Exam 2 PDF

**Exam 2** PPROM/PROM \[pg165\] - PROM (premature/prelabor rupture of membranes): the spontaneous rupture of the amniotic membranes prior to the onset of true labor - PPROM (preterm premature/prelabor rupture of membranes): the prelabor spontaneous rupture of membranes after 20 weeks...

**Exam 2** PPROM/PROM \[pg165\] - PROM (premature/prelabor rupture of membranes): the spontaneous rupture of the amniotic membranes prior to the onset of true labor - PPROM (preterm premature/prelabor rupture of membranes): the prelabor spontaneous rupture of membranes after 20 weeks of gestation and prior to 37 weeks of gestation (ATI ch. 10 pg 69) Preterm labor (PTL) - Preterm labor is uterine contractions and cervical changes that occur between 20 and 36 weeks and 6 days of gestation. Preterm labor can be categorized as very preterm (less than 32 weeks of gestation), moderately preterm (32 to 34 weeks of gestation), and late preterm (34 to 36 weeks of gestation). Shorter gestation is associated with increased neonatal risks. (ATI ch. 10 pg 67) - Bloody discharge, uterine contractions becoming regular, cervical dilation and effacement Diabetes: pregestational/gestational {pg 176\] - Pregestational diabetes: blood glucose levels above the normal range but below the cutoff for overt or clinical diabetes in the nonpregnant woman. - Gestational Diabetes: an impaired tolerance to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level during pregnancy should range between 60 and 99 mg/dL before meals or fasting, and less than or equal to 120 mg/dL 2 hr after meals. (ATI ch 9 pg 61) Hyperemesis Gravidarum \[pg 173\] - Excessive N/V (possibly r/t elevated hCG levels) that is prolonged past 16 weeks gestation or that causes weight loss, dehydration, nutritional deficiencies, electrolyte imbalances, ketonuria (ATI ch. ) Gestational Trophoblastic Disease/Molar pregnancy/Hydatidiform Mole \[pg 202\] - proliferation and degeneration of trophoblastic villi in the placenta that becomes swollen, fluid-filled, and takes on the appearance of grape-like clusters. The embryo fails to develop beyond a primitive state and these structures are associated with choriocarcinoma, which is a rapidly metastasizing malignancy - risk factors: maternal age \40, previous molar pregnancy Hypertensive disorders \[pg 181\] \[ATI ch9 pg 63\] - Chronic hypertension - Hypertension (systolic BP of 140 mm Hg or greater or diastolic pressure of 90 mm Hg or greater) before conception - Super imposed preeclampsia: - Women with chronic hypertension who develop new-onset or increased proteinuria and manifest other signs and symptoms such as an increase in liver enzymes or creatinine; present with thrombocytopenia; manifest with symptoms of right upper quadrant pain and headaches, blurred vision, or scotoma; and may develop pulmonary edema or congestion - Gestational hypertension - begins after the 20th week of pregnancy, describes hypertensive disorders of pregnancy whereby the client has an elevated blood pressure at 140/90 mm Hg or greater recorded on two different occasions, at least 4 hr apart. There is no proteinuria - Preeclampsia - Traditionally, preeclampsia has been diagnosed when proteinuria occurs with GH. However, current research indicates that clients who have preeclampsia may not exhibit proteinuria. Therefore, the diagnosis of preeclampsia can be made in the absence of this finding. Report of headaches might occur along with episodes of irritability. Edema can be present - Severe preeclampsia - consists of blood pressure that is 160/110 mm Hg or greater, proteinuria greater than 3+, oliguria, elevated blood creatinine greater than 1.1 mg/dL, cerebral or visual disturbances (headache and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and right upper-quadrant pain, and thrombocytopenia - Eclampsia - Severe preeclampsia manifestations with the onset of seizure activity or coma. Eclampsia is usually preceded by headache, severe epigastric pain, hyperreflexia, and hemoconcentrations, which are warning manifestations of probable convulsions HELLP Syndrome \[pg 190\] - variant of GH in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction. HELLP syndrome is diagnosed by laboratory tests, not clinically. - H: Hemolysis resulting in anemia and jaundice - EL: Elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, and nausea and vomiting - LP: Low platelets (less than 100,000/mm3), resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly disseminated intravascular coagulation. - Tests: Liver enzymes, Blood creatinine, BUN, uric acid, CBC, Clotting studies, Chemistry profile, U/A, 24hr urine, nonstress test, doppler blood flow analysis, daily kick sounds Placenta previa \[pg 192\] - Low lying/marginal/partial/complete placental placements - occurs when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus - Classified into three types dependent on the degree to which the cervical os is covered by the placenta - Complete or total: The cervical os is completely covered by the placental attachment - Incomplete or partial: The cervical os is only partially covered by the placental attachment - Marginal: The placenta is attached in the lower uterine segment but does not reach the cervical os - Low-lying: The exact relationship of the placenta to the internal os has not been determined - Risk factors: Previous placenta previa, Uterine scarring, Maternal age greater than 35 years, Multifetal gestation, Multiple gestations, Smoking - Tests: hgb/hct, cbc, blood typing and Rh, coag profile, Kleihauer-Betke test (used to detect fetal blood in maternal circulation) ,US, fetal monitoring - Findings: Painless, bright red vaginal bleeding during the second or third trimester, Uterus soft, relaxed, and nontender with normal tone, Fetus in a breech, oblique, or transverse position, Reassuring FHR, Vital signs within normal limits Placenta abruptia \[pg 194\] - referred to as abruptio placentae, is bleeding at the decidual-placental interface that causes partial or complete placental detachment prior to delivery of the fetus - Vaginal bleeding, sharp abdominal pain, and tender rigid uterus - Tests: hgb/hct, cbc, blood typing and Rh, coag profile, Kleihauer-Betke test (used to detect fetal blood in maternal circulation), US, BPP Ectopic pregnancy \[pg 200\] - abnormal implantation of a fertilized ovum outside of the uterine cavity usually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage - second most frequent cause of bleeding in early pregnancy and a leading cause of infertility - Findings: unilateral stabbing pain and tenderness to lower abdominal quadrant, referred shoulder pain, with or without vaginal bleeding, hemorrhage or shock if severe - Perform hCG, progesterone testing and US Intrahepatic Cholestasis {pg 174\] - obstetric cholestasis, is the most common pregnancy-specific liver disease. A reversible type of hormonally influenced cholestasis, it frequently develops in late pregnancy in individuals who are genetically predisposed - characterized by generalized itching, often with pruritus of the palms of the hands and soles of the feet with no other skin manifestations, most often presents in the late second or early third trimester of pregnancy and affects approximately 1% of pregnancies in the United States - Multigestational/twins: monoamniotic/monozygotic & diamniotic/dizygotic \[pg169\] - Greatest risk twin to twin transfusion - Cord entanglement TORCH infections \[209\] - an acronym that stands for Toxoplasmosis, Other (hepatitis B), Rubella, and Cytomegalovirus and HSV - teratogenic UTI/pyelonephritis \[209\] - Most common bacterial infections during pregnancy - Associated w/ risk to mother and fetus, can contribute to PTL/PTB, LBW, pyelonephritis, increased risk of perinatal mortality. Can be symptomatic or asymptomatic. Group B Strep (GBS) \[211\] - bacterial infection that can be passed to a fetus during labor and delivery - Complications: PTL/PTB, UTI, intrauterine infection, endometriosis after delivery, if transmitted to baby: pneumonia, RDS, sepsis, meningitis - cultures are performed at 36 0/7 and up to 37 6/7 weeks of gestation - IV loading dose (bolus), followed by intermittent IV bolus every 4 hr; typically Pen G or ampicillin VEAL CHOP Variable decelerations \[314\] - Transitory, abrupt slowing of FHR 15/min or more below baseline for at least 15 seconds, variable in duration, intensity, and timing in relation to uterine contraction - Causes: cord compression, prolapsed cord, nuchal cord (around fetal neck) - Interventions: reposition mom, discontinue oxytocin, perform/assist vaginal exam, assist w/ amnioinfusion if ordered, administer oxygen if ordered Early decelerations \[314\] - Slowing of FHR at the start of contraction with return of FHR to baseline at end of contraction - No nursing intervention needed Late decelerations \[317\] - Slowing of FHR after contraction has started with return of FHR to baseline well after contraction has ended - Causes: uteroplacental insufficiency causing inadequate fetal oxygenation - Nursing interventions: place mom in side lying position, discontinue oxytocin, increase fluids, elevate legs, administer oxygen if ordered Accelerations \[313\] Prolonged decelerations \[318\] Category I \[308\] - All of the following are included in the fetal heart rate tracing: - Baseline fetal heart rate of 110 to 160/min - Baseline fetal heart rate variability: moderate - Accelerations: present or absent - Early decelerations: present or absent - Variable or late decelerations: absent Stages of Labor \[259\] \[ATI ch 11 new book\] 5 P's \[ATI ch 11\] - Powers \[245\] - Divided into 2 categories - involuntary uterine contractions resulting in dilation and effacement of the cervix, known as primary power - the voluntary expulsive efforts of the birthing woman during the second stage of labor, known as secondary powers - Passageway \[247\] - birth canal that is composed of the bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal opening). The size and shape of the bony pelvis must be adequate to allow the fetus to pass through it. The cervix must dilate and efface in response to contractions and fetal descent - Passenger \[248\] - Consists of the fetus and the placenta. The size of the fetal head, fetal presentation, fetal lie, fetal attitude, and fetal position affect the ability of the fetus to navigate the birth canal. The placenta can be considered a passenger because it also must pass through the canal - Fetal skull - fetal head usually accounts for the largest portion of the fetus to come through the birth canal - Fetal attitude/posture - Relationship of fetal body parts to one another - **Fetal flexion:** Chin flexed to chest, extremities flexed into torso - **Fetal flexion:** Chin flexed to chest, extremities flexed into torso - Fetal lie - relationship of the maternal longitudinal axis (spine) to the fetal longitudinal axis (spine) - **Transverse: **Fetal long axis is horizontal, forms a right angle to maternal axis, and will not accommodate vaginal birth. The shoulder is the presenting part and can require delivery by cesarean birth if the fetus does not rotate spontaneously - **Parallel or longitudinal: **Fetal long axis is parallel to maternal long axis, either a cephalic or breech presentation. Breech presentation can require a cesarean birth - Fetal presentation - part of the fetus that is entering the pelvic inlet first and leads through the birth canal during labor. can be the back of the head (occiput), chin (mentum), shoulder (scapula), or breech (sacrum or feet) - Cephalic (head first) - Breech (pelvis or feet first) - Shoulder (shoulder first) - Fetal Position - relationship of the presenting part of the fetus (sacrum, mentum, or occiput), preferably the occiput, in reference to its directional position as it relates to one of the four maternal pelvic quadrants. It is labeled with three letters - Right (R) or left (L): The first letter references the side of the maternal pelvis - Occiput (O), sacrum (S), mentum (M), or scapula (Sc): The second letter references the presenting part of the fetus - Anterior (A), posterior (P), or transverse (T): The third letter references the part of the maternal pelvis - Station - Measurement of fetal descent in centimeters with station 0 being at the level of an imaginary line at the level of the ischial spines, minus stations superior to the ischial spines, and plus stations inferior to the ischial spines - Position \[254\] - position of the woman during labor and birth - client should engage in frequent position changes during labor to increase comfort, relieve fatigue, and promote circulation. Position during second stage is determined by maternal preference, provider preference, and the condition of the mother and the fetus - Psychological \[250\] - Maternal stress, tension, and anxiety can produce physiological changes that impair the progress of labor. - care of laboring woman should also focus on providing emotional support and information to empower the woman's decision making, with the goal of making the woman and family feel cared-for and safe APGAR - score is assigned based on a quick review of systems that is completed at 1 and 5 min of life that allows nurse to rapidly assess extrauterine adaptation and intervene with appropriate nursing actions (ATI ch 23 pg 159) - 0-3 severe distress - 4-6 moderate difficulty - 7-10 minimal/no difficulty adjusting to extrauterine life Shoulder dystocia \[pg 362\] - one of biggest complications with large babies - a birth complication that requires additional maneuvers to relieve impaction of the fetal shoulder. This unpredictable and unpreventable obstetric emergency places the laboring mother and neonate at risk of injury and complications - Risk factors: fetal macrosomia, maternal diabetes, hx of shoulder dystocia, protracted labor/prolonged labor, excessive weight gain - Assessment findings: 1^st^ sign retraction of fetal head against maternal perineum after delivery of head (turtle sign), delay in delivery of shoulders after delivery of head Tachysystole - Uterine contraction lasting longer than 90 seconds or 5 or more contractions in 10 minutes. Can result in progressive deterioration in fetal status and hypoxemia that result in an abnormal FHR. May result in abruptio placenta or uterine rupture, which are rare complications - Causes: Most common- meds for cervical ripening, induction, and augmentation; spontaneous or labor stimulated, abruption, MVA, DV/IPV, dehydrations, preeclampsia, methamphetamine use - Nursing Actions: change position, hydration, IV bolus, reduce anxiety/pain, administer tocolytic Post partum hemorrhage