Family Health Exam 2

Osteoarthritis

- Def: develops as wear and tear on the joints breaks down the cartilage in the joint, causing bone to rub one bone. treatment aims to reduce pain, improve function of the affected joint, and slow disease progression - Patho: as OA progresses, slow developing changes occur to the joints synovium, subchondral bone, and cartilage. joint no longer moves smoothly, causing mobility problems. involves weight bearing joints of the hips and knees, digits of hands and big toe, and cervical and lumbar spine - Cause 1. Idiopathic: no identifiable cause, but believed to be caused by mechanical and molecular factors. divided into localized or generalized, with localized affecting 1-2 joints and generalized affecting 3 or more joints 2. Secondary: caused by an underlying condition such as injury, congenital malformation, metabolic, endocrine, or neuropathic disease, or other medical cause - Risk Factors: old age, jobs requiring heavy lifting, obesity, certain medical conditions, diabetes, hypothyroid, gout, paget disease, joints from sports or accidents or repetitive injuries - Prevention: maintain ideal body weight and participate in regular moderate exercise program - Manifestations: pain and stiffness, tenderness to touch, swelling, crackling or grating of joint, and bone spurs - Diagnostics: x-ray, MRI, ultrasound, blood tests, joint fluid analysis - Surgery: purpose of surgery is to remove damage, relieve pain, and restore function of the joint. five types of surgeries 1. Arthroscopy and Joint Irrigation: small arthroscope consisting of a small fiberoptic light source, magnifying lens, and camera is inserted into the joint to visualized the joint structures. small surgical instruments might be inserted into the joint to remove or trim structures causing pain. combined with joint irrigation often, in which a fluid is injected into the joint to allow for visualization of the joint structure more easily and to help remove debris and infection in the joint 2. Joint Resurfacing: small amount of bone is removed at the articulating surface of the joint, and a metal replacement is fitted over the end of the bone 3. Osteotomy: entails surgical removal of a wedge of bone above or below the joint to realign the joint and shift the weight away from the damaged portion of the joint. to redistribute weight, the tibia and femur are reshaped. surgical staples or screws are inserted to stabilize the repositioned bones 4. Joint Fusion: arthrodesis, used to permanently fuse 2 or more bones together at a joint using pins, plates, screws, and rods 5. Arthroplasty: total joint replacement, the surgeon removes the damaged joint surfaces and replaces them with plastic, metal or ceramic prostheses. may be joined with cement, or contain porous surfaces that stimulate bone growth to hold the prothesis in place - Meds: OTC medications, analgesics, topical analgesic creams, rubs, and sprays. cortisone injections - Affects Who?: children and adolescents can develop juvenile OA, secondary OA related to a congenital abnormality, genetic condition, or joint injury. occurs only in the 1 or 2 joints affected by the abnormality or injury. pregnant woman due to increased weight, have increased pain related to OA. older adults should use narcotics over NSAIDs - Nursing Care: reduce pain, maintain mobility and function, and help patients learn how to use assistive devices. if severe they may need pre and and postop care. encourage weight loss programs for obese. promote balanced nutrition

DVT

- Def: blood clot that forms along the intimal lining of a large vein, usually in a leg - Cause: venous thrombi occur at sites where the vein is normal, but blood flow is low. arterial thrombi occur at sites of arterial plaque rupture. DVT common complication of hospitalization, surgery, and immobilization. other factors include venous injury, cancer, pregnancy, oral contraceptive or hormone replacement use, clotting disorders, obesity, and personal or family history of DVT - Affects Who?: all ages. infants and children can increase risks by prematurity and sepsis newborns. risks for older infants and children include congenital heart disease, cardiac catheterization, and nephrotic syndrome. DVT in adolescents and young adults risks includes woman using contraceptives containing estrogen and progestin (combined hormonal). pregnant women risks include inherited clotting disorders and pregnancy related changes to the body. blood volume and pressure in the leg veins and pelvis are also increased during pregnancy. hormonal changes increase the stress on blood vessels and may increase clotting factors in the blood for pregnant women. more likely in the left leg for pregnant women. heparin preferred for pregnant woman, because warfarin can cross the placenta and have teratogenic effects on the fetus. risks for older adults include age and cancer and cancer therapy

Fractures

- Def: break in the continuity of a bone. common in patients who experienced trauma and in older adults. vary in type, location, and severity - Patho: classified according to the break pattern of the bone - Cause: strength of the force acting against the bone, and the strength of the gone contribute to the development of a fracture. when the force acting on the bone is greater than the bone strength, the bone will fracture. strength of the bone is related to the nutritional status and presence of pathologic conditions such as osteoporosis, bone cancer, or paget disease - Healing: three phases including inflammatory, reparative, and remodeling 1. Inflammatory: damage to the bone, blood vessels, and surrounding tissues cause bleeding and formation of a hematoma around the injury. inflammatory cells, macrophages and neutrophils, enter the wound and degrade debris and bacteria in the area. phase lasts until osteoblasts and endothelial cells begin to proliferate at the fracture site, few days 2. Reparative: fibroblasts, osteoblasts, and chondroblasts begin to secrete collagen to form fibrocartilage, which develops into a soft callus that joins the fractured bone. endothelial cells begin to form blood vessels in the damaged area. once the soft callus is formed, it is replaced by woven bone through endochondral ossification, which forms a hard callus 3. Remodeling: woven bone is replaced by highly organized lamellar bone which is stronger and more compact, with better blood circulation compared to woven bone - Risk Factors: age, presence of bone disease, and poor nutrition - Manifestations: pain due to tissue trauma and a visible fracture on an x-ray. others can include swelling from inflammation, and numbness due to nerve damage. internal or external loss of blood may result in hypovolemic shock or ecchymosis. if the fractured pieces of bone grate against each other, crepitus may be heard - Complications 1. Compartment Syndrome: when edema and swelling cause increased pressure in a muscle compartment, leading to decreased blood flow and potential muscle and nerve damage. if ischemia to the compartment continues for a long time, the muscles and nerves may die, and limb may need to be amputated. symptoms include severe pain and tenderness, swelling, paresthesia, pallor, numbness or paralysis, and decreased or absent pulse and poikilothermia (normalization to room temperature). common in lower leg and forearm. its an emergency, remove the cast. to prevent compartment syndrome elevate and ice to reduce swelling and delaying casting until swelling is gone 2. DVT: refer to DVT notes 3. Fat Emboli: occurs in conjunction with closed long bone or pelvic fractures. fat emboli released from the bone barrow enters the bloodstream, and becomes trapped in the pulmonary and dermal capillaries. patients releasing large amounts of fat, can experience a fat embolism. respiratory consequences. neurologic symptoms include confusion, restlessness, seizures or coma. transient petechial rash covers the upper anterior trunk, arms, and neck and the buccal mucosa and conjunctiva. other symptoms include Purtscher Retinopathy (sudden loss of vision) and mild fever. treatment includes oxygen administration 4. Infection: patients with greater soft tissue damage or with a compromised immune system are at higher risk. signs include warmth, redness, pain, swelling, stiffness, fever, chills, and purulent drainage. treatment includes antibiotics and hygiene care - ER Care: immobilize the fracture and prevent infection. nurse should apply splints above and below the joint to reduce mobility and prevent further damage if care is outside a medical facility. if the patient's bleeding, nurse should apply a pressure dressing, and sterile dressings should be applied to all open wounds. once stabilized, nurse should assess the extremities for pulses, movement, and sensation. ice packs may be used for swelling. patients may also be treated for shock - Diagnostics: x-ray, patient history, physical assessment, other imaging studies, blood tests - Surgery: two types include external fixation and internal fixation 1. External fixation: metal pins and screws are placed into the bone above and below the fracture, then attached to a metal bar outside the skin. nurse monitors for infection and neurovascular function 2. Internal Fixation: when the bone is placed with nails, screws, pins, wires, plates, or rods into the bone to hold it in place. plates are attached on the outer surface of the bone, whereas rods may be inserted through the marrow space in the center of the bone - Meds: analgesics for pain. if severe, opioids or patient-controlled analgesics. anticoagulants to prevent or treat DVT - Casts and Splints 1. Cast: rigid device used to immobilized, support, and protect fractured bones and surrounding soft tissue. applied to a stable fracture after it has been reduced. made of plaster or fiberglass. fiberglass is lighter, more x-ray compatible. plaster fits better. nurse care includes performing neurovascular assessments, palpating for hot spots, report drainage, assess for compartment syndrome, and educate about cast care 2. Splint: provides less support than a cast, but easily adjusted for swelling and prevents compartment syndrome. made with velcro straps. used to stabilize fresh injuries before swelling has subsided - Traction: use of weights, ropes, and pulleys to apply force to a fractured bone to maintain proper alignment of the bone for healing. helps stretch muscles that have contracted or are producing muscle spasms. two types include skin traction and skeletal traction 1. Skin Traction: equipment such as splints, bandages, and boots are placed on the injured limp, and a force is applied to soft tissues such as skin, muscles, and tendons through the use of a weight and pulley system. skin traction is used to control muscle spasms, to maintain alignment of a fracture before or after internal fixation, or provide traction of skeletal pins become infected and must be removed 2. Skeletal Traction: used when greater force needs to be applied to the fracture or when skin traction is contraindicated. pins, wires, or screws are surgically implanted into the bone under sterile conditions under anesthesia - Affects Who?: all ages. infants will have inconsolable crying, crying when area around broken bone is touched, limited movement of an extremity, swelling of an extremity, or deformity of an area or extremity. risks for infants include long bone fractures including cesarean birth, breech birth, and low birth weight. fractures in toddlers has nursemaid's elbow, occurs when a caregiver pulls a child by the hand with a quick motion. symptoms include holding the arm stiffly and not wanting to use it. treatment is reduction of the joint. fractures in children include long bone fractures from sports and play. spiral also common in children. adolescent fractures come from athletes and poor nutrition. older adults occurs due to menopause and osteoporosis - Nursing Care: pain management, patient teaching, assessment for complications, and emotional support. maintain proper alignment. promote mobility, monitor neurovascular status, and prevent infection

Hip Fractures

- Def: break in the neck, head, or trochanter region of the upper femur. often result in long-term functional impairment in older adults - Patho 1. Intracapsular: occur at the head or neck of the femur within the capsule of the hip joint. 2. Extracapsular: divided into intertrochanteric or subtrochanteric. occur within the trochanter region, between the neck and diaphysis of the femur. intertrochanteric takes place between the neck and lesser or greater trochanter. subtrochanteric occurs below the lesser trochanter - Cause: result of trauma. older adults is falling. motor vehicle or bike crashes common - Risk Factors: old age and osteoporosis. other factors include chronic medical conditions that cause fragile bones like endocrine disorders, intestinal disorders, or cancer. nutritional problems. some medications that weaken bone or cause dizziness - Prevention: preventing falls - Manifestations: severe pain in the hip, upper thigh, groin, or lower back. stiffness and bruising and swelling in hip area - Complications: result from major loss of mobility and include DVT, pressure injuries, UTIs, pneumonia, and muscle atrophy. other complications include postoperative infection, mental deterioration, avascular necrosis, and nonunion or malunion of the bone - Diagnostics: based on physical exam and imaging tests. CT scans and MRIs - Surgery: take place ASAP after fracture. type of surgery depends on condition and location, and severity of fracture. hip replacement is the best option for patients with previous joint damage from arthritis. complications include dislocation of the prosthesis, infection, and delayed healing 1. Intracapsular: using individual screws that slides within the barrel of a plate. if fracture displaced, ORIF surgery conducted to realign fracture 2. Extracapsular: use of compression hip screw into the marrow canal of the bone through an opening made in the greater trochanter. nail secured in place by screws at the top and bottom of the nail - Meds: pain medications, antibiotics, anticoagulants, anti-inflammatory agents - Affects Who?: children and adolescents occurs during car crashes. may involve epiphyseal plate, lies between head and neck of femur. treatment includes casting or repair surgery. young adults includes maintaining natural hip anatomy and mechanism for treatment. older adults might not be capable of returning to independent lifestyle after a hip fracture. move the patient early - Nursing Care: manage pain, promote mobility, and prevent complications such as infection and DVT. also, referring patient to a PT or OT, home healthcare, or assistive device supply stores. provide emotional support and encouragement. assess fall risks for patients. plan effective pre and postoperative care. promote psychosocial wellness. provide thorough discharge instructions. administer pain meds. turn patient every 2 hours. apply compression stockings. conduct passive ROM. assess neurovascular status. clean abrasions with sterile solution. provide teaching. call close friend oy family for visitation as tolerated

Infertility: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: inability to conceive despite engaging in unprotected sexual intercourse for a prolonged period of time or at least 12 months. factors include decreased sperm production, endometriosis, ovulation disorders, and tubal occlusions. partners can experience stress - Risk Factors 1. Female: age greater than 35, more than 1 year of coitus w/ out contraceptives, atypical secondary sexual characteristic (abnormal body fat or hair growth), hormonal and adrenal gland disorders, pelvic and abdominal surgery, past spontaneous abortions, abnormal uterine contours, history of disorders that can contribute to scar tissue, sexual history, exposed to hazardous teratogenic materials in home or work, overweight, underweight, anorexia, alcohol, tobacco, heroin, methadone 2. Male: mumps especially after adolescence, endocrine disorders, genetic disorders, anomalies in reproductive system, history of STIs, sexual history, alcohol, tobacco, heroin, methadone, exposed to hazardous teratogenic materials in home or work, exposed to high temperatures to scrotum - Meds: ovarian stimulation-medications are prescribed to stimulate the ovary to produce follicles including clomiphene citrate and letrozole. other medications used to support ovulation include metformin. appropriate antimicrobial medications for pre-existing infections - Diagnostics 1. Female: a) Pelvic Examination: assesses for uterine or vaginal anomalies b) Hormone Analysis: evaluates hypothalamic-pituitary-ovarian axis to include blood prolactin, FSH, LH, estradiol, progesterone, and thyroid hormone levels c) Postcoital Test: evaluates coital technique and mucus secretions d) Ultrasonography: transvaginal or abdominal ultrasound procedure performed to visualize reproductive organs e) Hysterosalpingography: outpatient radiological procedure in which dye is used to assess the patency of the fallopian tubes. assess for history of allergies to iodine and seafood prior to beginning the procedure f) Hysteroscopy: radiographic procedure in which the uterus us examined for defect, distortion, or scar tissue that can impair successful impregnation g) Laparoscopy: procedure in which gas insufflation under general anesthesia is used to observe internal organs 1. Male: a) Semen Analysis: test is the first in an infertility workup because its less expensive and less invasive. can be repeated if needed b) Ultrasonography: ultrasound procedure performed to visualize testes and abnormalities in the scrotum. transrectal ultrasound is performed to assess the ejaculatory ducts, seminal vesicles, and vas deferens - Nursing Care: encourage couples to express and discuss their feelings and recognize infertility as a major life stressor. assist the couple to consider options, and provide education to assist in decision making. explain role of genetic counselor, reproductive specialist, geneticist, and pharmacist in providing psychosocial and medical care. monitor for adverse effects associated with medications to treat infertility. advise that the use of medications to treat female infertility can increase the risk of multiple births by more than 25%. provide information regarding assisted reproductive therapies. make referrals to grief and infertility support groups 1. Genetic Counseling: assist in the construction of family medical histories of several generations. provide emotional support. client responses vary. make referrals to support groups and provide follow-up - Patient Education: provide and clarify information pertaining to the risk of or the occurrence of genetic disorders within a family preceding, during, and following a genetic counseling session

Infant Complications: Newborn Seizures: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: manifestation of a serious underlying disease. common cause is hypoxic-ischemic encephalopathy, or cellular damage to due to a hypoxic perinatal episode. seizures exhibit oral movements, oculomotor deviations, and apnea during seizure activity - Risk Factors 1. Metabolic: hyperglycemia, hypoglycemia, PKU, hypocalcemia, hypomagnesemia 2. Toxic: uremia, kernicterus 3. Prenatal Infection: toxoplasmosis, syphilis, cytomegalovirus, herpes, hepatitis 4. Postnatal Infection: bacterial or viral meningitis, sepsis, brain abscess 5. Trauma During Birth: hypoxia, intracranial hemorrhage, subarachnoid or subdural hemorrhage, intraventricular hemorrhage 6. Miscellaneous: degenerative disease, narcotic withdrawal, stroke, benign familial newborn seizures - Expected Findings: based on type of seizure 1. Clonic: slow rhythmic jerking movements. 1-3 movements per second a) Focal: face, or upper or lower extremities on 1 side of the body. can involve neck or trunk. newborn is conscious b) Multifocal: migrate randomly from 1 part of body to another. movements can start at different times 2. Tonic: extension, stiffening movements a) Generalized: extension of all limbs, upper limbs maintain stiffly flexed position b) Focal: sustained posturing of 1 limb. asymmetric posturing of trunk or neck 3. Subtle: most common in premature newborns. horizontal eye deviation, repetitive blinking, fluttering of eyelids, starting, sucking or other oral/buccal/tongue movements, arm movements resembling swimming or rowing, leg movements resembling pedaling, apnea 4. Myoclonic: rapid jerks that involve flexor or muscle groups a) Focal: upper extremity flexor muscles. no changes in EEG b) Multifocal: asynchronous twitching of several parts of the body. no changes in EEG c) Generalized: bilateral jerks of upper and lower limbs. associated with EEG discharges - Labs: blood glucose levels, blood electrolytes, CSF analyzed for blood, protein, glucose, and cultured - Diagnostics: electroencephalogram (EEG), which is a continuous video EEG. CT scan. ultrasound. echoencephalography - Nursing Care: early recognition of seizure activity. monitor vital signs. continue routine newborn assessments. administer anti-seizure medications as prescribed. administer medications as prescribed for underlying cause. respiratory support if hypoxia present. encourage infant-parent bonding - Patient Education: be aware of newborns status and treatment plan. understand home medications and safe administration

Infant Complications: Substance Exposed Infants: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: maternal substance use during pregnancy consists of any use of alcohol or drugs. intrauterine drug exposure can cause anomalies, neurobehavioral changes, and evidence of withdrawal in the neonate. changes depend on drug or combination of drugs used, dosage, route, metabolism and excretion by mom and fetus, timing, and length of exposure. substance withdrawal in the newborn occurs when the mother uses drugs that have addictive properties during pregnancy including illicit substances, heroin, opiates, alcohol, tobacco, methadone, and prescription medications 1. Fetal Alcohol Spectrum Disorder (FASD): results from exposure of the fetus to the chronic or periodic intake of alcohol during pregnancy. specifically to children who exhibit a triad of characteristic facial features, growth restriction, and neurodevelopmental deficits and a confirmed history of maternal alcohol consumption. FAS newborns are at risk for congenital physical defects and long term complications including feeding problems, CNS dysfunction, behavioral difficulties, language abnormalities, delayed growth and development, and poor maternal-newborn bonding - Risk Factors: maternal use of substance prior to knowing she is pregnant. maternal substance use and addiction - Expected Findings: monitor neonate for abstinence syndrome (withdrawal) and increased wakefulness using the neonatal abstinence scoring system that assess for and scores the following 1. CNS: increased wakefulness, high pitched, shrill cry, incessant crying, irritability, tremors, hyperactive with increased moro reflex, increased deep-tendon reflexes, increased muscle tone, abrasions and/or excoriations on the face and knees, and convulsions 2. Metabolic, Vasomotor, and Respiratory: nasal congestion with flaring, frequent yawning, skin mottling, tachypnea greater than 60/min., sweating, and temperature greater than 37.2C (99F) or temperature greater than 38.3C (101F) 3. GI: poor feeding, regurgitation (vomiting), diarrhea, and excessive, uncoordinated, and constant sucking - Heroin Withdrawal: neonatal abstinence syndrome including low birth weight and SGA, decreased moro reflexes, jittery, hyperactive, and hypothermia or hyperthermia. infant has shrill persistent cry - Methadone Withdrawal: neonatal abstinence syndrome including increased incidence of seizures, sleep pattern disturbances, higher birth weights, and higher risk of SIDS - Cocaine Withdrawal: infant can appear normal or exhibit neurologic problems at birth. newborn can exhibit neurobehavioral depression or excitability. high pitched cry, abnormal sleep patterns, excessive sucking, hypertonicity, tremors, irritability, inability to console, and poor tolerance to changes in routine - Marijuana Exposure: decrease in newborn birth weight and length, fetal growth - Methamphetamine Withdrawal: small head circumference, SGA, agitation, vomit, rapid respiratory rate, bradycardia or tachycardia, jitteriness, sleep pattern disturbances, emotional disturbances, and delayed growth and development - Fetal Alcohol Syndrome: craniofacial features include microcephaly, small eyes with epicanthal folds, and short palpebral fissures, thin upper lip, flat midface and indistinct philtrum. lack of stranger anxiety and appropriate judgement skills. many vital organ anomalies. prenatal and postnatal growth restriction. developmental delays and neurologic abnormalities. IQ deficit. diminished fine motor skills. ADD - Tobacco Exposure: prematurity, low birth weight, increased risk for SIDS, increased risk for bronchitis, pneumonia, developmental delays - Labs: CBC, blood glucose, calcium, electrolytes, drug screen of urine or meconium to reveal the agent used by the mother, hair analysis - Meds 1. Phenobarbital - Classification: anticonvulsant - Intended Effect: decrease CNS irritability and control seizures for newborns who have alcohol or opioid withdrawal - Nursing Actions: assess IV site frequently. check for any medication incompatibilities. decrease environmental stimuli. cluster cares to minimize stimulation. swaddle the newborn to reduce self-stimulation and protect skin from abrasions. monitor and maintain fluids and electrolytes. administer frequent, small feedings of high calorie formula, can require gavage feedings. elevate the newborn's head during and following feedings, and burp newborn to reduce vomiting and aspiration. try various nipples to compensate for a poor suck reflex. have suction available to reduce the risk for aspiration. for newborns who are withdrawing from cocaine, avoid eye contact and use vertical rocking and a pacifier. prevent infection. initiate a consult with child protective services. consult lactation services to evaluate whether breastfeeding is desired or contraindicated to avoid passing narcotics in breast milk. methadone is not contraindicated during breastfeeding. morphine and clonidine may be administered to decrease CNS irritability - Diagnostics: chest X-Ray for FAS to rule out congenital heart defects - Nursing Care: perform ongoing assessment of newborn using neonatal abstinence scoring system assessment, as prescribed. elicit and assess reflexes. monitor newborns ability to feed and digest intake. offer small frequent feedings. swaddle newborn with legs flexed. offer non-nutritive sucking. monitor newborns fluids and electrolytes with skin turgor, mucous membranes, fontanels, daily weights, and I&O. reduce environmental stimuli (decrease lights, lower noise level) - Patient Education: refer mother to a drug and/or treatment center. discuss SIDS importance and prevention activities due to increased rate in newborns of mothers who used methadone

Newborn Complications: Large for Gestational Age (LGA)/Macrosomic Newborn: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: occurs in neonates who weigh above 90th percentile or more than 4,000g (8.8lbs). can be preterm, postmature, or full term. at risk for birth injuries. uncontrolled hyperglycemia during pregnancy can lead to congenital defects with most common being congenital heart defects, tracheoesophageal fistula (TEF), and CNS anomalies - Risk Factors: newborns who are postmature, maternal diabetes mellitus during pregnancy, genetic factors, maternal obesity, and multiparity - Expected Findings: weight above 90th percentile (4,000g), large head, plump and full-faced (cushingoid appearance) from increased subcutaneous fat. manifestations of hypoxia including tachypnea, retractions, cyanosis, nasal flaring, and grunting. birth trauma (fractures, shoulder dystocia, intracranial hemorrhage, CNS injury). sluggishness, hypotonic muscles, and hypoactivity. tremors from hypocalcemia. hypoglycemia. respiratory distress from immature lungs or meconium aspiration - Labs: blood glucose levels to monitor closely for hypoglycemia. ABGs can be prescribed due to chronic hypoxia in utero secondary to placental insufficiency. CBC shows polycythemia (Hct greater than 65%) from in utero hypoxia. hyperbilirubinemia resulting from polycythemia as excessive RBCs break down after birth. hypocalcemia can result in response to a long and difficult birth - Diagnostics: chest X-Ray to rule out meconium aspiration syndrome - Nursing Care 1. Prior to Delivery: prepare client for possibly vacuum assisted or cesarean birth. prepare to place client in McRoberts position (lithotomy position with legs flexed to chest to maximize pelvic outlet). prepare to apply suprapubic pressure to aid in the delivery of the anterior shoulder, which is located inferior to the maternal symphysis pubis. assess newborn for birth trauma (broken clavicle, Erb-Duchenne paralysis) 2. For a Newborn Whose LGA Following Delivery: obtain early and frequent heel sticks (blood glucose testing). initiate early feedings or IV therapy to maintain glucose levels within the expected reference range. provide thermoregulation with an isolette. identify and treat any birth injuries

Infertility: Defintions? Male and Female Risks and Causes? Testing?

- Def: inability to conceive despite engaging in unprotected sexual intercourse for a prolonged period of time or at least 12 months - Male Risks/Causes: mumps especially before adolescence, endocrine disorder, genetic disorder, anomalies in reproductive system, intercourse frequency, history of STIs, alcohol, tobacco, heroin, methadone, exposed to hazardous teratogenic materials - Female Risks/Causes: age 35+, 1+ year of unprotected sex, atypical secondary sexual characteristics, pelvic and abdominal procedures, past episodes of spontaneous abortions, abnormal uterine contours of history of disorders that contribute to formation of scar tissue blocking the ovum or sperm, intercourse frequency, number of partners, history of STIs, exposed to hazardous teratogenic materials, overweight, underweight, anorexia, alcohol, tobacco, heroin, methadone - Testing: pelvic exam, hormone analysis, post-coital test, ultrasonography, hysterosalpingography, hysteroscopy, laparoscopy, semen analysis

Osteoporosis

- Def: porous bones, a metabolic bone disorder characterized by loss of bone mass, increased bone fragility, and increased risk of fractures. reduced bone mass caused by imbalance in the processes that influence bone growth and maintenance - Patho: involve an imbalance in activity of osteoblasts that form new bone and osteoclasts that resorb bone. peak bone mass is at age of 35, formation occurs more rapidly than resorption. loss is accelerated if the diet is deficient in vitamin D and calcium. osteoporosis effects the diaphysis (shaft of the bone) and the metaphysis (portion of the bone between the diaphysis and epiphysis). diameter of the bone increases, thinning the outer supporting cortex. as osteoporosis progresses, trabeculae are lost from cancellous bone (spongy tissue of bone), and the outer cortex thins to the point where even minimal stress will fracture the bone - Cause 1. Primary: either type 1, associated with menopause, or type 2, associated with decreasing bone formation that accompanies the aging process. type 1 is linked to estrogen deficiency resulting in increased calcium reabsorption from bone as the lack of estrogen renders the body more sensitive to PTH. type 2 results as the kidneys lose ability to process vitamin D, causing decreased calcium absorption, which in turn increases sensitivity to PTH and bone reabsorption 2. Secondary: occurs as the result of a disease process or a deficiency or as an effect of a drug - Risk Factors: depends on bone mass achieved between ages 25-35 and after, how much bone mass is lost. certain diseases, lifestyle habits, and ethnic backgrounds increase risk. unmodifiable risk factors include being female, think, and small frame. others include gender, family history, age, ethnicity, other chronic diseases, and current low bone mass - Prevention: poor nutrition, body weight, substance abuse, sedentary lifestyle - Manifestations: loss of height, progressive curvature of the spine, low back pain, and fractures of the forearm, spine, or hip. bone loss occurs without symptoms. dorsal kyphosis and cervical lordosis develop - Complications: - Diagnostics: dual-energy x-ray absorptiometry (DEXA), measures bone density in the lumbar spine or hip. bone density tests repeated using T-scores. T-score between -1.0 and -2.5 indicates low bone density, or osteopenia. T-score of -2.5 or below indicates osteoporosis. ultrasound measures bone density. lab tests including alkaline phosphatase, may be elevated following fracture, and serum bone G1a protein (osteocalcin), can be used as a marker of osteoclastic activity and is an indicatory of bone turnover - Surgery: - Meds: pharmacotherapy such as hormonal agents, bisphosphonates, and selective estrogen receptor modulators. calcium gluconate and other calcium compounds used to treat and prevent osteoporosis - Affects Who?: children associated with spinal bifida or cerebral palsy causing limited pressure on the bones. as a result, bones in effected extremities and the spine have lower mass. other factors in children include children immobilized as a result of casting or bracing for treatment of a disorder or injury. adolescent athletes at risk to due to amenorrhea and low bone mass and disordered eating. pregnant women causes bone loss but is restored after birth. older adults experience menopause and decreasing estrogen, accelerating bone loss in women - Nursing Care: planning and implementing interventions to prevent the disease, manifestations, and resulting injuries. health promotion activities to prevent or slow osteoporosis focus on calcium intake, exercise, and health-related behaviors. relieve acute pain. manage nutrition

Contraception: Natural Family Planning: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho 1. Abstinence: abstaining from having sexual intercourse eliminates the possibility of sperm entering the vagina 2. Coitus Interruptus (Withdrawal): withdrawal of penis from vagina prior to ejaculation 3. Calendar Rhythm Method: determining fertile days by tracking the menstrual cycle to estimate the time of ovulation, which occurs about 14 dats before the onset of the next cycle. used to facilitate conception or be used as a natural contraceptive. if trying to conceive, client must have intercourse during the fertile period. if trying to prevent, client would abstain from intercourse during fertile period 4. Standard Days Method (Cycle Beads): uses standard number of fertile days for each cycle. color coded and located on a stringed necklace 5. Basal Body Temperature (BBT): temperature of the body at rest. prior to ovulation, the temperature drops slightly and rises during ovulation. identifying the time of ovulation is a symptom-based method that can be used to facilitate or avoid conception 6. Cervical Mucus Ovulation Detection Method: symptom based method in which the client analyzes cervical mucous to determine ovulation. following ovulation, the cervical mucus becomes thin and flexible under the influence of estrogen and progesterone to allow for sperm viability and motility. ability for mucus to stretch between the fingers is greatest during ovulation. this is the spinnbarkeit sign. fertile period begins when he cervical mucus is thin, slippery, and lasts until 4 days after the last day of cervical mucus having this appearance 7. 2-Day Method: symptom based method that involves checking for vaginal secretions daily, with no analysis of secretions. after 2 days without the presence of secretions, the fertile period has passed - Risk Factors 1. Abstinence: if complete abstinence is maintained, there's no risks 2. Coitus Interruptus (Withdrawal): possible pregnancy 3. Calendar Rhythm Method: various factors can affect and change the time of ovulation and cause unpredictable menstrual cycles. possible pregnancy due to miscalculating fertile period or nor abstaining from intercourse during fertile days 4. Standard Days Method (Cycle Beads): do not use if menstrual cycles are short or long. possible pregnancy. less effective with hormonal contraceptives, IUD, breastfeeding 5. Basal Body Temperature (BBT): possible pregnancy 6. Cervical Mucus Ovulation Detection Method: assessment of cervical mucus characteristics can be inaccurate if mucus is mixed with semen, blood, contraceptive foams, or discharge from infections. sexual arousal or intercourse, or use of deodorants, douches, medication, or lubricants can alter cervical mucus appearance and affect accuracy. possible pregnancy 7. 2-Day Method: possible pregnancy - Patient Education 1. Abstinence: refrain from sexual intercourse. discuss permissible sexual activities with partners 2. Coitus Interruptus (Withdrawal): be aware that pre-ejaculatory fluid can leak from the penis prior to ejaculation. it can contain sperm, which can fertilize an ovum 3. Calendar Rhythm Method: maintain a diary. accurately record the number of days in each menstrual cycle, counting from the first day of menses for a period of at least six menstrual cycles. start of the fertile period is figured by subtracting 18 days from the number of days in the shortest menstrual cycle. end of the fertile period is established by subtracting 11 days from the number of days of the longest cycle 4. Standard Days Method (Cycle Beads): start the first day of the menstrual cycle. use the rubber ring to advance one bead per day. red bead is the first bead and marks the first day of the menstrual cycle. brown beads are non-fertile days. white beads are fertile days 5. Basal Body Temperature (BBT): take temperature immediately after waking up and before getting out of bed. if working at night, take temperature after awakening from the longest sleep cycle. use a thermometer that records temperature to the tenths. record the temperatures on a specialized graph. first day the temperature drops or elevates is considered the first fertile day. fertility extends through 3 consecutive days of temperature elevations. use this method with the calendar method to increase effectiveness 6. Cervical Mucus Ovulation Detection Method: use this method with the calendar method to increase effectiveness. engage in good hand hygiene prior to and after assessment. begin examining mucus from the last day of the menstrual cycle. mucus is obtained from the vaginal introitus. use fingers or tissue paper to examine the cervical mucus. stretchy consistency of egg whites is a good example of how cervical mucus appears during ovulation. do not a douche prior to assessment 7. 2-Day Method: if vaginal secretions are present 2 days in a row, avoid unprotected intercourse to prevent pregnancy

Contraception: Hormonal: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho 1. Combined Oral Contraceptives (COCs): contains estrogen and progestin, which acts by suppressing ovulation, thickening the cervical mucus to block semen, and altering the uterine decidua to prevent implantation 2. Progestin-Only Pills (minipill): oral progestins that provide the same action as combined oral contraceptives, which decreases the chance of fertilization and implantation 3. Emergency Oral Contraceptive: morning-after pill that prevents fertilization from taking place by inhibiting ovulation and the transport of sperm 4. Transdermal Contraceptive Patch: contains estrogen and progesterone or progestin, which is delivered at continuous levels through the skin into subcutaneous tissue. inhibits ovulation by thickening cervical mucus 5. Injectable Progestins: medroxyprogesterone is an IM or subcutaneous injection given to a female client every 11-13 weeks. it inhibits ovulation and thickens cervical mucus 6. Contraceptive Vaginal Ring: flexible silicone ring that contains etonogestrel and ethinyl estradiol, which are delivered at continuous levels vaginally 7. Implantable Progestin: small, thin rods consisting of progestin that are implanted by the provider under the skin of the inner upper aspect of the arm. prevents pregnancy by suppressing the ovulatory cycle and thickening cervical mucus 8. Intrauterine Device (IUD): chemically active T-shaped device that is inserted through the cervix and placed in the uterus by the provider. releases a chemical substance that damages sperm in transit to the uterine tubes and prevents fertilization - Risk Factors 1. Combined Oral Contraceptives (COCs): clients with a history of thromboembolic disorders, stroke, heart attack, coronary artery disease, gallbladder disease, cirrhosis or liver tumor, headache with focal neurologic findings, uncontrolled hypertension, diabetes mellitus with vascular involvement, breast or estrogen related cancers, pregnancy, lactating, less than 6 weeks postpartum, or smoking are advised not to take oral contraceptive medications. oral contraceptive effectiveness decreases when taking medications that affect liver enzymes (anticonvulsants, antifungals, some antibiotics) 2. Progestin-Only Pills (minipill): oral contraceptive effectiveness decreases when taking medications that affect liver enzymes (anticonvulsants, some antibiotics). contraindications include bariatric surgery, lupus, severe cirrhosis, liver tumors, and current or past breast cancer 3. Emergency Oral Contraceptive: method is contraindicated if a client is pregnant or has undiagnosed abnormal vaginal bleeding 4. Transdermal Contraceptive Patch: same as those of oral contraceptives. avoid applying patch to skin rashes or lesions. less effective in clients greater than 198 lbs 5. Injectable Progestins: avoid massaging injection site following administration to avoid accelerating medication absorption, which will shorten the duration of its effectiveness. contraindications include breast cancer, evidence of current cardiovascular disease, abnormal liver function, liver tumors, and unexplained vaginal bleeding. this method can impair glucose tolerance for clients with diabetes mellitus, and increase diabetes risk for clients who don't have diabetes mellitus 6. Contraceptive Vaginal Ring: blood clots, hypertension, stroke, heart attack. vaginal irritation/discomfort, increased vaginal secretions 7. Implantable Progestin: method has increased risk of ectopic pregnancy if pregnancy occurs. contraindications include unexplained vaginal bleeding. infection can occur at site 8. Intrauterine Device (IUD): best used by clients in a monogamous relationship due to risk of STIs. can cause irregular menstrual bleeding. risk of bacterial vaginosis, PID, uterine perforation, or uterine expulsion. must be removed in the event of pregnancy. contraindications include acute pelvic infection, abnormal uterine bleeding, and severe uterine distortion - Patient Education 1. Combined Oral Contraceptives (COCs): medication requires a prescription and follow up appointments with the provider. routine pap smears and breast exams might be needed. medication requires consistent and proper use to be effective. regular menstrual cycles should occur during the last 7 days. observe for and report manifestations of complications (chest pain, shortness of breath, leg pain, headache, vision changes, hypertension). if missing a dose, if 1 pill is missed, take one ASAP. if 2-3 pills are missed, follow the manufacturers instructions. instruct the client on the use of alternative forms of contraception or abstinence to prevent pregnancy until regular dosing is resumed. if nausea occurs, take at bedtime 2. Progestin-Only Pills (minipill): take the pill at the same time daily to ensure effectiveness secondary to a low dose of progestin. don't miss a pill. might need another form of birth control during the first month of use to prevent pregnancy 3. Emergency Oral Contraceptive: pill is taken within 72 hours after unprotected coitus. provider will recommend OTC antiemetic to be taken 1 hour prior to each dose to counteract the adverse effects of nausea that can occur with high doses of estrogen and progestin. be evaluated for pregnancy if menstruation does not begin within 21 days. consider counseling about contraception and modification of sexual behaviors that are risky. copper IUD can be used up to 5 days following unprotected intercourse as an emergency contraceptive, but a prescription is required 4. Transdermal Contraceptive Patch: apply patch to dry skin overlying subcutaneous tissue of the buttock, abdomen, upper arm, or torso excluding breast area. requires patch replacement once a week. apply the patch the same day of the week for 3 weeks with no application on the fourth week 5. Injectable Progestins: start of injections should be during the first 5 days of the menstrual cycle and every 11-13 weeks after. injections in postpartum non-breastfeeding clients should begin within 5 days following delivery. for breastfeeding clients, injections should start in the sixth week postpartum. keep follow up appointments. maintain an adequate intake of calcium and engage in weight bearing exercise to decrease risk of osteoporosis. do not massage after IM injections because it decreases the absorption and effectiveness of the medication 6. Contraceptive Vaginal Ring: insert the ring vaginally. perform ring replacement after 3 weeks, and placement of new vaginal ring within 7 days. insertion should occur on the same day of the week monthly. if removed for greater than 4 hours, replace with new ring and use a barrier method of contraception of 7 days 7. Implantable Progestin: avoid trauma to the area of implantation. wear condoms for protection against STIs 8. Intrauterine Device (IUD): device must be monitored monthly by clients after menstruation to ensure the presence of the small string that hangs from the device into the upper part of the vagina to rule out migration or expulsion of the device. sign a consent form prior to insertion. pregnancy test, pap smear, and cervical cultures should be negative prior to insertion. if pregnancy is suspected after IUD insertion, a sonogram can be needed to rule out ectopic pregnancy

Contraception: Surgical Procedures: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho 1. Female Sterilization (Bilateral Tubal Ligation): procedure consists of severance and/or burning or blocking the fallopian tubes to prevent fertilization 2. Male Sterilization (Vasectomy): procedure consisting of ligation and severance of the vas deferens, which prevents sperm from traveling - Risk Factors 1. Female Sterilization (Bilateral Tubal Ligation): risk of ectopic pregnancy if pregnancy occurs 2. Male Sterilization (Vasectomy): bleeding, infection, anesthesia reaction, hematomas, kidney stones, chronic pain - Patient Education 1. Male Sterilization (Vasectomy): following the procedure, scrotal support and moderate activity for a couple of days is recommended to reduce discomfort. sterility is delayed until the proximal portion of the vas deferens is cleared of all remaining sperm. alternate forms of birth control must be used until the vas deferens is cleared of sperm. follow up with the provider for sperm count testing. sperm count must be zero on 2 consecutive tests to confirm sterility. reversal can be done by complicated and expensive procedure. prior to procedure, sperm can be banked for future use

Contraception: Barrier: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho 1. Male Condom: thin sheath used to cover the penis during sex as a contraceptive or as protection against infection. can be made of latex rubber, polyurethane, or natural membrane 2. Female Condom: vaginal sheath made of nitrile, a nonlatex synthetic rubber with flexible rings on both ends that is pre-lubricated with a spermicide 3. Spermicide: chemical barrier that is available in a variety of forms, and destroys sperm before they can enter the cervix. causes vaginal flora to be more acidic, which is not favorable for sperm survival 4. Diaphragm: dome-shaped cup with a flexible rim made of silicone that fits snugly over the cervix. effectiveness is increased with the use of a spermicidal cream or gel placed into the dome and around the rim. available in different sizes 5. Cervical Cap: silicone rubber cap that fits tightly around the base of the cervix. serves as a physical barrier against sperm entering the cervix. use with a spermicide increases its effectiveness. cervical caps come in 3 sizes 6. Contraceptive Sponge: small, round, concave-shaped, polyurethane sponge containing spermicide. fits over the cervix and acts as a physical/chemical barrier against sperm from entering the vagina - Risk Factors 1. Male Condom: condoms can rupture or leak, potentially resulting in pregnancy. condoms made of latex should not be worn by those who are sensitive or allergic to latex 2. Spermicide: contraindicated in clients who have cervical infections. spermicides that contain nonoxynol-9 can cause lesions and increase the risk of HIV if used more than twice daily. clients at high risk for STI should not use products containing N-9 3. Diaphragm: not recommended for clients who have a history of toxic shock syndrome (TSS), cystocele, uterine prolapse, or frequent recurrent UTIs. increased risk of acquiring TSS, which is caused by a bacterial infection. clinical findings include high fever, faint feeling, drop in BP, watery diarrhea, headache, macular rash, and muscle aches. proper hand hygiene aids in prevention of TSS, as well as removing the diaphragm promptly 6-8 hours following coitus. risk of allergic reaction and UTIs 4. Cervical Cap: not for clients who have abnormal pap test results or have history of TSS 5. Contraceptive Sponge: risk of TSS if left in the vagina greater than 24 hours - Patient Education 1. Male Condom: place a condom on the erect penis, leaving an empty space at the tip for a sperm reservoir. following ejaculation, withdraw the penis from the vagina while holding the rim of the condom to prevent any semen spillage to the vulva or vaginal area. can use in conjunction with spermicidal gel or cream to increase effectiveness. check expiration date prior. latex and polyurethane condoms protect against STI, but natural skin condoms do not because of their small pores. polyurethane condoms can slip or lose shape more easily than latex, and therefore might not be as effective. only water-soluble lubricants should be used with latex condoms, to avoid condom breakage 2. Female Condom: closed end of the condom pouch is inserted into the vagina by the client prior to intercourse and anchored around the cervix. the open ring of the condom covers the labia. the condom is removed and thrown away after each act of intercourse. do not use in conjunction with a male condom 3. Spermicide: plan to insert spermicide 15 minutes before sex. spermicide is only effective for 1 hour after insertion, but should not be removed until 6 hours after intercourse. fold films prior to use and insert in the vagina, where it will dissolve 4. Diaphragm: be properly fitted with a diaphragm by a provider. replace every 2 years and refit for a 20% weight fluctuation, after abdominal or pelvic surgery, and after every pregnancy. the diaphragm requires proper insertion and removal. prior to coitus, the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim. the diaphragm can be inserted up to 6 hours before intercourse and must stay in place 6 hours after intercourse but for no more than 24 hours. spermicide must be reapplied with each act of coitus. empty the bladder prior to insertion of the diaphragm, to decrease pressure on the urethra. diaphragm should be washed with mild soap and warm water after each use 5. Cervical Cap: insert up to 6 hours before intercourse, and leave in place at least 6 hours after intercourse but for no more than 48 hours at a time. replace every 2 years and refit after any gynecological surgery, birth, or any major weight fluctuation 6. Contraceptive Sponge: one size fits all. moisten with water prior to insertion in the vagina. should be left in place for 6 hours after the last act of intercourse and provides protection for up to 24 hours

Contraception: Intrauterine Methods: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho 1. Transcervical Sterilization: insertion of small flexible agents through the vagina and cervix into the fallopian tubes. results in development of scar tissue in the tubes, preventing conception. exam must be done after 3 months to ensure fallopian tubes are blocked - Risk Factors 1. Transcervical Sterilization: perforation can occur. unwanted pregnancy can occur if a client has unprotected sex during the first 3 months following the procedure. increased risk of ectopic pregnancy if pregnancy occurs - Patient Education 1. Transcervical Sterilization: normal activities can be resumed by most clients within 1 day of the procedure

Newborn Complications: Tracheoesophageal Fistula: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: GI anomaly that can occur independently or together with an EA. TEF alone can include a variety of abnormal connections between the esophagus and trachea. TEF and EA combined include a blind esophagus pouch and/or abnormal connection between the esophagus and trachea. presence of TEF places the infant at risk for aspiration and respiratory complications - Risk Factors: history of polyhydramnios, cardiac anomaly, cleft lip/palate, neural tube defects - Expected Findings: depends on specific defect present. excessive oral secretions. drooling. feeding intolerance (gagging, coughing during feeding, spitting up, gastric distention). respiratory distress and cyanosis - Meds: anti-reflux medications, antacids - Diagnostics: prenatal ultrasound - Nursing Care: position supine with head of bed elevated. orogastric tube to low-continuous suction. monitor for signs of respiratory distress. don't feed infant who has excessive oral secretions with respiratory distress until a provider is consulted

Antepartum Complications: Ectopic Pregnancy: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: abnormal implantation of a fertilized ovum outside the uterine cavity, usually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage. cause in frequent bleeding in early pregnancy and cause for infertility - Risk Factors: any factor that compromises tubal patency including STIs, assisted reproductive technologies, tubal surgery, and contraceptive intrauterine device (IUD) - Expected Findings: unilateral stabbing pain and tenderness in lower abdominal quadrant. menses that is delayed (1-2 weeks), lighter than usual, or irregular. scant, dark, red, or brown vaginal spotting 6-8 weeks after normal menses, red, vaginal bleeding if rupture has occurred. referred shoulder pain due to blood in the peritoneal cavity irritating the diaphragm or phrenic nerve after tubal rupture. findings of hemorrhage and shock (hypotension, tachycardia, pallor, dizziness) if a large amount of bleeding has occurred - Labs: serum levels of progesterone and hCG to help determine whether pregnancy has occurred and whether it is likely to be ectopic - Meds: medical management if rupture has not occurred and tube preservation desired. methotrexate inhibits cell division and embryo enlargement, dissolving the pregnancy. salpingostomy is done to salvage the fallopian tube if not ruptured. laparoscopic salpingectomy (removal of tube) is performed when the tube has ruptured - Diagnostics: transvaginal ultrasound shows an empty uterus. use caution if vaginal and bimanual examination are used - Nursing Care: replace fluids, and maintain electrolyte balance. provide client education and psychological support. administer medications as prescribed. prepare client for surgery and postoperative nursing care. provide emotional care and support. provide referral for client and partner to pregnancy loss support group. obtain serum hCG and progeseterone levels, liver and renal function studies, CBC, and type and Rh - Patient Education: if taking methotrexate, avoid vitamins containing folic acid to prevent a toxic response to the medication. use protection against sun exposure (photosensitivity)

Infant Complications: Plagiocephaly: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: acquired condition that occurs from cranial molding in infancy. infant's head becomes asymmetric or oblique in shape due to flattening of the occiput. attributed to the supine sleep position - Risk Factors: placing infant in supine sleep position, torticollis - Expected Findings: oblique shape of head, asymmetrical skull and facial features, flattened occiput, frontal and parietal bossing, prominent cheekbone, anterior displacement of an ear, possible decreased ROM in neck if torticollis present - Nursing Care: refer parents to physical therapy for neck exercises. assist parents in proper use of skull-molding helmet - Patient Education: understand the importance of daily tummy time when infant is awake. limit time infant is in a car seat, bouncer, or swing. understand importance of alternating the infants head position during sleep. helmet needs to be worn 23 hours per day usually for 3 months. continue to place infant in supine position for sleep

STIs: Gonorrhea: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: bacterial infection spread by genital to genital contact. can also be spread by anal to genital or oral to genital contact. also, transmitted to newborn during delivery. if untreated, neonate can become blind - Labs: endocervical culture preferred for females. urine cultures. anal or oral cultures - Nursing Care: provide client education regarding disease transmission. identify and treat all sexual partners. administer erythromycin to all infants following delivery. report disease by provider - Patient Education: take all medications as prescribed. repeat the culture within 3-4 weeks to assess for medication effectiveness. there is a possibility of decreasing effectiveness of oral contraceptives. adhere to safe sex practices

STIs: Group B Streptococcus (GBS): Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: bacterial infection that can be passed to a fetus during labor and delivery. part of the vaginal flora for nonpregnant clients, and some pregnant - Labs: vaginal and rectal cultures are performed at 35-38 weeks gestation - Nursing Care: administer intrapartum antibiotic prophylaxis to the following clients to decrease transmission to the neonate: clients who are GBS positive, client with unknown GBS delivering at less than 37 weeks, client with maternal fever 38C(100.4F) or greater, and client with ROM for 18 hours or longer - Patient Education: notify labor and delivery nurse of GBS status. decrease neonatal risks by being screened for GBS at 35-38 weeks gestation

Newborn Complications: Preterm Newborn: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: birth occurs after 20 weeks of gestation, and before completion of 37 weeks gestation. late preterm birth occurs from 34-36 6/7 week gestation. risk for variety of complications due to immature organ systems, degree depends on gestational age. decreased risk for complications closer the newborn is to 40 weeks gestation. - Risk Factors: maternal gestational hypertension, multiple pregnancies that are closely spaces, adolescent pregnancy, lack of prenatal care, maternal substance use, smoking, previous history of preterm delivery, abnormalities of the uterus, cervical incompetence, placenta previa, preterm labor, and PROM - Expected Findings: ballard totals less than 37 weeks gestation, periodic breathing consisting of 5 to 10 second respiratory pauses, followed by 10 to 15 second compensatory rapid respirations. manifestations of increased respiratory effort and/or respiratory distress including nasal flaring or retractions of the chest wall during inspirations, expiratory grunting, and tachypnea. apnea which is a pause in respirations 20 seconds or greater. low birth weight. minimal subcutaneous fat deposits. head large in comparison with the body, and small fontanels. wrinkled features with abundance of lanugo covering back, forearms, forehead, and sides of face, and few or no creases on soles of feet. skull and rib cage feel soft. eyes closed if newborn is born at 22-24 weeks of gestation. weak grasp reflex. inability to coordinate suck and swallow. weak or absent gag, suck, and cough reflex. weak swallow. hypotonic muscles, decreased level of activity, and a weak cry for more than 24 hours. lethargy, tachycardia, and poor weight gain - Labs: CBC showing decreased Hgb and Hct as a result of slow production of RBCs, urinalysis and specific gravity, increased PT and aPTT time with an increased tendency to bleed, serum glucose, calcium, bilirubin, and ABGs - Diagnostics: chest X-Ray, head ultrasounds, echocardiography, eye exams - Nursing Care: perform rapid initial assessment. perform resuscitative measures if needed. assess newborns ability to consume and digest nutrients. before feeding by breast or nipple, the newborn must have an intact gag reflex and be able to suck and swallow to prevent aspiration. monitor I&O and daily weight. monitor newborn for bleeding from puncture sites and GI tract. ensure and maintain thermoregulation in a newborn who is preterm by using radiant warmer. manifestations of hypothermia include apnea, cyanosis, hypoglycemia, feeding intolerance, lethargy, irritability, and bradycardia. administer respiratory support measures, such as surfactant and/or oxygen administration. administer parental or enteral nutrition and fluids as prescribed (most preterm newborns who are less than 34 weeks gestation will receive fluids either by IV and/or gavage feedings). provide for nonnutritive sucking, such as using a pacifier while gavage feeding. minimize the newborns stimulation. cluster nursing care. touch the newborn very smoothly and lightly. keep lighting dim and noise levels reduced. position the newborn in neutral flexion with extremities close to the body to conserve body heat. prone and side lying positions are preferred to supine with body containment using blanket rolls and swaddling, but only in the nursery under monitored supervision. perform skin assessment tool daily to minimize risk of skin breakdown. encourage skin to skin whenever possible to reduce preterm infant stress. protect newborn against infection by enforcing hand hygiene and gowning procedures. evidence of infection includes temperature instability, lethargy, irritability, cyanosis, bradycardia or tachycardia, apnea or tachypnea, feeding intolerance, and glucose instability. observe newborn for findings of dehydration or overhydration (resulting from IV nutrition and fluid administration). dehydration is when the urine output is less than 1mL/kg/hr, urine-specific gravity greater than 1.015, weight loss, dry mucous membranes, absent skin turgor, and depressed fontanel. overhydration is seen when urine output is greater than 3mL/kg/hr, urine-specific gravity less than 1.001, edema, increased weight gain, crackles in lung, and intake greater than output - Patient Education: remain informed about and engaged in the care of the preterm newborn

Newborn Complications: Postmature Infant: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: born after completion of 42 weeks gestation. can be due to the following: 1. Dysmaturity from Placental Degeneration and Uteroplacental Insufficiency: results in chronic fetal hypoxia and fetal distress in utero. fetal response is polycythemia, meconium aspiration, and/or neonatal respiratory problems. perinatal growth is higher when a postmature placenta fails to meet increased oxygen demands of the fetus during labor 2. Continued Growth of Fetus in Utero: due to the placenta continuing to function effectively and the newborn becomes LGA at birth. leads to difficult delivery, cephalopelvic disproportion, as well as high insulin reserves and insufficient glucose reserves at birth. neonatal response can be birth trauma, perinatal asphyxia, a clavicle fracture, seizures, hypoglycemia, and/or temperature instability (cold stress) - postmature newborns have an increased risk for aspirating meconium passed by the fetus in utero. persistent pulmonary hypertension (persistent fetal circulation) is a complication that can result from meconium aspiration. there's an interference in the transition from fetal to neonatal circulation, and the ductus arteriosus (connecting the main pulmonary artery and the aorta) and foramen ovale (shunt between right and left atria) remain open, and fetal pathways of blood flow continue - Risk Factors: unknown, but there is a higher incidence in first pregnancies and in clients who have had a previous postmature pregnancy - Expected Findings: wasted appearance, thin with loose skin, having lost some of the subcutaneous fat. peeling, cracked, and dry skin. leathery from decreased protection of vernix and amniotic fluid. long, thin body. meconium staining of fingernails and umbilical cord. hair and nails can be long. alertness similar to a 2 week old newborn. difficulty establishing respirations secondary to meconium aspiration. hypoglycemia due to insufficient stores of glycogen. clinical findings of cold stress. neurological manifestations that become apparent with the development of fine motor skills. macrosomia - Labs: blood glucose levels to monitor for hypoglycemia. ABGs secondary to chronic hypoxia in utero due to placental insufficiency. CBC to show polycythemia from decreased oxygenation in utero. Hct elevated from polycythemia and dehydration - Diagnostics: cesarean birth, chest X-Ray to rule out meconium aspiration syndrome - Nursing Care: monitor vital signs. administer and monitor IV fluids. moisturize the skin with a petrolatum-based ointment. use mechanical ventilation if needed. administer oxygen as prescribed. prepare and/or assist with exchange transfusion if hematocrit is high. provide thermoregulation in an isolette to avoid cold stress. provide early feedings to avoid hypoglycemia. identify and treat any birth injuries

STIs: Syphilis: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: caused by bacterium Treponema Pallidum. can have long term complications if not treated adequately. has three stages. transmitted through oral, vaginal or anal sex, and to unborn child - Labs 1. Serology Tests: nontreponemal (VDRL and rapid plasma reagin) and treponemal (enzyme immunoassay, immunoassays). nontreponemal tests are used for screening, then treponemal tests for detecting antibodies specific for syphilis to confirm the diagnosis. this sequence of nontreponemal then treponemal tests is considered the standard for testing 2. Microscopic: examination of the primary lesion - Patient Education: abstain from sexual contact until sores have completely healed. partners need to be tested and treated. adhere to safe sex. report disease by provider. after treatment, report headache, fever, tachycardia, and myalgia. could be indicative of jarisch-herxheimer reaction and be reported to provider

STIs: Chlamydia: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: caused by chlamydia trachomatis and is a bacterial infection. if transmitted to neonate, it can cause conjunctivitis and pneumonia after delivery - Labs: endocervical swab culture of cervical discharge. urine culture specimen as alternative - Nursing Care: instruct client to take entire prescription as prescribed. identify and treat all exposed sexual partners. clients who are pregnant should be retested 3 weeks after completing the prescribed regimen - Patient Education: doxycycline might reduce the effectiveness of oral contraceptives. if continued sex, be aware of STI status of partners, and use barrier contraceptive. state disease by provider

Postpartum Complications: Coagulopathies: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: coagulopathies are suspected when the usual measures to stimulate uterine contractions fail to stop vaginal bleeding 1. Idiopathic Thrombocytopenic Purpura (ITP): coagulopathy that is an autoimmune disorder in which the life span of platelets is decreased by antiplatelet antibodies. can result in severe hemorrhage following cesarean birth or lacerations 2. Disseminated Intravascular Coagulation (DIC): coagulopathy in which clotting and anticlotting mechanisms occur at the same time. client is at risk for internal and external bleeding, as well as damage to organs resulting from ischemia caused by microclots - Risk Factors 1. ITP: genetic in origin 2. DIC: can occur secondary to other complications including abruptio placentae, amniotic fluid embolism, missed abortion, fetal death in utero, severe pre-eclampsia or eclampsia (gestational hypertension), HELLP syndrome, septicemia, cardiopulmonary arrest, hemorrhage, and hydatidiform mole - Expected Findings: physical assessment findings include unusual spontaneous bleeding from the gums and nose (epistaxis). oozing, trickling, or flow of blood from incision, lacerations, or episiotomy. petechiae and ecchymoses. excessive bleeding from venipuncture, injection sites, or slight traumas. hematuria. GI bleeding. tachycardia, hypotension, and diaphoresis - Labs: CBC with differential and blood typing an crossmatch. clotting factors include platelet levels (thrombocytopenia) decreased, fibrinogen levels decreased, PT prolonged, fibrin split product levels increased, and D-Dimer test (specific fibrin degradation fragment) increased - Diagnostics: correction of the underlying cause. splenectomy which can be performed b the provider if ITP does not respond to medical management. surgical intervention (hysterectomy) for DIC is performed by the provider as indicated - Nursing Care: assess skin, venipuncture, injection sites, lacerations, and episiotomy for bleeding. monitor vital signs and hemodynamic status. monitor urinary output, usually by insertion of an indwelling urinary catheter. transfuse platelets, clotting factors, other blood products, or volume expanders. assist in preparing the client for a splenectomy if ITP does not respond to medical management and provide postsurgical care. ensure optimal oxygenation. DIC focus is on assessing for and correcting the underling cause (removal of dead fetus or placental abruption, treatment of infection, pre-eclampsia, or eclampsia). administer fluid replacement, which can include blood and blood products. administer pharmacological interventions including antibiotics, vasoactive medications, and uterotonic agents. administer supplemental oxygen. provide protection from injury

Newborn Complications: Hyperbilirubinemia: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: elevation if serum bilirubin levels resulting in jaundice. normally appears on the head, and then progresses down the thorax, abdomen, and extremities 1. Physiologic Jaundice: benign resulting from newborn physiologic of increased bilirubin production due to the shortened lifespan and breakdown of fetal RBCs and liver immaturity. newborn exhibits increase in unconjugated bilirubin levels 72-120 hours after birth, with a rapid decline to 3 mg/dL 5-10 days after birth 2. Pathologic Jaundice: result of underlying disease. appears before 24 hours of age or is persistent after day 14. in the term newborn, bilirubin levels increase more than 0.5mg/dL/hr, and peaks at greater than 12.9mg/dL, or is associated with anemia and hepatosplenomegaly. caused by a blood group incompatibility or an infection, but can be the result of RBC disorders 3. Acute Bilirubin Encephalopathy: when bilirubin is deposited in the brain. occurs once all of the binding sites for bilirubin are used within the body, resulting in necrosis of neurons. bilirubin levels higher than 25mg/dL place the newborn at risk. can result in permanent damage including dystonia and athetosis, upward gaze, hearing loss, and cognitive impairments 4. Kernicterus: irreversible, chronic result of bilirubin toxicity. newborn demonstrates many of the same manifestations of bilirubin encephalopathy with hypotonia, severe cognitive impairments, and spastic quadriplegia - Risk Factors: increased RBC production or breakdown, Rh or ABO incompatibility, decreased liver function. maternal ingestion of diazepam, salicylates, or sulfonamides close to birth. maternal diabetes, oxytocin during labor, neonatal hyperthyroidism, ecchymosis or hemangioma, cephalohematomas, and prematurity - Expected Findings: yellowish tint to skin, sclera, and mucous membranes. to verify jaundice, press the newborns skin on the cheek or abdomen lightly with one finger. then, release pressure, and observe the newborn's skin color for yellowish tint as the skin is blanched. note time of jaundice onset. assess underlying cause by reviewing the maternal, prenatal, family, and newborn history. hypoxia, hypothermia, hypoglycemia, and metabolic acidosis can occur as a result of hyperbilirubinemia and can increase the risk of brain damage - Labs: elevated serum bilirubin level can occur. monitor newborns bilirubin levels every 4 hours until the level returns to normal. assess maternal and newborn blood type to determine whether there is ABO incompatibility. occurs if newborn has blood type A or B, and the parent is type O. review Hgb and Hct. direct Coombs test reveals the presence of antibody-coated (sensitized) Rh-positive RBCs in the newborn. check electrolyte levels for dehydration from phototherapy - Meds: (therapeutic) phototherapy used for newborn's bilirubin should start to decrease within 4-6 hours after starting treatment - Diagnostics: transcutaneous bilirubin level is a noninvasive method to measure a newborn's bilirubin level - Nursing Care: observe the skin and mucous membranes for jaundice. monitor vital signs. 1. Phototherapy: set up if prescribed. maintain an eye mask over the newborn's eyes for protection of corneas and retinas. keep newborn undressed. for a male newborn, a surgical mask should be placed (like a bikini) over the genitalia to prevent possible testicular damage from heat and light waves. be sure to remove the metal strip from the mask to prevent burning. avoid applying lotions or ointments to the skin because they absorb heat and cause burns. remove newborn from phototherapy every 4 hours, and unmask the newborns eyes, checking for inflammation or injury. reposition the newborn every 2 hours to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. check the lamp energy with a photometer per protocol. turn off phototherapy lights before drawing blood for testing 2. Observe Newborn for Effects of Phototherapy: bronze discoloration is not a serious complication. maculopapular skin rash is not a serious complication. development of pressure areas. dehydration includes poor skin turgor, dry mucous membranes, and decreased urinary output. elevated temperature - encourage patients to hold and interact with newborn when phototherapy lights are off. monitor elimination and daily weights, watching for evidence of dehydration, check the newborns axillary temperature every 4 hours during phototherapy because temperature can become elevated, feed newborn early and frequently every 3-4 hours this will promote bilirubin excretion in the stools, encourage continued breastfeeding of the newborn and supplementation with formula can be prescribed. maintain adequate fluid intake to prevent dehydration. reassure the parents that most newborns experience some degree of jaundice. explain hyperbilirubinemia, its causes, diagnostic tests, and treatment to parents. explain that the newborns stool contains some bile that will be loose and green. administer an exchange transfusion for newborns who are at risk for kernicterus - Patient Education: discharge instructions include remembering and adhering to the newborns plan of care. infants who have low to moderate risk of hyperbilirubinemia should receive follow up care within 2 days. infants at higher risk should be seen within 24 hours

Infant Complications: Hyperbilirubinemia: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: elevation of bilirubin levels resulting in jaundice, usually in the head then the thorax, abdomen, and extremities. jaundice is physiologic or pathologic 1. Physiologic Jaundice: benign, and has no other manifestations and shows evidence at 24 hours old 2. Hemolytic Disease: of the newborn (HDN) or pathologic jaundice, is a result of an underlying disease. HDN appears before 24 hours of age. in the term newborn, normal unconjugated bilirubin is 0.2-1.4mg/dL. levels must exceed 5mg/dL before jaundice is observed. usually caused by blood group incompatibility or isoimmunization. 3. Kernicterus (bilirubin encephalopathy): when the certain pathologic conditions exist in addition to increased bilirubin levels, the newborn has an increased permeability of the BBB to unconjugated bilirubin. newborn has potential or irreversible brain damage. it's a neurologic syndrome caused by bilirubin depositing in brain cells. survivors can experience neurologic damage, cerebral palsy, seizures and display cognitive impairment, ADHD, delayed or abnormal motor movement, behavioral disorders, perceptual problems, or sensorineural hearing loss - Risk Factors: (pathologic hyperbilirubinemia) blood bilirubin level in the high risk zone on the hour-specific nomogram. Rh or ABO incompatibility with positive direct COOMBS test. cephalohematoma or significant bruising. appearance of jaundice within 24 hours of birth. ineffective, difficult breastfeeding. gestational age 3-36 weeks. sibling who has jaundice. hereditary hemolytic disease, east asian or asian-american race - Expected Findings 1. Physical Assessment Findings: yellowish tint to skin, sclera, and mucous membranes and nails. to verify jaundice, press the newborn's skin on the cheek or abdomen lightly with 1 finger. then release pressure, and observe the skin color for yellowish tint as the skin is blanched. note the time of jaundice onset to distinguish between physiologic and pathologic jaundice. assess underlying cause by reviewing the maternal prenatal, family, and newborn history. hypoxia, hypothermia, hypoglycemia, and metabolic acidosis can increase the risk of brain damage despite lower blood levels of bilirubin 2. Findings of Kernicterus: very yellowish skin, lethargy, hypotonic, poor feeding, decreased activity, high pitched cry, temperature instability - Labs: elevated blood bilirubin level can occur. monitor bilirubin level until it returns to normal. use of hour-specific blood bilirubin levels to predict newborns at risk for hyperbilirubinemia is the gold standard for monitoring newborns greater than 35 weeks gestation. assess maternal and newborn blood type to determine whether there is a presence of ABO incompatibility. this occurs if the newborn has blood type A or B, and mother is type O. review Hgb and Hct. direct COOMBS test reveals the presence of antibody-coated (sensitized) Rh-positive RBCs in newborn. check electrolyte levels for dehydration from phototherapy - Diagnostics: transcutaneous bilirubin level is a noninvasive method to measure a newborns bilirubin level - Nursing Care: observe the skin and mucous membranes for jaundice. monitor vital signs. 1. Phototherapy: set up if prescribed. maintain an eye mask over the newborn's eyes for protection of corneas and retinas. keep newborn undressed. for a male newborn, a surgical mask should be placed (like a bikini) over the genitalia to prevent possible testicular damage from heat and light waves. be sure to remove the metal strip from the mask to prevent burning. avoid applying lotions or ointments to the skin because they absorb heat and cause burns. remove newborn from phototherapy every 4 hours, and unmask the newborns eyes, checking for inflammation or injury. reposition the newborn every 2 hours to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. check the lamp energy with a photometer per protocol. turn off phototherapy lights before drawing blood for testing 2. Observe Newborn for Effects of Phototherapy: bronze discoloration is not a serious complication. maculopapular skin rash is not a serious complication. development of pressure areas. dehydration includes poor skin turgor, dry mucous membranes, and decreased urinary output. elevated temperature - encourage patients to hold and interact with newborn when phototherapy lights are off. monitor elimination and daily weights, watching for evidence of dehydration, check the newborns axillary temperature every 4 hours during phototherapy because temperature can become elevated, feed newborn early and frequently every 3-4 hours this will promote bilirubin excretion in the stools, encourage continued breastfeeding of the newborn and supplementation with formula can be prescribed - Patient Education: observe for rebound effect. bilirubin initially rises after treatment is discontinued but resolves without additional intervention

Postpartum Complications: Pulmonary Embolus: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: embolus occurs when fragments or an entire clot dislodges and moves into circulation. pulmonary embolism is a complication of DVT, that occurs if the embolus moves into the pulmonary artery or one of its branches and lodges in a lung, occluding the vessel and obstructing blood flow to the lungs. acute pulmonary embolus is an emergency situation - Risk Factors: same as those for DVT - Expected Findings: apprehension, pleuritis chest pain, dyspnea, tachypnea, hemoptysis, tachycardia, cough, syncope, crackles with breath sounds, elevated temperature, hypoxia - Meds: medications listed under DVT. thrombolytic therapy to break up blood clots can be prescribed including alteplase, streptokinase. similar adverse effects and contraindications as anticoagulants - Diagnostics: ventilation/perfusion lung scan, magnetic resonance angiography, spiral computed tomography, pulmonary angiogram, embolectomy to surgically remove the embolus - Nursing Care: place the client in a semi-Fowler's position with the head of the bed elevated to facilitate breathing. administer oxygen by mask

STIs: Candidiasis: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: fungal infection - Labs: sample of discharge used for application to pH paper. saline and potassium chloride wet mount smear - Diagnostics: pH less than 4.5. wet mount potassium hydroxide prep, which indicates presence of yeast buds, hyphae, pseudohyphae - Patient Education: avoid tight fitting clothing, and wear cotton lined underpants. remove damp clothing ASAP. avoid douching. increase dietary intake of yogurt with active cultures. if infections are recurrent or frequent, diabetes should be ruled out

Infant Complications: Chromosomal Abnormalities: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: genetic disorders are passed from 1 generation to the next due to a disorder in a gene or chromosome. genetic disorders can occur at the moment of fusion of sperm and egg or earlier, during meiotic divisions of the egg or sperm - Risk Factors: parent who has existing genetic disorder or inborn error of metabolism, previous child born with genetic disorder or inborn error of metabolism, previous stillbirth, close relative with genetic disorder or inborn error of metabolism, parents closely related, parent known carrier of a genetic disorder, women older than 35 or man older than 55, exposure to infectious or environmental toxins - Diagnostics: DNA analysis of parents prior to conception, newborn screening. tests during pregnancy include blood AFP level (increased for NTD, decreased for chromosomal abnormality), chorionic villus sampling, amniocentesis, ultrasonography - Nursing Care: obtain complete family history. perform physical assessment of parents for any abnormalities. refer for genetic screening. provide emotional support and guidance. refer to support groups. perform physical exam of newborn for any abnormalities. monitor affected infants closely, including cardiac and respiratory status, and feeding difficulties - Patient Education: be aware of expected outcomes for infant. observe for manifestations and report to provider if needed

Infant Complications: Failure to Thrive: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: inadequate growth resulting from inability to obtain or use calories required for growth. infant who falls below 5th percentile for weight, or has a pattern of consistent weight loss - Risk Factors: IGR, disturbed parent-child interactions, dysfunctional parenting behaviors, poverty, family stress, insufficient breastfeeding, cerebral palsy, congenital heart disease, hepatic disease, cystic fibrosis, down syndrome, gastroesophageal reflux, premature birth - Expected Findings: less than 5th percentile on growth chart, malnourished appearance, no fear of strangers, minimal smiling, decreased activity level, withdrawal behavior, developmental delays, feeding disorder, wide eyed gaze, stiff or flaccid body - Nursing Care: obtain nutritional history. observe parent-child interactions. obtain baseline height and weight. observe for low weight, malnourished appearance, and manifestations of dehydration. weigh newborn daily. maintain I&O and calorie counts. teach parents how to recognize and respond to infant's hunger cues. establish a routine for eating that includes usual times, duration, and setting. reinforce proper positioning, latching on, and timing for breastfeeding mothers. provide 24kcal/oz. formula as prescribed. administer multivitamin supplements as prescribed. teach parents how to mix formula properly. provide developmental stimulation. encourage parents to maintain eye contact and face to face during feedings, talk to infant while feeding, burp infant, keep quiet environment and avoid distractions, be persistent and calm during 10-15 minute refusal to ear, and never force infant to eat

Infant Complications: Complications of the Preterm Infant: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: infant who is born alive before completion of 37 weeks gestation. late preterm or early preterm - Risk Factors: maternal low socioeconomic level, maternal poor nutritional status during pregnancy, lack of prenatal care, multiple pregnancies, gestational hypertension, placental problems, previous preterm birth. maternal smoking, alcohol, or drug use during pregnancy. maternal age younger than 20, maternal infection, PROM, premature separation of placenta, closely spaced pregnancies - Expected Findings: head large in proportion to chest, thin skin with visible veins, lanugo abundant over body, vernix caseosa, few or no sole creases, ear cartilage soft and pliable, poor suck/swallow reflex hypotonicity, males have testicles undescended and few rugae on scrotum, and females have prominent clitoris and labia minora. frequent periods of apnea, temperature instability, hypoglycemia, and weak and high pitched cry - Labs: CBC, ABGs, blood glucose, blood cultures, electrolytes, urinalysis, bilirubin - Nursing Care: facilitate bonding with parents and siblings. weigh daily or as condition warrants. monitor respiratory status. RDS common, supplemental oxygen or assisted ventilation often required, apnea episodes common, continuously monitor oxygen saturation and respiratory rate, assess breath sounds for crackles, wheezing, and stridor. monitor temperature, provide external sources of warmth, prevent heat loss, maintain neutral thermal environment. monitor cardiac status, assess HR and rhythm, monitor for murmurs, monitor skin color for cyanosis, mottling and pallor. monitor BP. monitor pulses and capillary refill times. monitor GI status, assess for abdominal distention, monitor for regurgitation and gastric residuals, monitor bowel sounds, monitor amount and color and consistency of stools, monitor blood glucose level. monitor genitourinary status, assess genitalia, monitor urine for amount, color, and pH. monitor neurologic-musculoskeletal status, assess motor activity, assess reflexes, assess head circumference and fontanels, provide stimuli. monitor skin, monitor for redness, irritation, blisters, abrasions, or discoloration. pay attention to areas where monitoring equipment, IVs, or other equipment comes in contact with skin. assess skin turgor and texture. assess for birthmarks, rashes, and lesions. assess IV sites for manifestations of infection or infiltration - Patient Education: visit newborn and call for updates when unable to visit. express feelings. continue breastfeeding. understand treatment plan, equipment, and monitors. utilize resources of support as needed

Newborn Complications: Newborn Infection/Sepsis (Sepsis Neonatorum): Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: infection can be contracted by the newborn before, during, or after delivery. more susceptible to micro-organisms due to their limited immunity and inability to localize infection. infection can spread rapidly into the bloodstream. newborn sepsis is the presence of micro-organisms or their toxins in the blood or tissues of the newborn during the first month after birth. manifestations of sepsis are subtle and can resemble other diseases. nurse often notices during routine care. prevention starts perinatally with screenings, prophylactic interventions, and use of sterile and aseptic techniques. appropriate umbilical care helps prevent sepsis and infection - Risk Factors: PROM. prolonged labor, toxoplasmosis, rubella, cytomegalovirus, and herpes (TORCH). chorioamnionitis, preterm birth, low birth weight, maternal substance use, maternal UTI, meconium aspiration, HIV transmitted from parent to newborn perinatally through the placenta and postnatally through the breast milk - Expected Findings: temperature instability, suspicious drainage (eyes, umbilical stump), poor feeding pattern (weak suck, decreased intake), vomit, diarrhea, hypoglycemia, hyperglycemia, abdominal distention, apnea, retractions, grunting, nasal flaring, decreased O2, color changes (pallor, jaundice, petechiae), tachycardia or bradycardia, tachypnea, low BP, irritability and seizure activity, poor muscle tone and lethargy - Labs: CBC with differential, C-reactive protein. blood, urine, and cerebrospinal fluid cultures and sensitives. chemical profile to show a fluid and electrolyte imbalance - Nursing Care: assess infection risks (review maternal health record). monitor for clinical findings of opportunistic infection. monitor vital signs continuously. monitor I&O and daily weight. monitor fluid and electrolyte status. monitor newborns visitors for infection. obtain specimens (blood, urine, stool) to assist in identifying the causative organism. initiate and maintain IV therapy as prescribed to administer electrolyte replacements, fluids, and medications. isolation precautions as indicated. administer medications as prescribed (antibiotics, antivirals, or antifungals). initiate and maintain respiratory support as needed. assess IV site for evidence of infection. provide newborn care to maintain temperature. clean and sterilized all equipment to be used. provide emotional support to the family - Patient Education: discharge instructions include understanding and adhering to infection control. use clean bottles and nipples for each feeding. discard any unused formula. perform proper hand hygiene. promote adequate rest for newborn, and decrease physical stimulation

Infant Complications: Necrotizing Enrerocolitis: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: inflammatory disease of the GI mucosa caused by ischemia or hypoxia. ischemia results in death of mucosal cells leading to necrotic patches that interfere with digestion - Risk Factors: prematurity, respiratory distress syndrome, polycythemia, exchange transfusion, IGR, shock, asphyxia, receiving enteral feedings, pre-existing infection, GI vascular compromise, immature GI host defense - Expected Findings: abdominal distention, gastric residuals, bloody stools, periods of apnea begin or worsen, hypotension, lethargy, poor feeding, decreased urinary output - Labs: CBC with differential, ABGs, coagulation studies, blood culture, electrolytes - Diagnostics 1. Abdominal X-Rays: sausage shaped dilation of intestine. marked distention of intestine. characteristic soapsuds appearance of intestinal wall due to air infiltration. free air in abdominal cavity if perforation has occurred - Nursing Care: treatment beings with prevention. withhold feedings for 24-48 hours from newborns who suffered birth asphyxia. initiate feeding with breast milk, which has a protective effect against the development of NEC. discontinue all feedings at first manifestation of NEC. administer IV or TPN to rest the GI tract. insert NG tube for abdominal decompression. administer IV antibiotics as prescribed. handle abdomen carefully to prevent intestinal perforation. measure abdominal girth above the umbilicus every 4-8 hours. assist with serial abdominal x-rays every 4-6 hours. monitor vital signs. perform all routine newborn assessments. prepare newborn and family for surgical intervention, if indicated. removal of necrotized portion of bowel. temporary colostomy if possible. facilitate bonding

Infant Complications: Phenylketonuria: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: inherited metabolic disorder in which the newborn lacks the enzyme phenylalanine hydroxylase. this enzyme converts phenylalanine, an essential amino acid, into tyrosine. lack of this enzyme leads to accumulation of phenylalanine in the newborn's bloodstream and tissues, which causes cognitive impairment - Risk Factors: PUK is inherited as an autosomal recessive trait. women who have PKU or have had a child with PKU can undergo genetic testing to determine the risk of PKU in future children - Expected Findings: growth failure, frequent vomiting, irritability, musty odor to urine, microcephaly, heart defects, blue eyes, very fair skin, and light blonde hair - Labs 1. Newborn Metabolic Screen: blood spot analysis performed after the newborn has ingested a source of protein, and usually within 2 days of birth. expected range of phenylalanine in newborns is 0.5-1mg/dL. some states require a repeat newborn metabolic screen when the newborn is 1-2 weeks of age 2. Guthrie Test: confirms diagnosis when blood spot analysis is positive - Nursing Care: focused on dietary intake. initiate dietary restrictions as soon as PKU is diagnosed, or within 7-10 days of birth. place newborn on a formula low in phenylalanine. intake should be 20-30mg phenylalanine per kg of body weight per day. monitor phenylalanine level goal is a phenylalanine level between 2-8mg/dL. monitor phenylalanine levels in newborns who are breastfeeding. breast milk contains phenylalanine, so exclusively breastfeeding might not be possible. monitor newborn for findings of PKU. provide parents with education and support. consult with registered dietitian. provide referrals to support groups

Newborn Complications: Neonatal Substance Withdrawal: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: intrauterine drug exposure can cause anomalies, neurobehavioral changes, and evidence of withdrawal in the neonate. changes depend on the specific drug or combinations of drugs used, dosage, route of administration, metabolism and excretion by the parent and fetus, timing of drug exposure, and length of drug exposure. substance withdrawal in the newborn occurs when the parent uses drugs that have addictive properties during pregnancy including illegal drugs, alcohol, tobacco, and prescription medications. fetal alcohol syndrome (FAS) results from chronic or periodic intake of alcohol during pregnancy. daily intake of alcohol increases the risk of FAS. newborns with FAS are at risk for specific congenital physical defects and long-term complications including feeding problems, CNS dysfunction (cognitive impairment, cerebral palsy), ADD, language abnormalities, microcephaly, delayed growth and development, and poor maternal newborn bonding - Risk Factors: maternal use of substances prior to knowing they are pregnant, and maternal substance use during pregnancy - Expected Findings: monitor neonate for abstinence syndrome (withdrawal) and increased wakefulness using the neonatal abstinence scoring system that assesses for and scores the following: 1. CNS: high pitched, shrill cry, incessant crying, irritability, tremors, hyperactivity with increased moro reflex, increased deep tendon reflexes, increased muscle tone, disturbed sleep pattern, hypertonicity, convulsions 2. Metabolic, Vasomotor, and Respiratory Findings: nasal congestion with flaring, frequent yawning, skin mottling, retractions, apnea, tachypnea greater than 60/min., sweating, temperature greater than 37.2C (99F) 3. GI: poor feeding, regurgitation (projectile vomiting), diarrhea, excessive, uncoordinated, constant sucking - Opiate Withdrawal: manifestations of neonatal abstinence syndrome - Heroin Withdrawal: low birth weight, SGA, manifestations of neonatal abstinence syndrome, increased risk of SIDS - Methadone Withdrawal: manifestations of neonatal abstinence syndrome, increased incidence of seizures, sleep pattern disturbances, stillbirth, SIDS, higher birth weights (compared to with heroin exposure) - Marijuana Withdrawal: preterm birth, intrauterine growth restriction, long-term effects such as deficits in attention, cognition, memory, and motor skills - Amphetamine Withdrawal: preterm or SGA, drowsiness, jitteriness, sleep pattern disturbances, respiratory distress, frequent infections, poor weight gain, emotional disturbances, delayed growth and development - Alcohol Withdrawal: jitteriness, irritability, increased tone and reflex responses, seizures - Fetal Alcohol Syndrome: facial anomalies including small eyes, flat midface, smooth philtrum, thin upper lip, eyes with wide spaced appearance, epicanthal folds, strabismus, ptosis, poor suck, small teeth, and cleft lip or palate. many vital organ anomalies such as heart defects, including atrial and ventricular septal defects, tetralogy of fallot, patent ductus arteriosus. developmental delays and neurologic abnormalities. prenatal and postnatal growth delays. sleep disturbances - Tobacco: prematurity, low birth weight, increased risk for SIDS, increased risk for bronchitis, pneumonia, and developmental delays - Labs: done to differentiate between neonatal drug withdrawal and CNS disorders. CBC, blood glucose, thyroid-stimulating hormone, thyroxine, triiodothyronine, drug screen of urine or meconium to reveal the substance used by the parent, and hair analysis - Meds: based on withdrawal manifestations 1. Morphine Sulfate: opioid 2. Phenobarbital - Classification: anticonvulsant - Intended Effect: decrease CNS irritability and control seizures for newborns who have alcohol or opioid withdrawal - Nursing Actions: assess IV site frequently. check for any medication incompatibilities. decrease environmental stimuli. cluster cares to minimize stimulation. swaddle the newborn to reduce self-stimulation and protect skin from abrasions. monitor and maintain fluids and electrolytes. administer frequent, small feedings of high calorie formula, can require gavage feedings. elevate the newborn's head during and following feedings, and burp newborn to reduce vomiting and aspiration. try various nipples to compensate for a poor suck reflex. have suction available to reduce the risk for aspiration. for newborns who are withdrawing from cocaine, avoid eye contact and use vertical rocking and a pacifier. prevent infection. initiate a consult with child protective services. consult lactation services to evaluate whether breastfeeding is desired or contraindicated to avoid passing narcotics in breast milk. methadone is not contraindicated during breastfeeding - Diagnostics: chest X-ray for FAS to rule out congenital heart defects - Nursing Care: perform ongoing assessment of newborn using neonatal abstinence scoring system assessment, as prescribed. elicit and assess reflexes. monitor newborns ability to feed and digest intake. offer small frequent feedings. swaddle newborn with legs flexed. offer non-nutritive sucking. monitor newborns fluids and electrolytes with skin turgor, mucous membranes, fontanels, daily weights, and I&O. reduce environmental stimuli (decrease lights, lower noise level) - Patient Education: utilize a drug and/or alcohol treatment center. understand the importance of SIDS prevention activities due to the increased rate in newborns of parents who used methadone

Postpartum Complications: Lacerations and Hematomas: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: lacerations that occur during labor and birth consist of the tearing of soft tissues in the birth canal and adjacent structures including the cervical, vaginal, vulvar, perineal, and/or rectal areas. episiotomy can extend and become a third or fourth degree laceration. a hematoma is a collection of clotted blood within tissues that can appear as a bulging bluish mass. hematomas can occur in the pelvic region or higher in the vagina or broad ligament. pain, rather than noticeable bleeding, is the distinguishable finding of hematomas. client is at risk for hemorrhage or infection due to laceration or hematoma - Risk Factors: operative vaginal birth, precipitous birth, cephalopelvic disproportion, size and abnormal presentation or position of the fetus, prolonged pressure of the fetal head on the vaginal mucosa, and previous scarring of the birth canal from infection, injury, or operation - Expected Findings 1. Laceration: sensation of oozing or trickling of blood. excessive rubra lochia with or without clots. physical assessment findings include vaginal bleeding even though the uterus is firm and contracted. continuous trickle of bright red blood from vagina, laceration, episiotomy 2. Hematoma: pain, pressure sensation in rectum (urge or defecta) or vagina, and difficulty voiding. physical assessment findings include bulging, bluish mass or area of red-purple discoloration on vulva, perineum, or rectum. - Diagnostics: repair and suturing of the episiotomy or lacerations is done by the provider. ligation of the bleeding vessel or surgical incision for evacuation of the clotted blood from the hematoma is done by the provider - Nursing Care: assess pain. visually or manually inspect the vulva, perineum, and rectum for lacerations and/or hematomas. evaluate lochia. continue to assess vital signs and hemodynamic status. attempt to identify the source of the bleeding. assist the provider with repair procedures. use ice packs to treat small hematomas. administer pain medication. encourage sitz baths and frequent perineal hygiene

Infant Complications: Meningocele/Myelomeningocele: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: neural tube defects (NTD) that are present at birth and affect the CNS and spine. defects occur when the neural tube fails to close during the third to fourth week of embryonic development. defects also classified as spina bifida 1. Meningocele: protrusion of a sac-like cyst that contains meninges and spinal fluid 2. Myelomeningocele: protrusion of a sac like cyst that contains meninges, spinal fluid, and a portion of spinal cord and nerves - Risk Factors: use of medications or illict drugs during pregnancy, malnutrition during pregnancy, insufficient intake of folic acid during pregnancy, exposure to radiation or chemicals during pregnancy, pre-pregnancy obesity, diabetes mellitus, hyperthermia, or low levels of vitamin B12. previous newborn who has a neural tube defect - Expected Findings: protrusion of a sac like cyst midline of the spine: cysts are commonly found in the lumbar or lumbosacral area. sensory and/or neuromotor dysfunction. type and severity of dysfunction dependent on location of defect. observe lower extremities for movement and response to stimuli. possible constant dribbling of urine and loss of feces. possible limb deformities - Diagnostics 1. Maternal Testing During Pregnancy: elevated alpha-fetoprotein levels in maternal blood, chorionic villi sampling, amniocentesis, ultrasound 2. Newborn Testing: MRI, ultrasound, CT scan, neurologic evaluation - Nursing Care: assess for infant-parent attachment. assess cyst. perform routine newborn assessments. assess neurologic status. obtain accurate measurements of output. assess fontanels, and monitor head circumference

Newborn Complications: Small for Gestational Age (SGA) Newborn: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: newborn birth weight is at or below 10th percentile, and who has intrauterine growth restriction. common complications include perinatal asphyxia, meconium aspiration, hypoglycemia, polycythemia, and instability of body temperature - Risk Factors: congenital or chromosomal anomalies. maternal infections, disease, or malnutrition. gestational hypertension and/or diabetes. maternal smoking, drug, or alcohol use. multiple gestations. placental factors (small placenta, placenta previa, decreased placental perfusion). fetal congenital infections (rubella, toxoplasmosis) - Expected Findings: weight below 10th percentile, normal skull but reduced body dimensions, hair is sparse on scalp, wide skull sutures from inadequate bone growth, dry and loss skin, decreased subcutaneous fat, decreased muscle mass particularly over the cheeks and buttocks. thin, dry, yellow, and dull umbilical cord rather than gray, glistening, and moist. draw abdomen rather than well-rounded. respiratory distress and hypoxia. wide eyed and alert, which attributed to prolonged fetal hypoxia. hypotonia. evidence of meconium aspiration. hypoglycemia. acrocyanosis - Labs: blood glucose for hypoglycemia, CBC will show polycythemia resulting from fetal hypoxia and intrauterine stress. ABGs can be prescribed due to chronic hypoxia in utero due to placental insufficiency - Diagnostics: chest X-Ray to rule out meconium aspiration syndrome - Nursing Care: support respiratory efforts, and suction the newborn as necessary to maintain an open airway. provide a neutral thermal environment for the newborn (isolette or radiant heat warmer) to prevent cold stress. initiate early feedings (SGA require more frequent feedings). administer parenteral nutrition if necessary. maintain adequate hydration. conserve the newborn's energy level. prevent skin breakdown. protect newborn from infection. provide support to the newborn's parents and extended family - Patient Education: participate in caring for the newborn. anticipate home care needs

Newborn Complications: Congenital Anomalies: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: newborns can be born with congenital anomalies involving all systems. often diagnosed prenatally. nurse should provide emotional support to the parents whose newborn is facing procedures or surgeries to correct the defects. major anomalies causing serious problems include the following: 1. Congenital Heart Disease (CHD): atrial septal defects, ventricular septal defects, coarctation of the aorta, tetralogy of fallot, transportation of the great vessels, stenosis, atresia of valves 2. Neurological Defects: neural tube defects, hydrocephalus, anencephaly, encephalocele, meningocele, myelomeningocele 3. GI Problems: cleft lip/palate, diaphragmatic hernia, imperforate anus, tracheoesophageal fistula/esophageal atresia (EA), duodenal atresia, omphalocele, gastroschisis, umbilical hernia, intestinal obstruction 4. Musculoskeletal Deformities: clubfoot, polydactyly, developmental dysplasia of the hip 5. Genitourinary Deformities: hypospadias, epispadias, exstrophy of the bladder, ambiguous genitalia 6. Metabolic Disorders: phenylketonuria, galactosemia, hypothyroidism 7. Chromosomal Abnormalities - congenital anomalies are identified soon after birth by APGAR and a brief assessment indicating the need for investigation. once identified, congenital anomalies are treated in a pediatric setting 1. Cleft Lip/Palate: failure of lip or hard or soft palate to fuse 2. Tracheoesophageal Atresia: failure of the esophagus to connect to the stomach 3. Phenylketonuria (PKU): inability to metabolize the amino acid phenylalanine 4. Galactosemia: inability to metabolize galactose into glucose 5. Hypothyroidism: slow metabolism caused by maternal iodine deficiency or maternal anti-thyroid medications during pregnancy 6. Neurologic Anomalies (Spina Bifida): neural tube defect in which the vertebral arch fails to close 7. Hydrocephalus: excessive spinal fluid accumulation in the ventricles of the brain 8. Patent Ductus Arteriosus: noncyanotic heart defect in which the ductus arteriosus connecting the pulmonary artery and the aorta fails to close after birth 9. Tetralogy of Fallot: cyanotic heart defect characterized by a ventricular septal defect, stenosis of the pulmonary valve, and hypertrophy of the right ventricle 10. Down Syndrome: trisomy 21, which is the most common trisomic abnormality with 47 chromosomes in each cell - Risk Factors: genetic and/or environmental factors include maternal age greater than 40 years, chromosome abnormalities such as Down Syndrome, viral infections such as Rubella, excessive body heat exposure during the first trimester (neural tube defects), medications and substance use during pregnancy, maternal obesity, radiation exposure, maternal metabolic disorders (phenylketonuria, diabetes mellitus), poor maternal nutrition such as folic acid deficiency (neural tube defects), newborns who are preterm, newborns who are SGA, oligohydramnios or polyhydramnios - Expected Findings: monitor newborn for evidence of congenital anomalies 1. Cleft Lip/Palate: opening in the lip or palate 2. Tracheoesophageal Atresia: excessive mucous secretions and drooling, periodic cyanotic episodes and choking, abdominal distention after birth, immediate regurgitation after birth 3. Duodenal Atresia: abdominal distention, bilious vomiting, failure to pass meconium in the first 24 hours 4. PKU: can result in cognitive impairment if untreated. not evident at birth, but till be identified with neonatal screening 5. Galactosemia: can result in failure to thrive, cataracts, jaundice, cirrhosis of liver, sepsis, and cognitive impairment if untreated. this will not be evident at birth, but will be identified with neonatal screening 6. Hypothyroidism: can result in hypothermia, poor feeding, lethargy, jaundice, and cretinism if untreated. not evident at birth, can be identified at 6 weeks by manifestations of bradycardia, abdominal distention, coarse dry hair, and thick dry skin, which can progress to delayed CNS development 7. Neurologic Anomalies (Spina Bifida): protrusion of the meninges and/or spinal cord 8. Hydrocephalus: enlarged head and bulging fontanels. sunsetting sign is common in which the whites of the eyes are visible above the iris 9. Patent Ductus Arteriosus: murmurs, abnormal HR or rhythm, breathlessness, and fatigue while feeding 10. Tetralogy of Fallot: respiratory difficulties, cyanosis, tachycardia, tachypnea, and diaphoresis 11. Down Syndrome: oblique palpebral fissures or upward slant of eyes, epicanthal folds, flat facial profile with a depressed nasal bridge and a small nose, protruding tongue, small low set ears, short broad hands with a 5th finger that has 1 flexion crease instead of 2, deep crease across the center of the palm (called simian crease), hyperflexibility, hypotonic muscles - Diagnostics: prenatal screening for congenital anomalies can be done by ultrasound and multiple-marker screening (triple and quad screen). confirmation of a diagnosis depends on the anomaly. prenatal diagnosis or confirmation of congenital anomalies is often made by amniocentesis, chorionic villi sampling, or ultrasound. pulse oximetry readings for CHD. routine testing of newborns for metabolic disorders (inborn errors of metabolism) include: a Guthrie test for PKU is done to show elevations of phenylalanine in the blood and urine. it is not reliable until the newborn has ingested sufficient amounts of protein. monitor blood and urine levels of galactose (galactosemia). measure thyroxine (hypothyroidism). cytologic studies (karyotyping of chromosomes), such as a buccal smear, uses cells scraped from the mucosa from inside the newborns mouth - Nursing Care: nursing interventions for congenital anomalies are dependent on the type and extent of the anomaly. establish and maintain adequate respiratory status. establish and maintain extrauterine circulation. establish and maintain adequate thermoregulation. administer medications as prescribed such as thyroid replacement for hypothyroidism. educate parents regarding preoperative and postoperative treatment procedures. encourage parents to hold, touch, and talk to newborn. ensure parents provide consistent care to newborn. provide parents with information about parent groups or support systems 1. Neurologic Anomalies (Spina Bifida): protect the membrane with a sterile covering and plastic to prevent drying. observe for leakage of cerebrospinal fluid. handle the newborn gently by positioning them prone to prevent trauma. prevent infection by keeping the area free from contamination by urine and feces. measure the circumference of the newborns head to identify hydrocephalus. assess newborn for increased intracranial pressure 2. Hydrocephalus: frequently reposition the newborns head to prevent sores. measure the newborns head circumference daily. assess for manifestations of increased intracranial pressure (vomiting, shrill cry) 3. Patent Ductus Arteriosus: educate the parents about surgical treatment 4. Tetralogy of Fallot: conserve the newborns energy to reduce the workload on the heart. administer gavage feedings, or give oral feedings with a specialized nipple. elevate the newborn's head and shoulders to improve respirations and reduce the cardiac workload. prevent infection. place the newborn in a knee-chest position during respiratory distress 5. Cleft Lip/Palate: encourage expression of parental concerns, grief, and fears. monitor the newborns weight daily while hospitalized. monitor for manifestations of dehydration. encourage parental attachment. suction nose and mouth gently with bulb syringe as needed to clear airway. position infant facilitate drainage of secretions. educate parents on feeding requirements of infants Nutrition 1. Cleft Lip/Palate: determine the most effective nipple for feeding. can use specialized bottles, cups, or syringes to feed the infant. infants who have cleft lip can achieve breastfeeding with changes in positioning. feed the newborn in the upright position to decrease aspiration risk. feed the newborn slowly, and burp them frequently so that they do not swallow air. cleanse the mouth with water after feedings 2. Tracheoesophageal Atresia: withhold feedings until esophageal patency is determined. elevate the head of the newborns crib to prevent gastric juice reflex. supervise the first feeding to observe for this anomaly 3. Duodenal Atresia: withhold feedings until surgical repair is done and newborn has begun to pass stools. administer IV fluids as prescribed. monitor for jaundice 4. PKU: specialized synthetic formula in which phenylalanine is removed or reduced. parent should restrict meat, dairy products, diet drinks (artificial sweeteners), and proteins during pregnancy. aspartame must be avoided 5. Galactosemia: give the newborn a soy-based formula because galactose is present in milk. eliminate lactose and galactose in the newborns diet. breastfeeding is contraindicated

Newborn Complications: Hypoglycemia: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: newborns source of glucose stops when the umbilical cord is clamped. if newborns have other physiological stress, they can experience hypoglycemia due to inadequate gluconeogenesis or increased use of glycogen stores. newborn glucose should be between 40-60mg/dL. hypoglycemia in the first 3 days of life is defined as levels less than 40mg/dL. untreated can result in seizures, brain damage, or death - Risk Factors: maternal diabetes mellitus, preterm infant, LGA or SGA, stress at birth (cold stress, asphyxia) - Expected Findings: poor feeding, jitteriness/tremors, hypothermia, weak cry, lethargy, flaccid muscle tone, seizures/coma, irregular respirations, cyanosis, apnea - Labs: obtain a lab specimen to verify a bedside glucose finding less than 45mg/dL - Nursing Care: obtain blood by heel stick for glucose monitoring. an asymptomatic at risk newborn who has a blood glucose level less than 25mg/dL in the first 4 hours, or less than 35mg/dL from 4 hours to 24 hours of age, should be offered oral feedings to increase levels to greater than 45mg/dL. initiate IV dextrose for a symptomatic newborn. provide frequent oral and/or gavage feedings or continuous parenteral nutrition early after birth to treat hypoglycemia. monitor the neonate's blood glucose level closely per protocol. monitor IV if neonate is unable to feed orally. maintain skin to skin contact to treat hypothermia

Infant Complications: Respiratory Distress Syndrome: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: occurs as a result of surfactant deficiency in the lungs and is characterized by poor gas exchange and ventilatory failure. complications related to RDS include pneumothorax, pneumomediastinum, retinopathy of prematurity, bronchopulmonary dysplasia, infection, and intraventricular hemorrhage - Risk Factors: preterm gestation, perinatal asphyxia, maternal diabetes mellitus, PROM, maternal use of barbiturates or narcotics close to birth, cesarean birth, multifetal, cold stress, sepsis, airway obstruction, hypoglycemia - Expected Findings: tachypnea (resp. greater than 60/min.), nasal flaring, grunting, retractions, labored breathing with prolonged expiration, fine crackles on auscultation, cyanosis, unresponsiveness, flaccidity, and apnea with decreased breath sounds - Labs: culture and sensitivity of the blood, urine, and cerebrospinal fluid. blood glucose - Meds 1. Beractant, Poractant Alfa, Calfactant: lung surfactant. prescribed for newborns who are premature and have RDS. it restores surfactant and improves respiratory compliance. nursing actions includes performing a respiratory assessment including ABGs, respiratory rhythm, and rate and color before and after administration of agent. provide suction to newborn prior to administration of medication. assess endotracheal tube placement. avoid suctioning of endotracheal tube for 1 hour after administration of the medication - Diagnostics: ABGs reveal hypercapnia (excess CO2 in blood) and respiratory or mixed acidosis. chest x-ray - Nursing Care: suction newborns mouth, trachea, and nose as needed. maintain thermoregulation. correct respiratory acidosis with ventilatory support. correct metabolic acidosis by administering sodium bicarbonate. maintain adequate oxygenation, prevent lactic acidosis, and void toxic effects of oxygen. decrease environmental stimuli

Infant Complications: Congenital Hypothyroidism: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: occurs due to an absent or nonfunctioning thyroid gland in a newborn. thyroid hypofunction can be caused by maternal iodine deficiency or maternal anti-thyroid medications during pregnancy - Risk Factors: female, low birth weight or birth weight greater than 4.5kg (4,500g), and maternal low iodine levels during pregnancy - Expected Findings: excessive sleeping, enlarged tongue, respiratory difficulty, poor sucking, cool and dry skin on extremities, jaundice, subnormal temperature and respiratory rate and pulse, short and thick neck, hypotonia with decreased deep tendon reflexes, and abdominal distention and constipation - Labs: newborn metabolic screen for blood spot analysis performed within 2 days of birth. T3, T4, and TSH levels. blood lipid levels - Meds: synthetic thyroid hormone (sodium levothyroxine), vitamin D - Diagnostics: X-rays to evaluate bone growth. ultrasound of thyroid - Nursing Care: monitor vital signs. monitor respiratory status. monitor weight. assess for feeding difficulties. treatment is administration of synthetic thyroid hormone (sodium levothyroxine). administer medication as prescribed. medication must be taken indefinitely. administer supplemental vitamin D to support rapid bone growth. monitor thyroid levels (T4, T4, and TSH) - Patient Education: understand the importance of proper medication administration

Newborn Complications: Birth Trauma or Injury: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: occurs during childbirth resulting in physical injury to a newborn. most injuries are minor and resolve rapidly. other injuries can require some intervention. few are serious enough to be fatal. types of birth injuries include: 1. Skull: linear fracture, depressed fracture 2. Scalp: caput succedaneum, hemorrhage 3. Intracranial: epidural or subdural hematoma, contusions 4. Spinal Cord: spinal cord transaction or injury, vertebral artery injury 5. Plexus: brachial plexus injury, Klumpke's palsy 6. Cranial and Peripheral Nerve: radial nerve palsy, diaphragmatic paralysis - Risk Factors: maternal age is younger than 16 or older than 35, fetal macrosomia, abnormal or difficult presentations, prolonged labor, precipitous labor, oligohydramnios, cephalopelvic disproportion, multifetal gestation, congenital abnormalities, internal FHR monitoring, forceps or vacuum extraction, external version, cesarean birth - Expected Findings: irritability, seizures within the first 72 hours, and decreased level of consciousness are manifestations of a subarachnoid hemorrhage. facial flattening and unresponsiveness to grimace that accompanies crying or stimulation, as well as eyes remaining open, are findings to assess for facial paralysis. a weak or hoarse cry is characteristic of laryngeal nerve palsy from excessive traction on the neck. flaccid muscle tone can signal joint dislocations and separation during birth. flaccid muscle tone of extremities suggests nerve plexus injuries or long bone fractures. flaccid arm with the elbow extended and the hand rotated inward, absence of the moro reflex on the affected side, sensory loss over the lateral aspect of the arm, and intact grasp reflex are manifestations of Erb-Duchenne paralysis (brachial paralysis). localized discoloration, ecchymosis, petechiae, and edema over the presenting part seen with soft-tissue injuries - Diagnostics: birth injuries are normally diagnosed by a CT scan, X-Rat of suspected area of fracture, or neurological exam to determine paralysis of nerves - Nursing Care: review maternal history for factors that can predispose the newborn to injuries. review APGAR scoring that might indicate a possibility of birth injury. perform frequent head to toe physical assessments. obtain vital signs and temperature. promote parent-newborn interaction as much as possible. administer treatment to the newborn based on the injury and according to the providers prescriptions - Patient Education: discharge instructions include understanding the injury and management of the injury, and perform parent-newborn bonding

Postpartum Complications: Postpartum Hemorrhage: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: occurs if the client loses more than 500mL of blood after vaginal birth, or more than 1,000mL of blood after a cesarean birth. two complications that can occur following PPH is hypovolemic shock and anemia - Risk Factors: uterine atony or history of uterine atony, overdistended uterus, prolonged labor or oxytocin induced labor, high parity, ruptured uterus, complications during pregnancy, precipitous delivery, administration of magnesium sulfate therapy during labor, lacerations and hematomas, inversion of uterus, subinvolution of the uterus, retained placental fragments, and coagulopathies (DIC) - Expected Findings: increase or change in lochia pattern (return to previous stage, large clots). physical assessment findings include uterine atony (hypotonic or boggy), blood clots larger than a quarter, perineal pad saturation in 15 minutes or less. constant oozing, trickling, or frank flow of bright red blood from the vagina. tachycardia and hypotension. pallor of skin and mucous membranes, cool, and clammy with loss of turgor. oliguria - Labs: Hgb and Hct, coagulation profile (PT), blood type and crossmatch - Meds 1. Oxytocin: uterine stimulant that promotes uterine contractions. nursing actions include assess uterine tone and vaginal bleeding. monitor for adverse reactions of water intoxication (lightheadedness, nausea, vomiting, headache, malaise). these reactions can progress to cerebral edema with seizures, coma, and death 2. Methylergonovine: uterine stimulant that controls postpartum hemorrhage. nursing actions include assess uterine tone and vaginal bleeding. don't administer to clients who have hypertension. monitor for adverse reactions including hypertension, nausea, vomiting, and headache 3. Misoprostol: uterine stimulant that controls postpartum hemorrhage. nursing actions include assess uterine tone and vaginal bleeding 4. Carboprost Tromethamine: uterine stimulant that controls postpartum hemorrhage. nursing actions include assess uterine tone and vaginal bleeding. monitor for adverse reactions including fever, hypertension, chills, headache, nausea, vomiting, and diarrhea - Nursing Care: firmly massage the uterine fundus. monitor vital signs. assess for source of bleeding including assess fundus for height, firmness, and position. if uterus is boggy, massage fundus to increase muscle contraction. assess lochia for color, quantity, and clots. assess for clinical findings of bleeding from lacerations, episiotomy site, or hematomas. assess bladder for distention. insert and indwelling urinary catheter to assess kidney function and obtain an accurate measurement of urinary output. maintain or initiate IV fluids to replace fluid volume loss with IV isotonic solutions, such as lactated Ringer's or 0.9% sodium chloride, colloid volume expanders such as albumin, and blood products (packed RBCs and fresh frozen plasma). provide oxygen at 10-12L/min. via nonrebreather face mask, and monitor oxygen saturation. elevate clients legs to a 20-30 degree angle to increase circulation to essential organs - Patient Education: limit physical activity to conserve strength, to increase iron and protein to promote the rebuilding of RBC volume, and to take iron with vitamin C to enhance absorption

Postpartum Complications: Retained Placenta: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: placenta or fragments of the placenta remain in the uterus and prevent the uterus from contracting, which can lead to uterine atony or subinvolution. a placenta that has not been delivered within 30 minutes of the birth is a retained placenta - Risk Factors: partial separation of a normal placenta, entrapment of a partially or completely separated placenta by a constricting ring of the uterus, excessive traction on the umbilical cord prior to complete separation of the placenta, placental tissue that is abnormally adherent to the uterine wall, and preterm births between 20-24 weeks of gestation - Expected Findings: physical assessment findings include uterine atony, subinvolution, or inversion. excessive bleeding or blood clots larger than a quarter. return of lochia rubra once lochia has progressed to serosa alba. malodorous lochia or vaginal discharge. elevated temperature - Labs: Hgb and Hct - Meds 1. Oxytocin: to expel retained fragments of the placenta. uterine stimulant that promotes uterine contractions and expels the retained fragments of the placenta. nursing actions include assess uterine tone and vaginal bleeding, and monitor for adverse reactions of water intoxication (lightheadedness, nausea, vomiting, headache, malaise) which can progress to cerebral edema with seizures, coma, and death - Diagnostics: manual separation and removal of the placenta is done by the provider. D&C if oxytocic's are ineffective in expelling the placental fragments - Nursing Care: monitor the uterus for fundal height, consistency, and position. monitor lochia for color, amount, consistency, and odor. monitor vital signs. maintain or initiate IV fluids. anticipate surgical interventions (D&C, hysterectomy) if postpartum bleeding is present and continues - Patient Education: after becoming stable, limit physical activity to conserve strength. increase iron and protein intake to promote the rebuilding of RBC volume

Antepartum Complications: Spontaneous Abortion: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: pregnancy ends as result of natural causes before 20 weeks gestation. types include threatened, inevitable, incomplete, complete, and missed - Risk Factors: chromosomal abnormalities, maternal illness (such as type 1 diabetes mellitus), advanced maternal age, premature cervical dilation, chronic maternal infections, maternal malnutrition, trauma or injury, anomalies in fetus or placenta, substance use, and antiphospholipid syndrome - Expected Findings: abdominal cramping or pain, rupture of membranes, dilation of cervix, fever, manifestations of hemorrhage (hypotension, tachycardia) - Labs: Hgb and Hct if considerable blood loss, clotting factors monitored for disseminated intravascular coagulopathy (DIC) a complication with retained products of conception, WBC for suspected infection, serum human chorionic gonadotropic (hCG) levels to confirm pregnancy - Meds: analgesics and sedatives, prostaglandin as a vaginal suppository, oxytocin, broad-spectrum antibiotics in septic abortion, Rho(D) immune globulin, suppresses immune response of clients who are Rh-negative - Diagnostics: ultrasound to determine presence of viable or dead fetus, or partial or complete products of conception within the uterine cavity. exam of cervix to observe if it is opened or closed. dilation and curettage (D&C) to dilate and scrape the uterine walls to remove uterine contents for inevitable and incomplete abortions, dilation and evacuation (D&E) to dilate and evacuate uterine contents after 16 weeks gestation. prostaglandins and oxytocin to augment or induce uterine contractions and expulse products of conception - Nursing Care: perform pregnancy test, observe color and amount of bleeding (count pads), maintain client on bed rest, inform client of risks for falls due to sedative medications prescribed, avoid vaginal exams, assist with ultrasound, administer medications and blood products as prescribed, determine how much tissue has passed and save passed tissue for examination, assist with termination of pregnancy as indicated, use lay term "miscarriage" with clients because the medical term "abortion" can be misunderstood, provide client education and emotional support, and provide referral for client and partner to pregnancy loss support groups - Patient Education: notify provider of heavy, bright red vaginal bleeding, elevated temperature, or foul-smelling vaginal discharge. small amount of discharge is normal 1-2 weeks. take prescribed antibiotics. refrain from tub baths, sexual intercourse, or placing anything into vagina for 2 weeks. discuss grief and loss with the provider before attempting another pregnancy

Antepartum Complications: Abruptio Placentae: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: premature separation of the placenta from the uterus, which can be a partial or complete detachment. occurs after 20 weeks gestation, usually in the third trimester. has significant maternal and fetal morbidity and mortality and is a leading cause of maternal death. coagulation defect, such as disseminated intravascular coagulopathy (DIC), is often associated with moderate to severe abruption - Risk Factors: maternal hypertension (chronic or gestational), blunt external abdominal trauma (motor-vehicle crash, maternal bleeding), cocaine use resulting in vasoconstriction, previous incidents of abruptio placentae, cigarette smoking or other nicotine use, premature rupture of membranes, and multifetal pregnancy - Expected Findings: sudden onset of intense localized uterine pain with dark red vaginal bleeding. area of uterine tenderness can be localized or diffuse over uterus and board like. contractions with hypertonicity. fetal distress. clinical findings of hypovolemic shock - Labs: Hgb and Hct decreased, coagulation factors decreased, clotting defects (disseminated intravascular coagulation), cross and type match for possible transfusions, Kleihauer-Betke Test (used to detect fetal blood in maternal circulation) - Diagnostics: ultrasound for fetal well-being and placental assessment. biophysical profile to ascertain fetal well-being - Nursing Care: palpate the uterus for tenderness and tone. perform serial monitoring of the fundal height. assess FHR pattern. immediate birth is the management. administer IV fluids, blood products, and medications as prescribed. administer oxygen 8-10L/min. via face mask. monitor maternal vital signs, observing for declining hemodynamic status. perform continuous fetal monitoring. assess urinary output and monitor fluid balance. provide emotional support for client and family

Infant Complications: Newborn Sepsis: Patho? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: presence of micro-organisms or their toxins in the blood or tissues of the newborn during the first month after birth. manifestations are subtle and resemble other diseases - Risk Factors: nosocomial exposure in the NICU, premature birth, PROM, maternal infection, invasive procedures, TPN, congenital anomalies, diminished immune response - Expected Findings: temperature instability, suspicious drainage, poor feeding pattern, vomit, diarrhea, poor weight gain, abdominal distention, large residual if feeding by gavage, apnea, retractions, grunting, cyanosis, and nasal flaring. decreased O2. color changes. tachycardia or bradycardia. tachypnea or apnea. low BP. irritability and seizure activity. poor muscle tone and lethargy - Labs: CBC. blood, urine, and cerebrospinal fluid cultures and sensitivities. positive blood cultures indicate presence of infection/sepsis. chemical profile shows a fluid and electrolyte imbalance - Meds: combination of ampicillin with an aminoglycoside or a third generation cephalosporin. nursing actions include initiating and maintaining respiratory support as needed. assess IV site for evidence of infection. provide newborn care to maintain temperature. maintain standard precautions. clean and sterilize all equipment to be used - Nursing Care: assess infection risks. monitor for findings of opportunistic infection. monitor vital signs. monitor I&O and daily weight. monitor fluid and electrolyte status. restrict any visitors with infections. obtain specimens to assist in identifying the causative organism. initiate and maintain IV therapy as prescribed to administer electrolyte replacements, fluids, and medications. administer medications as prescribed - Patient Education: demonstrate to client and family how to perform proper infection control measures and hand washing. understand infection control. understand how to properly use clean bottles and nipples for each feeding. discard any unused formula. supervise hand hygiene. ensure adequate rest for newborn, and decrease physical stimulation. provide emotional support to the family

Antepartum Complications: Gestational Trophoblastic Disease: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: proliferation and degeneration of trophoblastic villi in the placenta that becomes swollen, fluid-filled, and takes on the appearance of grape-like clusters. embryo fails to develop beyond a primitive state and these structures are associated with choriocarcinoma, which is a rapidly metastasizing malignancy. two types of molar growths include complete mole and partial mole a) Complete Mole: all genetic material is paternally derived, ovum has no genetic material or material is inactive, contains no fetus, placenta, amniotic membranes or fluid. no placenta to receive maternal blood. hemorrhage into uterine cavity occurs, and vaginal bleeding results. approx. 20% of complete moles progress toward a choriocarcinoma b) Partial Mole: genetic material derived from maternally and paternally. normal ovum is fertilized by 2 sperm or 1 sperm in which meiosis or chromosome reduction and division did not occur. often contains abnormal embryonic or fetal parts, an amniotic sac, and fetal blood, but congenital anomalies are present. approx. 6% of partial moles progress toward a choriocarcinoma - Risk Factors: prior molar pregnancy, clients in early teenage years or older than age 40 - Expected Findings: excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels. rapid uterine growth more than expected for duration of pregnancy due to overproliferation of trophoblastic cells. bleeding is often dark brown resembling prune juice, or bright red that is either scant or profuse and continues for a few days or intermittently for a few weeks and can be accompanied by passage of vesicles. anemia from blood loss. clinical findings of pre-eclampsia that occur prior to 24 weeks gestation - Labs: serum level of hCg is persistently high compared with expected decline after weeks 10-12 of pregnancy - Meds: Rho(D) immune globulin to client who is Rh-negative. chemotherapeutic medications for findings of malignant cells indicating choriocarcinoma - Diagnostics: ultrasound reveals a dense growth with characteristic vesicles, but no fetus in utero. suction curettage is done to aspirate and evacuate the mole. post-surgery, Rh-negative clients are given Rho(D)immune globulin. following mole evacuation, client should undergo a baseline pelvic exam and ultrasound scan of the abdomen. serum hCG analysis following molar pregnancy to be done weekly for 3 weeks, then monthly for 6 months up to 1 year to detect GTD - Nursing Care: measure fundal height. assess vaginal bleeding and discharge. assess GI status and appetite. monitor for manifestations of pre-eclampsia. administer medications as prescribed. Rho(D) immune globuline to the client who is Rh-negative. chemotherapeutic medications for findings of malignant cells indicating choriocarcinoma. advise client to save clots or tissue for evaluation. provide client education and emotional support - Patient Education: consider pregnancy loss support groups referred by the nurse. use reliable contraception as a component of follow-up care. avoid using an intrauterine device (IUD). follow-up is important due to increased risk of choriocarcinoma

Newborn Complications: Respiratory Distress Syndrome (RDS)/Asphyxia/Meconium Aspiration: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: result of surfactant deficiency in the lungs and is characterized by poor gas exchange and ventilatory failure. surfactant is a phospholipid that assists in alveoli expansion. surfactant keeps alveoli from collapsing and allows gas exchange to occur. atelectasis (collapsing of a portion of lung) increases the work of breathing. as a result, respiratory acidosis and hypoxemia can develop. birth weight alone is not an indicator of fetal lung maturity. complications from RDS are related to oxygen therapy and mechanical ventilation. pneumothorax, pneumomediastinum, retinopathy of prematurity, bronchopulmonary dysplasia, infection, and intraventricular hemorrhage - Risk Factors: preterm gestation, perinatal asphyxia (meconium staining, cord prolapse, nuchal cord), maternal diabetes mellitus, PROM, maternal use of barbiturates or narcotics close to birth, maternal hypotension, cesarean birth without labor, hydrops fetalis (massive edema of fetus caused by hyperbilirubinemia), maternal bleeding during third trimester, hypovolemia, genetics: white males - Expected Findings: tachypnea (resp. rate greater than 60/min.), nasal flaring, expiratory grunting, retractions, labored breathing with prolonged expiration, fine crackles on auscultation, cyanosis, unresponsiveness, flaccidity, and apnea with decreased breath sounds (manifestations of worsened RDS) - Labs: ABGS, CBC with differential, culture and sensitivity of the blood, urine, and cerebrospinal fluid. blood glucose - Meds 1. Beractant, Calfactant, Lucinactant - Classification: lung surfactant - Intended Effect: restores surfactant and improves respiratory compliance for newborns who are premature and have RDS - Nursing Actions: perform a respiratory assessment including ABGs, respiratory rhythm, and rate and skin color before and after administration of agent. provide suction to newborn prior to administration of medication. assess endotracheal tube placement. avoid suctioning of the endotracheal tube for 1 hour after administration of the medication. factors that can accelerate lung maturation in the fetus while in utero include increased gestational age, intrauterine stress, exogenous steroid use, and ruptured membranes - Diagnostics: chest X-Ray - Nursing Care: suction newborns mouth, trachea, and nose as needed. maintain thermoregulation. provide mouth and skin care. correct respiratory acidosis with ventilatory support. correct metabolic acidosis by administering sodium bicarbonate. maintain adequate oxygenation, prevent lactic acidosis, and avoid toxic effects of oxygen. monitor pulse oximetry. provide parenteral nutrition as prescribed. monitor lab results, I&O, and weight to evaluate hydration status. decrease stimuli

Postpartum Complications: Uterine Atony: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: results from inability of the uterine muscle to contract adequately after birth. can lead to postpartum hemorrhage - Risk Factors: retained placental fragments, prolonged or precipitous labor, oxytocin induction or augmentation of labor, overdistention of the uterine muscle, magnesium sulfate administration as a tocolytic, anesthesia and analgesia administration, trauma during labor and birth from operative delivery (forceps, vacuum, cesarean) - Expected Findings: increased vaginal bleeding. physical assessment findings include uterus that is larger than normal and boggy with possible lateral displacement on palpation, prolonged lochial discharge, irregular or excessive bleeding, tachycardia and hypotension, pallor of skin and mucous membranes and cool and clammy with loss of turgor - Meds: as noted for postpartum hemorrhage - Diagnostics: bimanual compression or manual exploration of the uterine cavity for retained placental fragments by the provider. surgical management, such as a hysterectomy - Nursing Care: ensure the urinary bladder is empty. monitor the fundal height, consistency, and location. monitor lochia for quantity, color, and consistency. perform fundal massage if indicated. if uterus becomes form, continue assessing hemodynamic status. if uterine atony persists, anticipate surgical intervention, such as a hysterectomy. express clots that can have accumulated in the uterus, but only after the uterus is firmly contracted. it is critical not to express clots prior to the uterus becoming firmly contracted, because pushing on an uncontracted uterus can invert the uterus and result in extensive hemorrhage. monitor vital signs. maintain or initiate IV fluids - Patient Education: rapid intervention is required. health care team will explain the purpose of the interventions as they are performed. after becoming stable, limit physical activity to conserve strength. increase iron and protein intake to promote the rebuilding of RBC volume

STIs: HIV/AIDS: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: retrovirus that attacks and causes destruction of T lymphocytes. causes immunosuppression in the client. client severely immunosuppressed develop AIDS. HIV is transmitted from the mother to a neonate perinatally through the placenta and postnatally through breast milk - Labs: obtain informed maternal consent prior. testing begins with an antibody screening test, such as enzyme immunoassay (EIA). confirmation of positive results is conformed by western blot test or immunofluorescence assay. use rapid HIV antibody test for client in labor. screen clients for STIs. obtain frequent viral load levels and CD4 cell counts throughout pregnancy - Nursing Care: goal is to keep CD4 cell counts greater than 500cells/mm^3. provide counseling prior to and after testing. refer client for mental health consultation, legal assistance, and financial resources. use standard precautions. administer antiretroviral prophylaxis, triple medication antiretroviral, or highly active antiretroviral therapy as prescribed. encourage immunization against hep. B, pneumococcal infection, haemophilus influenzae type B, and viral influenza. encourage use of condoms' to minimize exposure of partner to infection. review plan for scheduled caesarean birth at 38 weeks for maternal viral load of more than 1,000copies/mL. vaginal birth can be an option for a client who has a viral load of less than 1,000 copies/mL at 36 weeks of gestation. wear gloves when caring for newborn after delivery. infant should be bathed after birth before remaining with the mother - Patient Education: discuss HIV and safe sex with client. continue to use barrier protection during sexual activity to prevent further exposure to HIV virus, which would increase the viral load. discharge instructions include do not breastfeed, consider meeting with providers specializing in care of HIV clients. report disease by provider

STIs: HPV: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: some types can cause genital warts and cervical cancers. spread through oral, vaginal, and anal sex. when large, widespread, it can occlude the birth canal, genital warts can complicate vaginal delivery - Labs: pap test with or without HPV co-testing. females 21-39 should have pap every 3 years, females 30-65 should have pap and HPV test every 5 years, females older than 65 should have regular screenings - Diagnostics: genital warts can be diagnosed by the provider based on appearance during physical exam. based on pap result, colposcopy and biopsy can be performed to diagnose cervical precancer and cancer - Patient Education: vaccines are recommended to protect against low-risk types of HPV that cause genital warts and high risk types of HPV that cause cancer. vaccine is indicated for ages 9-26 years, ideally at 11-12 years old. three doses of the vaccine will be received during a 6 month period. consider abstinence or safe sex. if therapy is deferred until after delivery, remember that lesions are infectious

STIs: Trichomoniasis: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: spread penis to vagina or vagina to vagina - Labs: sample of discharge is used for application to pH paper, and a wet mount and whiff test is performed - Diagnostics: wet mount saline prep indicates the presence of trichomonad. pap smear can detect presence of trichomonads - Nursing Care: identify and treat all sexual partners. educate client regarding safe sex - Patient Education: avoid alcohol while taking this medication and for 3 days after treatment due to the disulfiram-like reaction that occurs (severe nausea, vomiting). take all medication as prescribed. understand the possibility of decreasing effectiveness of oral contraceptives

Postpartum Complications: Deep-Vein Thrombosis: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: thrombophlebitis is a thrombus that is associated with inflammation. thrombophlebitis of the lower extremities can be superficial or deeps veins. associated with the femoral, saphenous, or popliteal veins. postpartum client greatest risk for deep vein thrombosis (DVT) and can lead to a pulmonary embolism - Risk Factors: pregnancy, cesarean birth, operative vaginal birth, pulmonary embolism or varicosities, immobility, obesity, smoking, multiparity, age greater than 35 years, history of thromboembolism - Expected Findings: leg pain and tenderness. physical assessment findings include unilateral area of swelling, warmth, and redness. hardened vein over the thrombosis. calf tenderness 1. Heparin: anticoagulant that's given IV to prevent formation of other clots and to prevent enlargement of the existing clot. nursing actions include initially, IV heparin is administered by continuous infusion for 3-5 days with doses adjusted according to coagulation studies. protamine sulfate, the heparin antidote, should be readily available to counteract the development of heparin-induced antiplatelet antibodies. monitor aPTT (1.5-2.5 times the control level of 30-45 seconds). client education includes report bleeding from the gums or nose, increased vaginal bleeding, blood in urine, and frequent bruising 2. Warfarin: anticoagulant used for treatment of clots. it is administered orally and is continued by the client for approx. 3 months. nursing actions include phytonadione, the warfarin antidote, should be readily available for prolonged clotting times. monitor PT (1.5-2.5 times the control level of 11-12.5 seconds) and INR of 2-3. client education includes watch for bleeding from the gums or nose, increased vaginal bleeding, blood in urine, and frequent bruising. use birth control to avoid pregnancy due to the teratogenic effects of warfarin. oral contraceptives are contraindicated because of the increased risk for thrombosis - Diagnostics: doppler ultrasound scanning, computed tomography, magnetic resonance imaging - Nursing Care 1. Prevention of Thrombophlebitis: maintain sequential compression device until ambulation established. if bed rest is prolonged longer than 8 hours, use active and passive ROM to promote circulation in legs if warranted. initiate early and frequent ambulation postpartum. measure the lower extremities for fitted elastic thromboembolic hose to lower extremities. client education includes avoid prolonged periods of standing, sitting, or immobility. elevate both legs when sitting. avoid crossing the legs. maintain fluid intake of 2-3L each day from food and beverages to prevent dehydration. discontinue smoking 2. Management of Thrombophlebitis: facilitate bed rest and elevation of the client's extremity above the level of the heart. encourage the client to change positions frequently. administer intermittent or continuous warm moist compresses. DON'T massage the affected limb to prevent thrombus from dislodging and becoming an embolus. measure the client's leg circumferences. provide thigh-high antiembolism stockings for the client at high risk for venous insufficiency. administer analgesics. administer anticoagulants for DVT - Patient Education: precautions while receiving anticoagulants include avoid taking aspirin or ibuprofen (increases bleeding), use an electric razor for shaving, avoid alcohol use (inhibits warfarin), brush teeth gently using a soft toothbrush, avoid rubbing or massaging legs and avoid periods of prolonged sitting or crossing legs

Mobility/DVT: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: thrombus is a clot that forms in a vein or artery. when the formation occurs in a vein its venous thrombosis. DVT is a result of venous thrombosis deep in the muscle tissue. blood clots can travel to the lungs. three factors are associated with the formation of a thrombus (Virchow's Triad) including circulatory stasis, vascular damage, and hypercoagulability. vascular damage stimulates the clotting cascade. platelets aggregate at the site of the trauma, when circulatory stasis is present. platelets and fibrin form the initial clot. RBCs become trapped in the fibrin meshwork, and thrombus grows in the direction of the blood flow. triggers the inflammatory response. causing tenderness, swelling, and erythema in the area of the thrombus - Risk Factors: orthopedic procedures, atrial fibrillation, acute myocardial infarction, and ischemic stroke - Expected Findings: aching pain in the affected extremity, dull or tight feeling in the calf, tenderness, swelling, warmth, cyanosis, and erythema. often asymptomatic - Labs: D-dimer, PT, PTT, activated partial prothrombin time (aPTT), bleeding time, and platelet count - Meds: anticoagulants such as heparin, warfarin, low molecular weight heparins, direct thrombin inhibitors, and factor Xa inhibitors. NSAIDs - Diagnostics: duplex venous ultrasonography (measures velocity of blood flow in veins, and visualizes the vein), plethysmography (measures changes in blood flow through veins), MRI , ascending contrast venography (injected contrast medium to assess location and extent of venous thrombosis) - Nursing Care: elevate legs with slight knee flexion when in bed, apply warm and moist compresses to leg using 2 hours on and off, administer analgesics. monitor lab values to assess effectiveness of anticoagulant therapy. assist with ambulation. inspect legs and feet and record findings every 8 hours - Patient Education: explain venous thrombosis and its treatment to the client

STIs: TORCH Infections: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: toxoplasmosis, other infections (hepatitis), rubella virus, cytomegalovirus, and herpes simplex virus (HIV). group of infections that can negatively affect a pregnant client. infections can cross the placenta and have teratogenic effects on the fetus. rubella can cause fetal consequences, and HSV can cause miscarriage, preterm labor, and IGR - Labs: for herpes, obtain cultures from clients who have HSV or are at or near term - Diagnostics: TORCH screen includes immunologic survey used to identify existence of these infections in the mother (to identify fetal risks) or newborn (detection of antibodies against infections), prenatal screenings - Nursing Care: monitor fetal well-being. for rubella, immunization of clients who are pregnant is contraindicated because rubella infection can develop. these clients should avoid crowds and young children. clients who have low titers prior to pregnancy should receive immunizations. discuss safe sex with client. provide client with emotional support - Patient Education: adhere to prevention practices, including correct hand hygiene and cooking meat properly. avoid contact with contaminated cat litter. prevent exposure of cytomegalovirus by frequent hand hygiene before eating, and after handling infant diapers and toys. cesarean section recommended for clients in labor who have active genital herpes lesions or early findings of impending outbreak (vulvar pain, itching)

Postpartum Complications: Inversion of the Uterus: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: turning inside out of the uterus and can be partial or complete. uterine inversion is an emergency and can result in postpartum hemorrhage and requires immediate intervention - Risk Factors: retained placenta, tocolysis, fetal macrosomia, nulliparity, uterine atony, vigorous fundal pressure, abnormally adherent placental tissue, fundal implantation of the placenta, excessive traction applied to the umbilical cord, short umbilical cord, and prolonged labor - Expected Findings: pain in lower abdomen. physical assessment findings include vaginal bleeding which is a hemorrhage, complete inversion as evidenced by fundus presenting as a mass in the vagina, prolapsed inversion as evidenced by a large and red rounded mass that protrudes 20-30 cm outside the introitus, incomplete inversion as evidenced by the palpation of a smooth mass through the dilated cervix, dizziness, low blood pressure, increased pulse (shock), and pallor - Meds 1. Terbutaline: tocolytic that is used to relax the uterus prior to the provider's attempt at replacement of the uterus into the uterine cavity and uterus repositioning. nursing actions include following replacement of the uterus into the uterine cavity closely observe the client's response to treatment and assess for stabilization of hemodynamic status. avoid aggressive fundal massage. administer oxytocic's as prescribed. administer broad-spectrum antibiotics for infection prophylaxis - Diagnostics: manual replacement of the uterus into the uterine cavity and repositioning of the uterus by the provider - Nursing Care: assess for an inverted uterus including visualize the introitus and perform a pelvic exam. maintain IV fluids. administer oxygen. stop oxytocin if it is being administered at the time uterine inversion occurred. avoid excessive traction on the umbilical cord. anticipate surgery if nonsurgical interventions and management are unsuccessful

STIs: Bacterial Vaginosis (BV): Risks? Signs? Symptoms? Treatment? Curable or Manageable? Impact on Fertility?

- Risks: new or multiple sex partners, unprotected sexual practices - Signs & Symptoms: thin, white, or gray discharge with a fish-like odor, especially after sex. physical assessment findings include discharge in the vaginal vault, which can be sampled for microscopy - Treatment: metronidazole, clindamycin, probiotic lactobacilli used for prevention - Curable or Manageable: curable - Impact on Fertility: related to reduction in the lactobacilli in the vaginal flora. if left untreated, it can increase a woman's chances of developing PID, which can lead to infertility. can cause preterm labor and preterm birth

STIs: Bacterial Vaginosis (BV): Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: vaginal infection most common in females 14-49 years old. it cannot be related to sexual activity. related to reduction in the lactobacilli in the vaginal flora - Labs: sample of the vaginal discharge applied to pH (nitrazine) paper. saline and potassium hydroxide (KOH) wet smear test - Diagnostics: pH greater than 4.5 wet mount saline prep, which indicates presence of clue cells. positive whiff test with release of fishy odor - Patient Education: avoid alcohol while taking metronidazole due to a disulfiram-like reaction (severe nausea and vomiting). take all medications as prescribed. understand the possibility of decreasing effectiveness of oral contraceptives. treatment is not usually indicated for sexual partners, but recommended to prevent recurrence. adhere to safe sex

Antepartum Complications: Vas Previa: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: when the fetal umbilical vessels implant into the fetal membranes rather than the placenta. variations include velamentous insertion of the cord, succenturiate insertion of the cord, and battledore insertion of the cord a) Velamentous Insertion of the Cord: cord vessels begin in the branch at the membranes and then course to the placenta b) Succenturiate Insertion of the Cord: placenta has divided into 2 or more lobes and not 1 mass c) Battledore Insertion of the Cord: marginal insertion. increased risk of fetal hemorrhage - Diagnostics: ultrasound for fetal well-being and vessel assessment - Nursing Care: closely monitor the client during labor and delivery for excessive bleeding

Antepartum Complications: Placenta Previa: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus. abnormal implantation results in bleeding during the third trimester of pregnancy as the cervix begins to dilate and efface. three types dependent on the degree to which the cervical os is covered by the placenta includes complete or total, incomplete or partial, marginal, and low-lying a) Complete or Total: cervical os is completely covered by placental attachment b) Incomplete or Partial: cervical os is only partially covered by the placental attachment c) Marginal: placenta is attached to the lower uterine segment but does not reach the cervical os d) Low-Lying: exact relationship of the placenta to the internal os has not been determined - Risk Factors: previous placenta previa, uterine scarring (previous cesarean birth, curettage, endometritis), maternal age greater than 35 years, multifetal gestation, multiple gestations, smoking - Expected Findings: painless, bright red vaginal bleeding during the second or third trimester. uterus soft, relaxed, and nontender with normal tone. fundal height greater than usually expected for gestational age. fetus in a breech, oblique, or transverse position. reassuring FHR. vital signs with normal limits. decreasing urinary output, which can be a better indicator of blood loss - Labs: Hgb and Hct for blood loss assessment, CBC, blood type and Rh, coagulation profile, Kleihauer-Betke Test (used to detect fetal blood in maternal circulation) - Meds: corticosteroids to promote fetal lung maturation if early delivery is anticipated (cesarean birth) - Diagnostics: transabdominal or transvaginal ultrasound for placement of the placenta. fetal monitoring for fetal well-being assessment - Nursing Care: assess for bleeding, leakage, or contractions. assess fundal height. refrain from performing vaginal exams (can exacerbate bleeding). administer IV fluids, blood products, and medications as prescribed. corticosteroids, such as betamethasone, promote fetal lung maturation if early delivery is anticipated (cesarean birth). have oxygen equipment available in case of fetal distress - Patient Education: adhere to bed rest. do not insert anything into the vagina because it can worsen bleeding

Postpartum Complications: Subinvolution of the Uterus: Pathophysiology of Diagnosis? Risk Factors? Expected Findings? Labs? Meds? Diagnostics? Nursing Care? Patient Education?

- Patho: when the uterus remains enlarged with continued lochial discharge and can result in postpartum hemorrhage - Risk Factors: pelvic infection and endometritis. retained placental fragments not completely expelled from the uterus - Expected Findings: prolonged vaginal bleeding, and irregular or excessive vaginal bleeding. physical assessment findings include uterus that is enlarged and higher than normal in the abdomen relative to the umbilicus, boggy uterus, and prolonged lochia discharge with irregular or excessive bleeding - Labs: blood, intracervical, and intrauterine bacterial cultures to check for evidence of infection and endometritis - Meds 1. Methylergonovine: uterine stimulant used to promote uterine contractions and expel the retained fragments of the placenta. nursing actions include assess the uterine tone and vaginal bleeding, and assess for signs of infection such as increased uterine tenderness 2. Antibiotic Therapy: can be prescribed to prevent or treat infection - Diagnostics: dilation and curettage (D&C) is performed by the provider to remove retained placental fragments or to debride placenta insertion site, if indicated - Nursing Care: monitor fundal position and consistency. monitor lochia for color, amount, consistency, and odor. monitor vital signs. encourage the client to use activities that can enhance uterine involution including breastfeeding, early and frequent ambulation, and frequent voiding

STIs: HIV/AIDS: Risks? Signs? Symptoms? Treatment? Curable or Manageable? Impact on Fertility?

- Risks: IV drug use, multiple sexual partners, maternal history of multiple STIs - Signs & Symptoms: fatigue and influenza like findings. fever, diarrhea, weight loss, lymphadenopathy, rash, anemia - Treatment 1. Antiretroviral Therapy (ART): all HIV infected clients should be treated with combination therapy. this is given orally and should be taken ASAP throughout pregnancy and before the onset of labor or cesarean birth. ART can cause bone marrow suppression 2. Highly Active Antiretroviral Therapy (HAART): decreases the transmission to the child. intrapartum includes IV zidovudine 3 hours prior to scheduled cesarean section until birth. nurse should administer zidovudine to the infant at delivery and for 6 weeks following birth - Curable or Manageable: manageable - Impact on Fertility: HIV is transmitted from the mother to a neonate perinatally through the placenta and postnatally through the breast milk. treatment and early identification decreases the incidence of perinatal transmission. avoid amniocentesis and episiotomy to avoid the risk of maternal blood exposure. use of internal fetal monitors, vacuum extraction, and forceps during labor should be avoided due to risk of fetal bleeding. newborn administration of injections and blood testing shouldn't take place until after first bath. if HIV positive and taking antiviral medications, client should be informed that they can transmit the infection to the neonate

STIs: Group B Streptococcus (GBS): Risks? Signs? Symptoms? Treatment? Curable or Manageable? Impact on Fertility?

- Risks: history of positive culture with previous pregnancy. risks for early onset neonatal GBS include positive GBS culture in current pregnancy, prolonged (18hr or more) rupture of membranes, preterm delivery, low birth weight, use of intrauterine fetal monitoring, and intrapartum maternal fever (38C, 110.4F or greater) - Signs & Symptoms: preterm labor and delivery, chorioamnionitis, infections of urinary tract, maternal sepsis, endometritis after delivery - Treatment: penicillin G or ampicillin. administer penicillin 5 million units initially IV bolus, followed by 2.5 million units intermittent IV bolus every 4 hours during the intrapartum period. client can receive ampicillin 2 g IV initially, followed by 1 g every 4 hours - Curable or Manageable: curable with early detection - Impact on Fertility: can cause pneumonia, respiratory distress syndrome, sepsis, and meningitis if transmitted to the neonate

STIs: Syphilis: Risks? Signs? Symptoms? Treatment? Curable or Manageable? Impact on Fertility?

- Risks: multiple partners, unprotected sexual practices - Signs & Symptoms 1. Primary Stage: client can notice a chancre, which is a painless papular lesion at the site of infection. chancres can progress to an ulcerated area. females report of inguinal lymph node edema can indicate internal lesions (vaginal or cervical) 2. Secondary Stage: client can notice skin rashes, such as a maculopapular rash on the palmar surface of the hands and soles of the feet 3. Tertiary Stage: damage to the internal organs can occur for which clients can notice the manifestations including difficulty coordinating muscle movements and blindness Physical Assessment Findings 1. Primary Stage: provider can observe a chancre in the genital area 2. Secondary Stage: provider can observe skin rashes, such as rough, red or reddish brown spots on the palms of the hands and soles of the feet and lymphadenopathy - Treatment: Penicillin G IM in a single dose. if the duration of syphilis is unknown, 3 doses recommended. safe during pregnancy. doxycycline or tetracycline orally, if allergic to penicillin as alternative therapy. don't administer if pregnant - Curable or Manageable: curable - Impact on Fertility: if left untreated or undiagnosed, it can be transmitted to neonate and cause stillborn birth or congenital abnormalities. infection of eyes leading to blindness or nervous system (headache, numbness, paralysis, dementia)

STIs: HPV (Human Papilloma Virus): Risks? Signs? Symptoms? Treatment? Curable or Manageable? Impact on Fertility?

- Risks: multiple partners, unprotected sexual practices - Signs & Symptoms: bumps in the genital area that might not itch or hurt, vaginal discharge, dyspareunia, and bleeding after intercourse. physical assessment findings include small warts or a group of warts in the genital area that can have a cauliflower like appearance, and abnormal changes to the cervix that can be detected by a Pap Test - Treatment: client-applied creams, such as bichloroacetic acid (BCA), which is safe for using during pregnancy, and imiquimod, which is recommended for people age 14 and older who are not pregnant. provider-administered therapy, such as trichloroacetic acid (TCA) application, which is considered safe to use during pregnancy. podophyllin can be used but not recommended during pregnancy - Curable or Manageable: manageable - Impact on Fertility: when large and widespread it can occlude the birth canal, and genital warts can complicate a vaginal delivery. cesarean recommended. during pregnancy, lesions can expand and obscure the birth canal. this can interfere with the descent of the fetus, as well as the client's ability to urinate and defecate. if therapy is deferred until after delivery, remember that lesions are infectious

STIs: Chlamydia: Risks? Signs? Symptoms? Treatment? Curable or Manageable? Impact on Fertility?

- Risks: multiple sexual partners, unprotected sex - Signs & Symptoms: in males its penile discharge, dysuria, and testicular edema or pain. females its dysuria, urinary frequency, spotting or postcoital bleeding, vulvar itching, and gray-white discharge. physical assessment findings include mucopurulent endocervical discharge, and easily induced endocervical bleeding - Treatment 1. Doxycycline: used as a treatment, but contraindicated during pregnancy 2. Azithromycin or Amoxicillin: prescribed during pregnancy 3. Erythromycin: administered to all infants following delivery. this is the medication of choice for ophthalmia neonatorum. this antibiotic is both bacteriostatic and bactericidal, and thus provides prophylaxis against Neisseria Gonorrhoeae and Chlamydia Trachomatis - Curable or Manageable: curable - Impact on Fertility: can lead to pelvic inflammatory disease (PID), which can cause infertility and ectopic pregnancy. if not treated during pregnancy, can cause premature rupture of membranes, preterm labor, and postpartum endometritis. if transmitted to neonate, it can cause conjunctivitis and pneumonia after delivery

STIs: Trichomoniasis: Risks? Signs? Symptoms? Treatment? Curable or Manageable? Impact on Fertility?

- Risks: multiple sexual partners, unprotected sex, history of STIs, previous episode of trichomoniasis - Signs & Symptoms: in males its urethral draining, itching, or irritation, and dysuria or pain with ejaculation. in females its yellow-green, frothy, vaginal discharge with foul odor, dyspareunia and vaginal itching, and dysuria. physical assessment findings include discharge in the vaginal vault during speculum examination, which can be sampled for microscopy, strawberry spots on the cervix (tiny petechiae), and a cervix that bleeds easily - Treatment: metronidazole or tinidazole orally. metronidazole is not given during the first semester of pregnancy due to the teratogenic effects on the fetus - Curable or Manageable: curable - Impact on Fertility: if left untreated in females, can lead to PID, and can cause infertility. pregnant clients are more likely to have preterm delivery and PROM

STIs: Gonorrhea: Risks? Signs? Symptoms? Treatment? Curable or Manageable? Impact on Fertility?

- Risks: multiple sexual partners, unprotected sexual practices, age younger than 25 if sexually active - Signs & Symptoms: if anal lesions present there is anal itching or irritation, rectal bleeding, diarrhea, painful defection. if oral lesions present there is ulcerations of the lips, tender gums, pharyngitis. in males its dysuria, testicular edema or pain, penile discharge (white, green, yellow, clear) sometimes profuse. in females its often no manifestations but dysuria, vaginal bleeding between periods, and dysmenorrhea. physical assessment findings include yellowish-green vaginal discharge, and easily induced endocervical bleeding - Treatment: Ceftriaxone IM and azithromycin PO - Curable or Manageable: curable - Impact on Fertility: if left untreated can lead to PROM, preterm birth, postpartum sepsis and endometritis, chorioamnionitis, and neonatal sepsis. can be transmitted to a newborn during delivery. if left untreated in females, it can cause tubal scarring and lead to PID which can cause infertility. also, if left untreated the neonate can experience ophthalmia neonatorum, which can cause blindness

STIs: Candidiasis: Risks? Signs? Symptoms? Treatment? Curable or Manageable? Impact on Fertility?

- Risks: pregnancy, diabetes mellitus, oral contraceptives, recent antibiotic treatment, obesity, diet high in refined sugars - Signs & Symptoms: vulvar and vaginal pruritus, painful urination due to excoriation from itching. physical assessment findings include speculum examination including thick, creamy, white, cottage cheese-like vaginal discharge, vulvar and vaginal erythema and inflammation, and white patches on vaginal walls - Treatment: topical therapies recommended for use in pregnant clients 1. Fluconazole: can be prescribed as a single low dose to clients who are not pregnant or lactating 2. OTC Treatments: such as clotrimazole, are available to treat candidiasis and are used for 3-7 days. however, it is important for the provider to diagnose candidiasis initially - Curable or Manageable: curable - Impact on Fertility: during pregnancy, treated to relieve discomfort and prevent oral thrush in the neonate

STIs: TORCH Infections: Risks? Signs? Symptoms? Treatment? Curable or Manageable? Impact on Fertility?

- Risks: toxoplasmosis caused by consumption of raw or undercooked meat or handling cat feces. manifestations are similar to influenza or lymphadenopathy. other infections can include hepatitis A and B, syphilis, mumps, parvovirus B19, and varicella-zoster. can be associated with congenital anomalies. rubella is contracted through children who have rashes or neonates who are born to clients who had rubella during pregnancy. cytomegalovirus (member of herpes virus family) is transmitted by droplet infection from person to person, through semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces, and blood. latent virus can be reactivated and cause disease to the fetus in utero or during passage through the birth canal. HSV is spread by direct contact with oral or genital lesions. transmission to fetus is greatest during vaginal birth if the client has active lesions - Signs & Symptoms: manifestations of toxoplasmosis include fever and tender lymph nodes. manifestations of rubella include rash, mild lymphedema, and fever. HSV initially presents with lesions and tender lymph nodes - Treatment: administer antibiotics as prescribed. treatment of toxoplasmosis includes sulfonamides or a combination of pyrimethamine and sulfadiazine (potentially harmful to fetus, but parasitic treatment is essential) - Curable or Manageable: manageable - Impact on Fertility: negatively affect client who is pregnant. infections can cross the placenta and have teratogenic effects on the fetus. rubella can cause fetal consequences (miscarriage, congenital anomalies, death). HSV can cause miscarriage, preterm labor, and intrauterine growth restriction

Fetal Well-Being: Routine Diagnostic Tests? Nursing Interventions? Patient Education?

- Routine Diagnostic Tests 1. Ultrasound a) Abdominal (external): safe, noninvasive, painless transducer moved over abdomen to obtain image. have full bladder for procedure - Nursing Interventions: client prep. includes explaining the procedure and that it presents no known risks to self or fetus, advise to drink 1 quart of water prior, and assists client into supine position w/ a small pillow under their head and knees. ongoing care includes applying an ultrasonic/transducer gel to the client's abdomen before the transducer is moved over the skin to obtain a better fetal image, ensuring that the gel is at room temp. or warmer, allow client to empty bladder at end of procedure, and provide with a washcloth or tissues to wipe away gel after completion of ultrasound - Patient Education: fetal and maternal structures can be pointed out as the ultrasound procedure is performed b) Transvaginal: invasive procedure where a probe is inserted vaginally to allow for more accurate evaluation. doesn't require full bladder. useful in obese clients in 1st trimester to detect ectopic pregnancy, abnormalities, and establishing gestational age. used in third trimester also, in conjunction with abdominal scanning to evaluate for preterm labor - Nursing Interventions: prep client by assisting into a lithotomy position, vaginal probe is covered with a protective device such as a condom, lubricated with water-soluble gel, and inserted by client or examiner. ongoing care includes during the procedure the position of the probe or tilt of the table can be changed to facilitate the complete view of the pelvis, and inform client they might feel pressure as the probe is moved - Patient Education: fetal and maternal structures can be pointed out as the ultrasound procedure is performed c) Doppler (Blood Flow Analysis): noninvasive external ultrasound to study the maternal-fetal blood flow by measuring velocity at which RBCs travel in the uterine and fetal vessels using a handheld ultrasound device that reflects sound waves from moving target. useful in IUGR and poor placental perfusion, and adjunct in pregnancies at risk due to hypertension, diabetes mellitus, multiple fetuses, or preterm labor 2. Biophysical Profile: real-time ultrasound to visualized physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. combines FHR monitoring (nonstress test) and fetal ultrasound - Nursing Interventions: prepare the client following the same nursing management principles as those used for an ultrasound 3. Nonstress Test: used for antepartum evaluation of fetal well-being performed during third trimester. noninvasive that monitors response of FHR to fetal movement. Doppler transducer (used to monitor FHR) and a tocotransducer (used to monitor contractions) are attached externally to the abdomen to obtain tracing strips. client pushes button attached to monitor whenever they feel a fetal movement, which is noted on the tracing. allows nurse to assess FHR in relationship to fetal movement - Nursing Interventions: client prep. includes seating the client in a reclining chair or in a semi-Fowler's or left-lateral position, apply conduction gel to abdomen, and apply 2 belts to abdomen and attach the FHR and contraction monitors. ongoing care includes instructing the client to press the button on the handheld event marker each time they feel the fetus move, if there's no fetal movements (fetus sleeping) the vibroacoustic stimulation (sound source, usually laryngeal stimulator) can be activated for 3 seconds on the abdomen over the fetal head to awaken sleeping fetus, and test is completed within 20-30 minutes 4. Contraction Stress Test (nipple, oxytocin) a) Nipple: client lightly brushing palm across nipple for 2 minutes, causing the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins. repeated after 5 minute rest period b) Oxytocin: used if nipple stimulation fails and consists of IV administration of oxytocin to induce contractions - Nursing Interventions: client prep. includes obtaining and documenting a baseline FHR, fetal movement, and contractions for 10-20minutes, and explaining the procedure to the client, and obtaining informed consent. ongoing care includes initiating nipple stimulation unless client is having spontaneous contractions. instruct client to roll a nipple between their thumb and fingers or brush the palm across a nipple. client should stop when a contraction begins. monitor and provide adequate rest periods for the client to avoid tachysystole of the uterus 5. Amniocentesis: aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a clients uterus and amniotic sac under direct ultrasound guidance locating the placenta and determining the position of the fetus. performed after 14 weeks gestation. alpha-fetoprotein (AFP) can be measured from amniotic fluid between 15-20 weeks, 16-18 ideal. can be used to assess for neural tube defects in the fetus or chromosomal disorders. evaluated to follow up a high level of AFP in maternal blood a) PreProcedure - Nursing Interventions: explain procedure to client, and obtain informed consent - Patient Education: empty bladder prior to procedure to reduce its size and reduce risk of inadvertent puncture b) Intraprocedure - Nursing Interventions: obtain and document baseline vital signs and FHR prior to procedure, assist client into supine position, place wedge under right hip to displace uterus off the vena cava, and place a drape over the client exposing only the abdomen. prepare client for ultrasound to locate the placenta. cleanse abdomen with a antiseptic solution prior to administration of a local anesthetic by the provider - Patient Education: understand there will be a feeling of slight pressure as the needle is inserted. continue breathing, because holding breath will lower the diaphragm against the uterus and shift the intrauterine contents c) Postprocedure - Nursing Interventions: monitor FHR, administer Rho(D) immune globulin to client if they are negative - Patient Education: report to provider if experiencing fever, chills, leakage of fluid or bleeding from insertion site, decreased fetal movement, vaginal bleeding, or contractions after the procedure 6. Percutaneous Umbilical Cord Blood Sampling: method used for fetal blood sampling and transfusion. obtains fetal blood from umbilical cord by passing a fine-gauge, fiber-optic scope (fetoscope) into amniotic sac using amniocentesis technique. blood is aspirated from the umbilical vein - Nursing Interventions: administer medication as prescribed, offer support, and monitor FHR as prescribed following the procedure - Patient Education: count fetal movements 7. Chorionic Villus Sampling: assessment of a portion of the developing placenta (chorionic villi), which is aspirated through a thin sterile catheter or syringe inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance. first trimester alternative to amniocentesis, provides earlier diagnosis of any abnormalities. performed at 10-13 weeks gestation - Nursing Interventions: obtain informed consent, and provide ongoing education and support - Patient Education: drink 1-2 glasses of fluid prior to the test, and avoid urination for several hours prior to testing. full bladder necessary for testing 8. Quad Marker Screening: blood test that ascertains information about the likelihood of fetal birth defects. can be performed instead of maternal AFP blood level yielding more reliable findings. tests for hCG, AFP, estriol, and inhibin A 9. Maternal Alpha-Fetoprotein Blood Levels: screening tool used to detect neural tube defects. abnormal findings, client should be referred to a quad marker screening, genetic counseling, ultrasound, and amniocentesis - Nursing Interventions: preprocedure includes discuss testing with client, draw blood sample, and offer support and education as needed - Patient Education: provide as needed

Antepartum Care: Routine Diagnostics? Labs?

- Routine Diagnostics 1. Blood & Urine Tests: assessment for presence of human chorionic gonadotropin (hCG). hCG production can start as early as day of implantation, and can be detected early as 7-8 days before expected menses. production of hCG begins with implantation, peaks at 60-70 days gestation, declines around 100-130 days of pregnancy, and then plasma levels remain at this lower level for remainder of pregnancy. high levels of hCG indicate multifetal pregnancy, ectopic pregnancy, hydatidiform mole (gestational trophoblastic disease), or genetic abnormality like Down Syndrome. low levels of hCG suggest miscarriage or ectopic pregnancy. some meds can cause false-positive or false-negative results (anticonvulsants, diuretics, tranquilizers). home pregnancy test urine sample should be first voided during morning specimens and follow directions for accuracy - Labs 1. Blood Type and Rh Factor: blood type screen (A, B, AB, or O), Rh factor (negative or positive) 2. Rubella (German Measles) Immunity: if the mother is non immune, immunization is recommended after birth 3. Hepatitis B Screening: if the mother is hep. B surface antigen positive, the newborn will receive hep. B vaccine and hep. B immune globulin within 12 hours of birth 4. Sexually Transmitted Infection Screen (VDRL): if positive, requires treatment to prevent transmission to fetus 5. HIV: if positive, requires counseling and treatment to prevent transmission to fetus 6. Maternal Serum Alpha Feto Protein: between 15-20 weeks. high levels indicate neural tube defects or multiples. low levels indicate fetal trisomy syndromes 7. GDM Screen: between 24-28 weeks, glucose tolerance test 8. Hemoglobin and Hematocrit: detects iron deficiency anemia 9. Group B Streptococcus (GBS): vaginal and rectal swabs taken at 35-37 weeks gestation. if positive, mothers given antibiotics in labor to avoid transmission to the fetus 10. Ultrasound: 1st trimester confirms pregnancy and cardiac activity, 2nd trimester verifies dates, evaluates fetal growth and health, location of placenta and assesses amount of amniotic fluid, 3rd trimester evaluates fetal activity, growth of fetus, and verifies placental position 11. Amniocentesis: 1st trimester detects genetic disorders, 2nd trimester, detects blood sensitization, 3rd semester assessment of lung maturity 12. Triple or Quad Screen: detects genetic disorders (MAFP, hCG, unconjugated estriol, inhibin A) 13. Nuchal Translucency (NT): ultrasound assessment of thickness of fetal nuchal fold 14. Chorionic Villus Sampling (CVS): detects chromosomal abnormalities

Contraception: BRAIDED

- provides informed consent for each contraception method B: benefit R: risk A: alternatives I:inquires D: decision to withdraw method E: explanation D: documentation of informed consent

Newborn: Complications

1. Neonatal Substance Withdrawal: maternal substance use during pregnancy consists of use of alcohol or drugs 2. Hypoglycemia: source of glucose for the newborn stops when the umbilical cord is clamped. if the newborns have other physiological stress, they can experience hypoglycemia due to inadequate gluconeogenesis or increased use of glycogen stores 3. Respiratory Distress Syndrome (RDS)/Asphyxia/Meconium Aspiration: result of surfactant deficiency in the lungs, and characterized by poor gas exchange and ventilatory failure 4. Preterm Newborn: birth occurs after 20 weeks gestation, and before completion of 37 weeks gestation 5. Small for Gestational Age (SGA) Newborn: birth weight is at or below 10th percentile and has intrauterine growth restriction 6. Large for Gestational Age (LGA)/Macrosomic Newborn: neonates whose weight is above 90th percentile or more than 4,000g (8.8lbs) 7. Postmature Newborn: born after completion of 42 weeks gestation 8. Newborn Infection/Sepsis (Sepsis Neonatorum): infection can be contracted by the newborn before, during, or after delivery. can be spread fast through the bloodstream 9. Birth Trauma or Injury: during childbirth resulting in physical injury to a newborn 10. Hyperbilirubinemia: elevation of serum bilirubin levels resulting in jaundice 11. Congenital Anomalies: can be born with anomalies involving all the systems. often diagnosed prenatally 12. Tracheoesophageal Fistula: GI anomaly that can occur independently or together with an EA. alone can include a variety of abnormal connections between the esophagus and trachea. TEF and EA combined include a blind esophagus pouch and/or abnormal connection between the esophagus and trachea

Hypertension (HTN) In Pregnancy

1. Pre-Eclampsia: increase in BP after 20 weeks gestation, accompanied by proteinuria - Signs of Worsening Pre-Eclampsia: BP 160/110 on 2 occasions, proteinuria (5+ in 24 hrs), oliguria (<500mL urine in 24hrs), visual changes, severe headaches, nausea, vomiting, hyperreflexia, pitting edema, epigastric pain, and fetal growth restriction 2. HELLP Syndrome: hemolysis of RBCs, elevated liver enzymes, low platelets 3. Eclampsia: occurrence of a seizure during antepartum, intrapartum, or postpartum period 4. Care of Eclampsia: magnesium sulfate IV bolus or sedation if needed, antihypertensive agents to reduce BP, position side lying, pad the side rails, lung sounds, oxygen per face mask, and evaluate fetal heart tones

Antepartum: Complications

1. Spontaneous Abortion: when a pregnancy ends as the result of natural causes before 20 weeks gestation if a fetus weighs less than 500g 2. Ectopic Pregnancy: abdominal implantation of a fertilized ovum outside of the uterine cavity, usually in the fallopian tube. can result in tubal rupture causing fatal hemorrhage 3. Gestational Trophoblastic Disease: proliferation and degeneration of trophoglastic villi in the placenta that becomes swollen, fluid-filled, and takes on appearance of grape-like clusters. embryo fails to develop beyond primitive state and these structures associated with choriocarcinoma, which is rapidly metastasizing malignancy 4. Placenta Previa: placenta is implanted in the lower uterine segment or over the internal cervical os. low lying, partial, marginal, complete. onset and bleeding is slow onset, may be scant or profuse, bright red bleeding. pre-eclampsia is absent. uterine tone is soft, relaxed tone, normal uterine contour. pain is labor pain only. FHT is usually present 5. Abruptio Placentae: premature separation of a normally implanted placenta from the uterine wall. marginal, central, complete. onset and bleeding is sudden onset, maybe external or concealed, dark colored bleeding. pre-eclampsia may be present. uterine tone is firm to hard abdomen, may enlarge or change shape. pain is severe and steady pain. FHT present or absent 6. Vas Previa: when the fetal umbilical vessels implant into the fetal membranes rather than the placenta. types include velamentous insertion of cord, succenturiate insertion of cord, and battledore insertion of cord

Postpartum: Complications

1. Superficial and Deep Vein Thrombosis: thrombus that is associated with inflammation (thrombophlebitis). lower extremities can be superficial or deep veins, most often of the femoral, saphenous, or popliteal veins. postpartum greatest risk for DVT leading to a pulmonary embolism 2. Pulmonary Embolus: embolus occurs when fragments or an entire clot dislodges and moves into circulation. pulmonary embolism is a complication of DVT that occurs if the embolus moves into the pulmonary artery or one of its branches and lodges in a lung, occluding the vessel and obstructing blood flow to the lungs. acute pulmonary embolus is an emergent situation 3. Coagulopathies (Idiopathic Thrombocytopenic Purpura and Disseminated Intravascular Coagulation): coagulopathies suspected when the usual measures to stimulate contractions fail to stop vaginal bleeding - Idiopathic Thrombocytopenic Purpura (ITP): autoimmune disorder coagulopathy in which the life span of platelets is decreased by antiplatelet antibodies. result in severe hemorrhage following cesarean birth or lacerations - Disseminated Intravascular Coagulation (DIC): coagulopathy in which clotting and anticlotting mechanisms occur at the same time. client is at risk for both internal and external bleeding, as well as damage to organs resulting from ischemia caused by microclots 4. Postpartum Hemorrhage: occurs if the client loses more than 500mL blood after vaginal birth, or more than 1,000mL blood after cesarean birth. two complications that can occur following PPH is hypovolemic shock and anemia 5. Uterine Atony: results from inability of the uterine muscle to contract adequately after birth. can lead to PPH 6. Subinvolution of the Uterus: when the uterus remains enlarged with continued lochial discharge and can result in PPH 7. Inversion of the Uterus: turning inside out of the uterus and can be partial or complete. emergency situation can result in PPH and needs immediate intervention 8. Retained Placenta: placenta or fragments of the placenta remain in the uterus and prevents the uterus from contracting, which can lead to uterine atony or subinvolution. placenta that hasn't been delivered within 30 minutes of birth is a retained placenta 9. Lacerations and Hematomas: lacerations that occured during labor and birth consist of tearing of soft tissues in the birth canal and adjacent structures including the cervical, vaginal, vulvar, perineal, and/or rectal areas. episiotomy can extend and become a third or fourth degree laceration. hematoma is a collection of clotted blood within tissues that can appear as a bulging bluish mass. can occur in the pelvic region or higher in the vagina or broad ligament. pain rather than noticeable bleeding is the distinguishable finding for hematomas. client at risk for hemorrhage or infection due to a laceration or hematoma

10 Common STIs

HIV, TORCH infections, group B streptococcus (GBS), chlamydia, gonorrhea, syphilis, HPV, trichomoniasis, bacterial vaginosis (BV), candidiasis