N330 Exam 2 Study Guide PDF

lOMoARcPSD|16365849 N330 Exam 2 Study Guide Nursing Medical Surgical Care of Adults 1 (California State University San Marcos) Scan to open on Studocu Studocu...

lOMoARcPSD|16365849 N330 Exam 2 Study Guide Nursing Medical Surgical Care of Adults 1 (California State University San Marcos) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849 Exam 2 Study Guide (Fall 23)  Dil/Eff/Stn o Dilation: the enlargement or widening of the cervical opening & canal (0-10 cm)  full dilation marks end of first stage of labor o Effacement: the shortening and thinning of the cervix during first stage of labor; expressed as 0 – 100% o  Effacement usually progresses faster than dilation in first pregnancy. They tend to progress together in subsequent pregnancies. o Station: measures degree of descent of the presenting fetal part through birth canal in relation to ischial spines (cm above/below)  Birth is imminent when presenting part is +4 or +5 cm o  SE of CLE o Continuous lumbar epidural  CI for CLE  5 P’s o Five major factors that affect the labor process o Fetal head is a major factor in determining the course of birth bc of it’s size and relative rigidity! o 1. Passenger: Fetus and Placenta  Size of fetal head (fontanels, molding)  Fetal presentation (cephalic/vertex, breech, shoulder) Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849  Fetal lie (spine of baby in relation to spine of mom, longitudinal/vertical vs transverse/horizontal/oblique)  Fetal attitude (posture assumed in utero; baby head measurements critical) head in complete flexion/ chin down --> smaller head diameter as head is more extended/ chin up --> anteroposterior diameter widens   Fetal Position (relationship of a reference pt on the presenting part (occiput, sacrum, mentum, sinciput) to the four quadrants of the mom’s pelvis  o 2. Passageway: Birth Canal  There are 4 basic types of pelvis shapes (gynecoid is classic female shape). Do not always predict a woman’s ability to birth vaginally bc of the many ways the baby can negotiate the pelvis and the accommodation of maternal soft tissues (cervix effaces and dilates). o 3. Powers: Contractions  Primary Powers: involuntary uterine contractions (signal beginning of labor)  Frequency, duration and intensity used to describe them Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849  Responsible for cervix effacement and dilation and baby descent  Ferguson reflex: stretch receptors in posterior vag cause oxytocin release which triggers mom’s urge to bear down  Secondary Powers: voluntary bearing-down efforts once cervix is dilated o 4. Position (of mother): laboring mom should be encouraged to find position most comfortable; second-stage labor position depends on individual situation o 5. Psychologic Response  True labor vs false o Vaginal examination reveals whether the woman is in true labor and enables examiner to determine whether membranes have ruptured True Labor Contraction False Labor Contractions Characteristics Regular, strong, long and close Irregular or only temporarily together regular Walking Makes contractions more intense Often stop with walking/ position change Felt usually in... Lower back and radiates to The back or abd above lower abd umbilicus Comfort True contraction continues Can often stop false labor measures despite comfort measure contractions  MEDS. (6) questions from/about meds/se/use/interventions o Pitocin  Action: Stimulates uterine smooth muscle, producing uterine contractions similar to those in spontaneous labor. It has antidiuretic and vasopressor effects.  The control of postpartum bleeding, each mother should receive this after delivery. It is given to augment and induce labor. It will normally follow the effects of Misoprostol.  *Short Half-Life, never piggybacked o BMZ (Bethametasone)  Off label use: decrease the incidence of respiratory distress syndrome in neonates (taken by mothers at risk for preterm delivery), RDS is common in premature babies  Mechanism of action: administered maternally and reaches the fetus, subsequently stimulates the synthesis of surfactant in the lungs o Terbutaline  Beta-adrenergic agonist  Use: relaxes smooth muscle, inhibiting uterine activity and causing bronchodilation  Widely used as a tocolytic (arrest labor after contractions and cervical change have occurred)  Being replaced by meds that are safer bc Terb causes many mom and baby adverse rxns (tachycardia & hyperglycemia) o Mag Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849  Stimulates uterine smooth muscle, producing uterine contractions similar to those in spontaneous labor. It has antidiuretic and vasopressor effects.  *cannot be piggybacked, foley is inserted since it effects the kidneys o Cervidil/prepadil  Mechanism of action: Produces contractions similar to those occurring during labor at term by stimulating the myometrium (oxytocic effect). Initiates softening, effacement, and dilation of the cervix ("ripening"). Also stimulates GI smooth muscle.  Reason for medication: Used to "ripen" the cervix in pregnancy at or near term when induction of labor is indicated.  Causes of fetal tachycardia o Normal fetal BP 110 – 160 bpm o Fetal tachycardia bpm > 160 bpm for 10 min or longer o Causes:  early sign of fetal hypoxemia (especially when associated with late decelerations and minimal or absent variability)  maternal fever or fetal infection (chorioamnionitis)  maternal hyperthyroidism or fetal anemia  in response to medications like  parasympatholytic drugs (atropine, hydroxyzine)  b-sympathomimetic drugs (terbutaline)  drugs (caffeine, cocaine or methamphetamines)  Fetal cardiac arrhythmias  IUR o Intrauterine resuscitation consists of applying specific measures with the aim of increasing oxygen delivery to the placenta and umbilical blood flow, in order to reverse hypoxia and acidosis. These measures include initial left lateral recumbent positioning followed by right lateral or knee-elbow if necessary, rapid intravenous infusion of a litre of non-glucose crystalloid, maternal oxygen administration at the highest practical inspired percentage, inhibition of uterine contractions usually with subcutaneous or intravenous terbutaline 250 microg, and intra-amniotic infusion of warmed crystalloid solution (National Library of Medicine, 2023).  SROM/AROM fetal surveillance o Determined individually for each woman o PPROM at less than 32 weeks is managed expectantly and conservatively o Vigilance for signs of infections o Fetal assessment o Antenatal glucocorticoids for all women with preterm PROM between 24 0/7 and 34 0/7 weeks of gestation o 7-day course of broad-spectrum antibiotics o Administering magnesium sulfate for fetal neuroprotection Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849  Stages of labor o First Stage of Labor: onset of regular uterine contractions to full cervix dilation  Latent/Early Phase (0-6 cm dilation)  Active Phase (6-10 cm dilation): greatest rate of cervical dilation occurs  Transition Phase* (may not be identified based on maternal physical sensations/behavior in women with epidural anesthesia; Not counted as a phase anymore) o Second Stage of Labor: Full cervix dilation to birth of baby  Latent phase (passive fetal descent) & Active pushing phase o Third Stage of Labor: Birth of baby to placental delivery o Fourth Stage of Labor: Placental delivery to first 2 hours after birth  Important to observe for complications; e.g. abnormal bleeding  Assessing baby position o External cephalic version (ECV)  An attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth  At 36-37 weeks, the success rate for ECV is approximately 65% and the risk for cesarean birth is reduced by 50%  Ultrasound scanning used during procedure  NST and Informed consent before procedure  Contraindications to ECV o Internal version  Rarely used; safety questionable  PTL (preterm labor) o Diagnosed clinically as regular contractions along with a change in cervical effacement or dilation or both or presentation with regular uterine contractions and cervical dilation of at least 2 cm that occurs at a preterm gestation o Preterm birth: occurs btwn 20 0/7 and 36 6/7 weeks gestation  Different than “low birth weight” which is < 2500 g regardless of age Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849 o Spontaneous vs Indicated preterm birth  Spontaneous (75%; initiation of labor process in absence of mom or baby illness)  Risk factors: infection, multifetal gestation, smoking, pre- pregnancy under or overweight, low SES, mom or baby stress, genetics  Cervical lengths: can’t predict imminent preterm birth o Cervical length > 30 mm in 2nd or 3rd trimester unlikely to preterm birth  Diagnostic test for preterm labor: Fetal Fibronectin (fFN) Test o fFN is a glycopreotine “glue” found in plasma & produced during fetal life o Test has high predictive value of who will NOT go into preterm labor. Presence of fFN alone not good predictor of preterm birth.  Indicated: (25%; iatrogenic; occur as a means to resolve mom or baby risk related to continuing pregnancy)  Ex. GDM, Pre-E, previous C section; seizures, fetal disorders o Interventions: Prevention (address risk factors) and early recognition o Lifestyle modifications: activity restriction (modified bed rest), restrict sexual activity (pelvic rest), and home care (no excessive force) o Suppression of uterine activity:  Tocolytics: meds given to arrest labor after uterine contractions and cervical change have occurred  Augmentation of labor o Stimulation of uterine contractions after labor has started spontaneously and progress is unsatisfactory o Common augmentation methods include oxytocin infusion and amniotomy o Active management of labor o Aggressive use of oxytocin so that the woman gives birth within 12 hours of admission to the labor unit  Back labor o Baby in OP position  Station o See page 1 for image o Centimeters above (- value) or below (+ value) the ischial spines o Birth imminent at +4/ +5 cm o Used to determine rate of descent of the fetus during labor o Engagement: usually corresponds to station 0; indicates the largest transvers diameter of the presenting part has passed through mom’s pelvic brim and into the TRUE PELVIS  EFM (external fetal monitoring) Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849 o The FHR can be monitored by either IA or EFM. The FHR and UA can be assessed by EFM using either the external or internal monitoring mode. o Category I: normal o Category II: indeterminate o Category III: abnormal o LTV (long term viability) o Early decels (see resources for VEAL/CHOP)  Early decelerations in response to fetal head compression  Lacerations o Interventions such as warm compresses, gentle perineal massage and stretching can decrease perineal lacerations/trauma o Vaginal lacerations often occur in conjunction with perineal lacerations; tend to extend up; can be from forcep use, rapid fetal descent or precipitous (quick) birth o Perineal Lacerations: o First degree: extends through the skin and structures superficial to muscles o Second degree: extends through fascia and muscles of perineal body o Third degree: continues through the external anal sphincter muscles o Fourth degree: extends completely through the anal sphincters (external and internal) and rectal mucosa  Cultural differences in labor(ie stoic) o Within cultures, women may have an idea of the “right” way to behave in labor and may react to the pain experienced in that way  Range from total silence to moaning/screaming --> DOES NOT necessarily indicate the degree of pain being experienced o Can influence pt’s choice of birth companion and role of the father (some are present and involved, others are not)  Nurse should not perceive it as a lack of concern, caring or interest Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849  Emergencies/prolapsed cord o Occurs when cord lies below the presenting part of the fetus o Contributing factors include: o Long cord (longer than 100 cm) o Malpresentation (breech) o Transverse lie o Unengaged presenting part o Interprofessional Care Management  Prompt recognition  Pressure off cord  Position change to keep pressure off the cord  Meconium-stained amniotic fluid o Indicates fetus has passed stool prior to birth o Dark green o Possible causes o Normal physiologic function of maturity o Breech presentation o Hypoxia-induced peristalsis o Umbilical cord compression o Interprofessional Care Management  Presence of an interprofessional team skilled in neonatal resuscitation is required  Shoulder dystocia o Head is born, but anterior shoulder cannot pass under pubic arch o 0.2% to 3%of all vaginal births are complicated by shoulder dystocia Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849 o Newborn more likely to experience birth injuries related to asphyxia, brachial plexus damage, and fracture o Mother’s primary risk stems from excessive blood loss from uterine atony or rupture, lacerations, extension of episiotomy, or endometritis o Interprofessional Care Management  McRoberts maneuver and suprapubic pressure  Gaskin maneuver  Nursing intervention if there is tachysystole o Stop/lower dose of labor-enhancing drugs o Treatments for tachysystole and fetal oxygen deprivation include placing the mother in the left lateral position, giving her oxygen, and increasing her IV fluids. Sometimes, additional medications can be given for fetal resuscitation. In some cases – especially if there is uterine rupture – an emergency C-section is necessary in order to prevent permanent harm to the fetus. o When physicians use labor-enhancing drugs, they must carefully monitor the fetus for signs of distress and be prepared to promptly respond if tachysystole occurs.  HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) o Considered to be a variant of preeclampsia  Leopolds o Performed using abdominal palpation; can be used to estimate fetal size o Help answer three Qs about fetal presentation, position & lie (and whether presenting part is flexed, extended, engaged, or free-floating):  (1) which fetal part is in the uterine fundus?  (2) Where is the fetal back located?  (3) What is the presenting fetal part?  Insulin needs in pregnancy o Antepartum Care  Goal is strict blood glucose control  Dietary modification  Exercise  Self-monitoring of blood glucose  Pharmacologic therapy  Fetal surveillance Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849  Women who require insulin or oral hypoglycemic agents for blood glucose control may have twice-weekly NSTs beginning at 32 weeks of gestation o Intrapartum Care  Blood glucose levels monitored hourly in labor  Maintain levels at 80 to 110 mg/dl  Infusion of insulin, if needed o Postpartum Care  Will return to normal glucose levels after birth  High risk for recurrent GDM in future pregnancies  ACOG recommends assessing all women who had GDM for carbohydrate intolerance with a 75-g, 2-hr OGTT or a fasting plasma glucose level at 6 to 12 weeks postpartum  Then, lifelong repeat screening at least every 3 years  DM counseling o Yes.  Pre-E Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849  Normal B/P in pregnancy, Dx of HTN o Normal BP in pregnancy: SBP < 140/ DBP < 90 o Gestational hypertension: onset of HTN without proteinuria or other systemic findings Dx for preeclampsia after week 20 of pregnancy  SBP > 140 or DBP > 90 … HTN should be recorded on TWO separate occasions at least 4 hrs apart after 20 wks gestation in previously normal pt  Only one reading (SBP or DBP) must be elevated to count  Resolves after giving birth (usually takes 6-12 months) o Chronic hypertension: HTN present BEFORE pregnancy or Dx before week 20 of pregnancy Downloaded by Hayat Sherif ([email protected])  lOMoARcPSD|16365849  Women with chronic HTN may acquire Pre-E or eclampsia; difficult to Dx Downloaded by Hayat Sherif ([email protected])