Exam 3 Flashcards
(169 cards)
1
Q
What is gestational hypertension?
A
o Gestational hypertension: Greater than 140/90 after 20 wks gestation
2
Q
What is preeclampsia, risks ect..
A
o Preeclampsia: HTN and proteinuria
• Severe: htn (>160/110), proteinuria (>3+), low platelets, neurologic symptoms, oligouria (changes in kidney function), epigastric pain
• Risks: primigravida, multifetal, interval (10yrs), obesity, exposure to trophoblast tissue, preexisting medical/genetic conditions, extremes of age (40), poor outcome in previous pregnancy, family/personal hx, thrombophilias, periodontal disease
3
Q
Nursing care for preeclampsia
A
- Nursing Care: assessments (hematocrit, platelet, liver function tests and 24hr urine for protein/week, 2x weekly= BP and urine protein, and BPP or NST at clinic. Daily FMC (normal 4/hr)
- Homecare: BP<500mg/day, normal platelet count, reassuring fetal status, no s/s or severe preeclampsia.
- If severe: drug of choice= magnesium sulfate
4
Q
What is Eclampsia?
A
o Eclampsia: seizures or coma in preeclamptic woman
5
Q
Nursing care for Eclampsia
A
• Nursing care: airway patent (turn to side, suction and 10L O2 via nonrebreather), observe and record convulsion activity, start IV fluids, give mag sulfate or other anticonvulsant, urinary cath, monitor BP, fetal and uterine status, lab work (kidney and liver function, coagulation system and drug levels. Provide hygiene and quiet environment, support and keep them informed. When stable assist with birth.
6
Q
Magnesium sulfate action
A
o Action: Prevention of seizures (interferes with release of Ach at the synapses- depressing cardiac conduction and decreasing neuromuscular and CNS irritability)
7
Q
Magnesium sulfate therapeutic level and dose
A
o Therapeutic Level: 4-7 mEq/l
o Dose: 4-6g over 15-30min, then 2g/hr
8
Q
Side effects of magnesium sulfate
A
o Side effects: warm, flushed, diaphoresis, burning at IV site
9
Q
Toxicity and antidote of magnesiam sulfate
A
o Toxicity:
• mild: lethargy, muscle weakness, decreased or absent DTR, dbl vision, slurred speech
• Worsening: bradycardia, bradypnea, hypotension, cardiac arrest
o Antidote: calcium gluconate or calcium chloride, and stop infusion
10
Q
Nursing care for magnesium sulfate
A
o Nursing care: vitals q30min, monitor FHR and contractions. Monitor I&O, proteinuria, DTRs, presence of HA’s, visual disturbances, LOC, and epigastic pain hourly. UO at least 30ml/hr.
11
Q
What is HELLP syndrome
A
Laboratory diagnosis for severe preeclampsia with hepatic dysfunction. Increased risk for adverse perinatal outcomes
Hemolysis, elevate liver enzymes, and low platelets
12
Q
o Hydatidaform mole
A
- Incidence: 1 in 1000 pregnancies
- Signs and symptoms: Early stages can’t be distinguished from normal pregnancy. Later stage vaginal bleeding occurs (may be dark brown like prune juice or can be bright red) and ca be scant or profuse. Anemia, excessive n & v, and abdominal cramps/pain. Good chance show signs of preeclampsia.
- Treatment: Most abort spontaneously. If not suction curettage offers a safe and rapid method of removing mole. Post-evacuation admin of Rh (D) immune globulin to women who are Rh negative
13
Q
Nursing care for Hydatidaform mole
A
• Nursing care: Nurse provides family with information about disease process and need of subsequent long course follow up and possible consequences of disease. Help family cope with pregnancy loss and recognize that this was not a normal pregnancy, encourage pt to express feelings (provide information about support groups) Explain the importance of postponing subsequent pregnancies.
14
Q
• Late pregnancy bleeding : Placenta previa
A
o Placenta previa: Placenta is implanted in the lower uterine segment such that it completely or partially covers the cervix or is close enough to the cervix
• Incidence: 1 in 200 pregnancies (c/s, more than 35-40 years of age, multiparity, history of suction and curettage, and smoking)
• Signs and symptoms: Painless bright red vaginal bleeding during the 2nd or 3rd trimester. Initial bleeding is small and often forms clots (bleeding can reoccur at any time. Vital signs may be normal so a better indicator is urinary output. Abd exam is soft, relaxed, nontender uturus with normal tone. Fundal height is often greater than expected for gestational age. Breech and transverse presentation is common.
15
Q
Late pregnancy bleeding: Abruptio placentae
A
o Abruptio placentae (placental abruption)
• Incidence: 1-75 to 1-226 (maternal hypertension, cocaine use, and abd trauma/ maternal battering, smokes, previous history, preterm PROM)
• Signs and symptoms: Vaginal bleeding (result in maternal hypovolemia so shock, oliguria, anuria), abd pain (mild to severe), uterine tenderness and contractions. Bleeding may be present through the vagina, may remain concealed, or both. If have c/s blood clots may be notes on entry to uterus. If a lot of bleeding has occurred the uterus will appears purple or blue and will have lost it contractility.
16
Q
• What is a cerclage, why is it indicated and when is it placed?
A
o Cerclage is the use of a non-absorbable suture to keep a premature dilating cervix closed; released when pregnancy is at term.
o Is indicated for Incompetent cervix and is placed at 11-15 weeks of gestation and is removed at 37/when spontaneous labor begins.
17
Q
• What are the normal physiologic changes that occur in the cardiovascular system related to pregnancy?
A
Increased cardiac output, HR and blood volume (plasma and RBC), slightly decreased BP
18
Q
• Describe nursing care in the prenatal, labor, and postpartum periods for women with heart disease : Prenatal
A
• Prenatal:
o preconception care, limit stress on heart (greatest b/t 28 and 32 wks of gestation.
o Signs of decompensation: increased fatigue/difficulty breathing, feelings of smothering, cough, palpitations, generalized edema, irregular rapid pulse, lung crackles, orthopnea, rapid RR, cyanosis of lips and nailbeds.
o Infections treated promptly- b/c they can accelerate the HR and spread to heart structures.
o Nutrition counseling, avoid valsalva with BM (when released causes blood to rush to the heart and overload the cardiac system)
o Med management (cardiac meds, anticoagulants- monitor PT and INR)
o Tests for fetal well-being and placental sufficiency. Close medical supervision
19
Q
• Describe nursing care in the prenatal, labor, and postpartum periods for women with heart disease : Intrapartum
A
• Intrapartum
o Calm environment (minimizes anxiety and promotes cardiac function). Head and shoulders elevated and resting on pillow, side-lying position
o Cardiac monitoring- EKG, BP, and O2, and FHR
o Antibiotics- penicillin prophylaxis, prevent bacterial endocarditis
o Open-glottis pushing
o Assist with 2nd stage (forceps or vacuum)- to decrease the length and workload of heart
o Epidural- provides better pain than narcotics and less hemodynamic alterations
20
Q
• Describe nursing care in the prenatal, labor, and postpartum periods for women with heart disease: Postpartum
A
• Postpartum-
o Monitor for cardiac decompensation- HIGH RISK for 1st 48hrs
o Good nursing assessment (vitals, O2, lungs and heart sounds, edema, bleeding, uterus, UP, pain (esp chest), emotional state, dietary intake, mom-baby interaction)
o Longer hospital stay- close monitoring of vitals. Semi-fowlers or side lying- head and shoulders elevated.
o Progressive, gradual activity
o Lactation generally okay
• Thiazide diurectics may suppress lactation. And can cause neonatal diuresis that leads to dehydration.
o Increased risk of usual pp complications: thrombus, infection, anema.
o Increased risk of congenital heart disease in neonate if parent has one.
21
Q
• What is the most critical time for possible decompensation related to heart disease?
A
1st 48hrs after birth are highest risk for decompensation d/t increased blood flow to heart, CO, blood volume. Decompensation= inability of heart to maintain sufficient cardiac output
22
Q
What assessment should be performed on the laboring and postpartum woman with heart disease?
A
Routine assessments for all laboring women, and ABGs, pulmonary artery catheter may be inserted to monitor hemodynamic status, ECG monitoring and continuous BP and O2 and continuous fetal monitoring.
23
Q
• How is CPR and foreign body airway obstruction care different for pregnant women (later in pregnancy).
A
Uterus should be displaced laterally for chest compressions (manually or towel under a hip), paddles of defib one rib interspace higher than usual. If CPR not effective in 5 min, c-birth if fetus viable.
In 2nd and 3rd tri- use chest thrusts rather than abdominal thrusts.
24
Q
• What is the most common medical disorder of pregnancy?
A
Anemia
25
• What are common signs and symptoms of anemia, what is the treatment?
Symptoms: fatigue, drowsiness, malaise, dizziness, weakness, HA’s, sore tongue, skin pallor, pale mucous membranes, loss of appetite, N&V
Treatment: increase iron rich food or iron supplementation.
26
• What can a woman do to increase iron absorption?
Diet rich in Vit C (citrus fruits, tomatoes, melons, and strawberries)
27
• What effect can asthma have on pregnancy? How is asthma managed in pregnancy?
Unpredictable effect, associated with uteroplacental insufficiency, IUGR, and preterm birth.
Managed- peak flow meters, avoid asthma triggers, education
28
• What is the most common reason for abdominal surgery during pregnancy?
appendicitis
29
• Why is appendicitis difficult to diagnosis in pregnancy?
Its pushed upward and to the right
30
• What is the most common cause of trauma in pregnancy?
Blunt abdominal trauma- MVAs and falls.
31
• How can trauma affect mom and fetus?
Mom- death from head injury or hemorrhagic shock.
Fetus- death from maternal death or placental abruption. Increase incidence of preterm labor and birth, PROM, fetomaternal transfusion, skull injuries, hypoxia.
32
• What is a major concern for the health of mom and fetus following blunt abdominal trauma?
Placental abruption. Also maternal death from head injury, serious hemorrhage
33
• What is the role of ultrasound in care of the pregnant woman who has experienced trauma?
Help establish gestation age, locate placenta, and evaluate cardiac activity (determine whether fetus is alive), and determine amniotic fluid volume.
34
• What are warning signs for PTL/PTB?
Biochemical markers: fetal fibronectins (glycoprotein found in plasma and produced during fetal life- vagnial swab) before 35wks= 25% accurate and before 28wks= 65% accurate.
Endocervical length- changes in cervical length occur before uterine activity- occurs over a period of weeks
S/S of preterm labor:
o Uterine activity: UCs >q10min for 1hr or more, painful or painless
o Discomfort: low abd cramping, may be accompanied by diarrhea. Dull, intermittent low back pain (below the waist). Painful, menstrual-like cramps. suprapubic pain or pressure. Pelvic pressure or heaviness; feeling that “baby is pushing down.” Urinary frequency
o Vaginal Discharge: change in character and amt of usual: thicker (mucoid) or thinner (watery), bloody, brown, or colorless, increased amt, odor. Rupture of amniotic membranes
35
• What is the definition of preterm labor (PTL)?
PTL: cervical changes and UC’s occurring b/t 20 and 37wks gestation. PTB: birth before end of 37th wk.
36
• What is the role of infections in PTL?
Only factor definitely shows to cause PTL
37
• What is the role of corticosteroids in PTL? Which ones are commonly used?
Promote fetal lung maturing. Antenatal glucocorticoids- IM inj. Stimulates fetal surfactant production. Common- Betamethasone 12mg (2 doses) q24h or Dexamethasone 6mg (4 doses) q12h.
38
• What lifestyle changes may be anticipated for the woman with PTL?
o Activity Restriction- Bed rest (modified is best) and limited work.
o Restriction of Sexual Activity- not effective at preventing preterm birth. If s/s of PTL after sex, obstain until 37wks.
o Home Care- “take it easy”- keep essentials w/i reach, eggcrate mattress, smaller more frequent meals. Activities, limited naps, and hygiene and grooming reduced boredom and maintains control and normalcy.
39
• What is the role of bedrest in PTL management?
No evidence in literature has supported the effectiveness of this intervention in reducing preterm birth rates. Intended to provide maternal rest and decrease stress. May disrupt family function and cause more maternal distress. Adverse effects- risk of thrombus formation, muscle atrophy, osteoporosis, and cardiovascular deconditioning.
40
• What is the relationship of PPROM to PTL/PTB?
PROM responsible for about 1/3 of all PTB. PROM results from weakening of amniotic membranes from inflammation, stress from UCs, or other factors that cause increased IUP.
41
• What is a major concern for the women with PPROM?
Chorioamnionitis (bacterial infection of amniotic cavity)- most often occurs after ROM of during labor. Risks: long labor, such as prolonged ROM, multiple vag exams, internal FHR and contraction monitoring. Also young age, low SES, nulliparity, preexisting lower genital tract infections.
Can lead to: dysfunctional labor, c-birth and infection, neonatal pneumonia, bacteremia, sepsis
42
• How are hypertonic and hypotonic labor dystocia different?
o Hypertonic labor dystocia- R/T fear and tension (unknown) UCs frequent and painfully strong- ineffective in causing cervical dilation and effacement. UCs in latent phase of 1st labor stage (less than 4cm).
Feeling exhausted and loss of control r/t pain and lack of progress
o Hypotonic labor dystocia- R/T cephalopelvic disproportion of fetal malposition. (More common) Rise in IUP during UCs not sufficient to promote cervical effacement and dilation. Normal progress in active 1st phase and then UCs become weak an insufficient or stop. Becomes exhausted and increased risk of infection.
43
• How is management different between the two?
o Hypertonic labor: therapeutic rest measures, analgesics (morphine) to inhibit UCs, reduce pain and encourage sleep. Rest and relaxation- hydrotherapy, massage, music, distracting activities.
o Hypotonic labor: rule out cephalopelvic disproportion. Augment labor with Pit, perform amniotomy, enhance progress of labor- position changes, ambulation, hydrotherapy
44
• What are maternal causes of labor dystocia
o Maternal causes:
• secondary powers (bearing-down efforts) compromised from large amounts of analgesia
• abnormal labor patterns: prolonged latent phase, protracted active phase dilation, secondary arres (no change), protracted descent, arrest of descent, and failure of descent
• alterations in pelvic structure: pelvic dystocia (contractures of pelvic diameters that reduced capacity of the body pelvis, inlet, midpelvis, or outlet) or soft-tissue dystocia (obstruction of birth passage by anatomic abnormality, such as placenta previa, uterine fibroids, ovarian tumor, full bladder, etc.)
• position of mom: alters relationship b/t UCs, fetus, and moms pelvis
• psychologic responses: hormones and neurotransmitters (catecholamines) released in response to stress (pain and lack of support person) can cause dystocia
45
• What are fetal causes of labor dystocia?
o Fetal causes:
• Anomalies: gross ascites, large tumors, open NTD, hydrocephalus
• Cephalopelvic disproportion (CPD): b/t size of fetus and size of moms pelvis. d/t macrosomia or malposition of presenting part
• Malposition: persistent occipitocposterior position (ROP or LOP)= severe back pain
• Malpresentation: breech (frank, complete, foolting)
• Multifetal pregancy
46
• What is a Bishop score and what is it used for?
Used to evaluate inducibility. Cervical ripeness is most important predictor of successful induction. 8 or more= induction of labor is usually successful.
47
• What are common methods of cervical ripening?
Chemical agents: prostaglandins- PGE1 and Cytotec (Misoprostol): ripens cervix, making it softer and causing it to begin to dilate and efface, stimulates UCs
Mechanical methods: balloon catheters to ripen and dilate cervix (pressure and stretching), hydroscopic dilators (absorb surrounding fluid and enlarge), laminaria tents and synthetic dilators containing Lamicel (mag sulfate) into endocervix. Amniotic stripping or sweeping- release of prostaglandins and oxytocin (insert finger and rotate 360 degrees to separate membranes from wall of cervix and lower uterine segment.
Physical methods such as sexual intercourse (prostaglandins in semen, and stimulation of contractions from orgasm), nipple stimulation (oxytocin), and walking (pressure on cervix by gravity)
48
• Describe methods of induction and augmentation
Induction of labor: (chemical or mechanical intiation of UCs before their spontaneous onset, to bring about birth) amniotomy (AROM)- labor usually w/i 12 hrs, committed to labor , oxytocin (high alert drug, tachyststole)
Augmentation: (stimulation of UCs after labor has started spontaneously but progress is unsatisfactory). Methods: Pit infusion and amniotomy. Noninvasive= empty bladder, ambulation and position changes, relaxation measure, nourishment and hydration, hydrotherapy. Active management of labor- aggressive use of Pit for birth w/i 12h of admission.
49
• What are possible detrimental effects of pitocin augmentation or induction?
Maternal hazards: placental abruption, uterine rupture, unnecessary c-birth d/t abnormal FHR and patterns, PPH, and infection. Placental perfusion diminished by too frequent or prolonged UCs= fetal hypoxia and acidemia
50
• What are nursing implications for using pitocin for augmentation or induction of labor?
o Teaching and support (reasons for oxytocin, effects to expect concerning UCs (intensity increases more rapidly, holds peak longer, and ends more quickly), update on progress
o Assessment: fetal status q15min during 1st stage and q5min during active phase of 2nd stage. Monitor UC pattern and uterine resting q15min in 1st stage and q5min in 2nd stage. Monitor BP, P, and R q30-60min, assess I&O, perfrom vag exam as indicated, monitor for side effects (N&V, HA, hypotension), observe emotional response
o Uterine tachysystole (more than 5 UCs in 10 min, or single contraction >2min, or contractions occurring w/i 1 min of each other)
o Rate of infusion to lowest dose to achieve acceptable labor progress. And document.
51
• What are maternal and fetal reasons for vacuum assisted or forceps assisted birth?
Forceps-assisted birth: 2 curved blades to assist in birth of fetal head.
o Maternal indications: Prolonged 2nd stage of labor and need to shorted for maternal reasons (maternal exhaustion or maternal cardiopulmonary or cerebrovascular disease)
o Fetal indications: fetus in distress or abnormal presentations, arrest of rotation, or extraction of head in a breech position.
Vaccuum- assisted birth: vacuum cup to fetal head, neg. pressure to assist in birth of head.
o Indications same as outlet forceps. Advantages are ease in which vacuum can be placed and less anesthesia needed. Less skill needed.
52
• Describe the complications that are more common for women who are obese.
o Venous thromboembolism
| o Cesarean birth- emergency ones
53
• What are maternal and fetal reasons for cesarean births?
o Maternal: specific cardiac or respiratory disease, conditions associated with increased ICP, mechanical obstruction of lower uterine segment (tumors, fibroids), mechanical vulvar obstruction (condylomata), hx of previous c-broth
o Fetal: abnormal FHR or patter, malpresentation, active maternal herpes lesions, maternal HIV, congenital anomalies
o Maternal-fetal: dysfunctional labor, placental abruption, placenta previa, elective c-birth
54
• Are cesarean sections more often done for the health of the mother or the fetus?
Fetus
55
• Describe nursing care for a woman with a prolapsed umbilical cord
o Call for assistance, notify MD immediately
o Glove hand and use a finger on either side of cord on presenting part to exert upward pressure to relieve cord compression- do not move hand! Another person can put rolled towel under R or L hip.
o Place woman in extreme trendelenburg or modified sims position, or knee-chest position
o If cord protruding from vagina= wrap in warm sterile NS solution- do not replace in vagina
o Administer O2 8-10L nonrebreather mask until birth
o Start IV fluids and increase rate
o Continue to monitor FHR continuously
o Explain to woman and support person what is happening and how it’s being managed.
o Prepare for immediate vag birth if fully dilated, otherwise c-birth
56
• What is a shoulder dystocia, what birth injuries is it associated with?
o Head is born, but anterior shoulder cannot pass under pubic arch (turtle sign- retraction of fetal head immediately following its emergence= early sign)
o Birth injuries R/T asphyxia (from delay of birth or trauma from maneuvers), brachial plexus damage (Erb palsy), and fracture
57
• Describe nursing care for the birth complicated with shoulder dystocia.
o Maneuvers- suprapubic pressure and maternal position changes
o McRoberts maneuver- legs flexed apart with knees on abdomen, causes sacrum to straighten and symphysis pubis to rotate toward moms head, angle of pelvic inclination is decreases which frees the shoulder.
o Hands and knees (Gaskin), squatting, or lateral recumbent positions
o Fundal pressure- associated with neurologic complications (should be avoided)
o Stay calm and immediately call for help. Help position mom, assist MD with maneuvers and techniques during birth, and document. Provide encouragement and support to reduce anxiety and fear. Examine newborn clavicle or humerus and brachial plexus injuries or asphyxia.
58
• What are signs and symptoms of a vaginal hematoma?
```
o A mass or swelling develops
o Agonizing anal/genital pain
o Shock/Fever
o Urinary retention
o Discolored skin
o Possible decrease in BP
o Tachycardia
o There will be a significant decrease/absence of lochia after birth
```
59
• What are risk factors for postpartum hemorrhage?
Uterine atony
o Overdistended uterus (large or multiple fetus, hydramnios, distention with clots)
o Anesthesia and analgesia
o Previous hx of uterine atony
o High parity
o Prolonged labor, pit-induced labor
o Trauma during labor and birth (forceps, vacuum, or c-birth)
o Unrepaired lacerations during labor and birth
o Retained placental fragments, manual removal of retained placenta
o Ruptured uterus or inversion of uterus
o Placenta accrete, increta, perceta
o Coagulation disorders
o Placental abruption or previa
o Magnesium sulfate during labor or post-partum
o Chorioamnionitis
o Uterine subinvolution
60
• What is the most common cause of postpartum hemorrhage?
o Uterine atony
61
• What medications are used to manage postpartum hemorrhage related to uterine atony?
o Oxytocin, methergine, hemabate, cytotec- cause contraction of uterus
62
• What are risk factors for uterine atony?
o Associated with high parity, hydramnios, macrosomic fetus, and multifetal gestation
63
• Describe nursing management of postpartum hemorrhage.
o Assess vital signs (are looking for signs of shock and hypovolemia/bleeding)
o Palpate pulses (quality, rate)
o Listen to heart and lung sounds
o Inspect: Skin color, temp, turgor, LOC, cap refill, neck veins, mucus membranes
o Observe for: presence or absence of anxiety, apprehension, restlessness, disorientation
o Measure BP, urinary output and pulse oximetry
o Assess fundus
o Give drugs to help manage bleeding: Pitocin, Methergine, 15-Methylprostaglandin, Dinoprostone, and Cytotec (all help the uterus to contract)
64
• Define retained placental tissue. (pg 826/Chap 34)
o Retention of all or part of the placenta in the uterus after birth
o Nonadherent Retained Placenta: results from partial separation of the normal placenta, entrapment of the partially or completely separated placenta by a hourglass constriction ring of the uturus of mismanagement of the third stage of labor. (is common in very preterm birth)
o Adherent Placental Tissue: Abnorma adherence of the placenta occurs for an unknown reason (is thought that zygotic implantation in an area of defective endometrium so that no zone of separation is present between the placenta and the decidua (with this one normal attempts to remove the placenta will not work and are likely to perforate/lacerate the uterine wall (severe PPH risk)).
65
• What are some possible findings and negative effects of retained placental tissue?o
Placenta accreta: slight penetration of the myometrium by placenta tropoplast
o Plcenta Increta: Deep penetration of myometrium by placental tropoplast
o Placenta pecreta: perforation of uterus by the placenta
o Bleeding
o Cesarean hysterectomy (2/3 of woman)
66
• Describe common sites of postpartum infection.
```
o Genital/Puerperal infection
o UTI
o Wound Infection (c/s, vaginal lacerations)
o Mastitis
o Respiratory infections
```
67
• Symptoms of postpartum infection
```
o Fever (38 degrees C for 2 consecutive days during first 10 days
o Increased pulse
o Chills
o Anorexia
o Nausea, fatigue, pelvic pain
o Foul smelling profuse locia
o Urinary retention
o Pyuria
o Redness/swelling
```
68
What is the most frequent type of cancer in kids?
Acute Lymphocytic Leukemia
69
When is acute lymphatic leukemia usually diagnosed?
Most often diagnosed between ages 2-6
70
What is acute lymphatic leukemia?
```
WBC overproliferation/lack of differentiation
Malignant cell is lymphoblast
Result
WBCs immature, nonfunctional, crowding
RBCs suppressed
Platelets suppressed
```
71
True or false, weight loss in kids always needs investigating
True, Weight loss-always needs further investigation in kids…never an expected finding
72
Symptoms of acute lymphatic leukemia
Low-grade fever
Pallor, lethargy (anemia)
Petechiae, bleeding, bruising (thrombocytopenia)
Abdominal pain, vomiting, anorexia
Bone, joint pain (invasion to bone periosteum)
Headache, unsteady gait (invasion to CNS)
Painless, generalized lymphadenopathy
73
Blast cell leukocytosis in bone marrow
Expect WBC differential: 5% or less blast cells
| ALL: 25% or greater blast cells
74
Can you give someone who's on chemo a live virus?
Although NO live virus vaccines should be given while undergoing chemotherapy
MMR
Varicella
OPV (oral form)
75
Hyper vs hypo thyrodism
Hyperthyroidism
-Grave’s Disease
Hypothyroidism
Congential or Acquired -(Hashimoto’s)
76
Patho review of type 1 diabetes
Autoimmune destruction of beta islet cells of pancreas
Insulin production is impaired
Insulin is needed to transport glucose into many cells of the body
Exceptions: brain, RBCs, WBCs, lens, intestinal mucosa, kidney epithelium
In the absence of glucose, cells requiring insulin for transport need energy so they use fat and protein, which produces excessive acidic waste products (ketones)
This leads to hyperglycemia, glucosuria, osmotic diuresis, dehydration, ketoacidosis, and electrolyte imbalance
77
Signs of type 1 diabetes
```
lydipsia (thirst)
Polyuria (enuresis and large amounts of urine)
Polyphagia (hunger)
Dehydration/constipation
Abdominal Pain
Nausea
Vomiting
```
78
Diabetic ketoacidosis
Increased blood glucose level (often >300mg/dL)
Fatigue
Weight loss despite increased appetite
Absence of Menstruation
Symptoms may be noticed and very quickly the patient has become extremely ill
79
Goals of diabetic treatment
```
vent diabetes related complications:
Blindness
Kidney Failure
Heart Disease
Amputation of Limb
```
80
Diabetes management
```
Insulin administration
Regulation of nutrition
Regulation of exercise
Stress management
Blood glucose monitoring
Urine ketone monitoring
```
81
Types of insulin
```
Humalog
Quick acting
Starts working 5-15 minutes
Peak action is 45-90 minutes
Stops working in 3-4 hours
```
```
Regular
Short acting
Starts working in 30 minute
Peak action is 2-5 hours
Stops working in 5-8 hours
```
```
Types of Insulin:
NPH or Lente
Intermediate acting
Starts working 1-3 hours
Peak action is 6-12 hours
Stops working in 16-24 hours
```
```
Ultralente
Long acting
Starts working 4-6 hours
Peak action is 8-20 hours
Stops working in 24-28 hours
```
82
True or false
| Remember hypoglycemia is likely to occur around 10am to 12noon due to peak of regular insulin time
True
83
Nutrition and diabetes
Encourage children to eat 3 meals with 3 snacks per day
| Meals consist of 55% complex carbohydrates, 15% protein & 30% fat
84
Monitoring your diabetes
```
Blood glucose: may check up to 4-6 times a day or more – frequent checks should enhance BS control
Glycosylated hemoglobin (HBGa1c) can give the care provider a clue related to diabetic control over the last 3-4 months
Urine Ketones: early sign of acidosis and should be tested for when BS is greater than 200mg/dl
Spilling ketones can occur with illness, infection, or with decreased food intake
```
85
What is hypoglycemia?
```
Hypoglycemia is a significant complication of diabetes
Defined as BS less than 60mg/dl
Can occur because of:
Too much insulin
Excessive exercise
Too little food
```
86
Signs and symptoms of hypoglycemia
```
Signs and Symptoms of Hypoglycemia:
Irritability
Stubbornness
Nervousness
Weakness
Dizziness Tremors
Sweating
Temper tantrums “not acting like themselves”
```
87
Treatment of hypoglycemia
Immediate quick absorbing carbohydrate/glucose source (15 grams)
Example: ½ glass oj, ½ glass sugared pop, life savers, cake icing, jelly.
If child is non-responsive, may administer glucagon injection
Monitor BS: if BS does not elevate by 15mg/dl, repeat dose of carbohydrate
88
Diabetic ketoacidiosis
Ketoacidosis is a severe complication of uncontrolled diabetes
Causes:
Initial presentation of Type I Diabetes Mellitus
Missed insulin injections
Inadequate insulin dosage in a known diabetic patient
Emotional Stress/trauma/surgery without adequate insulin adjustment
Intercurrent illness/infection without appropriate dose adjustment
89
Symptoms of diabetic ketoacidosis
```
Symptoms:
Behavior changes seen in hypoglycemia with vomiting
Abdominal pain
Kussmaul respirations
Sweet breath (acetone)
Signs of dehydration
High blood glucose level
If you are in doubt whether a child is hypoglycemic or hyperglycemic always give the fast acting carbohydrate first.
```
90
Complications of treating DKA
Dehydration/Shock
Hypokalemia
Hyperkalemia
Cerebral Edema
91
Pathophysiology of type 2 diabetes
Body develops resistance to insulin
Body not longer uses insulin correctly
As the need for insulin rises the pancreas gradually loses its ability to produce sufficient amounts to regulate blood sugar
92
Diabetes type 2
Contributors to the increase in Type II Diabetes:
Epidemic obesity
Decreased physical activity
Exposure to diabetes in untero
Children and Adolescents are typically between the ages of 10-19 when diagnosed (correlates with the onset of puberty)
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Remember normal cardiovascular changes associated with pregnancy
Cardiac output
Heart rate
Blood volume (plasma and RBC)
Blood pressure
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Postpartum nursing care
First 48 hours after birth are highest risk for decompensation
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Anemia
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Iron deficiency anemia
Symptoms
Fatigue, drowsiness, malaise, dizziness, weakness, headaches, sore tongue, skin pallor, pale mucous membranes, loss of appetite, nausea and vomiting
Treatment:
Increase intake of iron rich food
Iron supplementation
Associated with LBW and PTB
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Pulmonary disorders
Avoid histamine-releasing narcotics (Morphine and Demerol)
Fentanyl is better
Increased risk of postpartum hemorrhage
Oxytocin used – avoid Methergine, and Hemabate
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Minor trauma associated with major complications for pregnancy
Abruptio placentae
Fetomaternal hemorrhage
Preterm labor and birth
Fetal death
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True or false
| Trauma from accidents is most common cause of death in women of childbearing age
True
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Preterm labor
Preterm labor: cervical changes and uterine contractions occurring 20-37 weeks of pregnancy
Preterm birth: occurs before the completion of 37 weeks of pregnancy
Late preterm birth: between 34 -36 weeks
Increased risk for early death and long-term health problems
Very preterm: before 32 weeks
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Tocolytics
Contraindications (box 33-5, p 785)
Maternal
Fetal
Intent of tocolytic therapy
Allow time to intervene to decrease fetal morbidity and mortality
Betamimetics-ritodrine and terbutaline
Magnesium Sulfate – common, but weak evidence for use
Indomethacin (Indocin)-short term, before 32 weeks
Nifedipine (Procardia)
Dosing and nursing considerations (pp 788-789)
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1.
A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits:
B A respiratory rate of 10 breaths/min
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.
A nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is:
A Hypertension
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With regard to preeclampsia and eclampsia, nurses should be aware that:
B Preeclampsia results in decreased function in such organs as the placenta, kidneys, liver, and brain
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.
A woman with severe preeclampsia is being treated with an IV infusion of magnesium sulfate. This treatment is considered successful if:
B Seizures do not occur
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A woman with severe preeclampsia has been receiving magnesium sulfate by IV infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for:
A Hydralazine
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6.
Nurses should be aware that HELLP syndrome:
C Is characterized by hemolysis, elevated liver enzymes, and low platelets
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A woman presents to the emergency department complaining of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary health care provider finds that the cervix is closed. The anticipated plan of care for this woman is based on a probable diagnosis of which type of spontaneous abortion?
C Threatened
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The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa)
B Intense abdominal pain
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A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of:
D Placental abruption
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In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate?
A Administration of blood
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Signs of a threatened abortion (miscarriage) are noted in a woman at 8 weeks of gestation. What is an appropriate management approach for this type of abortion?
C Prepare the woman for an ultrasound and bloodwork.
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A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At the present time she is at the greatest risk for:
A Hemorrhage
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In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the:
D Degree of glycemic control during pregnancy
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Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that:
B The most important cause of perinatal loss in diabetic pregnancy is congenital malformations
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A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client understands that:
D Dietary management involves distributing nutrient requirements over three meals and two or three snacks
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Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Pregnant women with untreated hypothyroidism are at risk for all except:
B Macrosomia
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.
A pregnant woman at 14 weeks of gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. The primary goal of her treatment at this time is to:
C Reverse fluid, electrolyte, and acid-base imbalances
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Appendicitis is more difficult to diagnose during pregnancy because the appendix is:
D High and to the right
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A nurse is caring for a woman with mitral stenosis who is in the active stage. Which action should the nurse take to promote cardiac function?
A Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics.
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During a physical assessment of an at-risk client, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of:
D Cardiac decompensation
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Thalassemia is a relatively common anemia in which:
A An insufficient amount of hemoglobin is produced to fill the red blood cells
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5.
From 4% to 8% of pregnant women have asthma, making it one of the most common preexisting conditions of pregnancy. Severity of symptoms usually peaks:
B Between 24 to 36 weeks of gestation
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A pregnant woman with cardiac disease is informed about signs of cardiac decompensation. She should be told that the earliest sign of decompensation is most often:
B Decreasing energy levels
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1.
Which opiate causes euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, intrauterine growth restriction, and premature rupture of membranes?
A Heroin
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During pregnancy, alcohol withdrawal may be treated using:
C Benzodiazepines
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To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) with psychotic features:
D Is typified by auditory or visual hallucinations
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Nurses must be cognizant of the growing problem of methamphetamine use during pregnancy. When caring for a woman who uses methamphetamines, it is important for the nurse to be aware of which factor related to the abuse of this substance?
C Methamphetamine users are extremely psychologically addicted
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Screening questions for alcohol and drug abuse should be included in the overall assessment during the first prenatal visit for all women. The 4 Ps-Plus is a screening tool designed specifically to identify when there is a need for a more in-depth assessment. The 4 Ps include all except:
A Present
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.
A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring?
D The cervix is effacing and dilated to 2 cm.
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In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, the nurse includes which information?
B "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures."
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For a woman at 42 weeks of gestation, which finding requires more assessment by the nurse?
D One fetal movement noted in 1 hour of assessment by the mother
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A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority?
A Place the woman in the knee-chest position.
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A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of:
B A fetal heart rate (FHR) of 180 with absence of variability
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With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that:
C Its most important function is to afford the opportunity to administer antenatal glucocorticoids
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With regard to dysfunctional labor, nurses should be aware that:
B Women experiencing precipitous labor are about the only “dysfunctionals” not to be exhausted
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.
A nurse providing care to a woman in labor should be aware that cesarean birth:
C Is performed primarily for the benefit of the fetus
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Which statement is most likely to be associated with a breech presentation?
D High rate of neuromuscular disorders
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What is preeclampsia?
Preclampsia is a pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a previously normotensive woman.
♣ The cause of preeclampsia is unknown. No reliable test is available for routine screening or predicting preeclampsia.
♣ Preeclampsia is more common in primigravid women, multiparous women with a new partner, and women under age 19 or over age 40.
o Preeclampsia is a multisystem disease. Its pathophysiologic changes occur long before its clinical manifestations, such as hypertension. Preeclampsia can progress along a continuum from mild to severe preeclampsia and then to eclampsia.
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What is HELLP syndrome
HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction. The name HELLP is a mnemonic for its characteristics, which include:
♣ Hemolysis (the H in the mnemonic)
♣ Elevated liver enzymes (the EL)
♣ And a low platelet count (the LP).
o HELLP syndrome usually develops in the third trimester or within 48 hours after birth. Its clinical presentation is often nonspecific.
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What is the antidote for magnesium sulfate toxicity?
The antidote, calcium gluconate or calcium chloride, should be on the unit.
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Blood loss in pregnancy
Blood loss during pregnancy should always be regarded as a warning sign.
♣ Maternal risks from blood loss include hypovolemia, anemia, infection, preterm labor, and reduced oxygen delivery to the fetus.
♣ Fetal risks from maternal hemorrhage include blood loss or anemia, hypoxemia, hypoxia, anoxia, and preterm birth.
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What is a miscarriage?
A miscarriage (or spontaneous abortion) is a pregnancy that ends as a result of natural causes before 20 weeks of gestation. Some miscarriages occur for unknown reasons, but at least 50% result from chromosomal abnormalities. Fetal or placental maldevelopment and maternal factors account for many others.
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What are types of miscarriages?
The type of miscarriage and signs and symptoms direct care management.
♣ Types of miscarriage include threatened, inevitable, incomplete, complete, and missed.
♣ Signs and symptoms depend on the duration of pregnancy. Uterine bleeding, uterine contractions, and abdominal pain are ominous signs that suggest a threatened miscarriage.
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What is a Hydatiform Mole?
Hydatidiform mole is a benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic vesicles that hang in a grapelike cluster. Complete or partial hydatidiform mole can progress to gestational trophoblastic neoplasia, one of several types of gestational trophoblastic disease.
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Placenta previa and premature separation of the placenta (or abruptio placentae) are differentiated by the:
♣ Type of bleeding
♣ Uterine tonicity
♣ And presence or absence of pain.
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Placenta previa
In placenta previa, the placenta is implanted in the lower uterine segment so that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces.
♣ Placenta previa is characterized by painless, bright red vaginal bleeding in the second or third trimester.
♣ The uterus is soft, relaxed, and nontender with normal tone.
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Abruptio placentae
In abruptio placentae, part or all of a normally implanted placenta detaches from the uterus. Separation occurs in the area of the decidua basalis after 20 weeks of gestation and before the birth of the infant.
♣ Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions.
♣ However, in up to 20% of affected women, vaginal bleeding may be concealed.
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What is the most common endocrine disorder related to pregnancy?
Diabetes mellitus is the most common endocrine disorder related to pregnancy.
o Among women with pregestational diabetes, most have type 2 diabetes.
o Almost 90% of pregnant women with diabetes have gestational diabetes mellitus, which is any degree of glucose intolerance that begins or is first recognized during pregnancy.
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True or False,
In pregnant women with diabetes, lack of glycemic control before conception and in the first trimester may be responsible for fetal congenital malformations.
True
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Fetal and neonatal risks and complications of maternal diabetes include:
Fetal death
o Congenital malformations
o And birth injuries due to fetal macrosomia.
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Insulin requirements for pregnancy
For insulin-dependent women, insulin requirements increase as the pregnancy progresses and may quadruple by term as a result of insulin resistance created by placental hormones, insulinase, and cortisol. After birth, levels decrease dramatically. Breastfeeding affects insulin needs.
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True or False,
Because gestational diabetes mellitus usually develops after the first trimester of pregnancy, birth defects are less likely to occur than with pregestational diabetes.
True
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True or False,
Because gestational diabetes mellitus is asymptomatic in most cases, all women who do not have pregestational diabetes should undergo routine screening by history, clinical risk factors, or blood glucose testing with glucola screening.
True
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Cardiovascular changes in pregnancy typically include
♣ Increased intravascular volume
♣ Decreased systemic vascular resistance
♣ Cardiac output changes during labor and birth
♣ And intravascular volume changes just after childbirth.
o The stress of such normal maternal changes on a heart whose function is already taxed may cause cardiac decompensation, in which the heart cannot maintain sufficient cardiac output.
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True or False,
| Anemia affects 20% to 60% of pregnant women
True
Because anemia reduces the blood’s oxygen-carrying capacity, it increases the heart’s workload and can lead to congestive heart failure.
♣ Anemia also reduces the woman’s ability to tolerate blood loss during birth, and increases the risk of puerperal complications, such as infection.
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Are UTIs common in pregnancy?
True,
Urinary tract infections are a common medical complication of pregnancy. They require treatment with antibiotics. Pyelonephritis (or kidney infection) is a very serious medical complication of pregnancy and the second most common nondelivery reason for hospitalization.
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Baby blues
Mild postpartum depression (or “baby blues”) affects up to 60% of women after childbirth, but does not usually impair functioning. Severe postpartum depression can incapacitate a woman to the point that she cannot care for herself or her infant.
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What is the leading cause of maternal mortality?
Postpartum hemorrhage is a leading cause of maternal morbidity and mortality. Traditionally, it has been defined as the loss of more than 500 ml of blood after a vaginal birth or 1,000 ml of blood after a cesarean birth.
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What is Uterine Atony?
Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage, complicating about 1 in 20 births. It is associated with high parity, hydramnios, macrosomia, and multifetal gestation.
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What is the first sign of postpartum infection?
The first sign of postpartum infection is usually a fever of 38° C or more on 2 consecutive days in the first 10 postpartum days (not counting the first 24 hours after birth).
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What is the most common postpartum infection?
Endometritis is the most common postpartum infection. It usually begins as a localized infection at the placental site, but can spread to the entire endometrium. Other postpartum infections include:
o Wound infections, especially at the cesarean incision, episiotomy, or laceration repair site
o Urinary tract infections
o And mastitis, which is most likely among first-time mothers who are breastfeeding.
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Define preterm labor?
Preterm labor refers to uterine contractions and cervical changes (such as effacement and dilation) that occur between 20 and 37 weeks of pregnancy. Preterm birth is any birth that occurs before the completion of 37 weeks of pregnancy.
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What is the best reason to use a tocolytic?
The best reason to use a tocolytic (such as magnesium sulfate) is to gain enough time to administer glucocorticoids to accelerate fetal lung maturity and minimize respiratory complications in preterm infants. Tocolytics also allow time to transport the woman before birth to a hospital equipped to care for preterm infants.
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What is Chorioamniontitis?
Premature rupture of membranes can lead to chorioamnionitis, a bacterial infection of the amniotic cavity. This infection usually causes maternal fever, maternal and fetal tachycardia, uterine tenderness, and foul-smelling amniotic fluid.
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What is Dystocia?
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Dysfunctional labor (or dystocia) is a long, difficult, or abnormal labor caused by variations in the five factors affecting labor. Dystocia accounts for about 60% of all primary cesarean births in America. Signs of dystocia include uterine contraction changes and lack of progress in cervical dilation or fetal descent and expulsion.
o Obesity increases the risk of several pregnancy complications, including venous thromboembolism and cesarean birth. In an obese client, even routine procedures require more time and effort to accomplish.
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True or False,
| Oxytocin and prostaglandin are used to increase uterine contractility. Tocolytics are used to decrease it.
True
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Examples of Obstetric emergencies
Obstetric emergencies include meconium-stained amniotic fluid, shoulder dystocia, prolapsed cord, uterine rupture, and anaphylactoid syndrome of pregnancy. These problems occur rarely, but require immediate intervention to preserve the health or life of the mother and fetus or newborn.
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Causes of alteration in neurological status
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Trauma
Child Abuse
Hyperthermia
Acquired Medical Conditions
Brain Tumor
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Febrile seizures
Seizures resulting from the development of a fever (typically above 101.8)
Occurs most often as the temperature is climbing and not when it has been sustained
95-98% will not develop epilepsy or any neurological damage; typically benign but very frightening to parents/caregivers
Attempts to lower the temperature will not prevent a seizure; tepid sponge baths not recommended
Educate caregivers of importance of protecting child from further injury during seizure and observing exactly what happens during seizure
