Study guide maternity

What are postpartum blues?

"Baby Blues" - Mild, transient mood disturbance Postpartum Baby Blues - 10 days or less & resolves on its own - Signs: (not debilitating) • Crying & sadness but don't know why Fatigue, exhaustion - Emotionally labile, restless, fatigued, cries easily, sad - Usually peaks at 5 days, subsides by day 10 - Experienced by 60-80% of recently pregnant people

Why is keeping an infant warm important and what is brown fat?

- 02 consumption + energy is diverted from brain and cardiac functions to thermogenesis for survival - Increased 02 needs to burn brown fat--> Depleted brown fat stores - Increased glucose body consumption-> hypoglycemia - Hypoxia + Metabolic Acidosis - Decreased surfactant production -> Hard to breathe **Brown Fat - a type of fat that is activated in response to cold temperatures; produces heat to help maintain body temperature in newborns who cannot shiver.

What to do when there is too much bleeding

- Ask when the pad was changed last time -> if saturated in 15 min -> active bleeding. - Check signs of shock: HR high, BP low -> tachycardia as a compensation for low blood volume. - Empty the bladder -> full bladder prevents uterine involution. - Fundal assessment + fundal massage(every 15 minx 1-2 hours) to help uterus to firm up and compress the blood vessels. - Administer Oxytocin (Pitocin), Methergine or TXA (per protocol), blood transfusion (per orders), oxygen

What are the nurse's priority actions immediately after delivery?

- Assess Airway and Breathing -->if resuscitation is needed follow the NRP algorithm - Suction the mouth and nose -Drying infant to prevent heat loss - Thermoregulation + stimulation of breathing - Wrap in warm blanket, put a hat on (lose heat through head) + place under radiant warmer. - APGAR Care for baby first, meet their needs and THEN do APGAR scoring. Taken @1 minute and @5 minutes - Nurturing/attachment-skin to skin > golden hour - Identification/neonatal safety (baby bands) - Time of birth, birth parent's name, birthdate, matching numbers for parents and baby - Medical ID number for baby -Vital signs + Measurements - Newborn Meds if parents consent: Erythromycin, Hep B, Vit K - Physical exam

Episiotomy expected vs follow up

- Assess for REEDA (redness, ecchymosis, edema, discharge approximation) - wound can be open

Signs of PP hemorrhage

- Boggy, soft fundus - Saturated perineal pads within 15 min. - 1 hour Notify the HCP - Heavy bleeding with blood clots (days after birth) Blood clots - BIGGER than a quarter - Steady flow or "constant oozing of blood" from vagina -IV fluids for hypotension and start a secondary IV line for blood transfusion

Bowel expected vs follow up

- Bowel sounds present - Constipation (want to prevent straining especially if episiotomy has stitches) -> fiber, hydration, ambulation, stool softeners

Know about crib safety

- Crib should be empty, no stuffed animals/extra blankets - No loose or soft objects in crib can suffolate - Keep bulb syringe in crib - Baby should sleep in the crib, not in the parent's bed - Suffocatian "Baby BACK to sleep"-> always lay them on the back (SIDS prevention measure)

7. What are the warning signs of pregnancy? In other words, when would you tell a patient to call the clinic or come in to be checked prior to labor?

- Dilation + Effacement! - Timing of Contractions: come at regular intervals and get closer together - Change with Movement: contractions continue despite walking, moving, changing positions

2 HOUR GTT: one step process + fasting

- Drinks 75-gram glucose solution - Glucose is checked at 1 and 2 hours. These are abnormal values for the GTT: Fasting: > 92 1 hour: >180 2 hour: >153 One or more elevated values are indicative of GDM Advantage: same-day diagnosis, no need to return for 2nd step.

Uterus expected vs follow up

- Firm and midline - At the umbilicus after delivery 1 week: btw umbilicus and pelvis 2 weeks: in pelvis - Soft/boggy/deviated

Circulatory Expected -HR -Blood Volume -Murmurs -Color/perfusion

- HR: 110-160 bpm, BP: 60-80/40-50 (rarely taken on a well-baby) - Blood volume: 300 ml (even small bleed is a big issue) - Murmurs heard are normal: need time for shunts to close (transient), re-assess - Color/perfusion: consistent with baby's skin tone (Ex. not every baby will be pink, always good to check mucous membranes). Acrocyanosis is normal at birth.

What are the signs of respiratory distress?

- Nasal flaring - Retractions/ increased use of intercostal muscles - Grunting - Tachypnea > 60 breaths per minute - Cyanosis - Apnea lasting longer than 15 seconds

Potential reasons for late decelerations: RN Intervention:

- Patient has Diabetes Mellitus--> Compromised vascular blood flow. - Patient lies supine + compresses blood vessels. - reposition pt to the side; - 02 might be needed; - stop oxytocin; - prepare for C-section.

Powers

- Primary - uterine contractions(open the cervix): responsible for the dilation and effacement of the cervix - Secondary - expulsive efforts

Respiratory Expected -RR -Crackles -Abnormal

- RR: 30-60 - Crackles (ales) indicate fluid in the lungs & are expected immediately AFTER birth - Abnormal: persistent crackles, respiratory distress (grunting, retractions, nasal flaring, tachypnea)

When/why are Rhogam, MMR given

- Rhogam •Given for RH incompatibility. •Mom is Rh (-) and baby Rh (+). Baby's Rh (+) blood can be introduced into mom's bloodstream during labor -> mom starts forming antibodies against Rh (+). If mom gets pregnant again with Rh (+) baby, her antibodies will attack the fetus and cause Hemolytic disease of the newborn -> fatal for the fetus. Part of the discharge requirements from Postpartum unit. - MMR a) Given BEFORE a woman gets pregnant; b) If mom is non-immune + already pregnant -> do NOT give this vaccine. It is a live vaccine, therefore can harm fetus -> given to mom after the delivery before they leave the hospital.

Lochia expected vs follow up

- Rubra (up to 4 days): red, flow, some clots - Serosa (4-10): pinkish, flow, little clots/no odor - Alba (10-28): no flow, no color/odor/clots - Saturated the pad in 15 min -> active bleeding

Postpartum Depression

- Serious psychological diagnosis similar to MDD - Typically diagnosed at 4-6 weeks postpartum Postpartum Depression (PPD) - Experienced by up to 20% of recently delivered people - Most common complication of childbirth - Treated with both counseling and medications - 2 weeks or more - Onset within 4 weeks after delivery - Signs: (debilitating) Anxiety, panic Overwhelmed & stressed Persistent sadness & mood swings * Apathy (loss of interest) • Decreased appetite & anorexia • Insomnia: Inability to sleep - Requires interventions: • Longer maternity leave • Depression therapy • Medication • More frequent follow ups

Stages of labor 1 2 3 4

- Stage 1: Get to 10 cm =From onset of regular contractions to full cervical dilation (10 cm) - Latent: 0-6 cm dilation - Active: 6-10 cm dilation (progresses much faster) - Stage 2: From fully dilated/effaced to the Delivery of the baby - Latent phase - not pushing - Active phase - pushing • Stage 3: from delivery of the infant to the Placenta delivery - Stage 4: from the delivery of the placenta to the stabilization of the birth parent and infant. Don't let your client bleed to death!

GI Expected

- Suck/swallow reflex usually develops by 36-38 weeks (pre-term babies often have NG tube); - No bacteria in the gut until after 1ª week (sterile gut); - If born vaginally, covered with mother's microbiome -> helps establish infant's flora - 1st stool -> meconium. should be within 24 hours after birth:

Thermoregulation Expected

- Temperature: 36.5-37.5 C (97.7-99.5 F), axillary only - Tolerate a narrow range of temperatures: vulnerable to under and overheating - How babies thermoregulate: flexed position, peripheral vasoconstriction, increased metabolic rate, metabolism of brown fat

GU Expected

- Usually void right after birth but hard to see - Urine should be pale/straw-colored - May be blood-tinged with mucus: influence of mom's hormones - Expect a weight loss of 5-10% - A sign of adequate intake is the amount of diapers per day. - One/two diapers per every day old. Around 4" day, 6-8 diapers a day indicate adequate intake.

7. Know the relationship between a full bladder, fundal height and bleeding

- WDL Funds: midline, at umbilicus, firm; descends by one finger breadth per succeeding day - Full bladder causes deviation of uterus and delayed uterine involution

Infection prevention after delivery -Mastitis -C/Section Infection -Endometritis -Perineal Assessment

- breast inflammation that can lead to infection of breast tissue Prevention: breastfeed/pump 2-3 hrs, change bra often -Assessment/Interventions: Assess incision, change dressing appropriately, and educate on hand hygiene after using bathroom - infection of uterus Prevention: sterile technique during birth, prophylactic ABX, after C/S -REEDA, Perineal Care - washing with bottle, sitz bath, ice packs

Ductus Arteriosus

- connects pulmonary artery to aorta -> sends blood directly to systemic vasculature-> Bypasses lungs

Probable

- objective changes observed by the examiner that, when combined, with the presumptive signs, strongly suggest pregnancy . Abdominal enlargement . Goodell's sign: softening of the cervix . Chadwick's sign: violet color of vaginal mucous membrane . Hegar's sign: softening of lower uterine segment

Foramen Ovale

- shunt between right atrium to left atrium -> Bypasses lungs

Ductus Venous

- shunts 02 rich blood from liver straight to heart through inferior vena cava (liver not fully functional, so only a small amount of blood goes to it) -> Bypasses liver

Positive

- signs that can only be attributed to the presence of the fetus . Real time ultrasound exam . Fetal heart tones (usually heard 10-12 weeks by doppler) . Fetal movement palpated by HCP/ Fetal movements visible

What are newborn reflexes? Rooting Sucking Grasp/Palmer Moro Plantar Babinski

- stroke baby's cheek and they turn towards you - put finger in mouth and they suck - put finger in baby's hand and they grasp it - stretch out arms and let go to mimic falling and their arms try to catch themselves - put finger in baby's sole triggers flexion - stroke foot from heel in an upside J and their toes sprawl out

Patient safety after delivery 1. Assess V/S every ___minutes during the __ hour and then every___ minutes for the next two hours. 2. Fall risk assessment: 3. C/S pts: 4. Risk for DVTs: 5. Assess Funds / Hemorrhaging: 6. Assess for hemorrhoids

-15, first, 30 - Assist to bathroom, test legs before first time ambulating - Encourage cough and deep breathe, incentive spirometer - Prevention: Ambulate if possible, apply SCD, meds if high risk - Assessment: calves for pain, warmth, swelling, redness, Homen's sign - TX: anticoags - Fundal assessments/massage - Assess lochia

10. What are the expected skin changes? Increased skin pigmentation (WDL)

-> postpartum hyperpigmented areas become less pigmented over time.

The mechanisms that promote newborn breathing Mechanical Chemical Thermal Sensory Hormonal

-Compression of fetal chest while passing through birth canal -> once they come out the chest no longer compressed -> compression + recoil -Labor deprives oxygen -> pO2 decreases, pCO2 increases -› creates innate urge to breathe -Sudden cold environment stimulates breathing -Drying (tactile stimulation) stimulates breathing process -> always the 1st step when baby is out! -Increased norepinephrine and epinephrine -> stimulates cardiac output, surfactant release and promotion of pulmonary fluid clearance

Category 3

-Either .Absent variability with: -Recurrent late decelerations or -Recurrent variable decelerations or -Bradycardia Or -Sinusoidal pattern

Bladder expected vs follow up

-Empty q 2 hrs -Non-distended -Diuresis first 12 hrs -distended -> may displace the uterus and prevent involution

MS Changes - _______ in weight + gravid uterus -> shift in gravity--> prone to falls - ______ lower back - ________: forward flexion of neck + downward movement of shoulders -> compensate for the change in gravity.

-Gain -Lordosis Compensation

Renal Changes - _______ in blood volume means kidneys work ________ - Urinary _______: d/t enlarged uterus - Stress incontinence + _______ weakness possible - ________: dependent edema in lower legs during the day (gravity) that re-enters general circulation at night -> more blood volume -> more urine

-Increase, harder -frequency -sphincter -Nocturia

Category 2

-Moderate variability with recurrent late or variable decelerations -Minimal variability with recurrent variable decelerations -Absent variability without recurrent decelerations -Bradycardia with moderate variability -Prolonged decelerations -Tachycardia

What are common physiological changes during pregnancy?

-Neuro, Circulatory, Respiratory

Be able to identify fetal position (OP, OA, LOP, etc.) OA OP

-Occiput Anterior is the ideal position we want baby to be in. -the most painful position for the mother

GI Changes - _____ muscle relaxation caused by progesterone I/t delayed gastric emptying, decreased peristalsis -> constipation, heartburn + GERD (progesterone relaxes the esophageal sphincter); - ______ gums: effect of estrogen; - NV - As baby grows, everything gets compressed.

-Smooth -Bleeding

Reproductive Changes - ___________ circulation - Braxton-Hicks ________: occur after 4th month, stop with movement, do NOT lead to cervical dilation/effacement - _________ plug forms as a protective barrier - Breasts get ____, nipples get _____ and ________ pigmentation (vascularity), _______ on 3rd trimester

-Uteroplacental -contractions -Mucous -full, larger, darker, colostrum

Emotional

-baby blues are normal (cries, labile, fatigue): first 2 weeks -postpartum depression:4-6 weeks PP, treated with counseling and meds

Frequency Duration

-beginning of first contraction point to second contraction point -from start of point to end of point in one contraction

Presumptive

-changes felt by the pt; subjective .amenorrhea .urinary frequency .breast tendernerness .fatigue/nausea

Factors predisposing newborn to heat loss: - Thin skin with blood vessels _____ to the surface - _____________ shivering mechanism - _______ store of glucose, glycogen and fat - _______ body surface area relative to body weight - _______ of subcutaneous fat - ________ ability to change posture - ______ communicate if they are cold or hot

-close - Underdeveloped - Limited - Large - Lack - Limited - Cannot

Neuro Changes Difficulties with: - Prone to carpal tunnel syndrome: - Problems with sleep:

-concentration/ memory/ attention -d/t edema of the peripheral nerves. More common during the last trimester -d/t larger size of uterus ->compresses bladder more

Normal contractions .frequency .duration .intensity .rest

-contractions that are 2 - 3 mins apart in active labor. -60 seconds -60 mmHg -60 seconds or rest in between contractions

Endocrine Changes - Thyroid: Basal Metabolic Rate _____ - Parathyroid: slight hyperthyroidism -> fetus needs more ___ and Vit ___ - Pituitary: anterior _______ FSH+ LH to increase ________ production, posterior increases __________ production - Placenta: endocrine gland of pregnancy. An interface btw mother and fetus: ________ of oxygenation, nutrition, excretion, etc. Pancreas: increased _______ production, does not cross placenta -> fetus has to produce its own Maternal glucose: 1) Early pregnancy: levels _____ d/t high fetal demand, insulin antagonists have not kicked in = lower fasting glucose. 2) Pregnancy progresses: insulin antagonists -> _____ in insulin resistance to ensure plenty of glucose available for fetus.

-increase -Ca, D -suppresses, prolactin, oxytocin -exchange -insulin -decrease -increases

Respiratory Changes - 02 consumption ______ + Residual capacity _____ (air that remains in the lungs upon exhale) -> I/t lower reserves of 02, at risk for becoming hypoxic, get SOB easier. - Role of estrogen + relaxin: cause ligaments of rib cage to ___ --> _____ chest expansion--> able to take deeper breaths. - RR increases _____ breaths + ______ RR -> the amount of air exhaled increases -> loosing more CO2 (acid) -> pH increases -> slight alkalosis. This state of alkalosis with more pO2, less pCO2 makes it easier to dump extra 02 at the placental bed for the fetus. Lower CO2 allows to pick up fetal CO2 as a waste product to get rid of it.

-increases -decreases -relax -increased -deep, increased

Circulatory Changes - CO + HR increase: - BP: - Supine hypotension if laying supine -> -Blood volume increases 40-50% - Venous pressure increase: - Increase in _____ factors as a protective mechanism against bleeding -> risk for DVT. - RBC production increase: ____ carrying capacity increases; - Plasma volume _____: leads to physiological anemia -> hemodilution, dec in H+H

-more blood volume d/t uteroplacental circulation -slight changes, therefore always assess for HTN (high BP, headache, blurry vision, epigastric pain -> potential preeclampsia). -reposition -provides blood flow to uterus + fetus, maintains BP, accommodates for blood loss during labor -compression of iliac/inferior vena cava -> decreased blood flow to legs -> edema, varicosities, hemorrhoids -clotting -02 -increase

Homan's Sign expected vs follow up

-should be absent

Two step process - 1 hr and 3 hr Glucose Tolerance Test: Done 24-28 weeks gestation

1 HOUR GTT - Drink 50-gram glucose solution, BG is tested 1 hour later. - Serum glucose level > 140 › 3 hr GTT - Under 140, GDM ruled out 3 HOUR GTT : Patient fasts before test - Drink 100-gram glucose solution, BG is checked at 1 hr, 2 hr and 3 hours. Fasting: greater than 95 mg/dL 1 hour: greater than 180 mg/dL 2 hour: greater than 155 mg/dL 3 hour: greater than 140 mg/dL -If one than one of the values are abnormal -> GDM diagnosis -Diet and exercise are usually prescribed first, then if that doesn't bring the patient into glucose control then medications are considered.

Signs of TRUE Labor

1) Bloody Show: mucus and blood 2) Amniotic sac rupture 3) True labor contractions - Increased Frequency (regular & rhythmic) 4) Dilation and Effacement Dilation: how wide is the cervix (goal = 10 cm); Effacement: cervix get thinner and shorter (measured from 0 to 100%) * Descent. downward movement of the baby through the birth canal. Essential part of 2nd stage of labor.

Newborn medications

1) Erythromycin Ointment Prevention of Ophthalmia neonatorum (conjunctivitis that may cause blindness) -> give within 24 hrs to the lower eyelids 2) Vitamin K (Aquamephyton) - Helps produce clotting factors to prevent internal bleeding - Newborns at risk first week of life due to immature liver and sterile Gl tract - Give within 6 hours of birth 3) Hepatitis B Vaccine - Acts as a safety net, reducing the risk of getting the disease from moms or family members who may not know they are infected with hepatitis B - Provides antibodies against Hep B - Give within 24 hours from birth

Know what nursing responsibilities are in relationship to epidural

1) Monitor patient's VS (Blood Pressure!), LOC, perception of pain/level of pain relief 2) Monitor fetal HR (fetal bradycardia + decreased oxygenation) 3) Monitor major side effects 1. Headache -> punctured dura during epidural placement brady 2. Hypotension -> vasodilation -> decreased blood to uterus/brain/heart/lungs 3. Urinary retention -> makes it difficult to detect full bladder, needs assistance voiding/ catheter may be placed 4. Pruritus (itching) -> common SE, antihistamines might be given 5. Systemic toxicity->If the epidural catheter is inadvertently placed into the intrathecal space -> respiratory paralysis, loss of consciousness, and autonomic blockage can occur.

The nurse is interpreting the fetal monitor tracing below. Which of the following actions should the nurse take at this time? 1. Provide caring labor support. 2. Administer oxygen via tight-fitting face mask. 3.Turn the woman on her side. 4. Apply the oxygen saturation electrode to the mother.

1. Provide caring labor support.

What are priority actions when a patient's amniotic sac ruptures?

1.)Assess FHR strip (priority)-> making sure the baby is not in distress (when amniotic sac ruptures may be at risk for cord compression -> loosing the "cushion"). 2.) Confirm the rupture - Ask the patient about any sudden gush of fluid from vagina. Can also check for pooling of amniotic fluid in vaginal canal or use a pH strip to confirm the presence of amniotic fluid. 3.) Assess the fluid: color + odor - WDL -> straw-colored, smells like sea water. - A potential infection -> green, foul-smelling. 4.)Document the rupture -> increases the potential for infection. & Intection increces - Frequent handwashing + sterile gloving to check dilation. Instruct to avoid inserting anything to vagina + watch for any signs of infection/labor.

Be concerned when newborn loses >____%

10%

What is the range of normal for infant vital signs and when are we concerned? HR BP RR Temp

110-160 bpm 60-80 systolic/40-50 diastolic 30-60 36.5 - 37.5 C

The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible? Select all that apply. 1. Blood in the diaper. 2. Grunting during expiration. 3. Deep red coloring on one side of the body with pale pink on the other side. 4. Lacy and mottled appearance over the entire chest and abdomen. 5. Flaring of the nares during inspiration.

2. Grunting during expiration. 5. Flaring of the nares during inspiration.

A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min × 30 sec. Fetal heart rate is in the 140s with good variability and spontaneous accelerations. What should the nurse conclude when reporting the findings to the primary healthcare practitioner? 1. The woman is at high risk and should be placed on tocolytics. 2. The woman is in early labor and could be sent home. 3.The woman is at high risk and could be induced. 4The woman is in active labor and should be admitted to the unit.

2. The woman is in early labor and could be sent home. #1: no signs of being in high-risk. #2: Primigravida (will take longer to dilate/efface), latent Phase (only 2 cm dilated, 30% effaced), infrequent Contractions (q 12 minutes with short duration). FHR is WDL. The patient should be sent home at this time. #3: no signs of being in high-risk. #4: not an active phase of labor (active is 6-10 cm dilation)

An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

3. Fetal heart rate. --Amniotomy aka AROM (artificial rupture of amniotic sac) Risk of cord compression following the procedure -> Changes in FHR.

Moderate variability

6-25 bpm variation around baseline. WDL.

A newborn was born weighing 3,278 grams. On day 2 of life, the baby weighed 3,042 grams. What percentage of weight loss did the baby experience? Calculate to the nearest hundredth.

7.19% 3278-3042=236 /3278

Progesterone .secreted by

: corpus luteum, then by placenta - Inhibits uterus contraction-->prevents miscarriage - Strengthens the pelvic muscles for labor

Passenger -Head -Presentation -Fetal lie -Fetal attitude -Fetal position

: largest portion of fetus, fetal skull bones are not fused therefore moldable to fit through the birth canal : the part of the fetus that enters the pelvic inlet first (cephalic -> head first; breech -> butt/feet first; shoulder -> C-section!) : the relationship of fetal spine to maternal spine (we want LONGITUDINAL, the rest -> C-section) : the relation of fetal parts to each other: we want chin to chest -> easier to pass through the canal, less trauma. : The relationship of a reference point on the presenting part of the four quadrants of the birth parent's pelvis (ROP, etc)

Human Placental Lactogen .produced by

: placenta - Modifies metabolic state of the mother - Promotes the blood glucose to stay in the fetus (contributes to gestational DM); - Assists in lactation - Acts as a growth hormone for the baby

Human Chorionic Gonadotropin .produced by

: placenta -Support the function of corpus luteum -Hormone that is detected by pregnancy tests

Prolactin .produced by

: posterior pituitary -stimulates milk production -progesterone inhibits prolactin during pregnancy

Oxytocin .produced by

: the anterior pituitary - Milk letdown - Uterine contractions

Estrogen .secreted by

: the corpus luteum, then by placenta - Promotes development/growth of breasts, uterus; - Helps fetal organs to develop - With progesterone stimulates breast growth and milk duct development

Minimal variability

= < 5 bpm variation. 1) Fetus is sleeping. Moderate -> minimal for 20 min. Reassess. 2) Opioids administered to mom.

Marked variability

> 25 bpm variation. Related to Acute Hypoxic Episode -> Often seen right before a baby is delivered.

Rh, ABO incompatibilities

ABO: parent is type O, fetus is anything but O. Parent may develop antibodies and attack fetal BC -> cause mild problems usually and does not get worse with subsequent pregnancies.

The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is? 6 7 8 9

Appearance: pink body/blue extremity -> 1 (acrocyanosis) Pulse: HR 108 bpm (HR>100) -> 2 Grimace: lusty (energetic) cry -> 2 Activity: some flexion -> 1 Respiration: lusty (energetic) cry -> 2 Total: 8

Category 1

Baseline: 110-160 Moderate variability Late or Variable decelerations-absent Early decelerations: present or absent Accelerations: present or absent

A breastfeeding client, GI0 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

Correct answer: 2. Take into consideration the G+P -> she has been pregnant 10 times -> the uterus stretched for so many times, harder to involute, therefore uterus take the priority. Everything else is also important but funds takes priority now.

A 75-gram oral glucose tolerance test (OGTT) is ordered at or after 24 weeks' gestation for a pregnant client to assess her physiological response to which of the following pregnancy hormones? 1. Estrogen. 2. Progesterone. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

Correct answer: 3. Insulin antagonist! Makes glucose stay in blood longer.

A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? 1. "That is very concerning. I will request that your physician order an enema for you." 2. "Two days is not that bad. Some patients go four days or longer without a movement. 3. "You have been taking antibiotics through your intravenous. That is probably why you are constipated. 4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."

Correct answer: 4 Pt is 2 days post C/S, so It is WDL not to have a BM yet. The best advice here is ambulate and drink plenty of fluids, once normal diet returns recommend to consume high-fiber foods.

A G2 P2002 who is postpartum 6 hours from a spontaneous vaginal delivery is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary healthcare provider.

Correct answer: 4. #1: Heavy bleeding (lochia) is not normal -> the normal finding would be Moderate Lochia PP. #2: Fundus is firm, no massage needed. #3: The fundus is firm and at umbilicus, therefore it is unlikely that bladder is full. #4: Start assessment first by checking the fundus, then perineal suture. In this case fundus is firm, suture intact. Therefore, the other cources of bleeding are most likely d/t laceration in the birth canal -> has to be assessed By HCP.

Dietary, substance use, and vitamin counseling

Dietary - 300 cal/day increase over pre-pregnancy caloric needs - AVOID: mercury containing fish, unpasteurized products, raw fish Substance - Alcohol: Contraindicated -> teratogen - Caffeine: safety is unclear, recommended is <200 mg a day - Stevia: questionable -> safety is unclear Vitamin Increased need for iron, folic acid, protein, Vitamin A, C, D, B6, B12, & calcium -> prenatal vitamins are important

GTPAL

G - gravida: # of times pregnant T- term: # of pregnancies that lasted until term (37 weeks) P- preterm: # of pregnancies that were pre-term (20-37 weeks) A - abortion: # of abortions; spontaneous or induced (before 20 weeks) L- living children: # of living children

methylergonovine not for

NOT for clients with high blood pressure (preeclampsia & pre-existing HTN)

An epidural was administered 20 minutes ago and now the client reports feeling dizzy and nauseated. Which action should be performed first?

Obtain blood pressure

What are the 5 Ps of labor and why are they important?

Powers Passenger Passageway Position Psychological

A nurse is performing a postpartum assessment on a client who delivered vaginally. Which of the following actions will the nurse perform? Select all that apply. 1. Palpate the breasts. 2. Auscultate the carotid. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum.

Q1: Correct answers 1,3,4,5 BUBBLE-HE (Breasts, Uterus, Bowel, Bladder, Lochia, Episiotomy, Homan's, Emotions

During a postpartum assessment, the nurse assesses the calves of a client's legs. The nurse is checking for which of the following signs/symptoms? Select all that apply. 1. Pain. 2. Warmth. 3. Discharge. 4. Ecchymosis. 5. Redness.

Q2: Correct answers 1,2,5 High risk for DVT -> assess calves for signs of inflammatory response: pain, warmth, redness, edema.

Prenatal advice on maternal positioning

Supine hypotensive syndrome - Caused by mom lying on her back in mid to late pregnancy -> teach to avoid laying flat on the back -> if experiencing the S/S, turn them on their side to prevent blood vessel compression. - Supine position -> the enlarged uterus compresses the inferior vena cava -› significant drop in cardiac output and blood pressure -» dizziness, fainting

How is gestational diabetes diagnosed? What is the difference between a 2-hour GTT and a 3 hour?

Two step process - 1 hr and 3 hr Glucose Tolerance Test: Done 24-28 weeks gestation vs 2 HOUR GTT: one step process + fasting

Passageway

birth canal (Bony Pelvis + Soft tissues)

Urinalysis:

check for UTI (may cause preterm labor), check for protein (a sign of preeclampsia).

- Stretch marks (striae gravidarum):

connective tissue changes -> may fade over a period of a few months but will not disappear completely. No proven methods for prevention.

V-w or v-shaped dips E-mirror the contractions A-temp inc in HR L-lower HR after contractions

cord compression-- (inc in fetal blood volume dt blood backup -> compensatory mechanism such as drop in BP. May occur with or without uterine contractions) =reposition head compression--head squeezing during labor ok oxygen placental insufficiency(hypoxia) --if can't correct within minutes=deliver baby ASAP

- Varicose veins:

d/t extra blood and fluid pooling -> compression stocking may relieve the discomfort.

- Line Negra:

dark line from the symphysis pubis to xyphoid process.

RPR, VDRL (syphilis):

done at a prenatal visit, has to be treated with ABX. May lead to miscarriage or stillbirth.

Psychological

emotional state -cultural considerations -coping mechanisms

HIV:

has to be treated with antiretrovirals. Minimal risk of transmission (but still exists).

During contractions babies will

hold their breath & fetal oxygenation Key Terms for Uterine Contractions is impaired -reduce oxytocin

Herpes:

if active outbreak -> only C-section. Often antiretrovirals prescribed at 36 weeks gestation. Complications: blindness, deafness, organ damage.

Hgb, Hct:

if low H+H, may need iron supplements.

Hepatitis B surface antigen:

if mom is positive, then baby receives Hep B + Hep B immunoglobulin IM after delivery.

Rubella titer:

if non-immune will be given a vaccine after delivery.

Position

of mother

GBS:

rectal/vaginal swab at 36 weeks testing for streptococcus bacteria -> not an STD. Infant may get very sick if delivered vaginally -> give ABX during labor to prevent the infection.

Misoprostol

safe for clients with hypertension

The uterus should be ___ to palpation between contractions for at least 60 seconds

soft

- Melasma (Cloasma):

the mask of pregnancy, regresses within a year but may never disappear completely.

Gonorrhea:

treated with ABX. Complications: blindness, joint + blood infections.

Chlamydia:

treated with ABX. Complications: preterm birth, miscarriage, stillbirth.

Absent variability

undetectable variation around baseline. Hallmark of Hypoxia.

- Pruritic urticarial papules and plaques of pregnancy (PUPPP)/ Polymorphic eruption of pregnancy (PEP):

very scratchy, a lot of maternal discomfort but no adverse effects for mom/baby. Treated with antihistamines + topical steroids, oral steroids only in severe cases.

Breasts expected vs follow up

• Tenderness, lumpiness • No milk for the first 4 days -> Colostrum is present • Nipples intact • Cracked nipples • Painful breastfeeding

Cardiovascular

•Blood loss: •Vaginal birth: 300-500 mL (10% of blood volume) •C/S: 500- 1000mL (15%-30%) •Physiological Changes to Cope with Blood Loss: •Elimination of uteroplacental circulation •Loss of placental endocrine function that encouraged vasodilation •Mobilization of extravascular water stored during pregnancy

Immune System

•Check Rubella Status •Rhogam •ABO incompatibility

Musculoskeletal

•Dec. tone in abdominal muscles •Residual soreness from L&D •Joints stabilize 6-8 weeks PP & returns to pre-pregnancy size Except for feet, may be permanently inc. size *Separation of symphysis pubis, rare •Assess for diastasis recti (your belly sticks out because the space between your left and right belly muscles has widened) •Ability to ambulate •Musculoskeletal pain •Teach about resumption of exercise, kegels, stretching •Delay vigorous exercise until HCP okays resumption •No heavy lifting 4-6 weeks

Urinary Tract/Renal

•Edema of bladder, urethra, urinary meatus -» dec. urination •Dec. sensitivity to fluid pressures •Potential for incomplete emptying of bladder/distention *Diuresis w/in 12 hrs post delivery •Renal function normal 6 weeks PP •Measure first 2 voids •Assess for pain & burning w/ urination -> UTI •Techniques to assist with voiding -> peri-bottle •Straight cath if unable to void •Assess bladder and fundus, Remind pt to void q2 hrs •Pain management

Gastrointestinal

•Normal or inc. appetite •Potential for dec. bowel motility •Expect BM 2nd or 3rd PP Day •Risk for constipation •Hemorrhoids may be present •Assess bowel sounds & distention •Encourage fluids •Ambulation •Fiber in diet •Stool softeners •Comfort measures

Respiratory

•Quickly returns to prepregnant state •Dyspnea of pregnancy resolves •Reduction of diaphragmatic pressure •Calf tenderness, edema, homan's sign (pain behind knee upon dorsiflexion of foot) •Dizziness (teach pt to rise slowly) *Teach leg exercises if >8 hrs in bed