Maternal-Neonatal Nursing Module II Exam PDF

Maternal-Neonatal Nursing Module II Exam Chapter 4: Prenatal Care and Adaptations to Pregnancy ❖ Major goals of prenatal care: ensure a safe birth, teach healthy habits, educate about self-care and provide physical care, prepare parents for new responsibilities, develop partnership with...

Maternal-Neonatal Nursing Module II Exam Chapter 4: Prenatal Care and Adaptations to Pregnancy ❖ Major goals of prenatal care: ensure a safe birth, teach healthy habits, educate about self-care and provide physical care, prepare parents for new responsibilities, develop partnership with parents and family members ❖ Initial prenatal visit o History, weight and vitals, discuss discomforts, pelvic exam and transvaginal ultrasound o Labs (know these) ▪ Blood type/Rh factor ▪ CBC ▪ H&H ▪ VDRL (blood test that checks for syphilis) ▪ Rubella titer (normally comes back as “immune”; if “non-immune”, mom will need to be vaccinated within 6 weeks after delivery ) ▪ TB screening ▪ Hepatitis B ▪ HIV ▪ UA and UC ▪ Pap smear ▪ Vaginal culture: gonorrhea and chlamydia (can cause infant blindness if delivered vaginally) ❖ Early & regular prenatal care o Reduces low birth weight infants and decreases morbidity and mortality for moms and newborns o Schedule for uncomplicated pregnancies ▪ Conception to 28 weeks: every 4 weeks 24-28 weeks: blood glucose screening ▪ 29-36 weeks: every 2-3 weeks ▪ 37 weeks until birth: weekly o Primetime for teaching healthy habits (moms are highly motivated) ❖ Terms o Gravida: number of pregnancies; includes abortions o Para: a woman whose given birth to one or more children who’ve reached 20 weeks (age of viability) o Primipara: a woman whose given birth to her first child past age of viability o Primigravida: a woman who is pregnancy for first time o Nulligravida: a woman who has never been pregnant o Nullipara: a woman who has not given birth to a child past age of viability o Multipara: a woman who has given birth to two or more children children past age of viability o Abortion: termination of pregnancy  o Gestational age: prenatal age of development fetus calculated from first day of woman’s LNMP o Fertilization age: prenatal age of developing fetus as calculated from date of conception (two weeks less than gestational age) o Age of viability: 24 weeks when it’s capable of living outside of uterus ❖ TPALM o T: term (infant born after 37 weeks) o P: preterm (born after 20 weeks and before 37 weeks) o A: abortion (before 20 weeks either spontaneously or induced) o L: living (living children) o M: multiple (number of multiple gestations) ❖ NAEGELE’s rule o How to calculate: take the first day of LMP- subtract 3 months, add 7 days, and adjust the year (if needed) ❖ Signs of pregnancy o Presumptive ▪ Missed period ▪ N/V ▪ Increased urination ▪ Breast changes ▪ Quickening movement ▪ Increased pigmentation o Probable ▪ Positive pregnancy test (can be positive 6 days before missed period) ▪ Enlarged abdomen ▪ Hegar’s sign (softened uterus) ▪ Chadwick’s sign (blue colored vagina) ▪ Goodell’s sign (softening of cervical lip) ▪ Ballottement (fetus rounds) ▪ Palpable fetal outline ▪ Braxton-Hicks contractions o Positive ▪ Fetal heart tones ▪ Fetal movement ▪ Fetal skeleton on x-ray ▪ Fetal sonography ❖ Physiological changes (first trimester) o Nausea with or without nausea: teach about eating crackers or toast before getting out of bed, small frequent meals, increase vitamin B12 o Breast tenderness: supportive bra to reduce cracking, colostrum may be present o Urinary frequency: kegal exercises to help strengthen vagina, limit caffeine o Vaginal discharge: shower/bathe daily, wear cotton underwear, avoid tight clothing, no tampons, wipe front to back, have higher levels of glycogen which promotes the growth of candida albicans (potential risk of yeast infections) ❖ Physiological changes (second and third trimester) o Heartburn: use low sodium liquid antacids (Gelusil or Maalox), avoid sodium bicarb and alkaseltzers, avoid overeating, keep upright for 30 min after meals o Constipation and flatulence (gas): increase fluids to at least 8 glasses per day, increase exercise, establish BM schedule o Hemorrhoids: sitz baths, increase fiber, anesthetic ointment, cool hazel pads, and rectal suppositories o Backaches (due to lordosis): help with good body mechanics with shoulders back and head up, bend at knees and not waist, wear low heeled shoes o Round ligament pain: avoid jerky/quick movements, use pillows and good body mechanics o Leg cramps: dorsiflex foot, increase calcium intake o Headache: if continues then notify HCP (could be sign of gestational hypertension) o Varicose veins: elevate legs with rest, avoid standing for long periods of time, wear support stockings o Edema of feet and ankles: elevate legs with sitting, increase resting periods, no constrictive clothing o Faintness and dizziness: lay on left side to avoid supine hypotension syndrome o Fatigue: try to get 8-10 hours of sleep, it’s okay to take daytime naps o Dyspnea: sleep with many pillows under head to help expand lungs, avoid exertion ❖ Supine Hypotensive Syndrome o Occurs in 3rd trimester o Large weight of uterus compresses against inferior vena cava ▪ Reduces blood flow return to heart o Goal: avoid decrease in return of blood to heart ▪ Transport patient tilted or turned to side, preferably left ▪ Very important to maintain after 5th month o If patient has to lay suping, displace uterus to side ❖ Weight gain o Underweight: healthy gain is 1 lb per week after 1st trimester (28-40 total) o Normal: healthy gain is 1 lb per week after 1st trimester (25-35 total) o Overweight: healthy gain is 0.6 lb per week after 1st trimester (15-25 total) o Obese: healthy gain is 0.5 lb per week after 1st trimester (11-20 total) ❖ Nutritional needs o Iodine: brain development o Folic acid: prevents birth defects (400mcg/day is DRI) o Calcium: bone development (1000mg/day is DRI) o Iron: needed to make more blood to supply oxygen to baby (30mg/day is DRI) o Vitamin d: helps absorb calcium and promotes bone growth o Vitamin b12: nervous system development; prevents spinal and central nervous system birth defects o Protein: baby’s growthn (60g/day is DRI)  ❖ Pica: craving for and ingestion of nonfood substances such as clay, starch, raw flour, and cracked ice o Interventions: educate in nonjudgmental way o Risks to baby: nutritional deficients, possible parasitic infections or ingestion of toxic material ❖ Exercise during pregnancy: mild to moderate is good (such as walking) o Avoid: overheating such as saunas and tanning beds, strenuous exercise o Effects: elevated temp of 100.4, hypotension, increased heart rate due to increased workload, hormonal changes ❖ Traveling in pregnancy o Wear seatbelt below abdomen o Shouldn't be sitting for long periods of time due to increased risk for developing blood clots o Avoid locations that pose high risk of infectious diseases o No DEET (insect repellants): usually safe after first trimester ❖ Physiological adaptations (mother) o Seeking safe passage, securing acceptance, learning to give of themself, committing herself to her child o 1st trimester: ambivalence and emotional instability (mood swings, labile) o 2nd trimester: narcissism, more emotionally stabile o 3rd trimester: mood swings, preparation time for infant care ❖ Impact on the partner o Announcement phase: pregnancy is confirmed, acceptance o Adjustment phase: revise financial plans, purchases furniture for nursey, listens to fetal heartbeat o Focus phase: plans for labor, changes lifestyle, begins “feeling like a parent” ❖ Pregnant adolescents: may be in denial, have financial problems, shame or guilt, relationship problems with the infant’s father, low self-esteem, possible alcoholism or drug addiction ❖ Older couple: 35 years or older are considered “elderly primiparas”, advanced maternal age, places on high-risk pregnancy Chapter 5: Nursing Care of Patients with Complications During Pregnancy ❖ Fetal Diagnostic Testing o Ultrasound examination: use of high frequency sound waves; visualizes gestational sac in early pregnancy to confirm pregnancy; identifies site of implantation, verifies viability of fetus; determines EDD o Amniotic fluid volume: ultrasound scan measures the fluid pockets; 5-19sm is considered to be normal o Estimation of gestational age: ultrasound exam at 8 weeks o MRI: noninvasive radiological view of fetal structures including placenta; usually with high suspicion of anomaly o Kick count: assessment by mom; while on side, 1 hour after meal, count fetal movements  o Doppler ultrasound blood flow assessment: using high frequency sound waves to study blood flow through vessels; determines adequacy of blood flow o AFP (alpha fetal protein): identifies high levels which could indicate spina bifida, anencephaly, or gastroschisis o Amniocentesis: insertion of thin needle through abdominal uterine walls to identify abnormalities (can help identify down syndrome) o NST (non-stress test): identifies fetal compromises in poor placental function such as HTN, diabetes, or post-term gestation o BPP (biophysical profile): identify reduced fetal oxygenation in conditions with poor placental function with greater precision o Tests of fetal lung maturity evaluates whether fetus is likely to have respiratory complications in adaptation to extrauterine life o Lecithin/sphingomyelin ratio (L/S ratio): 2:1 ratio indicated fetal lung maturity o FSI (Foam stability index): known as the “shake test” ❖ Danger signs o Sudden gush of fluid from vagina ▪ Vaginal bleeding (possible abortion, ectopic pregnancy, hydatiform mole, or a sign of magnesium toxicity) o Abdominal pain (could indicate miscarriage) o Persistent vomiting (decreased volume can lead to preterm labor) o Epigastric pain (could indicate pre-eclampsia) o Face and hand edema (could indicate HTN) ▪ Feet edema: teach about elevating feet o Severe, persistent headache (cerebral disturbances): can be HTN ▪ Blurry vision and dizziness o Chills with fever- 100.4 (possibly an infection) o Dysuria or decreased urine volume ❖ Spontaneous Abortions (nonintentional) o Threatened: cramping with light spotting; closed cervix, no passed tissue, fetal tones can be heart ▪ Educate about bedrest and to avoid coitus o Inevitable: increased bleeding, cramping, dilated cervix ▪ Educate about bed rest and save peripads o Incomplete: bleeding, cramping, dilated cervix some tissue passed ▪ Uterus may be emptied by D&E or vacuum extraction o Complete: passage of all conception products, cervix closes and bleeding stops ▪ Give rhogam if necessary o Missed: fetus dies in utero but is not expelled, uterine growth ceases and sepsis is at high risk for occurring ▪ Will need D&E to evacuate fetus o Recurrent: two or more consecutive spontaneous abortions (habitual); usually due to incompetent cervix or progesterone levels inadequate to maintain pregnancy ❖ Induced abortion (intentional)  o Therapeutic: done to preserve the health of the mother ▪ Supportive care, D&E must be performed in sterile conditions o Elective: for other reasons other than the mother (ex-acephaly) ▪ Septic abortion is a huge risk to mother; may need counseling ❖ Nursing care after abortions o 4 stages of grief ▪ 1: shock and disbelief ▪ 2: seeking answers for why this happened; tears, loss of appetite, guilt ▪ 3: disorganization; feelings of purposelessness ▪ 4: reorganization; sad memories but return of daily functioning ❖ Procedures used for pregnancy termination o Vaccuum aspiration: cervical dilation with metal rods or laminaria with suction through plastic cannula to remove all POC (pieces of conception) o D&E: dilation of cervix as in vaccuum curettage followed by gentle scraping of uterine walls to remove POC o Mifepristone: oral med to be taken up to 70 days days gestation; often taken with prostaglandin agent o Nursing considerations: check vitals and assess for hemorrhaging ▪ May need to make mom NPO if getting anestheia to reduce risk of aspiration ❖ Hyperemesis gravidarum: severe nausea and vomiting o S/S: weight loss, dehydration, electrolyte imbalances, poor skin turgor, unusual stress, ambivalence, ketonuria, o Tx: r/o other dx, antiemetics, IV fluids, TPN if overly excessive o Nursing care: avoid food odors, intake and output, small meals, carbs, avoid stress, eat crackers before getting out of bed, keep emesis basin out of site, sit upright after meals ❖ Ectopic pregnancy: abdominal pain with light spotting o If ruptures: severe lower abdominal pain and vaginal bleeding will occur, possible shoulder pain (referred abdominal bleeding pain) o Tx: control bleeding; may reabsorb pregnancy, methotrexate (inhibits cell division), surgical removal o Nursing care: observe for s/s of hypovolemic shock, assess bleeding ❖ Hydatiform mole: chorionic villi developed vesicles resembling tiny grapes o S/S: bleeding, rapid uterine growth, no fetal heart activity, hyperemesis gravidarium, higher hCG levels, “snowstorm” pattern on ultrasound o Management: D&E, induced labor, contraception, monitor hCG levels for 1 year o Nursing: teach about contraception, importance of getting hCG levels for 1 year, grieving, teach about not getting preggo for 1 year, how to help with hyperemesis gravidarium and bleeding ❖ Placenta Previa: 3 different types- low (marginal), partial, total o S/S: painless vaginal bleeding (bright red), abnormal fetal presentation o PP complications: infection, hemorrhage, fetal compromise o Tx: bedrest, lay on left side, c-section  o Nursing care: monitor vaginal bleeding, vitals, FHR: 110-160, O2, no vaginal exams, prepare for c-section ❖ Abruptio Placenta o Risk factors: HTN, cocaine or alcohol use, smoking, poor nutrition, abdominal trauma, poor hx, folate deficiency o S/S: abdominal/low back pain, concealed bleeding possibly, dark-red vaginal bleeding, tender and firm uterus ▪ Blood accumulates in little pockets behind placenta and remains concealed, it’ll fill up with blood and the brownish old blood will seep out sides through the cervix o Tx: emergency c-section, monitor for DIC o Nursing care: vitals, FHR, monitor for shock and bleeding ❖ Hypertension o Before 20 weeks: chronic HTN o After 20 weeks ▪ Gestational (above 140/90) ▪ Preeclampsia (above 140/90, proteinuria, pitting edema, weight gain, abdominal pain, muscle twitching, blurry vision, headache, irritability) ▪ Eclampsia (preeclampsia with presence of seizures) Anticonvulsant therapy: mag sulfate; initiated at onset of labor and continued for 24 hours PP o Leading dose: 4-6g IV then 1-2g continuous infusion o Maintenance dose: only give if patellar reflex is present (make sure hypermagnesemia isn’t present), only give if respirations exceed 12 breaths per minute, and if urine output exceeds 100ml/4 hours) ❖ Calcium Gluconate: anecdote for mag toxicity o If pt has mag toxicity, stop infusion, contact HCP, stay with pt o Sign of mag toxicities: hypotension, uterine relaxation ▪ Remember if pt is on oxytocin, pt may not contract ❖ Rh incompatibility o If mom is Rh- and first baby is Rh+, mom will need rhogam o Given at 28 weeks and then within 72 hours PP o Prior to administration: indirect coombs, obtain consent, 2 nurse verification ❖ Gestational diabetes: extremely high levels in mom causes extra weight to be put on baby o Macrosomia: large for gestational age o Problems: hyperglycemia, hyperbilirubinemia, respiratory distress, hypocalcemia, congenital anomalies ▪ Check sugar as soon as it could drop (hypoglycemia) o Mothers should breastfeed if possible and exercise to lose weight as it can decrease development of type 2 diabetes ❖ Heart Disease and pregnancy  o S/S: orthopnea, persistent cough, moist lung sounds, dyspnea upon exertion, palpitations, fatigue on exertion, pitting edema of lower extremities, changes in FHR (meaning hypoxia or growth restriction) ▪ Due to increased levels of clotting factors, increased risk of thrombosis ▪ Heparin: prevents clots; teach about bruising, petechia, bleeding gums, nosebleeds, no vitamin K foods as it clots o Can cause: preterm labor, fetal growth restriction, congenital heart disease, fetal death ❖ Iron deficiency: when body stores of iron drop too low to support RBC production o Patho: depletion of RBCs o S/S: fatigue, SOB, depression, hair loss, brittle nails, frequent headaches, restless leg syndrome, increased cold sensitivity ❖ Folic Acid Deficiency o S/S: fatigue, gray hair, mouth sores, swollen tongue, forgetfulness, depression, loss of appetite, trouble concentrating, birth defects (anencephaly, spina bifida), poor growth o Folic acid foods: cauliflower, asparagus, brocolli, leafy greens, okra, avocado, beetroot, papaya, oranges, pears, lentils, seeds ❖ Infections during pregnancy o Toxoplasmosis, Other (hepatitis B, syphilis, group B beta strep), Rubella, Cytomegalovirus, Herpes simplex virus ❖ Rubella immunization o DON’T get preggo for at least 1 month after o Offered to PP women who are nonimmune o It's a live vaccine (why you wait til after birth) o Congenital rubella: crosses placenta with mother who has acute infection ▪ Results in abnormalities: cataracts, intrauterine growth retardation, mental retardation, sensorineural hearing loss, heart patent ductus arteriosus, pulmonary stenosis, thrombocytopenic purpura ▪ Classic triad: PDA, cataracts, deafness, +/- “blueberry muffin rash” ❖ Hepatitis B vaccine: series of 3; immunization at birth after first bath ❖ Congenital toxoplasmosis o S/S: hydrocephalus, lesions of organs, cirrhosis of liver and spleen enlargement o Risk factors: improper handling of cat litter, handling or ingesting contaminated meat o Teach: cook meat thoroughly, wash hands, avoid uncooked eggs or unpasteurized milk, wash fruits and veggies, avoid contaminated cat materials ❖ Group B strep: leading cause of perinatal infection with high mortality rate o Risk of exposure to infant is greater if PROM occurs or labor is long o GBS is a significant cause of maternal PP infection ▪ S/S: temperature within 12 hours PP, tachycardia, abdominal distension o Deadly to infant o Tx: penicillin ❖ UTI during pregnancy o Cystitis: burning with urination, increased frequency and urgency, slightly elevated temperature o Pyelonephritis: high fever, chills, flank pain/tenderness, nausea and vomiting ▪ Kidney infection- more severe!!!! o Know teaching!!!!