OB Exam 5|194 Questions with Verified Answers,100% CORRECT

OB Exam 5|194 Questions with Verified Answers prematurity - CORRECT ANSWER 37 weeks gestation~23-24 weeks gestation earliest age of viability extrauterinedemographics7% white15% non-whitesingle adolescents @ higher risk - less than 20 weeks count as abortion - prognosis deals with wt in the baby of the premature - March of Dimes: health care disparity on who gets better care premature infants - CORRECT ANSWER Organ systems are immature and lack adequate reserves of bodily nutrients Potential problems and care needs of preterm infant weighing 2000 g differ from those of term, postterm, or postmature infant of equal weightVast majority of high risk infants are those born less than 37 weeks Premature infants continued - CORRECT ANSWER Extremely low birth weightBirth weight is 1000 g or lessPractical and ethical dimensions of resuscitation (ET tubes not being small enough) Late preterm infantsPreviously referred to as near-termBorn between 34-0/7 and 36-6/7 weeks (vast majority of premature fall) *Greater risk of complications or death prior to 1 year of age* - may not be in hospital as long as preterm baby physiologic functions - CORRECT ANSWER Respiratory functionCardiovascular functionMaintaining body temperatureNeutral thermal environmentCentral nervous system function Maintaining adequate nutritionMaintaining renal functionMaintaining hematologic statusResisting infection Care management maintain body temperature - CORRECT ANSWER High risk infant susceptible to heat lossUnable to increase metabolic rateTransepidermal water loss is greater (gelatenous skin feeling) Should be transferred from delivery in a prewarmed incubator (use ziplock bag) Rapid changes in body temperature may cause apnea oxygen therapy - CORRECT ANSWER Hood therapy Nasal cannula Continuous positive airway pressure (CPAP) Mechanical ventilation (bypass machine, echmo, membrane O2, last resort) Neonatal resuscitation - color code enteral (purple), GI tubes and IV tubes to differentiate - lack O2 carrying capacity b/c lack develop alveoli or tension Respiratory function - CORRECT ANSWER Respiratory distress syndrome (RDS) (retractions, nasal flaring, cyanosis, grunt) Supportive care O2therapy Surfactant (thru ET tube directly into lungs) Nitric Oxide (thru ET tube, bind O2 to Hgb in incr. O2 levels given with surfactant) Surfactant - CORRECT ANSWER - given to make more compliant, to newborn - give mom bumethersone - surfactant produced between 24-28wks Care plan PP - CORRECT ANSWER Complications of O2 therapy - CORRECT ANSWER *Retinopathy of prematurity (ROP)*: retinal vessels injured and scar tissue forms b/c high O2 (grade 1-grade 4) *Patent ductus arteriosus (PDA)*: Left pulmonary and aorta, high pressure can reopen it and decr. O2 to lungs (tx with NSAIDs and surgery) *Bronchopulmonary dysplasia (BPD)*: abnormal growth in lungs b/c high pressure and high o2 levels (long term chronic, ventilators and pressure cx it, kids that go home and are on O2 monitor) - long term O2 can cause probs - large eyes in baby using O2 therapy Growth and development potential - CORRECT ANSWER Difficult to predict with accuracyCorrected ageAge of the preterm infant is corrected by adding gestational age and postnatal ageMilestones are corrected until age 2½ (crawl and walk delayed) VLBW survivors: 15% to 25% have neurologic or cognitive disability - if born at 34 wks, at 6 wks of age it would be the time for them to be full term and should start milestones ROP patho moment - CORRECT ANSWER - retina matures in utero and at term fully vascularized beds - prematurity = stop/arrest in develop of retina and when proceed it is abnormal - abnormal growth of new vessels, not just O2, general health, birth wt - restricting O2 does not prevent it, risk for other eye problems later in life patent ductus arteriosus (PDA) - CORRECT ANSWER passageway (ductus arteriosus) between the aorta and the pulmonary artery remains open (patent) after birth Bronchopulmonary Dysplasia (BPD) - CORRECT ANSWER -Etiology: Respiratory disorder often as a result of barotrauma - high inflating pressures, infection, meconium aspiration, asphyxia; complication of prematurity; the walls of the immature lungs thicken, making the exchange of oxygen and carbon dioxide more difficult; the mucous lining of the lung is reduced along with the airway diameter -Diagnosis: infant must work harder than normal to obtain sufficient oxygen for survival - not enough surfactant Thermoregulation - CORRECT ANSWER Patho: from last test S/S: resp distress, pale or cyanotic, mottled skin apnea, bradycardia, acrocyanosis around mouth Use: radiate heaters, warmers, hat, keep dry, skin to skin, kangaroo care Care plan for high risk newborn - CORRECT ANSWER Care plan cont. - CORRECT ANSWER Care plan continued - CORRECT ANSWER CNS functions - CORRECT ANSWER Complications r/t immaturity of CNS Periventricular - intraventricular hemorrhage (PVH or IVH): more premature usually, one or both sides, grade 1-4, grade 1&2 resolve without probs (reabsorbed), germinal matrix hemorrhage = scar, severe premies, VLBW) Developmental care: darken room, swaddle, bendy boards; - interventions: cluster care, every 4 hrs, v/s, diaper, feed all together, PT = hold baby and move back and forth to imitate in utero Nutrition needs - CORRECT ANSWER Complications r/t poor intake, ability to digest nutrients, stomach size (unable to suck, swallow, breathe) Necrotizing enterocolitis (NEC) Onset: unsure nonspecific symptoms (risk factors 10% LBW babies, 90% preterm, mortality w/ NEC 30%) s/s: decr. activity, hypotonia, apnea, recurrent bradycardia, abd occur later = distension, incr. residuals, bloody stools, abd tender, red) Dx Tx: meds (depends on severity, why they hold food b/c gut needs to be ready can have perforation and shock and incr. mortality) Prevention Nourishment (and feedings are increased very gradually; formula and breast milk can be incr. in cal, can hurt premie GI, feeding difficult, pacifiers for nonnutritive sucking, before formula may get TPN (risk thru IV = hyperglycemia bacterial infection may need to clean with bedodine) Feeding NEC risk factors - CORRECT ANSWER Care management nutritional care - CORRECT ANSWER Weight and fluid loss or gain (30g/day incr. may be spread out and diff) Insensible water loss (RDS, bil lights, replace fluids) Elimination patterns (doc freq) Oral feeding Gavage feeding (use gravity) Gastronomy feedingsParenteral fluids—TPNAdvancing feedingsNonnutritive sucking Care management skin to skin and environment - CORRECT ANSWER Skin careIncreased sensitivity and fragility (skicky skin) Braden Q or Neonatal Skin Condition Scoring (NSCS) should be used dailyAvoid the use of soap Environmental concernsNICU infants are exposed to high levels of auditory input - isolate and quiet Care management developmental care (pain) - CORRECT ANSWER Positioning (preemie do best on abd, keep fetal position) Reducing inappropriate stimuli (read response to pain, acute pain in neonate) Infant communication Infant stimulation (decr.) Kangaroo care Parental adapt to preterm infant - CORRECT ANSWER Parental adaptation to the preterm infantParental tasksAnticipatory griefParental responsesParental supportMaladaptationParent education - diff levels of understanding Discharge planning - CORRECT ANSWER Home care needs of the infant's parents are assessedInformation is provided about infant care Referrals for appropriate resourcesReferrals for home health assistanceParents need special instruction before they take home a high risk infant CPR Oxygen therapy SuctioningDevelopmental care - social work gets very involved, preemie can get medicaid while in hospital anticipatory grief - CORRECT ANSWER Experienced when told of the impending death of infantPrepares and protects parents who are facing a loss Parents who have an infant with a debilitating disease, but one that may not threaten the life of the child, also may experience anticipatory grief - loss of perfect child Loss of an infantHealth care professionals can help by: Involving family in the infant's careProviding privacyAnswering questionsPreparing the family for the inevitability of the deathGrowing emphasis on hospice and palliative care for infants and their families Ch. 37 perinatal loss - CORRECT ANSWER types and stages - put t-shirt on baby, counseling and take pics Substance abuse acquired probs of newborn - CORRECT ANSWER Ch. 35 maternal substance abuse: alcohol - CORRECT ANSWER ↑ of CNS abnormalitiesWithdrawal S/S:Hyperactivity, irritability, hyperreflexia, seizuresVasomotor, GI & respiratory difficulties may appearFAS 0.3 - 1.9 per 1000 live birthsRates ↑ Native Americans, Native Alaskans - FAS = fetal alcohol syndrome heroin - CORRECT ANSWER Withdrawal in 50-80% of infants of addictsOccurs 48-72 hrs of age (heroin), up to 1 wk. methadone (tx for mom) S/S of withdrawal syndrome (neonatal abstinence syndrome) JitteryHyperactiveShrill, persistent cryPoor feeding/suck reflex No Narcan! (not to baby b/c not technically overdose for the baby) *Meds - Phenobarbital, methadone, morphine, diazepam* Cocaine - CORRECT ANSWER No withdrawal BUT *Neurotoxicity* - SGA, placental abruption, hyperactive/hypersensitive to stimuli - neonatal abstinence syndrome: diarrhea, skin excoriation, *tx pheno, methadone, morphine* Care plan substance use - CORRECT ANSWER - baby can physically have injury = don't give narcan or incr. seizures Care of infant in withdrawal - CORRECT ANSWER Key points re: substance exposure - CORRECT ANSWER Nurse often is first to observe signs of newborn drug withdrawalProviding high-quality perinatal care to a varied population with multiple conditions is complicated by special needs of high risk, drug-dependent clientsSigns and symptoms of infant withdrawal vary in time of onset depending on type and dose of drug involvedRehabilitative measures must be included in the plan for care for the infant and parents to offer infant an opportunity for optimal development after discharge Neonatal sepsis - CORRECT ANSWER SourcesClassificationEarly onset - congenital (in utero contraction) Late onset - acquired (environmental exposure) Signs & symptomsVague and nonspecific (like NEC) ManagementAssessment/DxInterventions - *apnea, and bradycardia lethargy, poor feed, poor wt gain, irritability* RF: GBS, prolonged labor, ruptured mem, infection - pneumonia is most common GBS - CORRECT ANSWER Group B Streptococcus Early onset - usually in first 24 hours of lifeVertical transmission from vaginal canal to fetus/newbornS/S - severe RDS/sepsisCurrent practice (ACOG standards)*Universal screening 35-37 wks*.IAP (Intrapartum antibiotic prophylaxis)PCN/Ampicillin (+ test tx penicilin) Cefazolin for PCN allergiesNewborns - not routinely tx'ed unless symptomatic or mom had chorio. 48 hour observation (maybe) - GBS overwhelming and quick Inborn errors of metabolism - CORRECT ANSWER Phenylketonuria - 1 in 25,000 Galactosemia - 1 in 50,000 Congenital hypothyroidism - 1 in 5000 State law to test all newborns in USOther tests are included in screening - PKU - tx prevent long term probs, group cx by metabolic defect, change in protein/enzyme - thyroid galactosemia - look for sickle cell, cystic fibrosis PKU - CORRECT ANSWER Genetic mutation 12q24.1 - PAH geneCannot convert phenylalanine to tyrosineSeverity varies1 in 10,000 to 15,000Test is collected after 24 hrs post-milk ingestionIf not managed, severe cognitive deficiencies & diminished motor skills can occurS&SMicrocephalyUncoordinated motor movementSeizure activityTremorsMusty or mousy odor, especially in sweat, breath & urine - need feeding of milk before test is drawn - if not tx can cx motor probs - dont have right enzyme Management of PKU - CORRECT ANSWER Initially, infant must receive "medical food" -formula low in phenylalanineChildhood & adolescence - severely restricted diet - usually "medical food" - 300 to 500 mg of phenylalanine per day.Most experts say lifelong restrictions are necessary1 minute think-on-it - now that life expectancy & cognition has improved, what are some other problems that might emerge? - no kids of own - special diet Grieving loss of newborn - CORRECT ANSWER Loss can be associated withPregnancyBirthSex or appearance of childBirth defects or chronic illness Grief response - CORRECT ANSWER Acute distressIntense griefDisorganization ReorganizationSearch for meaningBittersweet grief Family aspects of grief: grandparents and siblings - CORRECT ANSWER GrandparentsComplicated by emotional pain by witnessing and feeling immense grief of their child SiblingsRespond more to response of parents Special losses - CORRECT ANSWER Prenatal diagnosis with negative outcomeLoss of one in a multiple birthAdolescent grief Complicated bereavement - CORRECT ANSWER Parents showing signs of complicated grief should be referred to grief counselingResponsibility of a qualified mental health professional to determine if parents are experiencing a normal, albeit intense, grief response or if they are also having a serious mental health problem such as depression Key points - CORRECT ANSWER Parental and infant attachment can begin before pregnancy with many hopes and dreams for the future Gestational age of baby influences neither severity of grief response nor bereavement process When a baby dies, all members of a family are affected, but no two family members grieve in the same way When birth represents death, the role of the nurse is critical in caring for the woman and her family, regardless of the age of woman or stage of gestation Understanding the grief process is fundamental in the implementation of the nursing process Assessment of each family member's perception and experience of loss is important Therapeutic communication and counseling techniques can help families identify their feelings, feel comfortable in expressing their grief, and understand their bereavement process Follow-up after discharge can be an important component in providing care to families who have experienced a loss Nurses need to be aware of their own feelings of grief and loss to provide a nonjudgmental environment of care and support for bereaved families High Risk pregnancy - CORRECT ANSWER Life or health of mother and/or fetus is jeopardized by a disorder - can be coincidence of pregnancy or cx by pregnancy (try to get best outcome at lowest risk) Risk factors of high risk pregnancy - CORRECT ANSWER Biophysical: Genetics (congenital) Nutrition (iron, folate, protein) Medical/Obstetric Disorders (previous problems/preterm, still birth, chronic/acute dz, later pregnancy and poor health in young people, associated with closeness of pregnancy/number/number of fetuses) Psychosocial: Smoking (IUGR) Substance abuse OTC/prescription drugs (use or abuse) Psychological Stress (anxiety, stress, depression) Sociodemographic: Low income Poor or lack of prenatal care Age (15, 35) Ethnicity (non-white 2x more likely, higher chronic dz, African Americans have double mortality rate) Environmental: Exposure to toxic substances, radiation Stress What can happen in high-risk pregnancy - CORRECT ANSWER Mom: PIH (preg induced HTN), Pulmonary embolism, Hemorrhage, Infection Fetal/Newborn: Anomalies, PTB, SIDS, RDS Assessment of high risk pregnancy - CORRECT ANSWER Standardized identification of risk factors Thorough history Continued assessment Growth patterns Biophysical assessments - fundal ht and maternal wt gain Nursing dx/Goals - CORRECT ANSWER FearAnxietyAltered parentingRole conflictSpiritual DistressIsolationAcute/chronic pain Feel supported, fear/anxiety managedMaximized outcome, minimized risk Interventions - CORRECT ANSWER Specific to disorder/riskUse visits as time to discuss, communicate therapeutically*Home care*?Phone callsInterview, reassess each visit Fetal assessment and nursing implications of high-risk infants - CORRECT ANSWER Risk factors Biophysical Kick counts US Biochemical Amniocentesis CVS PUBS Maternal assays Fetal monitoring NST CST Vibroacoustic stimulation Kick counts - CORRECT ANSWER - fetal movement - Used to monitor fetus in pregnancies complicated by conditions that may affect oxygenation -Lay somewhere quiet and count for 1 hr, 2/3 times per day, outpatient, make sure you have eaten because decr. glucose = decr. kicks -Healthy baby should move 10 times in 2 hours - If not move more than 2x in 1 hr follow up with monitor -If baby doesn't, may repeat test or come in hospital and do a non-stress test - *16-25wks* Preimplantation genetic screening - CORRECT ANSWER -Technique that has been used in conjunction with IVF to detect any possible defects: One or more cells is removed from the blastocyst and analyzed for chromosomal abnormalities & May increase risk of failed implantation. -In some cases considered professionally unethical - Must be done with in vitro fertilization prior to transfer to uterus Ethical concerns - aspirate out cell to do genetic testing, advised for ppl who have repeated losses or CF or other genetic dz - *performed on single cell removed from an embryo after 3-4 days* Chorionic Villus Sampling - CORRECT ANSWER - *removal and analysis of tissue specimen from fetal portion of placenta* - *diagnostic test* - *Between 10 and 12 weeks* - thru cervix or abd, done earlier than amniocentesis, not as safe - leading to bleeding, separated placenta, membrane rupture, or limb abnormality - test chromosomal abnormal - mom 35 y/o, abnormal 1st trimester, parents carrier for genetic dz Quad (multiple markers) screen - CORRECT ANSWER - *blood sampling to measure maternal serum alpha fetoprotein, unconjugated estriol, and hCG* - Maternal serum levels of Alpha-Fetoprotein (fetal liver fxn, increased in neural tube defect, decr. in trisomy 21) Unconjugated estriol (decr. trisomy 21) hCG (incr. trisomy 21) inhibin-A (helps accuracy of testing, incr. in trisomy 21) - *done between 16-18wks* - blood test, algorithm combo with maternal age, *predictive for single pregnancies only* - trisomy 18 = all levels are low Amniocentesis - CORRECT ANSWER *transabd aspiration of amniotic fluid for analysis* (*diagnostic test*) Indications: Genetics Maternal age 35 yo Previous abnormality Family history of chromosomal abnormalities Abnormal ultrasound or serum screen Fetal Maturity Fetal hemolytic dz. *Done after week 14* TeachingEmpty bladder - give RhoGam - test fetal lung maturity - wait 16 weeks for enough fluid, find pocket of fluid, long needle and draw out fluid Ultrasound (US) - CORRECT ANSWER - *noninvasive use of sound waves to determine fetal presence, size, position, and presentation and to detect abnormalities* For genetics purposes: Fetal nuchal translucency (FNT): *btw 11 & 14 weeks* = look at back of neck, if incr. fluid around neck = indicate trisomy 21 Physical anomalies: may need to retest Teaching: Full bladder (to push uterus up and out of the pelvis to scan better used in early trimester, later trimester you empty bladder bc pushing on it) Levels of ultrasonography Indications for use Fetal heart activity (chambers/size, valve defects) Gestational age (biparietal diameter and femur length, add in abd girth = predict wt and IUGR) Fetal growth Fetal anatomy Fetal genetic disorders and physical anomalies (gastro, ancephaly, renal issues) Placental position and function (doppler fxn) Adjunct to other invasive tests - *6-8 wks, 11-13 wks, 18-20 wks, not after that unless probs* Fetal well-being - CORRECT ANSWER Nonstress Test (NST): fetal monitor Oxytocin Challenge Test (OCT) Biophysical Profile Doppler Flow Studies Percutaneous Umbilical Blood Sampling (PUBS) Kick Counts Nonstress test - CORRECT ANSWER - *noninvasive detection of fetal heart accelerations in response to fetal movements* - well-oxygenated, non-acidotic fetus will have accelerations in heart rate. Results: Reactive - 2 accelerations in a 20 minutes period. (good) Nonreactive (no accel) - fetal monitor with button, when feel kick = push button, accel should occur when fetus kicks, done with DM pt because placenta is aging and baby getting bigger - must have eaten or won't get accurate test (eating helps the baby move around more) - done *after 26-28 wks* Oxytocin challenge test - CORRECT ANSWER - *stress test, evaluation of fetal ability to withstand decreased oxygen supply and physiologic stress of contractions (simulating labor)* How will fetus tolerate contractions Results: Positive - presence of late decelerations with at least 50% of the contractions (bad thing, late decel with contract) Negative - no late or significant variable decelerations Equivocal - various types - in L&D unit, if neg = c/s, start IV and oxytocin drip, warm towels over breast - done at *34 or more wks pregnant* Biophysical profile - CORRECT ANSWER - *assessment of fetal breathing, body movements, and muscle tone; amniotic fluid volume, FHR reactivity, and placental grade* Ultrasound assessment of fetus (combo with NST) Results: 8-10 reassuring 6-8 repeat in 24 to 48 hours 4 or less non reassuring, further testing, possible emergency delivery (try oxytocin challenge test) - look at amount of fluid, reactive NST, fetal kicks tone/movement (one extend and flex of extreme), fetal breathing movements noticeable chest rise and fall - if acidodic = fetus is flaccid, no tone - done *after wk 32* Doppler flow studies - CORRECT ANSWER -*use of umbilical or uterine doppler velocimetry to measure speed of RBCs* - over maternal naval - bood flow in umbilical vessels - how much resistance maternal system has deliver blood to baby = incr. resistance = decr. blood flow - done *after 24 wks* PUBS - CORRECT ANSWER - *sampling of fetal blood obtained by insertion of a needle into the uterine wall* percutaneous umbilical blood sampling Direct access to the fetal circulation during the *second and third trimesters*Most widely used method for fetal blood sampling and transfusionInsertion of needle directly into fetal umbilical vessel under ultrasound guidance - want to hit the cord (amnio=don't hit cord) - pick up if lysed cell in baby and transfuse blood to baby - transfuse small amounts, mLs - done *after wk 17-18* nipple stimulation test - CORRECT ANSWER noninvasive stress test in which nipple stimulation is used to initiate contractions vibroacoustic stimulation - CORRECT ANSWER noninvasive use of vibration and sound to detect fetal reactivity MSAFP - CORRECT ANSWER maternal serum alpha fetoprotein - evaluation of maternal blood sample to determine alpha fetoprotein levels Changes in maternal system during pregnancy - CORRECT ANSWER Blood volume incr. •O2demands incr. • Increased musculoskeletal stress (wt changes, collagen reforming) • Toleration of fetus by maternal immunologic system (diff genetic material) • Fetus is an allograft- genetically different tissue (life transplant reject) 4 types of hypertension in pregnancy - CORRECT ANSWER Preeclampsia-eclampsia: very late s/s, incr. BP after 20 wks, proteinuria and 1 severe factor (HTN 160/90, thrombocytopenia, impaired liver, pulm edema, seizures) • Chronic hypertension: high BP that predates pregnancy, prob is when either before or during preg • Chronic hypertension with superimposed preeclampsia: had HTN + added proteinuria, and severe probs after 20 wks • Gestational hypertension: high BP after 20 wks without others When was the onset? gestational hypertension - CORRECT ANSWER potentially life-threatening condition of high blood pressure; usually develops after the 20th week of pregnancy and is characterized by edema and proteinuria Chronic HTN with superimposed preeclampsia - CORRECT ANSWER worse prognosis than chronic alone HTN or preEclampsia alone -new onset of *proteinuria* after 20 wks -sudden increase up to 160/110 BP -severe preEclampsia symptoms Preeclampsia with severe features - CORRECT ANSWER Must have one of the following in addition to above BP ≥160 systolic or ≥110 diastolic on 2 occasions 6 hours apart Proteinuria ≥ 5 grams (5,000 mg) Cerebral or visual changes Epigastric /right upper quadrant pain, Fetal growth restriction Severe headache Impaired liver function Oliguria (less than 500mL/24 hours) Pulmonary Edema Thrombocytopenia Preeclampsia Defined - CORRECT ANSWER BP elevation after 20 weeks of gestation with proteinuria orany of the severe features of preeclampsia proteinuria: 300 mg protein in 24 hr urine (collect for 24 hr) - dip stick = not as accurate eclampsia - CORRECT ANSWER onset of seizures or coma in a woman with preeclampsia HELLP - CORRECT ANSWER severe preeclampsia with hemolysis, elevated liver enzymes, and low platelets. Chronic HTN - CORRECT ANSWER HTN before pregnancy or 20thweek of gestation Risk factors - CORRECT ANSWER nulliparous (first preg, never preg before) • Age (19, 40) • Diabetes •CHTN • Multiple gestation • Renal disease • Change in paternity: jumps back up in risk b/c more genetic material (Li & Wi, 2000) - any chronic condition, early eclampsia starts = worse and more likely to have it in future preg Theories of patho - CORRECT ANSWER pre-eclampsia: Ischemia of placenta • Dysfunctional response of immune system • Inheritance of genetic trait (wait generation to test mom and child) Final Outcome: Acute inflammatory response - spiral arteries remodel and open up to enhance blood flow normally, but in pre-eclampsia they do not remodel and poor blood flow = damage vessels from pressure Placental ischemia - CORRECT ANSWER decr. Spiral Artery Remodeling - incr. Vascular Resistance - Syncytiotrophoblast move to vessels - Leukocyte activation - Endothelial damage (increased pressure on vessel wall)- Inflammatory response: Inflammatory response through endothelial cell activation Three main things that occur to cause the s/s - CORRECT ANSWER 1. vasospasm 2. inter-vascular coagulation 3. capillary leak and permeability increased S/S of pre-eclampsia - CORRECT ANSWER PIH • Proteinuria (incr. perm) • Generalized edema (incr. perm) • Oliguria (30 ml/hr, vasospasm and decr. perfusion) • Blurred vision: vasospasm in retina • Headache: vasospasm • RUQ pain: liver swells • Hyperreflexia/clonus: push foot back and foot beats Morbidity and mortality - CORRECT ANSWER Maternal - one of the highest cause of maternal morbidity & mortality • Fetal - IUFD r/t uteroplacentalinsufficiency and abruption (incr. pressures) • Neonatal - Preterm birth, LBW • True maternal hazard is eclampsia (seizures) • WHO - 1 woman every 7 minutes dies from preeclampsia Tx: mag sulfate Nursing assessment of pre-eclampsia - CORRECT ANSWER • Medical Hx • ROS - HA, wt. gain (Generalized edema 1 lb per wk), blurry vision, RUQ or epigastric pain (can see stars called "scocotoma") • Blood Pressure - watch for variables, don't rely on your Dinemapp (manual BP) • Edema - pretibial, face, hands (pitting edema, may ask the family if they notice edema in face) • DTR's, ankle clonus (decr. with tx) • Fetal well-being - nonstress test, biophysical profiles • Doppler flow studies Lab tests - CORRECT ANSWER - Urine protein - Liver functions - LDH, AST, ALT - Platelet count - Uric acid - Clotting - PT/PTT/fibrinogen (esp if platelet count is low) - expect freq labs Trajectory/ Prognosis - CORRECT ANSWER • Trajectory varies - mild to severe symptoms • The earlier disease shows up, poorer the prognosis and more severe the disease - IUGR and incr. BP = late s/s, if severe and earlier = worst prognosis Goal of treatment for pre-eclampsia - CORRECT ANSWER optimize outcome of both mother and fetus Prevention - CORRECT ANSWER Lots of research, poor results• Low-dose ASA (81 mg/day), calcium, antihypertensives, magnesium, zinc, fish oil, antioxidants Gestational HTN/preeclampsia without severe features tx - CORRECT ANSWER • Fetal movement daily • Symptom assessment daily(from earlier assessment of s/s) • Plt/liver enzymes weekly• Weekly BP checks• No antihypertensives, no bedrest, no magnesium sulfate • Corticosteroids administration • Delivery if 37 0/7 wks Preeclampsia with severe features tx - CORRECT ANSWER If 37 wks, maternal stabilization then delivery• If 34 wks, *corticosteroids* (fetal lung maturity) • *Antihypertensives* (160/110) • Magnesium sulfate Postpartum for gestational HTN preeclampsia, CHTN with superimposed preeclampsia - CORRECT ANSWER - some may not develop until PP - 72 hours monitoring BP• Magnesium sulfate for severe preeclampsia (usually 24 hours)Inpatient Inpatient medications - CORRECT ANSWER MgSO4 (in documentation write "Mag Sulfate")-decr. acetylcholine in nerve terminals, decr. seizures. (SE: decr. BP, slows contractions, and resp. depression) - Antidote to MgSO4is Ca++gluconate (must be on hand) -Nsg assessment for MgSO4 (done q hr in PP or labor) • Respiratory assessment - look & listen (risk for pulm edema, give Ca Glu) •DTRs• UOP•LOC•BP Eclampsia - CORRECT ANSWER • Keep that airway open • Be ready! -SR up all the time, pad - Suction -O2 -Ca++gluconate (for resp. dep) - MgSO4 (seizures) - Call light Cure for preeclampsia/eclampsia? - CORRECT ANSWER Deliveryis the only truecure -the invader, the placental-fetal unit, is gone! Nsg diagnosis for pre-eclampsia - CORRECT ANSWER • RF ineffective breathing patterns r/t- Magnesium Sulfate respiratory depression • RF impaired gas exchange r/t - Possible pulmonary edema-MgSO4 (RR shallow) • Ineffective tissue perfusion r/t-HTN- Vasospasm- Hemorrhage (leak) • RF ↓CO r/t- HTN therapy- Cardiac issues • Fluid volume excess r/t- Increased vascular resistance, fluid - tissues and lungs • RF hemorrhage r/t- Uterine relaxation after delivery from MgSO4 • RF injury: Maternal- Seizure activity- MgSO4 treatment • RF injury: Fetal- Uteroplacental insufficiency- PT birth- abruption KD• Anxiety• Powerlessness (r/t stuck in hospital, IV, foley, leg bound = "there is nothing I can do" CHTN in pregnancy - CORRECT ANSWER 3x-5x more likely to have poor pregnancy outcome Maternal cardiovascular changes - CORRECT ANSWER • Physiological changes in CV system (↑VOL)• During pregnancy ↑ cardiac demands• If healthy, cardiac reserves are adequate Pregnancy and heart dz - CORRECT ANSWER • Cardiac changes -incr. BV, incr. SVR, drastic volume changes after delivery • In heart disease, work load is ↑ and risk ↑ for CV stress • Affects 1% childbearing population Maternal cardiac dz risk groups - CORRECT ANSWER Classification of organic heart disease (NYHA) - Class 1- asymptomatic - Class 2- symptomatic w/ inc. work - Class 3- symptomatic w/ ordinary activity - Class 4- symptomatic at rest Cardiac dz in pregnancy - CORRECT ANSWER • Highest rates of mortality:-MI- Marfan's syndrome- Cardiomyopathy- Pulmonary hypertension- Coarctation of aorta CV s/s during pregnancy - CORRECT ANSWER • Neck vein distention (gen. edema) • Cardiomegaly; heave/ dysrhythmias • Loud murmur / Tachycardia 120 (b/c blood flow incr.) • Fatigue @ rest • Dyspnea, moist cough & smothering feeling (pulm edema) • Exertional syncope• Clubbing/ cyanosis lips, nailbeds Goals with cardiac patients - CORRECT ANSWER •↓stress & cardiac workload (greatest at 28-32 wks) • Avoid cardiac decompensation • Avoid infection & treat early (to avoid decomp) • Proper nutrition Nursing care and management - CORRECT ANSWER • ASSESS for Cardiac Decompensation- cough, dyspnea, edema, rales, palpitations, tachy ,irreg pulses, murmurs, increased fatigue, lips blue • ASSESS support systems (home support) • PLAN -- decr. stressful activities, incr. rest • MONITOR esp careful for laboring pt. (want to avoid c/s) • Educate, family planning & F/U Nursing care: antepartum - CORRECT ANSWER • Nursing care plan • Review of systems, esp. cardiac & pulmonary• Watch for S/S cardiac decompensation • Lots of rest - 8 to 10 hrs/day• Restricted activity, some on bedrest• Nutrition - fluids/fiber, stool softener - no straining for BMs (don't want constipation that may be caused by iron prenatal vit and rest) - activity intolerance, decr. CO rt increased circulatory volume secondary to pregnancy and cardiac dz S/O data for cardiac decompensation - CORRECT ANSWER Labs for antepartum - CORRECT ANSWER •UA• CBC• Chemistry panel•ECG• Echocardiogram• Pulse oximetry• Fetal US & NSTs Delivery in cardiac decompensation patients - CORRECT ANSWER • *Attempt vaginal (more gradual volume change)* - C/S can cause large volume changes • Frequent VS, may see line placement (CVL) • Usually have early epidurals, assisted delivery, to decr. stress on heart (may use forceps or vacuum extraction) • *Side-lying delivery, no stirrups* (stirrups cx blood clot behind knee) Postpartum - CORRECT ANSWER Watch her like a hawk! Drastic fluid changes can cause cardiac decompensation CPR in the pregnant woman - CORRECT ANSWER • Changes- Uterus places weight on vena cava/aorta. What will you do? *tilt patient, roll towel under hip* - Enlarged uterus may displace diaphragm. What will you do? *place hands at the nipple line* - Heimlich maneuver - how would this differ? *do it higher up* HIV/AIDS - CORRECT ANSWER • Retrovirus • Targets the immune system • Fastest growing population is African Americans • 0.3% of pregnant women in US are HIV+ Neonatal and pediatric AIDS - CORRECT ANSWER • Neonatal/pediatric case totals have increased in direct proportion to maternal increases.• 80% of pediatric HIV pts. are result of perinatal transmission• 2009 - the US had 131 cases of perinatal transmission (peak was 1651 in 1991) Routes of transmission in HIV - CORRECT ANSWER • Sexual intercourse• Exposure to infected blood• Vertical transmission- Across the placenta- During birth- Breastfeeding What increases risk of perinatal transmission of HIV? - CORRECT ANSWER • High viral load • Low CD4 cell count • Malnutrition • No or poor PNC • No HIV screening prior to delivery • No tx with ARTs • Comorbid syphilis, herpes, chancroid Lab testing - CORRECT ANSWER • ELISA (enzyme linked immunosorbent assay) • Confirmed by Western blot or immunofluorescence assay ACOG reports - CORRECT ANSWER • No definite incr. in PTB, LBW, or pregnancy complications d/t Sero+ status (reports vary) • Some studies report slight incr. in PP endometritis • No definite evidence of disease progression with HIV+ status (during pregnancy) - no evidence that just b/c HIV you will have birthing complications Clinical manifestations in women with HIV - CORRECT ANSWER • Lymphadenopathy• Bacterial pneumonia• Fevers• Night sweats• Weight loss• Thrush• Diarrhea• Severe vag yeast infx• Abnormal PAP• Frequent HPV• Frequent BV (bacterial vaginosis) • Trichomonial infx• Genital herpes infection Fetal risk in HIV - CORRECT ANSWER • Sero+ mom transmits +antibody titer passively (not AIDS test just antibody against it) • Can seroconvert by 15-18 mths (can detect virus now) • Usually asymptomatic @ birth • Infected may present with: -SGA-FTT (failure to thrive)- Recurrent Infections Nsg Dx/ Tx Goals - CORRECT ANSWER • Risk for infection (fetal)• Risk for injury (maternal/fetal)• Knowledge deficit • Reduce perinatal transmission• Reduce risk for complications• Educate Management of HIV in pregnancy - CORRECT ANSWER • Education• Triple drug or HAART therapy • When to start? *after first trimester get Azt, Azt in IVPB during labor* • Emotional, psychological support • In L&D- C/S @ 38 wks for ↑ viral loads (bloodless c/s = cut and cauterize at the same time to decr. bleed) - No internal monitors - No forceps or vacuum extractor - Discourage breast feeding Barriers to ART regimen adherence - CORRECT ANSWER - Depression- Substance use- Young maternal age- Insufficient financial support- Social stigma- Fear of violence- Lack of self-efficacy- Nondisclosure of HIV to family/friends Perinatal Infections - CORRECT ANSWER • TORCH infections • T - toxoplasmosis • O - other (GC, syphilis, varicella, HBV, HIV) - depends on viral load • R - rubella (German measles) • C - cytomegalovirus • H - herpes simplex Toxoplasmosis - CORRECT ANSWER - parasite - DX before 20 wks = recommended terminated pregnancy - get 1st time when preg = pass onto fetus, if immune before = not passed on S/S: sore throat, fatigue, muscle ache, rash, these are rare - 1st trimester: less likely to get infected but SE worse - 2nd and 3rd trimester: more likely to get but less severe SE baby s/s: vision, incr. liver/spleen, jaundice, myocarditis, brain probs Cytomegalovirus (CMV) - CORRECT ANSWER herpes-type virus that usually causes disease when the immune system is compromised - largest virus, cx morbid/mortal more than herpes - contact with infected body fluids direct to MM/blood products/cross placenta - IUGR, still birth, deafness, vision, microcephaly, thrombocytopenia - most common transmitted in develop countries *Tx: acyclovir* Rubella Syndrome - CORRECT ANSWER - microcephaly - Patient ductus arteriosus - cataracts, DM, bone marrow dz, deafness - congenital defects cx maternal rubella infect during preg - mom incr. risk of spontaneous abort, fetal death, mental retardation, microcephaly in baby HSV (herpes simplex virus) - CORRECT ANSWER incr. risk in mom's having it as primary dz, immunity changes in pregnancy = more severe herpes - direct contact - transmit before 20 wks = worse, HSV within 28 days birth - seizures and death - eyes/microcephaly - going thru infected birth canal so have c/s delivery instead - genital HSV is most common hemorrhagic disorders - CORRECT ANSWER Spontaneous Abortion Incompetent Cervix (cervial insuff) Ectopic pregnancy Hydatiform mole Abruptio placenta Placenta previa DIC Spontaneous abortion - CORRECT ANSWER Pregnancy that ends before 20 wks. gestationAKA miscarriageOccurs in at least 15% of pregnancies (those that have been diagnosed) Patho of spontaneous abortion and S/S - CORRECT ANSWER 50% chromosomal abnormalitiesFetal factorsPlacental factorsMaternal factors S/S vary by type Threatened spontaneous abortion - CORRECT ANSWER S/SBloody vaginal d/cNot dilatedNo tissue passedMild cramping TxBedrest About 50% will abort Inevitable spontaneous abortion - CORRECT ANSWER S/SRuptured membranesDilated cervixMild-to-severe cramping Tx: D&C to prevent hemorrhage Incomplete spontaneous abortion - CORRECT ANSWER •Uterus retains part or all of placenta•Membranes rupture•Cervix dilates•Mild to severe cramping•D&C or vacuum aspiration performed Complete spontaneous abortion - CORRECT ANSWER •Uterus passes all products of conception.•Cervix closed.•Mild cramping - lot of bleeding, do cervical exam and no more bleeding and cervix is closed = all passed - intact depends on how long fetus had been dead prior to passing it Missed spontaneous abortion - CORRECT ANSWER •Uterus retains all products of conception.•Cervix closed•No cramping•Can develop clotting disorders or septic abortion - fetus dies inutero but no passage of tissue - no heartbeat on US, develop DIC or sepsis if tissue is not passed, Tx: depends on age of mom D&C - CORRECT ANSWER dilation and curettage - Cervix is manually dilated: can also dilate and do suction - Curette scrapes the walls: risk = perforation so do sounding to determine size of uterus first - same mechanism used for abortion and build up of tissue in postmenopausal women, may numb cervix, IV sedate - tenaculum has teeth used to grab and pull the cervix up so it can be reached Nursing Care (PP bleeding and breastfeeding care plan) - CORRECT ANSWER ABC stabilization Emotional support (tragic, teens) Education (may need to transfuse blood, outpatient, nothing vaginal for 6 months, monitor temperature and discharge) Cervical insufficiency - CORRECT ANSWER Premature dilation of the cervix (no contraction) Passive, painless Repeated in subsequent pregnancies (true dx) Risk factors Cervical damage Excessive D&C's (cervical surgery) DES exposure in utero (anomalies) Congenital anomalies - usually when fetus grows the pressure on the cervix will cause it to dilate Treatment of incompetent Cx - CORRECT ANSWER McDonald cerclage - done vaginally (clamp on cervix hold it and stitch it flat ribbon) Abdominal cerclage (c/s like incision, and permanent, always have c/s delivery after that, won't prevent pregnancy or D&C) - done before membranes reach cervix and before cervix is dilated Hydatiform Mole (Molar Pregnancy) - CORRECT ANSWER Gestation trophoblastic diseaseEither complete or partialComplete - empty egg is fertilized by sperm, sperm duplicates, 46,XXPartial - 2 sperm fertilize normal egg, 69, XXY (or XXX or XYY)Can become cancer (20% of complete moles) - cx pt to have CA s/s of molar pregnancy - CORRECT ANSWER Rapid uterine growth (placental tissue) Vaginal bleeding → anemia Dark brown d/c (old blood from hcg excess produced so positive preg test) Hyperemesis (due to extra Hcg) Early preeclampsia - high Hcg levels Nsg care of pt with molar pregnancy - CORRECT ANSWER Assessment Education No pregnancy for at least 1 yr (want to measure Hcg levels, could be sign of CA) bHCG levels - follow once a month - neoplastic = persistent trophoblastic tissue Placenta previa - CORRECT ANSWER Placenta is implanted in the lower uterine segment near or over the internal cervical os. Approximately 0.5% of births Low lying placenta - CORRECT ANSWER Placenta is implanted in the lower uterine segment, but does not reach the os. - not over the fundus but is close Marginal placenta - CORRECT ANSWER *Only the edge* of the placenta extends to the os. BUT it can move down further in labor. - when the uterus starts to contract it can cause the uterus to move out from behind it, can have bleeding Partial (incomplete) previa - CORRECT ANSWER Incomplete coverage of the internal os. - problem is not pregnancy, its labor, when cervix starts to move or dilate, nothing for the placenta to attach to total (complete) previa - CORRECT ANSWER Internal os is completely covered by the placenta valementous cord insertion - CORRECT ANSWER The umbilical cord inserts into the fetal membranes or Chorioamniotic membrane's, then traveled with in the membranes to the placenta between the amnion and chorion. The exposed vessels are not protected by Wharton's jelly in are vulnerable to rupture - usually cord attached to the placenta is in the middle (99%), so in this case the veins are not protected by the *wharton's jelly* - more common if one placenta in identical twins Vasa previa - CORRECT ANSWER Velamentous cord insertion, and vessels have no support system -exposed. - fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue. *exposed* - can harm the baby if it is coming out risk factors of previa - CORRECT ANSWER (*think scarred placenta*) Previous previa Previous C/S Induced abortion Multiple gestation (larger placenta, must find place to go) Closely spaced pregnancies (placenta separation decr. tissue quality) AMA (vascular) African or Asian race Smoking & Cocaine use (vasoconstriction) S/S of previa - CORRECT ANSWER *Painless* vaginal bleeding May be associated with uterine activity (not a lot of contractions) VSS initially (vital signs stable, can lose up to 40% of blood volume before shock) FHR assuring until severe placental detachment (until cervix dilate) Uterine tone - normal May see incr. fundal height (baby can't descend because placenta in way) May see oblique or breech lie (same as above) Dx of previa - CORRECT ANSWER US (scan and look for placenta) speculum exam (if patient comes in with bleeding you do speculum exam and then scan, not vaginal exam: fingers) Management of previa - CORRECT ANSWER Stable and 36 wks - expectant management (not term watch her and keep in hospital until bleeding stops, not deliver unless unstable) Unstable (bleeding continues), onset of labor, 36 wks gestation - usually C/S Vaginal birth maybe considered if previa is marginal (if bleeding is not too much, always be prepared to go back to OR) Delivery may not stop the bleeding Assess: History of bleeding Vital signs FHR, continuous EFM Previous US reports Labs (*CBC, clotting factors PT/PTT, type and cross match to get blood ready to go for transfusion*) Obtain IV access - at least one 16 G (to give blood, usually have two) O2 Stop the pitocin... Monitor blood loss Monitor maternal status Monitor fetal status For continued bleeding or labor, anticipate delivery... placental abruption - CORRECT ANSWER Premature separation of all or part of the placenta from the implantation site. - different grades Grade 1 (mild) - CORRECT ANSWER Vaginal bleeding with possible uterine tenderness and/or mild tetany (*rigidness, contract and not release on abd, not severe*). - mild, no maternal or fetal distress - 10-20% of detachment (sent to patho lab) Grade 2 (moderate) - CORRECT ANSWER 20 - 50 % separation Uterine tenderness and tetany (abd tenderness) with or without obvious bleeding. Fetal distress, but usually no maternal distress. - bleeding can be occult or apparent, like a bubble of blood Grade 3 abruption (severe) - CORRECT ANSWER 50 % separation Severe tetany, EXTREME pain, "boardlike" abdomen may be felt, with or without obvious bleeding (can be concealed). Maternal distress, fetal distress and death (if not in hospital, fluids and assistance needed). Incidence of abruption - CORRECT ANSWER 1% of all pregnancies Of this total...10% are severe, BUT 33% of infants with maternal abruption die (mostly due to prematurity) - complications from prematurity cx death Risk factors for abruption - CORRECT ANSWER *think causing a lot of pressure at uteroplacental interface* Maternal hypertension Cocaine use (vasoconstrict) Blunt abdominal trauma (car crash, abd trauma, fall) Maternal smoking Poor nutrition (placenta does not grow) Previous pregnancy with abruption S/S of abruption - CORRECT ANSWER Vaginal bleeding (dark red usually as apposed to bright red in previa) Abdominal pain (mild to severe, localized to severe) Uterine tenderness Contractions Maternal hypovolemia (shock) Coagulopathy (DIC in 10% to 30%) Lab values seen with abruption - CORRECT ANSWER dec. Hct/Hgb decr. platelets (DIC) Prolonged PT/PTT *Kleihauer-Betke stain* - fetal blood in maternal system (KB test): this close contact with the different bloods occurs in an abruption, Rh- mom's need RhoGam Outcomes - CORRECT ANSWER Maternal morbidity 1% Leading cause of maternal death Prognosis depends on many factors: Degree of abruption Blood loss DIC Time between occurrence of abruption & birth (*longer the time = the poorer the outcome*) Complications of abruption - CORRECT ANSWER Shock, hemorrhage DIC Infection *Couvelaire uterus* - purplish/copper color, decr. contractility (from DIC and hematoma problem is that it doesn't/can't contract like it should - hemorrhage) Rh sensitization - Rh - mother with Rh+ baby Management of abruption - CORRECT ANSWER Assess History of bleeding (blood everywhere) Maternal VS FHR, continuous fetal monitoring! Uterine tone (palpate, very painful!!!), contractions Labs to obtain CBC T&C Coag studies (PT, PTT, fibrinogen) Kleihauer-Betke possibly Venous access (2, one is 16G) Start O2 Stop the pitocin, if inducing...(tetany) MonitorBlood loss Maternal status Fetal status Prepare for delivery: Type of delivery will be determined by maternal & fetal status (use US) Mild abruption & 36 wks -sometimes expectant management Moderate to Severe abruption or 36 wks - delivery - problem with C/S = more bleeding and coag probs means won't stop bleeding afterwards Placenta increta, accreta, and percreta - CORRECT ANSWER placenta keeps growing into the myometrium and through, lots of scar tissue DIC in pregnancy - CORRECT ANSWER Cause: usually abruption, retained fetal demise, severe preeclampsia, HELLP, sepsis S/S: oozing from gums/nose, bruising, hematuria, tachycardia Management: fix the cause, replace fluids, give blood/maybe clotting factors, delivery???? - *never a primary diagnosis it is usually caused by something else* ectopic pregnancy - CORRECT ANSWER Aka "tubal" pregnancy Risk factors - STI (*especially PID*), tubal damage (tubes tied and reconstruct), previous ectopic, tubal ligation (if not effective) S/S Abdominal pain (*R or L LQ*) Missed period (*positive preg test*) Abnl vaginal bleeding Shoulder pain? (if ruptured, referral of pain from peritoneal bleeding) *Cullen sign* (peritoneal bleeding, bruising around umbilicus) Most important diagnostics: bHCG (preg test) Transvaginal ultrasound Tx -*Methotrexate* to dissolve OR Surgical removal Methotrexate (Rheumatrex) - CORRECT ANSWER destroys rapidly dividing cells - injection, follow very closely to make sure pregnancy is not continuing to grow - dissolves ectopic pregnancy, urine contains levels of drug metabolite that could be considered toxic for approx 72 hr after receiving - levels are highest in first 8hr - avoid getting urine on toilet seat, double flush - stools may contain residual drug for up to 7 days - SE: gastric distress, n/v, stomatitis, dizziness, rare: severe neutropenia, reversible hair loss, pneumonitis - avoid foods and vitamins containing folic acid, avoid gas forming foods, avoid sun exposure, avoid sexual intercourse until beta Hcg are undetectable - keep all scheduled appts, if severe abd pain call dr could be sign of rupture Induced abortion - CORRECT ANSWER Purposeful interruption of pregnancy before 20 weeks of gestation Elective (choose) Therapeutic (to save life of mom) The numbers of abortions in the United States have decreased significantly from 2000 to 2009. Legal and moral issuesIncidence: Abortion rates tend to be higher in women whose income is below the poverty level. Decisions about abortion: 1. concerned for or responsibility to others 2. not afford 3. having a baby would interfere with work, school, or other children 4. do not want to be pregnant and problems with SO or spouse First vs. Second trimester abortion - CORRECT ANSWER First-trimester abortion: Aspiration Medical abortion Methotrexate and misoprostol Mifepristone and misoprostol (*safer than 2nd trimester*) - complications infection and bleeding Second-trimester abortion: Dilation and evacuation Can be performed at any point up to 20 weeks of gestation, although more commonly performed between 13 and 16 weeks of gestation - used for patients having loss or elective Legal implications for Arkansas - CORRECT ANSWER - A woman must receive state-directed counseling that includes information designed to discourage her from having an abortion and then wait until the next day before the procedure is provided. - Health plans that will be offered in the state's health exchange under the Affordable Care Act can only cover abortion *when the woman's life is endangered, rape or incest, unless an optional rider is purchased at an additional cost.* - The parent of a minor must consent before an abortion is provided. - Public funding is available for abortion only in cases of life endangerment, rape or incest. - An abortion may be performed at or after 20 weeks post-fertilization (22 weeks after the woman's last menstrual period) only if the woman's life is endangered, rape, incest or if her physical health is severely compromised, *based on the spurious assertion that a fetus can feel pain at that point.* Mifepristone - CORRECT ANSWER Steroid compound. *Competitive receptor antagonist* at progesterone receptor. Use = abortifacent at high doses (--endometrial lining breakdown and cervical dilation) abortion pill Nsg Dx for elective abortion - CORRECT ANSWER Decisional Conflict r/t value system Fear r/t abortion procedure, potential complications, implications for future pregnancies, what others might think Anticipatory grieving r/t distress at loss or feelings of guilt Risk for infection r/t effects of the procedure, lack of understanding of preop and postop self-care Acute pain r/t effects of the procedure or postop events Insulin - CORRECT ANSWER Produced by beta cells of Islets of Langerhans in the pancreas Regulates blood glucose levels. Stimulates protein synthesis & stores free fatty acids - cells are starving, ketosis is when they use proteins for energy, cx increased fetal growth S/S of hypoinsulinemia - CORRECT ANSWER Hyperglycemia Glycosuria Polyuria Increased candidal infections (bacteria feed on the sugar, baby has increased urine output) Hydramnios (due to increased UO by baby, incr. amniotic fluid) S&S of vascular changes: PVD Retinopathy Nephropathy neuropathy pregestational diabetes - CORRECT ANSWER Diabetes Mellitus (Types I & II pregestational)Insulin secretion defect (type 1)Insulin action defect (type 2)OR both Type I - Insulin DeficientMay be caused by autoimmunityMore common in females Type II- Insulin ResistantMost prevalent type of diabetesCause unknown (sort of)RISK- obesity (apple), Fam Hx, age, sedentary, hx of prior gest diabetes, HTN Gestational diabetes - CORRECT ANSWER unidentified preexistent diseasemetabolic abnormality pronounced by pregconsequence of hormones of preg (HPL, E2, PROG) Any degree of glucose intolerance with first onset during pregnancy *Testing @ 28 Wks 1h GTT & 3h if abn.* *Most diet manageable* PP - pts. Should be reevaluated to determine if they have Type II DM - *very likely to develop type II* 1 hour glucose tolerance test - CORRECT ANSWER Patient drinks 50g Oral Glucose (Glucola), blood glucose drawn 1 hour later, no fasting required, if result is 140 mg/dL it constitutes as a positive screen. 3 hour glucose tolerance test - CORRECT ANSWER Administered following a 3 day high carb diet and 8 hour overnight fast, baseline fasting glucose level drawn, patient drinks 100g oral glucose, blood glucose drawn at 1, 2, and 3 hours. If two or more values are elevated then diagnosis of GD happens. During pregnancy - CORRECT ANSWER Glucose transported across placenta by diffusion. Fetal levels of glucose proportionate to maternal level - *Insulin is NOT transported across placenta.* - Fetal insulin is secreted @ 10 wks gestation. Pregnancy diabetogenesis - CORRECT ANSWER Hormones Estrogen & progesterone incr. insulin and decr. FBS in 1st trimester HPL, Cortisol & Insulinase are insulin-antagonist (spare glucose for fetal needs, more insulin resistance) in 2nd trimester - more circulating glucose for baby Insulin requirements double by 3rd trimester (26/27 wks), if mom's pancreas can not keep up it will show up insulin resistance (why they do testing at 28wks) Postpartum (endocrine changes) - CORRECT ANSWER - Decr. HORMONES after placental separation - Return to prepregnancy needs 7 to 10 days PP (if not breastfeeding) - Lactation maintains lower insulin requirements and glucose levels. - *Be sure to monitor glucose levels & watch for possible hypoglycemia!!!* Maternal changes with DM - CORRECT ANSWER incr Energy Needs incr. Insulin (if diabetic on insulin, b/c body has resistance) Requirements incr. Disease complications Vascular changes may cause PIH (vessel damage occurs) Renal disease Placental abruption Retinopathy Nausea, vomiting, & malnutrition Subsequent anemia & DKA Hydramnios in 10-20% R/T fetal urine ↑ PROM, PTL result (cause uterus to stretch even bigger, baby gets bigger so incr. C/S) Dystocia may ↑C/S Candidiasis UTI, Pyelonephritis Fetal risk with DM - CORRECT ANSWER Type I IUGR d/t maternal vascular problems Type II Macrosomia Congenital anomalies - Heart, CNS, skeletal R/F birth trauma *Hypoglycemia* *RDS: lungs not mature even if baby is large* *Hyperbilirubinemia* *Hypocalcemia* Maternal management control - CORRECT ANSWER Tight glycemic control preconceptional / early HgA1C 6-8% FBS 65-95mg/dl 2h PP 120 Patient & family educated: diet/exercise, reduce risk of developing Type II Healthy maternal/fetal outcome Maintaining physiologic balance - CORRECT ANSWER Diet ( kCals ADA) Exercise (low impact) Home glucose monitoring: gives them control in their treatment Meds (Humalin insulin if needed) Glyburide (oral hypoglycemic, can be used in pregnancy, Metformin is not recommended) Management of care - CORRECT ANSWER Preconceptual counseling More frequent PNC Evaluation of fetal status & wellness U/S & MSAFP @ 16-18 wks Home & office glucose screening Kick counts p 28wks NST & CST p 32 wks if NST nonreactive Amniocentesis for fetal maturity Baseline renal function (Cr) EKG, Eye exam UA, cultures & urine dipsticks Thyroid function (often coexist) Hgb A1C Insulin adjustments *maternal ID bracelet, glucose suggested* Intrapartal care of DM - CORRECT ANSWER During labor: Monitor glucose Q2h May be on insulin drip EFM essential C/S indications PIH Fetal distress/placental insufficiency CPD (cephalopelvic disproportion) Dystocia Postpartum care of DM - CORRECT ANSWER Insulin will need change in dosage! Assessments to focus on diabetic risk factors: Infection Healing Thrombus Family planning needs Health promotion and nutrition Nursing implications for mom's with DM - CORRECT ANSWER Assessments Education Planning Interventions Evaluations Family Involvement Resources for support Hyperemesis gravidarum - CORRECT ANSWER Excessive vomiting during 1sttrimester of pregnancy or beyond Beyond morning sickness N&V r/t *incr. HCG* incr. rate with multiples & molar (incr. HcG) pregnancies some suggest associated with psychological ambivalence (& relational difficulties) - This disorder is also *associated with* *hyperthyroidism & liver dysfunctions* s/s hyperemesis gravidarum - CORRECT ANSWER N&V Abd tenderness (sometimes diarrhea) - WT. Loss of 5% prepregnant wt - Dehydration - Fluid & electrolyte imbalance - Ketonuria - acetonuria complications of hyperemesis gravidarum - CORRECT ANSWER Acidosis Dehydration Ketosis Starvation Malnutrition F&E imbalance Fetal Death Goals and lab tests with HG - CORRECT ANSWER 1. Wt incr. 2. Balanced nutritional status 3. No vomiting CBC Electrolytes Liver enzymes Bilirubin levels Thyroid function test UA (check ketones, acetone) - Zofran does not have as much sleepiness but used to treat n/v Treatment of HG - CORRECT ANSWER Initial: NPO x48 hrs Hospitalization & rest IV replacement I&O Antiemetics (Zofran) TPN possible (can go home with that) Resume small, frequent meals. Clear liquids--*BRAT*--↓ Fat (*bananas, rice, applesauce, and toast*) Nsg implications of HG - CORRECT ANSWER Provide therapeutic environment Assess all dimensions (psychological) Assess support system Plan for home Education & f/u Evaluate weight gain & resolution of NV Home health if TPN