the pelvic floor muscles and helps the patient decrease the stress incontinence that occurs during sneezing and coughing. Sit-ups and abdominal exercises should not be performed until the patient's 4-week postpartum follow-up appointment. Pelvic tilt exercises consist of alternate arching and straightening of the back to strengthen the back muscles and relieve back discomfort.

Which postpartum infection is most often contracted by first-time mothers who are breastfeeding? a. Endometritis b. Wound infections c. Mastitis d. Urinary tract infections (UTIs)

c. Mastitis Rationale Mastitis is an infection in a breast, usually confined to a milk duct. Most women who suffer this are first-time mothers who are breastfeeding. Endometritis is the most common postpartum infection. Incidence is higher after a cesarean birth and not limited to first-time mothers. Wound infections are also a common postpartum complication. Sites of infection include both a cesarean incision and the episiotomy or repaired laceration. The gravidity of the mother and her feeding choice are not factors in the development of a wound infection. UTIs occur in 2% to 4% of all postpartum women. Risk factors include catheterizations, frequent vaginal examinations, and epidural anesthesia.

The nurse caring for a patient finds excessive postpartum bleeding caused by uterine atony. Upon further assessment, the nurse finds no improvement in the bleeding after administration of oxytocin (Pitocin).What does the primary health care provider prescribe to the patient? a. Paroxetine (Paxil) b. Sertraline (Zoloft) c. Misoprostol (Cytotec) d. Mirtazapine (Remeron)

c. Misoprostol (Cytotec) Rationale Oxytocin (Pitocin) is the primary drug administered to induce uterine contractions(UCs). When the uterus fails to respond to oxytocin, misoprostol (Cytotec) is administered to induce contractions. Paroxetine (Paxil) is an antidepressant drug used in the treatment of postpartum depression. Sertraline (Zoloft) is a selective serotonin reuptake inhibitor (SSRI) that serves as an antidepressant and is administered for postpartum depression. Mirtazapine (Remeron) is a drug used in the treatment of depression.

After reviewing a patient's medical reports, the nurse finds that the patient has multifetal gestation. What is the most likely complication associated with this? a. Vaginal hematomas b. von Willebrand disease (vWD) c. Postpartum hemorrhage (PPH) d. Abnormal development of limbs

c. Postpartum hemorrhage (PPH) Rationale The uterine walls are overstretched in multifetal gestation, so it contracts poorly afterbirth. This may cause uterine atony leading to PPH. Multifetal gestation does not cause vaginal hematomas, vWD, or abnormal limb development of the fetus. Vaginal hematomas occur more commonly in association with a forceps-assisted birth. vWD is a type of hemophilia, which is a hereditary bleeding disorder. Abnormal development of fetal limbs is usually a complication associated with teratogenic drugs.

The nurse is caring for a patient with excessive postpartum hemorrhage. The nurse observes that the patient's skin has turned grayish. What does the nurse infer from this finding? a. Risk of infection b. Evidence of severe pain c. Potential risk of hypovolemic shock d. Potential risk of impaired urinary elimination

c. Potential risk of hypovolemic shock Rationale If a patient with excessive postpartum hemorrhage shows signs such as grayish, cool, and clammy skin, the patient is at risk of developing hypovolemic shock. If the patient has foul-smelling lochia, then the patient might be at risk of infection. Every patient experiences pain after giving birth; however, a change in skin color does not result from pain. If the patient has not voided urine within 8 hours after birth, then the patient might be at risk of impaired urinary elimination.

Signs of a threatened abortion (miscarriage) are noted in a woman at 8weeks of gestation. What is an appropriate management approach for this type of abortion? a. Prepare the woman for a dilation and curettage (D&C). b. Place the woman on bed rest for at least 1 week and reevaluate. c. Prepare the woman for an ultrasound and bloodwork. d. Comfort the woman by telling her that if she loses this baby, she may attempt to get pregnant again in 1 month.

c. Prepare the woman for an ultrasound and bloodwork. Rationale Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine if the fetus is alive and within the uterus. If the pregnancy is lost, the woman should be guided through the grieving process. D&C is not considered until signs of the progress to an inevitable abortion are noted or the contents are expelled and incomplete. Bed rest is recommended for 48 hours initially. Telling the woman that she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy.

After reviewing the urinalysis reports of a pregnant patient, the nurse finds that the patient has preeclampsia. What did the nurse find in the patient's urinalysis report? a. Nitrites b. Ketones c. Proteins d. Leukocytes

c. Proteins Rationale Urinalysis of the patient during pregnancy helps to assess the patient's health. The presence of proteins in the urine indicates that the patient may have complications, such as preeclampsia. The presence of ketones in the urine sample indicates that the patient has improper nutrition. The presence of leukocytes and nitrates in the urine indicates that the patient has infection.

Which intervention will help prevent the risk of pulmonary edema in a pregnant patient with severe preeclampsia? a. Assess fetal heart rate (FHR) abnormalities regularly. b. Place the patient on bed rest in a darkened environment. c. Restrict total intravenous (IV) and oral fluids to 125 mL/hr. d. Ensure that magnesium sulfate is administered as prescribed.

c. Restrict total intravenous (IV) and oral fluids to 125 mL/hr. Rationale Pulmonary edema may be seen in patients with severe preeclampsia. Therefore the nurse needs to restrict total IV and oral fluids to 125 mL/hr. FHR monitoring helps assess any fetal complications. The patient is placed on bed rest in a darkened environment to prevent stress. Magnesium sulfate is administered to prevent eclamptic seizures.

The nurse has advised a pregnant patient to eat a diet rich in vitamin C and zinc. What would be the reason for the nurse to advise the patient to follow this diet? a. The patient is a long-time smoker. b. The patient has nausea and vomiting. c. The patient is taking iron supplements. d. The patient has a reduced metabolic rate.

c. The patient is taking iron supplements. Rationale Vitamin C helps in the absorption of iron; zinc absorption is reduced due to iron. Therefore any patient who is prescribed iron supplements should be advised to eat a diet rich in vitamin C and zinc. The patient who is a smoker needs a diet rich in vitamin C, but a diet rich in zinc is of no help to reduce the complications associated with smoking. Citrus fruits, which are rich in vitamin C, are helpful to prevent nausea and vomiting, but zinc-rich foods do not help control nausea. Zinc is a necessary source for various enzyme metabolic pathways, but not vitamin C. The patient with impaired metabolism need not be given vitamin C in the diet.

The GTPAL (gravidity, term, preterm, abortions, and living children) of a patient is 3-1-2-1-3. What does the nurse infer the patient has? a. Three pregnancies with one miscarriage, one preterm birth, and three living children b. Three pregnancies with two miscarriages, one preterm birth, and three living children c. Three pregnancies with one miscarriage, two preterm births, and three living children d. Three pregnancies with no miscarriages, two preterm births, and three living children

c. Three pregnancies with one miscarriage, two preterm births, and three living children Rationale The five-digit system GTPAL provides information on a woman's obstetric history. The GTPAL 3-1-2-1-3 indicates that the patient had three pregnancies, one term birth, two preterm births, one miscarriage, and three living children. If the patient has three pregnancies with one miscarriage, one preterm birth, and three living children, the GTPAL is denoted as 3-1-1-1-3. If the patient has three pregnancies with two miscarriages, one preterm birth, and three living children, the GTPAL is denoted as 3-1-1-2-3. If the patient has three children with no miscarriages, two preterm births, and three living children, the GTPAL is denoted as 3-1-2-0-3.

A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of what? a. Eclamptic seizure b. Rupture of the uterus c. Placenta previa d. Abruptio placentae

d. Abruptio placentae Rationale Women with hypertension are at increased risk for an abruption. Eclamptic seizure sare evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture presents as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa presents with bright red, painless vaginal bleeding. Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption).

Twenty-four hours after childbirth, a patient developed a high temperature of 100.4° F. Which monitoring action is most important for the nurse? a. Pulse rate b. Blood pressure c. Respiratory rate d. Assess for puerperal sepsis

d. Assess for puerperal sepsis Rationale Puerperal sepsis is a condition in which a woman's genital tract becomes infected due to low immunity caused by long labor, severe bleeding, or dehydration. Therefore the nurse should assess the patient for puerperal sepsis if the temperature of the woman after childbirth is raised to 100.4° F. Blood pressure is routinely assessed in postpartum patients to detect hemorrhage. A rapid pulse rate indicates the presence of hypovolemia as a result of hemorrhage. The respiratory rate is measured because hypoventilation can occur after a high subarachnoid block or epidural narcotic following a cesarean birth.

The nurse observes a patient had preeclampsia during the second trimester of her pregnancy. Which is the most likely reason for preeclampsia in this patient? a. Hypervitaminosis b. Severe hypotension c. Lower extremity edema d. Body mass index (BMI) of 34.2 kg/m2

d. Body mass index (BMI) of 34.2 kg/m2 Rationale A BMI of 34.2 kg/m2 indicates that the patient is obese. Obese patients are more likely to develop preeclampsia as compared with their counterparts who have normal weight. Hypervitaminosis, severe hypotension, and lower extremity edema are not associated with preeclampsia. Deficiency of vitamin B is associated with preeclampsia. Hypertension during pregnancy, which is also referred to as gestational hypertension, is associated with preeclampsia. Small amounts of lower-extremity edema are normal in pregnant patients.

While assessing a postpartum patient 24 hours after delivery, the nurse checks the lochia and finds that the patient is free of infection. Which observation related to the lochia led the nurse to make such a conclusion? a. Dark red with a foul odor b. Yellowish white with a fleshy odor c. Yellowish white with a foul odor d. Dark red with a fleshy odor

d. Dark red with a fleshy odor Rationale Lochia rubra is observed within 1 to 3 days. It is dark red and has a fleshy odor. If the lochia has a foul odor, it indicates that the patient has an infection. The lochia is yellowish white in color 10 days after delivery. Therefore the nurse would fi nd dark red lochia with a fleshy odor in a postpartum patient 24 hours after delivery.

A postpartum patient who had a cesarean section reports to the nurse a fever, loss of appetite, pelvic pain, and foul-smelling lochia. Upon assessment, the nurse finds that the patient has an increased pulse rate and uterine tenderness. The laboratory reports indicate significant leukocytosis. What clinical condition should the nurse suspect based on these findings? a. Cystocele b. Rectocele c. Hematoma d. Endometritis

d. Endometritis Rationale Endometritis is a common postpartum infection. It usually begins as a localized infection at the placental site and spreads to the entire endometrium. Fever, loss of appetite, pelvic pain, and foul-smelling lochia are symptoms of endometritis. An increased pulse rate and uterine tenderness are also common in this condition. Therefore the nurse can infer that the patient has endometritis. Cystocele is the protrusion of the bladder downward into the vagina. Rectocele is the herniation of the anterior rectal wall through the relaxed or ruptured vaginal fascia and rectovaginal septum. The symptoms reported by the patient are not indicative of these conditions. Because the nurse does not fi nd any collection of blood in the patient, the patient does not have hematoma.

The fasting plasma glucose levels are greater than 95 mg/dL in a patient with gestational diabetes mellitus. The patient is unwilling to take the prescribed insulin therapy. Which medication can be used in this case? a. Isotretinoin (Accutane) b. Enoxaparin (Lovenox) c. Terbutaline (Brethine) d. Glyburide (Micronase)

d. Glyburide (Micronase) Rationale If the patient is unwilling to take insulin therapy, oral hypoglycemic therapy can be used as an alternative. It involves the oral administration of glyburide (Micronase).Glyburide is preferred as minimal amounts of the medication cross the placenta to the fetus. Isotretinoin (Accutane) is prescribed for cystic acne and is not prescribed during pregnancy, because it is highly teratogenic. Enoxaparin (Lovenox) is used for anticoagulant therapy for recurrent venous thrombosis, pulmonary embolus, rheumatic heart disease, prosthetic valves, or cyanotic congenital heart defects in pregnancy. Terbutaline (Brethine) is a beta-adrenergic agent, which is used in the management of high blood pressure and heart pain.

A woman complains of excess vaginal bleeding after childbirth. The patient reports that the presence of excess blood is not continuous and denies any headaches or dizziness. What does the nurse suspect to be the cause of this excess bleeding? a. Oxytocin b. Hemorrhage c. Breastfeeding d. Increased activity

d. Increased activity Rationale Increased activity can cause excessive bleeding. Therefore postpartum women should not lift heavy weights and should go up and down stairs slowly. If the bleeding starts to get heavier, the patient should take a rest from being on her feet. Hemorrhage can occur after delivery when the uterus does not shrink completely. It can be caused by infection in the uterus or a residual placenta. However, infection or residual placenta is not associated with excess loss of blood; instead there will be a steady loss of blood. Hemorrhage conditions typically present with continuous loss of blood, leading to shock-type symptoms. There is no evidence that the patient is experiencing a hemorrhage situation. Breastfeeding immediately after delivery and in the early postpartum days increases the release of oxytocin. Oxytocin helps to decrease blood loss and reduces the risk for postpartum hemorrhage. Oxytocin strengthens and coordinates the uterine contractions (UCs), which help compress the blood vessels and promote hemostasis.

A pregnant patient after 20 weeks of gestation reports painless, bright red vaginal bleeding. Upon assessment, the nurse finds that the patient's vital signs are normal. Which condition does the nurse suspect in the patient? a. Eclampsia b. Preeclampsia c. Pyelonephritis d. Placenta previa

d. Placenta previa Rationale Placenta previa is indicated by painless, bright red vaginal bleeding during the second or third trimester of pregnancy. The patient's vital signs may be normal even after blood loss, because a pregnant patient can lose up to 40% of the blood volume without any signs of shock. Eclampsia is the onset of seizure activity in a patient with preeclampsia. Preeclampsia is indicated by hypertension and proteinuria after 20 weeks of gestation. Pyelonephritis is an infection caused by Escherichia coli organism, which is identified by fever, shaking chills, and aching in the lumbar area of the back.

A patient who is a gravida 5 para 4, 38 weeks gestation is being treated with magnesium sulfate for preeclampsia and is close to delivery. For what potential postpartum complication should the nurse prepare? a. Fetal seizure b. Pelvic hematoma c. Uterine subinvolution d. Postpartum hemorrhage

d. Postpartum hemorrhage Rationale A patient who is multiparous and receiving magnesium sulfate is at risk for a postpartum hemorrhage as a result of uterine atony. Based on the diagnosis of preeclampsia and use of magnesium sulfate, the patient is already at risk for maternal, not fetal, seizures. A pelvic hematoma is not associated with multiparity or preeclampsia. Uterine subinvolution is a delayed return of the enlarged uterus to normal size and function and results from placental fragments and pelvic infection.

With regard to medications, herbs, shots, and other substances normally encountered, the maternity nurse should be aware of what? a. No convincing evidence exists that secondhand smoke is potentially dangerous to the fetus. b. The greatest danger of drug-caused developmental deficits in the fetus is seen in the final trimester. c. Killed-virus vaccines (e.g., tetanus) should not be given during pregnancy, but live-virus vaccines (e.g., measles) are permissible. d. Prescription and over-the-counter (OTC) drugs that otherwise are harmless can be made hazardous by metabolic deficiencies of the fetus.

d. Prescription and over-the-counter (OTC) drugs that otherwise are harmless can be made hazardous by metabolic deficiencies of the fetus. Rationale Prescription and OTC drugs can be made hazardous by metabolic deficiencies of the fetus. This is especially true for new medications and combinations of drugs. The greatest danger of drug-caused developmental defects exists in the interval from fertilization through the first trimester, when a woman may not realize that she is pregnant. Live-virus vaccines should be part of postpartum care; killed-virus vaccines may be administered during pregnancy. Secondhand smoke is associated with fetal growth restriction and increases in infant mortality.

A patient is diagnosed with type 1 diabetes during pregnancy. The primary health care provider (PHP) finds that the off spring of the patient was born without any malformations. What is the possible reason for the absence of congenital anomaly in the off spring? a. The patient took vitamin supplements during pregnancy. b. The patient took calcium supplements during pregnancy. c. The patient maintained a stable blood pressure during pregnancy. d. The patient maintained an euglycemic condition during pregnancy.

d. The patient maintained an euglycemic condition during pregnancy. Rationale The rate of malformations is reduced if the patient with insulin-dependent diabetes maintains euglycemic (normal blood sugar level) during pregnancy. The euglycemic condition should be maintained until the 56th day of pregnancy, as it is the period of organ development of the fetus. Vitamin supplements are given to pregnant patients to maintain a healthy, nutritional diet. Calcium supplements are prescribed to pregnant patients to prevent problems such as osteoporosis in the fetus. Maintaining a stable blood pressure will prevent miscarriage during pregnancy.

A patient who had a cesarean birth is immobile in the immediate postoperative period. Which risk is increased in the patient as a result of the hypercoagulable state of the puerperal period? a. Thrombocytosis b. Thrombophlebitis c. Thrombocytopenia d. Thromboembolism

d. Thromboembolism Rationale Thromboembolism refers to the condition in which a blood vessel is blocked by a blood clot. As the postpartum period is characterized by a hypercoagulation state, the patient is at risk of thromboembolism. Thrombophlebitis is the inflammation of the vein and is not associated with hypercoagulation. Thrombocytopenia refers to the condition in which low levels of platelet are found in the blood. Thrombocytosis is a condition characterized by a significant increase in the number of platelets in the blood.

During a prenatal checkup, the patient who is 7 months pregnant reports that she is able to feel about two kicks in an hour. The nurse refers the patient for an ultrasound. What is the primary reason for this referral? a. To check fetal position b. To check gestational age c. To check for fetal anomalies d. To check for fetal well-being

d. To check for fetal well-being Rationale Fetal kick count is a simple method to determine the presence of complications related to fetal oxygenation and activity level. The fetal kick count during the third trimester of pregnancy is approximately 30 kicks an hour; a count lower than that is an indication of poor health of the fetus. Fetal anomalies may not affect the oxygenation levels of the fetus. The nurse already knows the gestational age of the fetus; therefore the nurse need not refer the woman for ultrasonography to fi nd the gestational age. Fetal position does not affect the activity level of the fetus.