NUR 221 Exam 2

What are some of the nursing considerations for Cervidil?

1.) Avoid use in women with asthma, glaucoma, and hypotension or hypertension. 2.) Use with caution if the woman has cardiac, renal, or hepatic disease, anemia, jaundice, diabetes, epilepsy, or genitourinary (GU) infections. 3.) Have the woman void before insertion.

How is category I defined in the fetal heart rate classification system?

1.) Baseline rate 110 to 160 beats/min 2.) Baseline FHR variability: Moderate 3.) Late or variable decelerations: Absent 4.) Early decelerations: Either present or absent 5.) Accelerations: Either present or absent:

What severe signs and symptoms of Preeclampsia should we evaluate for?

1.) Severe headaches 2.) Blurred or double vision 3.) Mental confusion 4.) Right upper quadrant abdominal or epigastric pain 5.) Nausea or vomiting 6.) Shortness of breath 7.) Decreased urinary output

What are the causes of Accelerations?

1.) Spontaneous fetal movement 2.) Vaginal examination 3.) Electrode application 4.) Fetal scalp application 5.) Fetal reaction to external sounds 6.) Breech presention 7.) Occiput posterior position 8.) Uterine contractions 9.) Fundal pressure 10.) Abdominal palpation

What are some of the nursing considerations for Cytotec?

1.) Avoid giving aluminum hydroxide and magnesium-containing antacids along with misoprostol. 2.) Use with caution in women with renal failure because the medication is eliminated through the kidneys. 3.) Have the woman void before insertion.

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

"I should drink adequate fluids and increase my intake of high-fiber foods."

What is the normal range for Creatinine?

0.6 - 1.2 mg/dL

How is category III defined in the fetal heart rate classification system?

1.) Absent baseline variability and any of the following: Recurrent late decelerations, recurrent variable decelerations, bradycardia 2.) Sinusoidal pattern

What are the symptoms of Magnesium toxicity?

1.) Absent deep tendon reflexes 2.) Respiratory depression 3.) Blurred vision 4.) Slurred speech 5.) Severe muscle weakness 6.) Cardiac arrest

What are the nursing actions for Nifedipine?

1.) Avoid concurrent use with Magnesium Sulfate because skeletal muscle blockade can result. 2.) Avoid immediate release or sublingual form due to increased risk for profound maternal hypotension.

What is the diagnostic criteria for Preeclampsia?

1.) Blood pressure (BP) reading >140/90 mm Hg x 2, at least 4 hours apart after 20 weeks of gestation in a previously normotensive woman. 2.) Proteinuria of >300 mg in a 24 hour specimen. 3.) Platelet count <100,000 u/L. 4.) Elevated blood levels of liver transaminases to twice the normal concentration. 5.) New development of serum creatinine >1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal diseases. 6.) Pulmonary edema 7.) Cerebral of visual disturbances

How is category II defined in the fetal heart rate classification system?

1.) Bradycardia not accompanied by absent baseline variability, tachycardia 2.) Minimal baseline variability, absent baseline variability not accompanied by recurrent decelerations, marked baseline variability 3.) No accelerations produced in response to fetal stimulation 4.) Recurrent variable decelerations accompanied by minimal or moderate baseline variability, prolonged decelerations (greater than or equal to 7 minutes but less than 10 minutes, recurrent late decelerations with moderate baseline variability, variable decelerations with other characteristics such as slow return to baseline, "overshoots" or "shoulders"

What are some cultural beliefs about pain?

1.) Chinese women may not exhibit reactions to pain, although exhibiting pain during childbirth is acceptable. They consider accepting something when it is first offered as impolite, therefore pain interventions must be offered more than once. Acupuncture may be used for pain relief. 2.) Arab or Middle Eastern women may be vocal in response to labor pain. They may prefer medication for pain relief. 3.) Japanese women may be stoic in response to labor pain, but they may request medication when pain becomes severe. 4.) Southeast Asian women may endure severe pain before requesting relief. 5.) Hispanic women may be stoic until late in labor, when they may become vocal and request pain relief. 6.) Native American women may use medications or remedies made from indigenous plants. They are often stoic in response to labor pain. 7.) African-American women may express pain openly. Use of medication for pain relief varies.

What should you teach the pregnant woman who is at risk for cardiac decompensation the importance of?

1.) Daily weighing: Sudden weight gain indicates fluid retention. 2.) Keeping all prenatal visit appointments, although they will be scheduled more frequently than for "normal" pregnant women. 3.) Limiting activity (depending on classification of her heart disease). Patients with class I or II cardiac disease need 10 hours of sleep every night and 30 minutes of rest after meals. Patients with class III or IV cardiac disease usually need bed rest for most of each day.

What are the nursing interventions for Late Decelerations?

1.) Discontinue oxytocin if infusing 2.) Assist woman to lateral (side-lying) position 3.) Administer oxygen at 10 L/min by nonrebreather face mask 4.) Correct maternal hypotension by elevating legs 5.) Increase rate of maintenance intravenous solution 6.) Palpate uterus to assess for tachysystole 7.) Notify physician or nurse-midwife 8.) Consider internal monitoring for more accurate fetal and uterine assessment 9.) Assist with birth (vaginal assisted or cesarean) if pattern cannot by corrected

What are the nursing interventions of Variable Decelerations?

1.) Discontinue oxytocin if infusing 2.) Change maternal position (side to side, knee chest) 3.) Administer oxygen at 10 L/min by nonrebreather face mask 4.) Notify physician or nurse-midwife 5.) Assist with vaginal or speculum examination to assess for cord prolapse 6.) Assist with amnioinfusion if ordered 7.) Assist with birth (vaginal or cesarean) if pattern cannot be corrected

What are the 7 Cardinal Movements?

1.) Engagement 2.) Descent 3.) Flexion 4.) Internal Rotation 5.) Extension 6.) Restitution and External Rotation 7.) Expulsion

What are the hospital precautionary measures for women with Preeclampsia?

1.) Environment: quiet, non-stimulating, lighting subdued 2.) Seizure precautions: Suction equipment tested and ready to use, oxygen administration equipment tested and ready to use, call button within easy reach 3.) Emergency medications available on the unit: Hydralazine, Labetalol, Nifedipine, Magnesium Sulfate, Calcium Gluconate or Calcium Chloride 4.) Emergency birth pack easily available

What is the emergency treatment if a patient with Preeclampsia has a seizure?

1.) Keep airway patent, turn head to one side, place pillow under one shoulder or back if possible. 2.) Call for assistance. Do not leave bedside. 3.) Raise side rails, and pad them with a folded blanket or pillow if possible. 4.) Observe and record convulsion activity.

What are the nursing actions for Labetalol?

1.) Less likely to cause excessive hypotension and tachycardia; less rebound hypertension than Hydralazine. 2.) Do not use in women with asthma, heart disease, or congestive heart failure. 3.) Do not exceed 80 mg in a single dose. 4.) Do not give more than 300 mg total in a 24 hour period.

What are the signs of preceding labor?

1.) Lightening 2.) Return of urinary frequency 3.) Backache 4.) Stronger Braxton Hicks contractions 5.) Weight loss of 0.5 to 1.5 kg (approximately 1 to 3 1/2 pounds) 6.) Surge of energy 7.) Increased vaginal discharge, bloody show 8.) Cervical ripening 9.) Possible rupture of membranes

What are the risk factors for Preeclampsia?

1.) Nulliparity 2.) Age >40 years 3.) Pregnancy with assisted reproduction techniques 4.) Interpregnancy interval >7 years 5.) Family history of preeclampsia 6.) Woman born small for gestational age 7.) Obesity/gestational diabetes mellitus 8.) Multifetal gestation 9.) Preeclampsia in previous pregnancy 10.) Poor outcome in previous pregnancy 11.) Preexisting medical/genetic conditions 12.) Chronic hypertension 13.) Renal disease 14.) Type 1 (insulin dependent) diabetes mellitus 15.) Antiphospholipid antibody syndrome 16.) Factor V Leiden mutation

What are the suggested measures for supporting a woman in labor?

1.) Provide companionship and reassurance. 2.) Offer positive reinforcement and praise for her efforts. 3.) Encourage participation in distracting activities and nonpharmacologic measures for comfort. 4.) Give nourishment (if allowed by obstetric health care provider). 5.) Assist with personal hygiene. 6.) Offer information and advice. 7.) Involve the woman in decision making regarding her care. 8.) Interpret the woman's wishes to other health care providers and to her support group. 9.) Create a relaxing environment. 10.) Use a calm and confident approach. 11.) Support and encourage the woman's support people by role-modeling labor support measures and providing time for breaks.

What should you teach the patient about assessing and reporting clinical signs of Preeclampsia?

1.) Take your blood pressure as directed. Always sit to take your blood pressure, and use your right arm each time for consistent and accurate readings. Support your arm on a table with a horizontal position at heart level. 2.) Report any increase in your blood pressure to your health care provider immediately. 3.) Dipstick test your clean catch urine sample as directed to assess proteinuria. 4.) Report to your health care provider if proteinuria is 1+ or more or if you have a decrease in urine output. 5.) Assess your baby's activity daily. Decreased activity (four or fewer movements per hour) may indicate fetal compromise and should be reported. 6.) Be sure to keep your scheduled prenatal appointments so that any changes in your or your baby's condition can be detected. 7.) Keep a daily log or diary of your assessments for your home health care nurse, or take it with you to your next prenatal visit. 8.) Report any headache, dizziness, or blurred vision to your health care provider immediately.

What are the 2 stages that the Second Stage of Labor is divided into?

1.) The latent phase, sometimes referred to as delayed pushing, laboring down, or passive decent, is the time from complete cervical dilation until the woman begins actively pushing. 2.) The active pushing phase, when the woman has strong urges to bear down as the Ferguson reflex is activated when the presenting part presses on the stretch receptors of the pelvic floor. This stimulation causes the release of oxytocin from the posterior pituitary gland, which provokes stronger expulsive uterine contractions.

What are the 2 stages that the First Stage of Labor is divided into?

1.) The latent phase, which extends from the onset of labor, characterized by regular, painful uterine contractions that cause cervical change, to the beginning of the active phase, when cervical dilation occurs more rapidly. 2.) The active phase, which is defined as the period during which the greatest rate of cervical dilation occurs, which begins at 6 cm, and ends with complete cervical dilation at 10 cm.

What is the emergency treatment for maternal hypotension with decreased placental perfusion?

1.) Turn woman to lateral position, or place pillow or wedge under hip to displace uterus. 2.) Maintain intravenous (IV) infusion at rate specified, or increase administration per hospital protocol. 3.) Administer oxygen by nonrebreather face mask at 10 to 12 L/minute or per protocol. 4.) Elevate the woman's legs. 5.) Notify primary health care provider, anesthesiologist, or nurse anesthetist. 6.) Administer IV vasopressor (e.g., ephedrine 5 to 10 mg or phenylephrine 50 to 100 mcg) per protocol if previous measures are ineffective. 7.) Remain with woman, continue to monitor maternal blood pressure and fetal heart rate (FHR) every 5 minutes until her condition is stable or per primary health care provider's order.

What instructions should you give the pregnant woman who is at risk for cardiac decompensation?

1.) Watch for and immediately report signs of cardiac decompensation or congestive heart failure: generalized edema; distention of neck veins; dyspnea, frequent, moist cough; or palpitations. 2.) Watch for and immediately report signs of thromboembolism; pain, redness, tenderness, or swelling in extremities or chest pain. 3.) Avoid constipation and thus straining with bowel movements (Valsalva maneuver) by taking in adequate fluids and fiber. A stool softener may also be helpful.

What three important questions does Leopold Maneuvers help to answer?

1.) Which fetal part is in the uterine fundus? 2.) Where is the fetal back located? 3.) What is the presenting fetal part?

What is the normal range for AST?

10 - 30 u/L

What is the normal range for ALT?

10 - 40 u/L

What is the normal FHR (fetal heart rate) range?

110 to 160 beats/min

What is the normal range for hemoglobin?

12 - 18 g/dL

What is the normal range for platelets?

150,000 - 400,000 cells/mcL

What is the normal range of hematocrit for women?

37 - 47%

What are the risk factors for Placenta Previa?

A history of previous cesarean birth, advanced maternal age (more than 35 to 40 years of age), multiparity, history of prior suction curettage, smoking and living at a higher altitude.

What is HELLP syndrome?

A laboratory diagnosis for a variant of preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver enzymes (EL), and low platelet (LP) count.

What does an abdominal examination reveal in regards to Placenta Previa?

A soft, relaxed, non-tender uterus with normal tone.

What is the criteria for a nonreactive Nonstress Test (NST)?

A test that does not demonstrate at least two qualifying accelerations within a 20 minute window.

What are Prolonged Decelerations of the FHR?

A visually apparent decrease in FHR of at least 15 beats/min below the baseline and lasting more than 2 minutes but less than 10 minutes.

What are Late Decelerations of the FHR?

A visually apparent, decrease in and return to baseline FHR associated with uterine contractions.

What are Early Decelerations of the FHR?

A visually apparent, gradual decrease in and return to baseline FHR associated with uterine contractions.

SAFETY ALERT (pg. 357):

After receiving a neuraxial block or opioid intravenously for pain, the woman should not be allowed to ambulate alone. She must either remain in bed or request assistance before attempting to get out of bed. The nurse assesses the woman for signs of orthostatic hypotension and return of sensation and motor function of the lower extremities prior to ambulation.

When is Amniocentesis possible?

After week 14 of pregnancy when the uterus becomes an abdominal organ and sufficient amniotic fluid is available for testing.

What is included in a Biophysicial Profile (BPP)?

Amniotic fluid volume (AFV), fetal breathing movements (FBMs), fetal movements, and fetal tone determined by ultrasound and fetal heart rate (FHR) reactivity determined by means of the non-stress test.

How is fetal tachycardia defined?

As a baseline FHR greater than 160 beats/min for 10 minutes or longer.

How is fetal bradycardia defined?

As a baseline FHR less than 110 beats/min for 10 minutes or longer.

How are Variable Decelerations of the FHR defined?

As a visually abrupt (onset to lowest point <30 seconds) and apparent decrease in FHR below the baseline. The decrease is at least 15 beats/min or more below the baseline, lasts at least 15 seconds, and returns to baseline in less than 2 minutes from the time of onset.

How are Accelerations of the FHR defined?

As a visually apparent abrupt onset to peak increase in FHR above the baseline rate. The peak is at least 15 beats/min above the baseline, and the acceleration lasts 15 seconds or more, with the return to baseline less than 2 minutes from the beginning of the acceleration.

How can Variability of the FHR be described?

As irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater. It is a characteristic of the baseline FHR and does not include accelerations or decelerations of the FHR. Variability is quantified in beats per minute and is measured from the peak to the trough of a single cycle.

MEDICATION ALERT (pg. 291):

If magnesium toxicity is suspected, prompt actions are needed to prevent respiratory or cardiac arrest. The magnesium infusion should be discontinued immediately. Calcium gluconate or calcium chloride (antidotes for magnesium sulfate) can be given intravenously.

What should you teach the patient about false labor?

Contractions: 1.) Occur irregularly or become regular only temporarily. 2.) Often stop with walking or position change. 3.) Can be felt in the back or the abdomen above the umbilicus. 4.) Can often be stopped through the use of comfort measures.

What should you teach the patient about true labor?

Contractions: 1.) Occur regularly, becoming stronger, lasting longer, and occurring closer together. 2.) Become more intense with walking. 3.) Are usually felt in the lower back, radiating to the lower portion of abdomen. 4.) Continue despite use of comfort measures.

What are some non-pharmacologic strategies to encourage relaxation and relieve pain?

Cutaneous Stimulation: 1.) Countepressure 2.) Effleurage (light massage) 3.) Therapeutic touch and massage 4.) Walking 5.) Rocking 6.) Change positions 7.) Application of heat or cold 8.) Transcutaneous electric nerve stimulation (TENS) 9.)Acupressure 10.) Water therapy (showers, baths, whirlpool baths) 11.) Intradermal water block Sensory Stimulation: 1.) Aromatherapy 2.) Breathing techniques 3.) Music 4.) Imagery 5.) Use of focal point Cognitive: 1.) Childbirth education 2.) Hypnosis 3.) Biofeedback

What is the management of choice if a pregnant patient has Placental Abruption?

Immediate birth is the management of choice if the fetus is at term gestation or the bleeding is moderate to severe and the mother or fetus is in jeopardy.

What is Preeclampsia?

Development of hypertension and proteinuria in a previously normotensive woman after 20 weeks of gestation or in the early postpartum period. In the absence of proteinuria, the development of new onset hypertension with the new onset of any of the following: thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms.

What are the causes of Late Decelerations?

Disruption of oxygen transfer from environment to fetus, resulting in transient fetal hypoxemia. Late decelerations are caused by the following: 1.) Uterine tachysystole 2.) Maternal supine hypotension 3.) Epidural or spinal anesthesia 4.) Placenta previa 5.) Placental abruption 6.) Hypertensive disorders 7.) Postterm gestation 8.) Intrauterine growth restriction 9.) Diabetes mellitus 10.) Intraamniotic infection

What are the causes of Early Decelerations?

Head compression resulting from the following: 1.) Uterine contractions 2.) Vaginal examination 3.) Fundal pressure 4.) Placement of internal mode of monitoring

What are the side effects of Neuraxial Anesthesia?

Hypotension, lightheadedness, dizziness, tinnitus, metallic taste, numbness of the tongue and mouth, bizarre behavior, slurred speech, convulsions, loss of consciousness, fever, urinary retention, pruritus, limited movement, longer second stage labor, increased use of oxytocin, increased likelihood of forceps or vacuum assisted birth and high or total spinal anesthesia.

What is Amnioinfusion?

Infusion of room temperature isotonic fluid (usually normal saline or Lactated Ringer's solution) into the uterine cavity if the volume of amniotic fluid is low.

How is Magnesium Sulfate administered?

Intravenously (piggyback) with an initial loading dose of 4 to 6 g infused over 15 to 30 minutes. This dose is followed by a maintenance dose that is diluted in an IV solution (e.g., 40 g in 1000 mL of Lactated Ringer's solution) and administered by an infusion pump at 2 to 3 g/hr. This dose should maintain a therapeutic serum magnesium level of 4 to 7 mEq/L.

If the woman develops severe Gestational Hypertension/Preeclampsia with severe features after 34 weeks gestation, what is the recommended treatment?

It is recommended that she gives birth promptly, because severe preeclampsia has been associated with increased rated of maternal morbidity and mortality and with significant fetal risks.

What is the medication of choice for preventing and treating seizure activity (Eclampsia)?

Magnesium Sulfate

What are the risk factors for Placental Abruption?

Maternal hypertension, whether chronic or pregnancy related, is the most consistently identified risk factor for abruption. Cocaine use is also a risk factor because it causes vascular disruption in the placental bed. Blunt external abdominal trauma, most often the result of motor vehicle accidents (MVAs) or maternal battering, is another frequent cause of placental abruption. Other risk factors include cigarette smoking, a history of abruption in a previous pregnancy, and preterm premature rupture of membranes.

What are the nursing considerations for Nubain?

May precipitate withdrawal symptoms in opioid-dependent women and their newborns. Assess maternal vital signs, degree of pain, FHR, and uterine activity before and after administration. Observe for maternal respiratory depression, notifying obstetric health care provider if maternal respirations are less than or equal to 12 breaths per minute. Encourage voiding every 2 hours, and palpate for bladder distention. If birth occurs with 1 to 4 hours of dose administration, observe newborn for respiratory depression. Implement safety measures as appropriate, including use of side rails and assistance with ambulation. Continue use of non-pharmacologic pain relief measures.

What kind of Variability is considered normal?

Moderate

What are the nursing interventions for Accelerations?

None required.

What are the nursing interventions for Early Decelerations?

None required.

NURSING ALERT (pg. 372):

Nurses should notify the physician or nurse-midwife immediately and initiate appropriate treatment of abnormal patterns when they see a prolonged deceleration.

What kind of pushing should you encourage a woman in labor to do?

Open glottis pushing for 6 to 8 seconds at a time.

What does open glottis pushing help to maintain?

Open glottis pushing helps to maintain adequate oxygen levels for the mother and fetus, thus enhancing fetal well being.

What are the clinical manifestations of Placenta Previa?

Placenta Previa is typically characterized by painless bright red vaginal bleeding during the second or third trimester.

What are the indications for Amniocentesis?

Prenatal diagnosis of genetic disorders or congenital anomalies (neural tube defects [NTDs] in particular), assessment of pulmonary maturity, and (rarely) diagnosis of fetal hemolytic disease.

What is Counterpressure?

Steady pressure applied by a support person to the sacral area with a firm object (e.g., tennis ball) or the fist or heel of the hand.

What is an Amniotomy?

The Artificial Rupture of Membranes (AROM), which is used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if progress begins to slow. Labor usually begins within 12 hours of AROM. Amniotomy can decrease the duration of labor by up to 2 hours, even without oxytocin administration.

What are the nursing interventions after an Amniotomy has been performed?

The color, odor, and consistency of the fluid are assessed (i.e., for the presence or absence of meconium or blood). The time of rupture is recorded. The woman's temperature should be checked at least every 2 hours after rupture of membranes, more frequently if signs or symptoms of infection are noted. If her temperature is 38 C (100.4 F) or higher, the nurse notifies the obstetric health care provider. The nurse assesses for other signs and symptoms of infection, such as maternal chills, uterine tenderness on palpation, foul-smelling, vaginal drainage, and fetal tachycardia. Comfort measures such as frequently changing the woman's underpads and perineal cleansing, are implemented.

What is Station?

The relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines and is a measure of the degree of descent of the presenting part of the fetus through the birth canal.

What is the Second Stage of Labor?

The stage in which the infant is born. This stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth.

What is the Fourth Stage of Labor?

The stage that begins with the expulsion of the placenta and lasts until the woman is stable in the immediate postpartum period, usually within the first hour after birth.

What is the First Stage of Labor?

The stage that begins with the onset of regular uterine contractions and ends with complete cervical effacement and dilation.

What is the Third Stage of Labor?

The stage that lasts from the birth of the baby until the placenta is expelled.

If a Nonreactive Stress Test requires further evaluation, what happens next?

The test is usually extended for an additional 20 minutes with the expectation that the fetal sleep state will change and the test will become reactive. During this time vibroacoustic stimulation (VAS) may be used to stimulate fetal activity. If the test does not meet the criteria after 40 minutes, a contraction stress test or biophysical profile (BPP) should be performed. Once the NST is initiated, it is usually repeated once or twice weekly for the remainder of the pregnancy.

What does Counterpressure help with?

The woman cope with the sensations of internal pressure and pain in the lower back.

NURSING ALERT (pg. 332):

The woman should be discouraged from using the Valsalva maneuver (holding one's breath and tightening abdominal muscles) for pushing during the second stage. This activity increases intrathoracic pressure, reduces venous return, and increases venous pressure. Cardiac output and blood pressure increase, and the pulse slows temporarily. During the Valsalva maneuver, fetal hypoxia may occur. The process is reversed when the woman takes a breath.

What is the purpose of Amnioinfusion?

To relieve intermittent umbilical cord compression that results in variable decelerations and transient fetal hypoxemia by restoring the amniotic fluid volume to a normal or near normal level.

What is the criteria for a reactive Nonstress Test (NST)?

Two accelerations in a 20 minute period, each lasting at least 15 seconds and peaking at least 15 beats/min above the baseline. (Before 32 weeks of gestation, an acceleration is defined as a rise of at least 10 beats/min lasting at least 10 seconds from onset to offset.)

What are causes of Variable Decelerations?

Umbilical cord compression caused by the following: 1.) Maternal position with cord between fetus and maternal pelvis 2.) Cord around fetal neck, arm, leg, or other body part 3.) Short cord 4.) Knot in cord 5.) Prolapsed cord

What are the clinical manifestations of Placental Abruption?

Vaginal bleeding, abdominal pain, uterine tenderness, and contractions.