OB EXAM 3 Past Paper Fall 2024 PDF

Postpartum Complications (11) Deep vein thrombosis Thrombophlebitis Deep Vein thrombosis Pulmonary Embolism ￮ Inflammation of the vein ￮ Collection of blood factors on a vessel wall...

Postpartum Complications (11) Deep vein thrombosis Thrombophlebitis Deep Vein thrombosis Pulmonary Embolism ￮ Inflammation of the vein ￮ Collection of blood factors on a vessel wall ￮ A mass composed of a thrombus and (Platelets and fibrin) amniotic fluid released into circulation. s/s ￮ Leg pain and tenderness ￮ Unilateral area of swelling, warmth, redness ￮ Pleuritic chest pain ￮ Harden vein over the thrombosis ￮ Dyspnea, Tachypnea/Tachycardia Nurse ￮ SCD [Sequential compression device] ￮ Elevation of client extremity above level of Place client in a semi-fowler position, care ￮ DO NOT MASSAGE IF RED,WARM ♡ ￮ Encourage client to change positions freq. ♡ with HOB elevated, O2, Meds, ￮ Fluids, Warm moist compress ￮ Anticoagulants [Warfarin & Heparin] Thrombolytic therapy♡ Uterine conditions Uterine Atony Subinvolution of the uterus Uterine involution ￮ Uterus isn’t contracting enough after birth → ￮ Uterus doesn’t shrink back to its normal size ￮ Uterus turns inside out after birth → a rare leads to bleeding. after birth → can cause bleeding and and dangerous condition that can cause severe discomfort. bleeding. ￮ Increased vaginal bleeding ￮ Prolonged vaginal bleeding ￮ Massive blood loss and shock ￮ Uterus larger than normal and boggy ￮ Uterus is enlarged & higher than normal ￮ Pain in lower ABD ￮ Tachycardia/Hypotension ￮ Boggy uterus ￮ Low blood pressure, increase pulse ￮ Pallor of skin & mucous membranes, Clammy ￮ Prolonged lochia discharge ￮ Pallor ￮ Bimanual compression/hysterectomy ￮ Blood, Intracervical, Intrauterine bacterial ￮ Manual replacement of the uterus cultures ￮ Maintain IV fluids ￮ FUNDAL MASSAGE FIRST!! ￮ D&C [performed by provider to remove ￮ ADM O2 ￮ Empty bladder remained placental] ￮ Stop oxytocin ￮ Measure to contact the uterus ￮ Provide fluids ￮ Methylergonovine ￮ Meds ￮ Breastfeeding, Ambulation, Freq. voiding Oxytocin ￮ ABX therapy Methylergonovine (DON'T GIVE TO HTN) Misoprostol Carbotropast Postpartum hemorrhage Blood loss of more than 1000 ml after ☆ MOST COMMON: UTERINE ATONY ￮ Prolonged labor, oxytocin-induced labor delivery. ￮ Retained placental fragments ￮ Overdistend uterus Any amount of bleeding that places the ￮ Lacerations of the perineal care mother in hemodynamic jeopardy ￮ Episiotomy ￮ Uterine inversion, Coagulation disorders, Hematoma Laboratory test: 1. Hgb & Hct [CBC] 2.Coagulation profile (PT) 3. Blood type & crossmatch  ￮ Firmly massage the uterine fundus ￮ Monitor vital signs ￮ Assess for source of bleeding ￮ Assess fundus for height, firmness, and position ￮ Assess lochia for color, quantity, clots ￮ Assess for bleeding from lacerations, episiotomy site, or hematomas. ￮ Maintain or initiate IV fluids to replace fluid volume loss ￮ Elevate the legs to a 20° to 30° angle to increase circulation to essential organ. Oxytocin Methylergonovine Misoprostol Carboprost tromethamine Tranexamic acid (Methergine) ￮ Uterine stimulant ￮ Uterine stimulant ￮ Uterine stimulant ￮ Uterine stimulant ￮ Antifibrinolytics ￮ Promotes uterine ￮ Controls PPH ￮ Control PPH ￮ Control PPH ￮ Works to improve blood contractions clotting ￮ Assess uterine tone & ￮ Assess uterine tone & ￮ Assess uterine tone & ￮ Assess uterine tone & ￮ Monitor vaginal bleeding, vaginal bleeding vaginal bleeding vaginal bleeding vaginal bleeding recommended to PPH within ￮ Monitor adverse rxn DO NOT GIVE TO HTN!!! ￮ Monitor adverse rxn ￮ Monitor adverse rxn 3 hour of birth DON’T GIVE TO ASTHMA Retained placenta Etiology Risk Factors Expected findings Dx & Nursing Care ￮ The placenta or fragments of the ￮ Partial separation of normal ￮ Excessive bleeding/blood clots ￮ Hgb/Hct placenta remain in the uterus and placenta ￮ Malodorous lochia or vaginal ￮ Manual separation and removal prevents the uterus from contracting. ￮ Excessive traction on umbilical discharge ￮ Monitor vitals, Uterus, Lochia ￮ Does not expel in 30 mins of birth cord ￮ Elevated temp ￮ Initiate fluids ￮ Preterm birth ￮ Uterine conditions ￮ d/c Postpartum shock Mild Moderate Severe Diaphoresis, Increased capillary refill Tachycardia, Postural hypotension Hypotension, Agitation, Confusion Cool extremities, Maternal anxiety Oliguria Hemodynamic, Instability Lacerations & Hematomas ♡ Small hematomas= Localized compression, ice packs, analgesics, and bed rest, Vitals♡ ♡Large hematomas= Require surgical intervention, including analgesics, antibiotics, and wound care, Vitals♡  Postpartum Infections Risk factors ○ UTI, Mastitis, Pneumonia ￮ Prolonged ROM, Retained placental ○ Hx of diabetes mellitus ￮ Bladder catheterization ○ Multiple vaginal exams after ROM ￮ Prolonged labor ○ Episiotomy/Lacerations ￮ Milk stasis [Blocked duct] // Nipple trauma // Poor feeding Endometriosis Wound infection Mastitis UTI S/S ￮ Fever, chills, Malaise, loss of ap ￮ Edema, warmth, redness ￮ Engorgement [Painful, ￮ Dysuria, Frequency ￮ Pelvic pain, Uterine tenderness ￮ Tenderness, Pain, Purulent tenderness of mass on one breast] ￮ Urgency ￮ Purulent & foul smelling lochia drainage, Fever ￮ Flu like S/S [headache,fever] ￮ Suprapubic pain ￮ Can progress to fever/malaise ￮ Fever, chills, malaise Test ￮ Vag & Blood CX ￮ Blood CX ￮ Blood cx ￮ UA/Urine culture (clean-catch) ￮ WBC, RBCs ￮ WBC, RBCs ￮ WBC, RBCs ￮ WBC, RBC, protein, bacteria Mgmt IV ABX, pain meds IV ABX ABX ABX, pain meds. Hand hygiene, Frequent uterine & ♡ ♡ ♡ ♡ Hand hygiene, Sitz bath, Perineal Emptying breast, Breastfeeding, Wipe front to back, Increase lochia assessments ♡ care, Warm/Cold compress ♡ cool compress♡ fluid intake ♡ ♡ // // Obtain frequent vital signs Assess pain Observe lochia for color, quantity, and consistency // Inspect incisions, // episiotomy, and lacerations Inspect breast ♡ Coagulopathies Idiopathic Thrombocytopenic Purpura (ITP) Disseminated intravascular coagulation (DIC) ￮ Autoimmune disorder that destroys healthy platelets with an ￮ A coagulopathy in which clotting and anticlotting mechanism unknown etiology occur at the same time. ￮ Severe hemorrhaging ￮ Internal/External bleeding, Damage to organs Risk ￮ Genetics ￮ Secondary to other complications factor (Missed abortion, fetal death, Eclampsia, Hemorrhage S/S ￮ Unusual spontaneous bleeding from the gums and nose ￮ Oozing, tricking, or flow of blood from incision, lacerations, or episiotomy ￮ Excessive bleeding from injection site ￮ Hematuria ￮ Gastrointestinal bleeding Labs CBCs, Platelet level Nurse Monitor vitals signs & hemodynamic status, monitor urinary output, Transfuse platelets, clotting factors, other blood care blood products, fluid volume replacement ♡ ♡ Postpartum affective disorders ♡ // // Assessments and screening Medications [Antidepressants] Community resources [Mental health center Seek // // // counseling Ask the client if they have thoughts of self harm Monitor interactions between the client and their newborn [failure to thrive]♡  Newborn Complications Compare the problems of the large-for-gestational-age infant with those of the small-for-gestational-age infant. Small for gestational age (SGA) Large for Gestational age (LGA) ￮ Weight < 10th percentile ￮ Weight > 4000g ￮ Weight < 2500g ￮ Weight > 90th percentile Risk ￮ Gestational hypertension and/or diabetes ￮ Risk for newborn injuries (Shoulder dystocia, clavicle fracture factors ￮ Maternal smoking, drug, or alcohol use ☆Maternal diabetes mellitus during pregnancy [HIGH glucose ￮ Struggle to maintain temp levels☆ Findings ￮ Normal skull, but reduced body dimension ￮ Large head ￮ Wide skull sutures from inadequate bone growth ￮ Plump and full face ￮ Dry, loose skin ￮ Retractions, cyanosis ￮ Respiratory distress and hypoxia ￮ Birth trauma ￮ Hypoglycemia ￮ Hypoglycemia Common ￮ Perinatal asphyxia ￮ Birth trauma prob. ￮ Difficulty with thermoregulation ￮ Hypoglycemia ￮ Hypoglycemia ￮ Polycythemia ￮ Polycythemia ￮ Hyperbilirubinemia ￮ Meconium aspiration ￮ Hyperbilirubinemia ￮ Birth trauma Nursing ￮ Blood glucose for hypoglycemia ￮ Blood glucose for hypoglycemia care & ￮ CBC will show polycythemia ￮ CBC will show polycythemia Mgmt ￮ Hyperbilirubinemia ☆ Support respiratory efforts, and suction the newborn as ￮ Possible vacuum assisted birth or c-section necessary to maintain an open airway ☆ ￮ ￮ Obtain blood glucose level ￮ Maintain adequate nutrition Initiate early feedings ￮ Identify and treat birth injuries Provide a neutral thermal environment for the newborn to prevent cold stress Gestational Age Variations Preterm Late Preterm Term Postterm 20 - 37 weeks 34-36 weeks 6/7 days 37-42 weeks Beyond 42 weeks Explain the special problems of the preterm infant. Preterm (20-37 weeks) ￮ Low birth weight ￮ Weak cry ￮ Scrawny appearance ￮ Musculoskeletal: poor muscle tone, minimal subcutaneous fat, decreased reflexes ￮ Integumentary: thin transparent skin, abundant vernix, plentiful lanugo, ￮ Head: poorly formed ear pinna, fused eyelids (22-24 wks), soft spongy skull bones, head bigger than body Complica. 1. Respiratory distress syndrome [insufficient surfactant lungs] ￮ Give additional surfactant, to help the alveoli open 2. Bronchopulmonary Dysplasia [chronic lung disease] ￮ Lungs to become stiff and noncompliant, but hard to get them off the ventilator onto their own 3. Apnea of maturity ￮ Normal @ birth, but no more than 20 seconds 4. Patent ductus arteriosus ￮ Murmur Nursing ￮ Promoting oxygenation ￮ Appropriate stimulation & developmental care mgmt ￮ Thermoregulation ￮ Pain management ￮ Nutrition and fluid balance ￮ Parental support ￮ Infection prevention ￮ Discharge preparation  Describe the characteristics and problems of the post term newborn. Postterm (After 42 weeks) Exp. finding ￮ Thin, loose skin ￮ Cold Stress ￮ Long, thin body ￮ Hair and nails cane be long Lab test / dx ￮ Blood glucose levels ￮ C-section studies ￮ CBC to show polycythemia ￮ Chest x-ray to rule out meconium staining Diabetic/Hypoglycemia Characteristics Nursing mgmt Signs of Hypoglycemia ￮ Large or small for gestational age ￮ Prevention of hypoglycemia ￮ At risk for birth trauma due to macrosomia ￮ Oral feedings, Neutral thermal ￮ More likely to have congenital anomalies environment, Rest periods ￮ Face is red, body is obese. ￮ Maintenance of F&E ￮ Respiratory distress syndrome ￮ Calcium level monitoring, Fluid ￮ Polycythemia therapy, Bilirubin level therapy ￮ Hypokalemia ￮ Parental support and education Birth Trauma/Injury Assess and plan care for the newborn sustaining trauma and birth injuries. Types: Risk factors Assessment Dx Procedures Nursing care 1. Skull ￮ Fetal macrosomia ￮ Irritability, seizures ￮ CT Scan ￮ Apgar scoring [ 2. Scalp Caput succedaneum ] ￮ Abnormal/difficult present. ￮ Unresponsiveness ￮ X-ray ￮ Head-to-toe assessment 3. Intracranial ￮ Prolonged labor ￮ Weak/hoarse cry ￮ Neurologic exam ￮ Vitals and temp. 4. Spinal cord ￮ Oligohydramnios ￮ Flaccid muscle ￮ Parent & newborn bonding [ 5. Plexus Brachial plexus ] ￮ Forceps/Vacuum ￮ ADM tx 6. Cranial/Peripheral nerve ￮ C-section Hyperbilirubinemia Explain the causes and significance of nonphysiologic jaundice. Etio. ￮ Elevation of serum bilirubin levels resulting in jaundice. ￮ Yellowish tint to skin, sclera, and mucous membranes. Risk ￮ Increased RBC Production factors ￮ Rh or ABO incompatibility ￮ Decreased liver function Types 1. Acute bilirubin encephalopathy: Is when the bilirubin is deposited in the brain. [Resulting in necrosis of neurons] 2. Kernicterus: Irreversible chronic result bilirubin toxicity Nurse Reduction of bilirubin levels // Early feeding // Phototherapy // Exchange transfusion // Education and support // Home mgmt phototherapy ♡ ♡ Describe the steps in normal bilirubin excretion and the development of physiologic, nonphysiologic, breastfeeding, and true breast milk jaundice. Physiologic Jaundice Pathologic Jaundice ￮ Occurs after the first 24 hours of life as a result of hemolysis of ￮ Begins in First 24 hours RBCs and liver immaturity ￮ Blood incompatibilities, Infection ♡ Feed baby, then it will pass in stool ♡ ♡ Feed baby, then PHOTOTHERAPY ♡ Breast milk Jaundice True Breast milk Often caused by a lack of sufficient intake Cause unknown  Newborn Infection (Sepsis neonatorum) ￮ Systemic infection from bacteria in the Risk factors Expected findings bloodstream ￮ Premature ROM ￮ Temperature instability ￮ Could be from strep, staph ￮ Prolonged labor ￮ Suspicious drainage (eyes, umbilical) ￮ Transmission: In utero, during/after labor ￮ Chronaminitos ￮ Poor feeding pattern ￮ Meconium Aspiration ￮ Hypoglycemia, hyperglycemia Laboratory test Nursing care ￮ CBC ￮ Assess infection risk ￮ Blood, Urine & Cerebrospinal fluid CX ￮ Monitor vital signs continuously, I&O ￮ Chemical profile to show F&E imbalance ￮ Promote adequate rest for newborn ￮ Monitor the newborn’s visitor for infection Newborn of Substance-Abusing mother ￮ Most common substances: tobacco, alcohol, and marijuana Nursing Assessment Nursing Management ￮ Maternal hx, Risk behaviors, ￮ Comfort promotion; stimuli ￮ Fetal alcohol syndrome: physical and mental disorders toxicity reduction appearing at birth and remaining problematic throughout the ￮ Newborns behaviors ￮ Nutrition child’s life. ￮ Withdrawal assessment ￮ Prevention of complications ￮ Neonatal abstinence syndrome: drug dependency acquired ￮ Parent-newborn interactions in utero manifested by neurologic and physical behaviors. Congenital anomalies Spina bifida Hydrocephalus 1) Atrial Septal Defect ￮ A neural tube defect in which the ￮ Excessive spinal fluid accumulation in ￮ hole in the septum between the R Atria vertebrae arch fails when close the ventricles of the brain 2) Ventricular Septal Defect protect the membrane with sterile covering, Frequently reposition the newborn head, observe for leakage of cerebrospinal fluid Measure the head circumf daily ♡ ♡ ￮ A hole in the septum between the R & ♡ ♡ L septum ♡ watch & wait, may need patch ♡ Risk factors: ○ AMA, Chromosomal abnormalities, Folic acid deficiency, Oligohydramnios/Polyhdyramnios, Respiratory Complications Nursing Assessment Nursing Management ￮ Risk factors: ￮ Supportive care; close monitoring - Preterm gestation, Perinatal ￮ Respiratory modalities: ventilation (CPAP, PEEP); asphyxia, Maternal diabetes mellitus, exogenous surfactant; oxygen therapy PROM, ￮ Antibiotics for positive cultures; correction of metabolic acidosis ￮ Assessment findings: ￮ Fluids and vasopressors; gavage or IV - Tachypnea, Nasal flaring, Grunting, feedings Retractions, Labored breathing, Crackles, ￮ Blood glucose level monitoring Cyanosis, Flaccidity, Apnea ￮ Clustering of care; prone or side-lying position ￮ Parental support and education ￮ Chest x-ray, Signs of pain in the newborn Sudden high pitched cry Facial grimacing Increased muscle tone, heart rate  Postpartum Adaptations and Nursing care Physiological Adaptations Reproductive System Uterus ￮ Fundus= top of the uterus above the openings of the fallopian tube ￮ Involution= Occurs with contractions of the uterine smooth muscle, where by the uterus returns to its pre pregnant state - Breastfeeding helps with involution. ￮ Subinvolution= When the process of involution does not occur properly [cause PPH, Blood clot & oxytocin] Uterine Assessment ￮ Fundal height by placing fingers on the ABD and measuring how many fingerbreadths. ￮ Fundus is midline in the pelvis OR displaced laterally [caused by a full bladder] ￮ Fundus is firm OR boggy [Massage if it boggy] ♡ Administer Oxytocin IM OR IV after the placenta is delivered to promote uterine contractions and to prevent PPH ♡ Lochia ￮ Three Stages of Lochia Cervix, Vagina, Perineum  ￮ Ovulation and Return of Menstruation - Interplay of hormones: Estrogen, Progesterone, Prolactin, and Oxytocin - Non-Lactating women: Return of menstruation 7-9 weeks - Lactating women: Return dependent on breast-feeding frequency and duration; anywhere from 2-18 months Breasts ￮ Observe for erythema, Breast tenderness, Cracked nipples, and indication of Mastitis ￮ If breast feedings, Assess effectiveness, Positioning, Condition of the nipple DON'T STIMULATE THE NIPPLES IF MOM IS NOT BREASTFEEDING Cardiovascular system ￮ Decrease in blood volume during the postpartum period ♡ Fluid intake Early ambulation Assess: ♡ ♡ Antithrombotic [to perfuse entire system, prevent blood clot] ￮ Vitals ￮ Pedal pulses [risk for DVT] ￮ Edema ￮ Skin turgor [Dehydration] ￮ Inspect lower extremities GI & Bowels Musculoskeletal System Integumentary System ￮ Joint returns to prepregnancy state by 6-8 weeks ￮ Pigmentation fades ￮ Stretch marks fade to siverly line. ￮ Diaphoresis is common for about a week. ￮ Loss of hair  Psychosocial Adaptations Psychological ￮ Attachment with parents and baby (skin-to-skin) adaptations Phases of Maternal 1. Taking-in (dependent): Time immediately after birth when the client needs others to meet her needs and relives Role attachment the birth process (PTSD) 2. Taking-hold phase: Second phase characterized by (dependent and independent) maternal behavior 3. Letting-go phase: Which woman establishes relationships with other (more interdependent) Emotional status ￮ Interactions w/ family ￮ Eye contact w/ infant ￮ Be alert for mood swings, Assessment: ￮ Level of independence ￮ Posture and comfort level with infant irritability, or crying episodes ￮ Energy levels ￮ Sleep and rest patterns Nursing Care of the Postpartum Client  Newborn Assessment & Nursing Care Physiological Transitioning Cardiovascular ￮ Switch from fetal to newborn circulation adaptation. ￮ Change from placenta to pulmonary gas exchange ￮ Changes in fetal structures: Foramen ovale, Ductus arteriosus, Ductus venosus, Umbilical arteries and veins Respiratory ￮ Initiation of Respirations Adaptations ￮ Role of surfactant (Prevent alveolar collapse) ￮ Respirations - 30-60 bpm - Irregular, shallow, unlabored - short periods of apnea (