Exam 3 Flashcards
1
Q
most common reason for doing prenatal testing is
A
advanced maternal age (35 years or older)
2
Q
advanced paternal age is more than
A
55 years
after that there is an increase in certain chromosomal abnormalities
3
Q
Reasons for prenatal testing (7)
A
- Maternal age > 35 years
- Birth of previous infant with chromosomal abnormalities or neural tube defect
- Chromosomal abnormality in family member
- Gender if mom is carrier of X-linked disorder
- Pregnancy after 3 or more spontaneous abortions
- Maternal Rh sensitization
- Elevated levels of maternal serum AFP
4
Q
the point of genetic counseling is to
A
help the family make some decisions and prepare them for the potential effects that may present in their baby
5
Q
it’s quite common for down syndrome babies to also have
A
cardiac anomalies
6
Q
multifactorial disorders
A
more than 1 gene is involved
also, environmental factors or sex of child may affect if it is expressed
Cardiac anomalies
Cleft lip and palate
Neural tube defects
7
Q
Teratogens
A
any factor that adversely affects the fertilized ovum, embryo, or fetus
8
Q
Causative agents
A
Maternal infectious agents Drugs, Rubella and Vaccine Pollutants Ionizing radiation Maternal hyperthermia Maternal co-morbidities
9
Q
1 factor that influences the teratogen’s effect on the pregnancy
A
maternal genome and fetal genotype
10
Q
Top 3 factors that influences the teratogen’s effect on the pregnancy
A
- maternal genome and fetal genotype
- stage of development when exposure occurs
- dose and duration of the exposure of the agent
11
Q
___ mcg of folic acid daily before conception is recommended to prevent ____
A
400
neural tube defects
12
Q
Women with epilepsy may be treated wth ___, which is a known tetratogen
A
Dilantin
13
Q
CVS, PUBS, and Amniocentesis are done at what times?
A
CVS: towards the end of the first trimester (10-13 wks)
A: Between 15 and 20 weeks
PUBS: after 16 wks - not until the woman is definitely into the second trimester
14
Q
Ultrasound can be done when?
A
anytime during the pregnancy
15
Q
In the third trimester, how can fetal wellbeing be assessed?
A
Nonstress Test
Biophysical Profile
16
Q
What is Amniocentesis and when is it done?
A
- Invasive test to identify chromosomal or biochemical abnormalities
- done Between 15 and 20 weeks
- there is a Risk of spontaneous abortion infection, ruptured membranes
17
Q
Why would Amniocentesis be done in the 3rd trimester (after 28 weeks)?
A
to assess:
- Fetal lung maturity
- Detects fetal hydrous and erythroblastosis fetalis
18
Q
CVS stands for what? What is it and when is it done? What are some risks?
A
Chorionic Villus Sampling
10-13 wks
Karyotyping to identify chromosomal abnormalities
Results in 48 hrs
Risks: 0.5% to 2.0% chance of spontaneous abortion and limb abnormalities
19
Q
PUBS stands for what? What is it and when is it done? What are some risks?
A
Percutaneous Umbilical Blood Sampling
after 16 wks
Blood gas, CBC, coag, Rh
Results in hrs
Risks: cord laceration, thromboembolic, infection, spontaneous ab, PROM (premature rupture of membranes)
20
Q
PTO, PROM
A
pre-term labor
premature rupture of membranes
21
Q
Women who have a high risk factor will start having NSTs at about
A
30-32 weeks gestation
22
Q
What is the optimal type of NST?
A
- At least 2 FHR acceleration within 20 minute period
- At least 15 beats above baseline
- Lasting at least 15 seconds
baby is awake/moving around
23
Q
What is an NST and what is the purpose? When is it done?
A
Assess fetal well-being – uteroplacental function
Noninvasive
After 28 wks
24
Q
Accelerations in FHR read during NST are indicative of
A
- Adequate O2 of CNS
- Healthy neural pathway from fetal CNS to FH
- Ability of FH to respond to stimuli
25
Biophysical Profile (BPP) is the ultrasound evaluation of 5 parameters in fetus:
1. Breathing movement
2. Movement of limbs or body
3. Tone – extension/flexion of extremities
4. Amniotic fluid index (AFI)
5. Reactive FHR with activity (NST)
26
When is BPP done?
Usually in 3rd trimester but may be done after 24 wks
27
8 to 10 on BPP =
normal (10 is highest grade possible)
28
4 to 6 on BPP =
possible compromise
29
0 to 2 on BPP =
high perinatal mortality
30
Indications for BPP
- Maternal diabetes mellitus
- Maternal heart disease
- Maternal chronic hypertension
- Maternal sickle cell anemia
- Maternal renal disease
- Hx previous stillbirths
- Rh sensitization
- Maternal preeclampsia or eclampsia
- Suspected post maturity
- Intrauterine growth restriction
31
Maternal Co-Morbidities
Acute and chronic illnesses:
- present before pregnancy
- develop during pregnancy
- affect fetal health and outcome
most affect fetal OXYGENATION at some level
32
What are some key Maternal Co-Morbidities that can affect fetal health and outcome? (12)
asthma
cystic fibrosis
cardiac anomalies
sickle cell
Thalassemia
diabetes
thyroid conditions
multiple sclerosis
Systemic Lupus Erythematosis
Developmental Disabilities
Physical Disabilities
Cancer
33
Signs of Psychosocial Distress
- Increasing Anxiety
- Inability to establish communication
- Inappropriate responses or actions
- Denial of pregnancy
- Inability to cope with stress
- Intense preoccupation with the sex of the baby
- Failure to acknowledge quickening
- Failure to plan and prepare for the baby (e.g. living arrangements, clothing, feeding supplies)
- Indications of substance abuse
34
There is a correlation between chronic behavioral/mental health disorders in the mother and ___
prematurity
35
Nursing Interventions for women with chronic behavioral/mental health disorders
Provide strategies to:
- help decrease anxiety
- keep her oriented to reality
- promote optimal functioning during pregnancy and while in labor
36
Smoking during pregnancy has serious health risks including:
- Bleeding complications
- Miscarriage
- Stillbirth
- Prematurity
- Placenta previa
- Placental abruption
- Low birth weight (LBW)
- Sudden infant death syndrome
37
When do organs complete formation and therefore teratogens have their greatest impact at this time?
9-12 weeks
38
Potential perinatal STIs
Chlamydia, Gonorrhea, Syphilis, HPV, HIV and AIDS
39
___ and ____ are particularly dire/toxic if the mother develops during the first trimester
Rubella and Toxoplasmosis
40
TORCH
```
Toxoplasmosis
Other: Varicella, Hepatitis B
Rubella
Cytomegalovirus
Herpes Simplex
```
41
Nursing Diagnoses for mom that's been exposed to Perinatal Infection
Ineffective Health Maintenance
Grieving
Readiness for Enhanced Knowledge
Ineffective Coping
42
Pre gestational DM means
Diabetes Mellitus existing before pregnancy
Type 1 diabetes
Type 2 diabetes
43
Gestational diabetes mellitus (GDM) is
any degree of glucose intolerance with onset or recognition during pregnancy (2nd or 3rd trim)
44
Pre diabetes is
impaired fasting glucose (IFG)
45
How does pregnancy impact insulin production?
Placenta produces hormones such as estrogen, cortisol and human placental lactogen --> these hormones INHIBIT the functioning of insulin, so the blood glucose level is INCREASED
46
First trimester, insulin need is
reduced
47
Second trimester, insulin need is
increased
48
Third trimester, insulin need is
gradually increasing up to 36 weeks
49
During delivery, insulin need
Maternal insulin requirement drops drastically to pre pregnancy level
intervention: frequent BS during labor
50
When breastfeeding, insulin need
mother maintains lower insulin requirement
51
Weaning breastfeeding, insulin need is
returned to prepregnancy level
52
Recommendations for ADA for patients with type 1 diabetes as soon as menstruation begins
patients are counseled on high risk of being pregnant to themselves and to baby
high risk of neonatal morbidity and mortality
53
The normal number of chromosomes in body cells other than reproductive cells is ____
46, or diploid.
54
Trisomy and monosomy are what?
Most common trisomy is what?
numerical abnormalities of single chromosomes.
The most common trisomy is Down syndrome, or trisomy 21, in which three copies of chromosome 21 are in each somatic cell.
55
polyploidy
refers to abnormalities involving full sets of chromosomes.
56
monosomy -- which is the only one compatible with postnatal life?
A monosomy exists when each body cell has a missing
chromosome, with a total number of 45.
The only monosomy compatible with postnatal life is Turner syndrome, or monosomy X (this person is always female)
most are lost in spontaneous abortion
57
According to ADA Guidelines for Preconception Care, what should the A1C levels be maintained at before attempting conception?
less than 6.5
58
What types of drugs might be contraindicated in pregnancy for type 1 diabetic patients?
Statins, ACEs, ARBs
59
Gestational diabetes is considered similar to type 2 diabetes in that
the patient has hyperglycemia but has hypo insulin production
60
About ___% of patients with gestational diabetes go on to develop type 2 diabetes later in life
20-25
61
Low Risk for gestational diabetes includes:
- Normal weight before pregnancy
- Under age 25
- No hx unexplained stillbirth
- No diabetes in immediate family
62
High Risk for gestational diabetes includes:
- Ethnicity: Af Am, Hisp, Native Am
- HTN
- Hypercholesterolemia
- GD or LGA in previous pregnancy
63
Symptoms warranting OGTT
- Persistent glycosuria on 2 visits
- Proteinuria
- Urinary frequency after first trimester
- Excessive thirst or hunger
- Recurrent monilial infections
- Polyhydramnios, suspected large fetal size, or increased fundal height for date
64
Does the nurse in the prenatal clinic develop the same care plan for Type 1, Type 2 and GDM?
YES - all about education and adherence
65
What is the treatment for Type 1, Type 2 and GDM mothers?
#1 is Diet
If not managed well on diet, add meds
Drugs for Type 1:
- Insulin - may be admitted during 2nd trimester to regulate
Drugs for Type 2 and GDM:
- Oral hypoglycemic (Glyburide & Metformin) may be effective -- Prescribed, though not approved by FDA (Category B / C)
- Insulin, if diet and oral hypoglycemics not effective
66
Any treatment for babies of Type 1, Type 2 and GDM mothers occurs when?
AFTER delivery
67
Danger signs for first trimester
abdominal pain and bleeding
also persistent vomiting and symptoms of infection
68
Hydatiform Molar Pregnancy (aka Gestational Trophoblastic Disease) -- symptoms, risks, treatment
Proliferation and degeneration of trophoblastic villi
no actual pregnancy
Symptoms:
- Vaginal bleeding, uterus growing rapidly which leads to size/date discrepancy
- excessive nausea/vomiting, abdominal pain
Risks:
- choriocarcinoma (cells become malignant)
- repeat mole
Tx: remove uterine contents (D+C) -- necessary
69
Ectopic Pregnancy
implantation of fertilized embryo occurs somewhere outside the uterus
the pregnancy cannot continue since the embryo cannot survive without supportive environment of uterus
most do occur in the fallopian tubes
first symptom is pain associated with the fact that embryo is growing where it shouldn't
70
causes of ectopic pregnancy
could be result of pelvic inflammatory disease
scarring or fibrosis in the tube
(can come from endometriosis or previous pelvic or tubal surgery)
IUD use
71
if ectopic pregnancy, patient presents with
amennorhea, nausea, vomiting
positive pregnancy test
sharp 1-sided abdominal pain with referred shoulder pain
vaginal spotting
low serum progesterone and low HCG levels
72
ectopic pregnancy diagnosis is made with what tool?
transvaginal ultrasound (woman inserts in her vagina and technician then manipulates)
73
Treatment of ectopic pregnancy in Fallopian Tubes (medical, surgical, emotional)
Medical:
If tube not ruptured, Methotrexate IM to dissolve embryo
Surgical:
- If tube not ruptured, laparoscopic salpingostomy to remove products of conception and salvage the tube
- If tube is ruptured, laparoscopic salpingectomy
Counseling
74
When does Spontaneous Abortion occur, and what are the signs?
- Before 20 weeks of gestation
- bleeding, cramping, abdominal pain, decreased symptoms of pregnancy
- most common in first trimester
- D & C if necessary
- Emotional support
75
Incompetent Cervix
aka Cervical Insufficiency
- Painless dilation and cervical effacement
- Before second trimester
- Bedrest until cerclage
- Cerclage:
McDonald
Shirodkar
76
haploid
The total number of chromosomes is a multiple of the haploid number of 23 (69 or 92 total chromosomes)
77
After 20 weeks vs. before 20 weeks
before 20 weeks: abortion
20 weeks: pre-term delivery
78
Another structural abnormality occurs when all or part of a chromosome is attached to another -- this is called
translocation
79
Most common cause of Spontaneous Abortion
chromosomal anomalies
80
Teratogens
are agents in the fetal environment that either cause or
| increase the likelihood that a birth defect will occur.
81
D+C
Dilatation and curettage
(stretching the cervical os to permit suctioning or scraping the
uterine walls)
82
3 types of spontaneous abortions:
threatened abortion
inevitable abortion
incomplete abortion
83
threatened abortion
vaginal bleeding occurs
cervix is still intact, as are the membranes
for this, when there has been bleeding, the treatment is bedrest, no sex
84
inevitable abortion
cervix has dilated, bleeding will continue, membranes have ruptured - eventually, the contents of the uterus will be expressed
85
incomplete abortion
all of the products of conception have not been expelled from the uterus - even more bleeding because placenta is still there
for this, they treat with D+C to make sure they removed all the contents
86
chorionic villus sampling (CVS)
a procedure to obtain a sample of chorionic villi for analysis of fetal cells.
87
placenta previa
abnormal implantation of placenta in the lower uterus
88
alpha-fetoprotein (MSAFP)
plasma protein produced by the fetus
89
neural tube defects
failure of the bony encasement of spinal cord or skull to close
90
Cerclage
treatment for Incompetent Cervix
aka Cervical Insufficiency where they put in basically a suture that just closes the cervix around the 12-14 week
may be left in until around 36 week or later
91
Hyperemesis Gravidarum
Excessive vomiting
Unable to retain fluids, which can lead to:
```
Dehydration
Electrolyte imbalance
Acid-Base imbalance
Starvation Ketosis
Weight Loss
```
92
Treatment for Hyperemesis Gravidarum
```
1. NPO + IVF
Emotional Support
2. Slowly add food
Monitor weight
Continue support
```
93
Danger signs during second trimester
```
vaginal bleeding
leaking amniotic fluid
glycosuria
abdominal pain
HTN/proteinuria
fundal height
absence of fetal movement
```
94
Rh Incompatibility
Rh- mom plus Rh+ dad
| AKA
95
Rh Isoimmunization
antibodies (which can cross the placenta) destroy the baby's RBCs resulting in massive hemolysis
96
RhoGAM is administered to every Rh- mother when?
28 -34 wks (prenatal dose)
97
RhoGAM is administered 24 to 72 hours post partum if
baby is Rh+
98
After delivery, if baby is Rh-, is RhoGAM needed?
no
99
Indirect Coombs
“antibody screen”
Measures number of Rh+ antibodies in mother’s blood
100
Direct Coombs
Detects antibody coated Rh+ cells in infant’s blood
Done after delivery on baby's cord blood - this is done on all babies as part of their type and screen
101
Negative indirect coombs means
Mother given RhoGAM
102
Positive indirect coombs “sensitized” means
Fetus monitored for hemolytic disease of the newborn (erythroblastosis fetalis)
103
Low levels of MSAFP suggest ____. Elevated MSAFP levels are associated with ____
low = chromosomal abnormalities such as trisomy 21
elevated = open NTDs and
body wall defects.
104
The lecithin/sphingomyelin (L/S) ratio is a test for
estimating fetal lung maturity.
105
phosphatidylglycerol (PG) and phosphatidylinositol (PI)
two other components of
surfactant
The presence of PG and PI
phospholipids supports the likelihood that the fetal lungs are mature
106
ΔOD450 (delta OD450)
| test
measure the optical density (OD) of the amniotic fluid stained
by bilirubin if the mother is Rh-negative and was sensitized after being exposed to Rh-positive blood.
107
karyotype
display imaged chromosomes from largest pair to smallest pair
108
PUBS
also called cordocentesis, involves the aspiration of fetal blood from the umbilical cord for prenatal diagnosis or therapy
109
late decelerations
decreases in the
| FHR persisting after the contraction ends
110
amniotic fluid index (AFI)
A method that adds
the depths of amniotic fluid in four uterine quadrants
volume sums greater than 10 cm are considered reassuring
volume sums less than 5 cm are considered oligohydramnios
higher than 18 to 20 cm suggests excess amniotic fluid volume, or hydramnios
111
perinatologist
medical specialist in high-risk pregnancy care from about 20 weeks of gestation through 4 weeks postpartum
112
cervical dilation and evacuation (D&E)
removal of fetal
| tissue, followed by vacuum or surgical curettage.
113
maceration of the fetus
discoloration, softening, and eventual tissue degeneration
-- of the fetus
114
bicornuate uterus
uterus with 2 horns
115
cerclage procedure
suturing of the cervix to prevent early dilation
116
salpingectomy
removal of the tube
117
gestational trophoblastic disease
occurs when trophoblasts (peripheral cells that attach the fertilized ovum to the uterine wall) develop abnormally.
118
After 20 weeks of pregnancy, the two major causes of hemorrhage are
placenta previa and abrupto placentae (Separation of a normally implanted placenta before the fetus is born)
119
Preeclampsia
A systolic blood pressure of 140 mm Hg or greater or a diastolic blood pressure of 90 mm Hg or greater occurring after 20 weeks of pregnancy that is accompanied by significant
proteinuria (≥0.3 g in a 24-hour urine collection, which usually correlates with a random urine dipstick evaluation of ≥1+).
Edema, although common in preeclampsia, is now considered to be nonspecific because it occurs in many pregnancies not complicated by hypertension.
120
postictal
the unresponsive state after a seizure
121
ABO incompatibility
occurs when the mother is blood type O and the fetus is blood type A, B, or AB. Types A, B, and AB blood contain a protein component (antigen) that is not present in type O blood.
122
Treatment of preeclampsia includes
reduced activity, reduction of environmental stimuli, and administration of medications to prevent generalized seizures.
and magnesium sulfate, but this can have serious CNS depression side effects
123
polydipsia
thirst
124
osmotic diuresis in diabetes
The kidneys attempt to excrete large volumes
of fluid in the vascular bed and the heavy solute load of glucose
produces the second hallmark of diabetes, polyuria and glycosuria
125
ketosis
accumulation of acids in the
| body
126
glycosuria
glucose in urine
127
Without glucose the cells starve,
so weight loss occurs, even though the person ingests large amounts
of food, which is called ____.
polyphagia
128
gluconeogenesis
formation of glycogen from noncarbohydrate sources such as proteins and fat
129
macrosomia
fetus that weighs more than 8.8 lb
| [4000 g]
130
shoulder dystocia
delayed or difficult birth of fetal shoulders after the head is born
131
caudal regression syndrome
failure of sacrum, lumbar spine, and lower extremities to develop
132
In addition to having an increased risk for congenital anomalies,
the infant of a mother with preexisting diabetes has an increased
risk for
hypoglycemia, hypocalcemia, hyperbilirubinemia, and
| respiratory distress syndrome
133
Viral infections that occur during pregnancy can be transmitted to the fetus in two ways:
across the placental barrier or by exposure to organisms during birth
134
Dystocia is
a general term that describes any difficult
| labor or birth.
135
hydramnios
excess volume of amniotic fluid
136
Hypotonic labor dysfunction
or secondary arrest, usually occurs
| during the active phase of labor, when progress normally quickens.
137
abruptio placentae
premature separation of placenta
138
Hypertonic labor dysfunction
is less common than hypotonic dysfunction and more often affects women in early labor with their first baby.
Contractions are uncoordinated and erratic in their frequency, duration, and intensity. The contractions are painful but ineffective.
Hypertonic dysfunction usually occurs during
the latent phase of labor.
139
Tocolytic drugs
drugs that inhibit uterine contractions
140
cephalopelvic disproportion
The head or shoulders may not be
| able to adapt to the pelvis if they are too large
141
uterine rupture
tear in uterine wall
142
Precipitate labor
one in which birth occurs within 3 hours of its
onset.
Intense contractions often begin abruptly rather than gradually increasing in frequency, duration, and intensity, as is typical of most labors.
143
Precipitate birth
occurs after a labor of any length, in or out of the hospital or birth center, when a trained attendant is not present to assist.
144
Chorioamnionitis
(intraamniotic infection), or inflammation of
the membranes, which may be associated with group B streptococci, Neisseria gonorrhoeae, Listeria monocytogenes, or species from
the general Mycoplasma, Bacteroides, and Ureaplasma in the amniotic fluid
145
oligohydramnios
loss of the amniotic fluid cushion for the fetus.
146
Preterm labor
begins after the 20th week but before the end of the 37th week of pregnancy.
147
Amniocentesis
transabdominal puncture of amniotic sac
may be done to obtain amniotic fluid for culture if chorioamnionitis is suspected because this infection would contraindicate stopping preterm labor.
148
placenta accreta
an abnormally adherent placenta
sometimes associated with Placenta previa (abnormal implantation of the placenta in lower uterus)
149
Occult (hidden) prolapse
The cord is compressed between the fetal presenting part and pelvis but cannot be seen or felt during vaginal examination.
the cord slips alongside the
fetal head or shoulders.
The prolapse cannot be palpated or seen but
is suspected because of changes in the FHR, such as sustained bradycardia or variable decelerations.
150
Cord prolapsed in front of the fetal head
The cord cannot be seen but can probably be felt as a pulsating mass during vaginal examination.
151
Complete cord prolapse
The cord can be seen protruding from the vagina.
152
Uterine Inversion
An inversion occurs when the uterus completely or partly turns inside
out, usually during the third stage of labor. Such an event is uncommon but potentially fatal.
153
```
anaphylactoid syndrome, often called amniotic
fluid embolism (AFE), occurs when
```
amniotic fluid is drawn into the
| maternal circulation and carried to the woman’s lungs.
154
Nursing care for the woman at risk for a preterm birth before 34 weeks of gestation focuses on
helping her delay birth long enough to provide time for fetal lung maturation with corticosteroids,
allow transfer to a facility that has neonatal intensive care,
or reach a gestation at which the infant’s problems with immaturity are less.
155
The main risk in prolonged pregnancy is
reduced placental function.
This may compromise the fetus during labor and result in meconium aspiration in the neonate.
156
The key intervention for umbilical cord prolapse is to
relieve pressure on the umbilical cord and to expedite delivery.
157
S+S of uterine rupture
signs of shock, abdominal pain, a sense of
tearing, chest pain, pain between the scapulae, abnormal fetal heart rate patterns, cessation of contractions, and palpation of the fetus
outside the uterus.
158
Anaphylactoid syndrome (formerly amniotic fluid embolism) is more likely to occur when
labor is intense and the membranes have
| ruptured.
159
Amniotomy
artificial rupture of the amniotic sac
160
chorioamnionitis
inflammation of the amniotic sac, usually caused by bacterial and viral infections
161
Vasa previa
in which fetal umbilical cord vessels branch over the amniotic sac rather than inserting into the placenta; fetal hemorrhage is a possibility if the membranes rupture
162
cephalopelvic disproportion
fetal head that is too large to fit through the mother’s pelvis
163
umbilical cord around the fetal body or neck
nuchal cord
164
chignon
Temporary caput or scalp edema
is common at the location of the vacuum extractor cup.
165
Infants born between 34 and 37 weeks of gestation are called
late preterm infants (LPIs) because they have many needs that are similar to those of preterm infants.
166
Preterm infants
born before the
| beginning of the 38th week of gestation
167
Low birth weight (LBW)
infants weighing 5 lb, 8 oz (2500 g) or less at birth and of any gestational age
168
Extremely-low-birth-weight (ELBW)
weigh 2 lb, 3 oz (1000 g) or less at birth.
169
Very-low-birth-weight (VLBW)
weigh 3 lb, 5 oz (1500 g) or less at birth.
170
Periodic breathing
the cessation of breathing for 5 to 10 seconds without other changes followed by 10 to 15 seconds of rapid respirations
Changes in color or heart rate do not occur.
171
Apneic spells
involve absence of breathing lasting more than 20 seconds or less if accompanied by cyanosis, pallor, bradycardia, or hypotonia
172
Signs of Inadequate Thermoregulation
```
Axillary temperature 98.4°F (36.9°C)
Abdominal skin temperature 97.7°F (36.5°C)
Poor feeding or feeding intolerance
Irritability followed by lethargy
Weak cry or suck
Decreased muscle tone
Cool skin temperature
Mottled, pale, or acrocyanotic skin
Signs of hypoglycemia
Signs of respiratory difficulty
Poor weight gain, if chronic
```
173
urine specific gravity in dehydration and over hydration in newborn
dehydration - USG > 1.01
over hydration -
174
Containment
simulates the enclosed space of the uterus,
prevents excessive and disorganized motor activity, and is comforting
to infants. It involves keeping the extremities in a flexed position with
swaddling, positioning devices, or with the nurse’s hands.
175
Corrected or developmental age is
the chronologic age minus the number of weeks the infant was born early
176
compliant vs noncompliant lungs
compliant = elastic
noncompliant = stiff
177
Bronchopulmonary dysplasia (BPD), also known as chronic lung disease, is
a chronic condition in which damage to the infant’s lungs requires prolonged dependence on supplemental oxygen. It occurs most often in infants less than 32 weeks’ gestational age and in one third of VLBW infants.
178
Intraventricular hemorrhage (IVH) is also called germinal matrix hemorrhage and periventricular-intraventricular hemorrhage. It is
bleeding into and around the ventricles of the brain.
The first few days of life are the
most common times for hemorrhage to occur.
It may also occur in term infants from asphyxia or trauma
179
Retinopathy of prematurity (ROP) is
a condition where injury to the blood vessels in the eye may result in visual impairment or blindness in preterm infants.
It occurs more often in preterm infants weighing less than 1000 g and less than 29 weeks of gestational age
180
Necrotizing enterocolitis (NEC) is
a serious inflammatory condition
| of the intestinal tract that may lead to cellular death of areas of intestinal mucosa.
181
Short bowel syndrome (SBS) is
a condition caused by a bowel that is
shorter than normal.
It is caused by congenital malformations of the GI tract or surgical resection that decreases the length of the small intestines.
182
Postterm infants are those who are born after
the 42nd week of gestation.
183
If placental insufficiency is present, decreased amniotic fluid volume (oligohydramnios) and compression of the umbilical cord may occur. The fetus may not receive the appropriate amount of oxygen and nutrients and may be small for gestational age. This condition results in hypoxia and malnourishment in
the fetus and is called
postmaturity syndrome
184
Small-for-gestational-age (SGA) infants are those who fall below the
____ percentile in size on growth charts.
tenth
185
LARGE-for-gestational-age (LGA) infants are those who fall above the
____ percentile in size on growth charts.
90
186
Late preterm infants, born between 34 and 36 weeks, are at risk for
respiratory, thermoregulation, and feeding problems as well as hypoglycemia, hyperbilirubinemia, acidosis, and sepsis.
187
Preterm infants differ in appearance from full-term infants. Some differences include:
small size, limp posture, red skin, abundant
| vernix and lanugo, and immature ears and genitals.
188
The ____ position is used for preterm infants because it decreases breathing effort and increases oxygenation.
prone
189
Common complications of preterm birth are (6):
```
respiratory distress syndrome
bronchopulmonary dysplasia
intraventricular hemorrhage
retinopathy of prematurity
necrotizing enterocolitis
short bowel syndrome
```
190
Infants with postmaturity syndrome may appear:
thin with loose skin folds
cracked and peeling skin
meconium staining
They may have respiratory difficulties at birth and suffer from hypoglycemia and inadequate temperature regulation.
191
In symmetric growth restriction, the infant is proportionally small; in asymmetric growth restriction, the head and length are _____ and the body is ____.
normal
| thin
192
Asphyxia is
insufficient oxygen and excess carbon dioxide in the blood and tissues.
193
transient tachypnea of the newborn (TTN)
develop rapid respirations soon after birth from inadequate absorption of fetal lung fluid.
Although the condition usually resolves within 24 to 48 hours, it is the most common respiratory cause of admission to NICU
194
Meconium aspiration syndrome (MAS) is
a condition in which there is obstruction, chemical pneumonitis, and air trapping caused by meconium in the lungs.
195
Persistent pulmonary hypertension of the newborn (PPHN) is a
a condition in which pulmonary vascular resistance remains high after birth and right-to-left shunting of blood occurs, causing severe respiratory difficulty.
196
bilirubin encephalopathy
the acute manifestation of bilirubin toxicity
can lead to kernicterus
197
kernicterus
the chronic and permanent result of bilirubin toxicity.
In this condition, bilirubin deposits cause yellowish staining of the brain, especially
the basal ganglia, cerebellum, brainstem, and hippocampus.
198
erythroblastosis fetalis
agglutination and hemolysis of fetal erythrocytes from maternal-fetal blood incompatibility
199
hydrops fetalis
a severe anemia that results in heart failure and generalized edema.
200
Phenylketonuria (PKU) is
a genetic disorder that causes CNS injury
| from toxic levels of the amino acid phenylalanine in blood.
201
Gastroschisis
a defect to the side of the abdomen, through which the intestines protrude.
They are not covered by peritoneum or skin and float freely in the amniotic fluid.
202
esophageal atresia (EA)
the esophagus is most commonly divided into two unconnected segments (atresia) with a blind pouch at the proximal end.
The cause is a failure of normal development during the fourth week of
pregnancy.
203
tracheoesophageal fistula
If the distal end is of the esophagus is connected to the trachea
The cause is a failure of normal development during the fourth week of
pregnancy.
204
omphalocele
the intestines protrude into the base of the umbilical cord.
205
Spina bifida is
failure of the vertebral arch to close.
It is seen by a dimple on the back, which may have a tuft of hair over it.
206
Meningocele is
protrusion of meninges and spinal fluid through the spina bifida, covered by skin or a thin membrane.
Because the spinal cord is not
involved, paralysis does not occur.
207
Myelomeningocele
protrusion of a membrane-covered sac through the spina bifida.
The sac contains meninges, nerve roots, the spinal cord, and spinal fluid.
The degree of paralysis depends on the location of the defect.
The infant may also have hydrocephalus, or it may develop after surgery.
208
Ventricular septal defect
is the most common type of
congenital heart defect.
It occurs alone or with other defects.
The opening in the septum ranges from the size of a pin to very large.
209
Patent ductus arteriosus is
a failure of the ductus arteriosus
| to close after birth.
210
In coarctation of the aorta,
blood flow is impeded through a constricted area of the aorta near the ductus arteriosus, increasing pressure behind the defect.
The blood pressure is higher in the upper extremities than in the lower extremities.
211
Tetralogy of Fallot has four characteristics:
1. a ventricular septal defect
2. aorta positioned over the ventricular defect
3. pulmonary stenosis
4. hypertrophy of the right ventricle.
212
In transposition of the great arteries, the positions of the ____ and the _____ are reversed.
the aorta and the pulmonary artery
213
ACyanotic Heart Defects example
Patent ductus arteriosus
214
Cyanotic Heart Defects example
transposition of the great vessels
215
Left-to-Right Shunting Defects examples
ventricular septal defects and
| patent foramen ovale.
216
Defects with Obstruction of Blood Outflow examples
Coarctation of the aorta and
| stenosis of the pulmonary or aortic valves
217
Defects with Decreased Pulmonary Blood Flow example
tetralogy of Fallot
218
Cyanotic Defects with Increased Pulmonary Blood Flow example
transposition of the great vessels
219
Asphyxia before or during birth may cause
apnea, acidosis, pulmonary hypertension, and possible death.
Neonatal resuscitation must
be initiated immediately.
220
In transient tachypnea of the newborn, respiratory difficulty in infants is caused by
failure of fetal lung fluid to be absorbed completely.
It usually resolves spontaneously with supportive care.
221
Nonphysiologic jaundice appears ____.
| Bilirubin levels rise ____ and than in physiologic jaundice. If untreated it may result in injury to the brain.
in the first 24 hours of life.
faster
222
Infants with polycythemia have increased viscosity of blood that may cause
thromboemboli, stroke, hyperbilirubinemia, and other complications.
223
Infants with phenylketonuria must be on a ____ diet to prevent severe intellectual disability.
low phenylalanine
224
How do we determine if it's amniotic fluid in PROM
Nitrazine paper to test the pH
| or send to the lab and see that the fluid has the appearance of ferns under the microscope i.e. ferning
225
About 50% of the time when there's PROM but no contractions,
the mom will go into labor in about 24 hours
the next 25% will go within 48 hrs
226
Criteria influencing the treatment plan for PROM
Establish gestational age
| Ultrasound to assess fetus
227
If LMP July 16, 2011, what is EDC?
May 1, 2012
228
polyhydramnios
excessive amniotic fluid
229
twin-to-twin transfusion
a serious disorder that occurs in identical twins and higher order multiples who share a placenta.
This occurs when the blood vessels of the babies’ shared placenta are connected.
This results in one baby (this twin is referred to as the recipient) receiving more blood flow, while the other baby (this twin is referred to as the donor) receives too little.
230
Generally speaking, if a pregnancy is triplets or more, they will be delivered at what kind of center?
Level 3 perinatal center with associated NICU
231
Preterm Labor “PTL” - weeks, contractions, effacement and dilation
Gestation 20-37 wks
Persistent uterine contractions - more than 6 in an hour- (4 every 20 mins or 8 per hour)
Cervical effacement at least 80%
Cervical dilation of more than 1 cm
232
Risk factors for preterm labor
```
Lack of prenatal care
Stress
Uterine anomalies
Multiple gestation
Polyhydramnios
Hx or current UTI
```
233
Tocolysis
medication to inhibit labor
234
Treatment for Preterm Labor If fetus viable:
-> hydrate
```
if contractions subside:
home on bedrest
no work
no sex
no distress
stress reduction
```
235
General notes for treatment of preterm labor
Careful maternal monitoring and FHR monitoring
Identify and report symptoms of fetal hypoxia
236
Treatment for Preterm Labor If fetus viable and labor is progressing
-> hydration
-> tocolysis
Nifedipine
MgSO4
Propranolol
-> corticosteroids (every 12 hrs for a couple days)
Dexamethasone
Betamethasone
237
tocolysis meds for PTL patients
Nifedipine
MgSO4 (magnesium sulfate)
Propranolol
238
3 types of hypertension that occur during pregnancy
1. Chronic hypertension -- not a function of pregnancy
Present before pregnancy (therefore, in first trimester also)
Possibly undiagnosed before prenatal visits
2. Gestational/Transient [aka Pregnancy-induced hypertension]
Develops in 2nd trimester
Hypertension with NO OTHER SYMPTOMS
3. Preeclampsia --> eclampsia
Hypertension
Proteinuria
239
chronic hypertension
Present before pregnancy (therefore, in first trimester also)
Possibly undiagnosed before prenatal visits
240
Gestational/Transient [aka Pregnancy-induced hypertension]
Develops in 2nd trimester
Hypertension with no other symptoms
treated with anti-hypertensive
241
If patient is in first trimester and has hypertension diagnosed, is it a function of pregnancy?
No
242
Preeclampsia --> eclampsia
Hypertension
| Proteinuria
243
What is the Second leading cause of maternal death - about 1/10-15 pregnancies?
Preeclampsia
244
Certain populations more at risk for pre-eclampsia
Age 35
Race – higher in African Americans
Socioeconomic status – lower asso. W/poor diets, increase in smoking
Primagravida 6-8 times more likely to develop PIH
Genetic predisposition , oxidative stress, and the release of immune factors cause placental dysfunction
Eclampsia is grand mal seizures as a result of the progression of preeclampsia
Eclampsia does not have a B/P correlation, or proteinuria, etc.
Mild pre can cause eclampsia
245
Symptoms of preeclampsia
B/P > 140/90 @ 20 wks or more
Proteinuria
Sometimes: pitting pedal edema, facial edema
246
Medical Management of preeclampsia - goals and meds
- > stabilize blood pressure
- > prevent eclampsia
nifedipine, hydralazine, labetolol
247
eclampsia
seizures and coma
248
Signs of mild preeclampsia (systolic, diastolic, proteinuria)
Systolic 140-160
Diastolic 90-110
Proteinuria 3-5 gm in 24˚
249
Signs of severe preeclampsia (systolic, diastolic, proteinuria)
Systolic > 160
Diastolic > 110
Proteinuria > 5 gm in 24˚
250
Medical Management to prevent eclampsia in patients with uncontrolled or high HTN
- Bedrest
- EFM
- IVF (NPO in case of c/s)
- Antihypertensive therapy:
labetalol, hydralazine
Magnesium Sulfate to prevent seizures
- Fetal gestation >34 wks –> deliver
- Corticosteroids
251
purpose of Magnesium Sulfate is to prevent
seizures
252
What is the focused assessment for a pt being tx with MgSO4?
- Vital signs -> blood pressure, temperature, FHR
- Neuro -> level of consciousness (A&Ox4), confusion, deep tendon reflexes, visual disturbances
- Pain -> headache, epigastric pain from liver
- Respiratory -> respirations and sPO2, coughing, SOB, dyspnea, rales/rhonchi
- Uterus/Placenta -> uterine rigidity, vaginal bleeding
- Urine -> output, protein, specific gravity
Weight (daily), pedal edema
- Labs
- P/S -> emotional state, knowledge -> teaching
253
key nursing intervention on MgSO4 is to assess
deep tendon reflexes
if they become diminished, it's a clear indicator that MgSO4 is reaching toxic levels and should be discontinued
254
If patient develops any signs of MgSO4 toxicity, the first step is always
stopping the infusion
255
For Magnesium Sulfate induced
Respiratory Depression or Respiratory Arrest,
institute Emergency Treatment (5 steps):
- STOP infusion immediately.
- Oxygen at 10LPM via face mask
- GIVE Calcium Gluconate 1 Gram slow IVP
(in Pre-eclampsia tray or Crash cart)
- Continuous Pulse Oximetry and ECG monitors
- Contact anesthesia for airway management (Rapid Response)
256
Antidote for Magnesium Sulfate
Calcium Gluconate
257
HELLP Syndrome - what is it and what are symptoms, what can it lead to and how do you treat?
Hemolysis, Elevated Liver enzymes and Low Platelets
Variant or Complication of Preeclampsia
Flu-like symptoms
Epigastric pain from distended liver
Jaundice
Multiple system organ failure
FFP or platelet transfusion
Delivery ASAP
258
What is the best treatment for HELLP
Delivery ASAP
259
Danger signs - 3rd trimester
Vaginal bleeding
Abdominal pain
Fundal height
Leaking amniotic fluid Absence of fetal movement
Glycosuria
HTN/Proteinuria
Abnormal fetal heart rate
260
All pregnant women are screened for GBS between ___ wks gestation via vaginal swab. If culture is positive, IV antibiotics are administered when?
35-37
at delivery
261
When is HIV retesting done during pregnancy?
34-36 wks
262
Chorioamnionitis can progress to
Septicemia (affecting both mom and baby)
263
How is Placenta Previa diagnosed?
prenatal ultrasound
264
Hemorrhagic Disorders: Placenta Previa
Painless bright red vaginal bleeding in third trimester
Presenting part – not engaged
Possibly transverse lie
Medical Management
No vaginal examinations!
- > c/s
- > NSVD possible for high partial
265
marginal/low-lying placenta previa
not covering cerivical os
potential for vaginal delivery
266
partial placenta previa
partially covering cervical os
risk of injury to placenta with vaginal exam
267
complete placenta previa
covers the cervical os completely
268
Hemorrhagic Disorders: Abruptio Placenta
Separation of the placenta from the uterine wall
Dx – ultrasound, clinical presentation
Severe pain and dark vaginal bleeding in third trimester
Not in labor or
Labor could be progressing normally
Classic symptom - "board-like" pressure
269
NSVD possible for Abruptio Placenta patient IF:
```
If in labor
If minimal bleeding
If hemodynamically stable
No uterine tenderness
No fetal distress
```
270
Moms at increased risk for Abruptio Placenta
- smoker
- hypertension
- other causes of reduced oxygenation in the placenta
- cocaine -- causes infarcs in the placenta
271
3 types of Abruptio Placenta
Marginal
Concealed
Complete
272
Precipitous Delivery
Rapid intense contractions
Labor less than 3 hrs
potential complication: trauma to the cervix as result of insufficient time for it to dilate (if baby is descending too fast)
273
Main nursing intervention with Precipitous Delivery
helping mom to control/avoid pushing with breathing techniques until cervix is dilated more
274
Dystocia
Long, difficult, or abnormal labor
As a result of
Powers
Passenger
Passageway
275
Dysfunctional Labor Pattern: Hypertonic
Strong, painful, ineffective contractions
Contributing factor: maternal anxiety
Occiput-posterior malposition of fetus
release of catecholamines which lead to myometrial dysfunction
***prolonged labor phase
fetal distress could occur early
276
Dysfunctional Labor Pattern: Hypotonic
Contractions decrease in frequency, intensity
Maternal and fetal factors that produce excessive uterine stretching
most common: too many drugs/pain meds
treatment: trying to stimulate contractions (enema, nipple stimulation, walking)
277
Structural dystocia
Shoulder Dystocia --> McRoberts Maneuver
Cephalo-Pelvic Disproportion (CPD)
Fetal Anomalies
IDM or LGA
all of these are indicates for a c section
278
Cephalo-Pelvic Disproportion (CPD)
baby's head is too big to fit through pelvis
279
Obstetric emergency if Uterine rupture comes with what kind of pain?
Sharp referred pain -> between scapula
280
Uterine inversion
uterus follows the placenta out
requires Surgical repair
281
Does Umbilical cord prolapse require c section?
yes
282
Chorioamnionitis “chorio”
- Maternal fever (100.4 F)
Plus
- WBC > 15,000
- Maternal tachycardia (> 100 bpm)
- Fetal tachycardia (> 160 bpm)
- Foul or strong-smelling amniotic fluid
- Tender uterus
283
____ are contraindicated in the presence of symptomatic Amniotic Fluid Infection.
Tocolytics
284
Tachycardia in FHR
> 160 bpm
285
Bradycardia in FHR
286
Baseline FHR is
FHR between contractions i.e. when nothing is happening
287
Closer to term, the ___ the resting heart rate can be
lower
normal could be 110-120 for a healthy full term baby
288
Accelerations
jump of 15
indicate good CNS and responsiveness
289
Variable decelerations are the result of
cord compression
onset varies with contractions
290
Late deceleration caused by
utero-placental insufficiency (lack of oxygenation to the baby)
occurs at peak of contraction
291
Early decelerations caused by
head compression
occurs at the beginning of the increment and peak of the contraction
292
At the peak of the contraction, is there oxygen flowing to the baby?
no
293
VEAL CHOP
Variable - cord compression
Early - head
Accelerations - OK
Late - placenta
294
Are there interventions for early decelerations?
No
295
What are the interventions for repeated variable or late decelerations?
```
Discontinue oxytocin
Lateral position change
Increase IVF rate
Oxygen per face mask
Palpate for hyperstimulation
Notify HCP
```
296
Post term Pregnancy
extends beyond 42 wks
Risk for fetal/neonatal problems
Increased maternal risk
Management—labor induction
297
Indications for induction
Post term pregnancy
Premature Rupture of Membranes (PROM)
Chorioamnionitis
HTN: Chronic, Gestational, or Preeclampsia (mild)
Maternal co-morbidities:
Diabetes
Cardiac or Respiratory
Psychosocial (including hx precipitous or rapid labor and distance to hospital )
```
Fetal compromise:
Intrauterine growth restriction (IUGR)
Oligohydramnios
Isoimmunization
Fetal demise
```
298
Bishop score
Determines how successful an induction of labor will be
299
Mechanical induction
Amniotomy = AROM
| Membrane Stripping
300
Medication induction
Cervical Ripening:
dinoprostone insert or gel
misoprostol (off-label)
laminaria
Synthetic Oxytocin IV
301
2 ways that labor is augmented (when cervix is not dilating)
Mechanical:
AROM
Membrane Stripping
Medication:
Synthetic Oxytocin IV
302
Indications for Cesarean Section - STAT
- Fetal distress (prolonged deceleration without recovery)
- Umbilical cord prolapse
- Placenta Abruptio
- Uterine rupture
- Hemorrhage
303
Indications for Cesarean Section - Scheduled
Repeat
Multiples
Infection: HIV, active herpes lesions
Previous 4th degree perineal laceration
Scheduled during last weeks
Placenta Previa
Presentation: Breech, Transverse
304
Indications for Cesarean Section - Non emergent
Failure to progress – prolonged labor
Failed labor induction
Macrosomia / CPD
Complications:
Preeclampsia and HELLP
Preterm labor (if progressing and 22-28 wks)
305
Major risks of c section
Respiratory Depression
Anesthetic gases or medications (epi/spinal)
Maternal or Newborn respiratory depression
Infection
-> Pre-operative prevention
Surgical Care Improvement Project Measure
306
General Anesthesia for c/s Preferred if
- Platelet count is less than 100,000
- Epidural/spinal is not effective
- “STAT” emergency section for fetal or maternal distress
307
Apnea of Prematurity
Apnea – not breathing >15 to 20 secs accompanied by pallor, hypotonia, cyanosis, and bradycardia
308
severe vs moderate prematurity
Severe prematurity
22 to 26 weeks
Moderate prematurity
26 to 30 weeks
309
GFR =
Grunting Flaring Retractions
310
Treatment for Meconium Aspiration Syndrome
Suctioning before first breath to prevent aspiration pneumonia
311
Symptoms of Sepsis
```
Temperature Instability
Feeding
Poor suck
Feeding intolerance
Hypoglycemia
Respiratory - “GFR”
Hypotonia
```
312
EMTALA
Emergency Medical Treatment and Labor Act
Federal law
Patients must be treated for all emergency conditions (including admission) regardless of ability to pay and can only be transported to another facility for a higher level of care.
