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RNSG 1412 Exam 3 Study Focus
MATERNITY/OB
1. Know the signs and symptoms, complications, and nursing care for a client with diabetes. Differentiate the effects of preexisting diabetes and gestational diabetes. Chapter 26 Diabetes is a disorder of: Carbohydrate metabolism caused primarily by a partial or complete lack of insulin secretion by the beta cells of the pancreas. - ↓ insulin = ↑ blood glucose (Hyperglycemia) - 1 st^ trimester: insulin need decreases - 2 nd^ and 3 rd^ trimesters: Insulin need increases Type 1 diabetes: - Insulin deficient, onset typically young, involves autoimmune destruction of pancreatic beta cells so they will be insulin dependent. Type 2 diabetes: - Insulin resistant, onset often after age 40, diet controlled or require insulin, associated with obesity - May be undiagnosed and discovered in her GDM screening or at postpartum visit 6 – 12 weeks Gestational Diabetes (GDM): - carbohydrate intolerance of variable severity that develops during pregnancy 3 classic symptoms of diabetes (3 P’s) and what causes them? - Polydipsia (increased thirst) - Polyuria (increased urination) - Polyphagia (increased hunger) - Caused b/c body needs insulin to carry glucose to cells, but without any or enough insulin the glucose accumulates making the body go into hyperglycemia. In attempt to correct this causes a chain reaction in the body to correct the imbalances resulting in the 3 Ps. Long-term complications: - Kidney damage - eye problems - cardiac issues (heart and blood vessels) - nerve damage Insulin/glucose affected during early and late pregnancy? 10/3/
Early (Fro m 1- 20 wks gestat ion)
- m ate rn al m eta bo lic rat es an d en er gy ne ed s ch an ge litt le - ↑ ins uli n rel ea se - hy po gl yc e mi a m ay oc cu r (n au sea, vomiting, anorexia)
- respiratory distress syndrome : ↑ insulin = ↓ cortisol = ↓ surfactant production Primary goal during pregnancy for a diabetic client - Normalization/maintenance of blood glucose levels HbA1c - Test reflects how well diabetes is controlled w/in past 3 months - Normal range should be less than 6%. Gestational Diabetes and how is it diagnosed - carbohydrate intolerance of variable severity that develops during pregnancy **Diagnostics:
- Glucose Challenge Test (GCT) o** around 24-28 wks gestation o women ingest 50g of oral glucose solution o 1hr later blood glucose is check o Test is bad/abnormal if blood glucose if greater than 140mg/dL and OGTT is needed - Gold standard for diagnosis is the Oral Glucose Tolerance Test (OGTT) To perform OGTT:
- Determine fasting plasma glucose level
- Ingest 100g of oral glucose solution
- Check levels at 1,2, and 3 hours
- GMD is diagnosed if blood glucose is abnormal or if two or more of the following values occur:
- Fasting, greater that 95mg/dL
- 1 hour, greater than 180mg/dL
- 2 hours, greater than 155mg/dL
- 3 hours, greater than 140mg/dL **Gestational Diabetes management
- Diet** : o Goal: avoid ketosis, euglycemia, appropriate weight gain o Eliminate simple sugars o ↓ carb intake o Divide calories into 3 meals and at least 3 snacks - Exercise: o Improves glucose metabolism o Offers cardiorespiratory benefits o Aids in weight control - Glucose level monitoring o Fasting glucose (no food for previous 4-hours) o 2-hour postprandial blood glucose (2 hours after meals) - Fetal surveillance
o kick counts o ultrasound o biophysical profile o nonstress and contraction test o amniocentesis How do the maternal, fetal and neonatal effects of Gestational Diabetes differ from the effects of preexisting diabetes?
- GDM typically develops during 3 rd^ trimester so it is not associated with and increased incident of major congenital abnormalities or spontaneous abortions. Most common cause of hyperglycemia for a diabetic client: Infection - Untreated hyperglycemia can cause ketoacidosis, coma, and maternal/fetal death - S/S of Hyperglycemia o Fatigue o Flushed, hot skin o dry mouth, ↑ thirst o Frequent urination o Rapid, deep respirations w/ acetone breath (Kussmauls breaths) o depressed reflexes o drowsiness What are the signs/symptoms of Hypoglycemia in the pregnant client and how do we treat it? S/S: - Shakiness - Sweating - Pallor - Disorientation - Blurred vision - Headache - Hunger Tx: - Give 15g of carbs (ie. 3 glucose tablets, 4 – 6 oz juice, 6 saltine crackers, 1 tbs of honey or syrup) - retest level after 15 minutes - If level is less than 70mg/dL, repeat Q 15 min until normal 2. What are the major nursing considerations for a client with heart disease? Chapter 26 Signs/Symptoms of cardiac disease? - Cough (frequent, productive, hemoptysis) - progressive dyspnea w/ exertion - orthopnea (SOB when laying down) - pitting edema of lower extremities/face/hands/sacral area - heart palpitations
Elements of postpartum management of a client with a cardiac disorder Postpartum mgmt.:
- Infection - hemorrhage - thromboembolism - These conditions can act together to precipitate postpartum heart failure. Nursing considerations: - Monitor VS for changes such as tachycardia - Note ↑ fatigue and other s/s of HF - review pt H&P - edu on importance of healthy diet folic acid and iron supplements - avoid extreme temperatures - allow for rest periods - discuss stress management strategies - no smoking or drug use - watch urine output (indicates hearts inability to circulate blood adequately to kidneys - If the mother cannot care for the newborn promote contact between the mother baby and family support - Breastfeeding creates extra demand on the heart - Mother and family may need teaching for S/S of cardiac complications and advised return if any arise, home visits and follow ups as needed. 3. What are the maternal and neonatal effects of HIV during pregnancy? Chapter 26 Fetal and neonatal effects of a pregnant woman with HIV? - Mom needs to be on three drug antiretroviral therapy (zidovudine (ZDV) is primary) o 100 mg PO 5 x’s daily o Initiated btwn 14 – 34 weeks gestation o Can be delayed up to 10 – 12 weeks if HIV is managed o Given to infants 6 – 12 hrs after birth (2 mg/kg Q 6 hours for 6 weeks after birth) - Infant HIV test can be positive for up to 18 months b/c of maternal antibodies in their systems. - Infected newborns are typically asymptomatic at birth, and will not show symptoms until around 1st^ year Early s/s of HIV infection: o enlarged liver and spleen o lymphadenopathy o failure to thrive o persistent thrush o cradle cap - They will often get infections like meningitis, pneumonia, osteomyelitis, septic arthritis, and septicemia. Nursing considerations: - Encourage (but do not force) early prenatal testing - infected mothers need to stay on medication regimen b/c it will reduce the chance that he fetus will get HIV
- Address psychosocial stigma and needs
o Pain in chest, abdomen, vertebrae, joints, or extremities o Pallor o Cardiac failure Management: o Monitor: CBC, serum iron, total iron binding capacity, and serum folate o Folic acid 4 mg/daily to increase RBCs o Goal: maintain healthy status and avoid hospitalization o Maintain adequate hydration o Adequate nutrition o Folic acid supplementation o Rest periods during day o Good hygiene to prevent infection o Prompt treatment o Reposition o Good skin care o Assist w/ ambulation and movement o Assist w/ splinting abdomen w/ pillow while coughing or deep breathing Continuous oxygen and fluids to prevent hypoxemia and dehydration both can stimulate the sickling process, as well as exertion, infection, acidosis and extreme temperatures.
6. Know the common causes, signs/symptoms, and interventions (meds too) for preterm labor and preterm premature rupture of membranes (PPROM). Chapter 27/pg. 580 – 81
Preterm premature rupture of membranes: < 37 weeks gestation; ↑ risk for
preterm labor < 34 wk
Causes: o Infection of vagina or cervix o Weak amniotic sac o Chorioamnionitis: intraamniotic infection o Previous preterm labor (esp if w/ PPROM) o Fetal abnormalities of malpresentation o Incompetent or short cervix o Overdistention of uterus o Maternal hormonal changes o Recent vaginal discharge o Stress or low socioeconomic status o Nutritional deficiencies S/S: pooling of fluid near cervix upon examination
Complications: o ↑ r/f infection ▪ Mom ↑ r/f postpartum infection ▪ Newborn ↑ r/f sepsis after birth ▪ Immature newborns (< 23 wks) ↑ r/f systemic infection o Chorioamnionitis: ▪ S/S – fever and uterine tenderness ▪ Most likely to precede preterm birth b4 34 wks o Oligohydramnios: loss of amniotic fluid r/t prolonged leaks thru ruptured membranes o Umbilical cord compression o ↓ lung volume o Deformities from compression Management: dependent on gestational age, infection (type), or fetal/maternal complications o 34 – 36 weeks: ▪ Labor induction ▪ Cesarean ▪ Test fetal lung maturity o < 34 weeks: consider r/f infection vs hazards of promoting birth
1. Determine true membrane rupture - Urinary incontinence, loss of mucus plug, increased vaginal discharge often mistaken for ROM - Avoid vaginal exams - Sterile speculum exam: assess for pooling of fluids in cervix, dilation, effacement - pH or Fern testing - assess fetal lung maturity - Identify infection - Transvaginal ultrasound 2. Gestation near term: > 34 weeks - Favorable uterus → cesarean - Unfavorable uterus w/o infection → labor delayed for 24 hours; antibiotics - Unsuccessful induction or infection → cesarean 3. Preterm Gestation: < 34 weeks - r/f infection vs r/f complications - cesarean more likely - considers: amt of amniotic fluids, gestational age, fetal lung maturity, and possible infection to mom or baby Medications: Maternal antibiotics
- intermittent or irregular mild low backpain - sensation of pelvic pressure - pain, discomfort, or pressure on vulva or thighs - change or increase in vaginal discharge - abdominal cramps with or without diarrhea - sense of “just feeling bad” or “coming down with something” Interventions : - if continuing pregnancy is not contraindicated, focus on stopping PLT - Identify and correct causing factor (infection, dehydration, polyhydramnios) - if multifetal, increase nutrition and rest - limit activity - use tocolytics to delay preterm birth. **7. What are the risk factors associated with post term (prolonged) pregnancy? Chapter 27 pg. 592 Prolonged pregnancy: Pregnancy lasting > 42 weeks
- Miscalculation of expected due date r/t irregular periods or forgotten last day of period
- Late or no prenatal care Complications: -** Placental insufficiency: reduced transfer of O2 and nutrients to fetus and CO2/waste removal - Fetal compromise (late decels or decreased variability) r/t inability to tolerate contractions - Cord compression r/t oligohydramnios - Respiratory distress r/t meconium aspiration - FGR and weight loss - Complications r/t Dysfunctional labor - Injury r/t traumatic birth - Inadequate postpartum uterine contractions to control bleeding - Psychological: fear r/t labor induction, possible cesarean, problems w/ baby - Fatigue 8. A. What is the priority when a cord prolapse occurs? - To relieve pressure on the cord to restore blood flow **B. What interventions will accomplish the goal? Chapter 27
- Position mom’s hips higher than head to shift fetal presenting toward diaphragm ▪ Knee – chest ▪ Trendelenburg position ▪ Hips elevated with pillow w/ side-lying position**
- If hip elevation doesn’t result in upward shift of fetus, vaginal elevation of fetus presenting part using a sterile gloved hand may be required. Maintain position **until physician orders it stopped.
- Avoid or minimize manual palpation or handling of cord** ▪ Vasospasm or trauma of cord vessels can further reduce umbilical blood flow **to/fro fetus
- Ultrasound exam can confirm FHA b4 cesarean
- 8 – 10 L/min via facemask
- Prompt delivery of fetus is priority
- Tocolytics such as Terbutaline give subQ** ▪ Inhibits contractions ▪ Increase placental blood flow **▪ Reduce intermittent pressure of cord
- Warm, saline-moistened towels retards cooling and drying of cord
- What is shoulder dystocia; what interventions may resolve it; what are the maternal and neonatal effects? Chapter 27 p. 575 Shoulder dystocia: delayed or difficult birth of shoulders resulting in impaction above the maternal symphysis pubis (“turtle sign”) Interventions:
- McRoberts’ Maneuver ▪** flexes thighs sharply against abdomen, which strengthens pelvic curve ▪ Supported squat has similar effect and adds gravity to pushing efforts - Suprapubic pressure: ▪ Pushes fetal anterior shoulder downward to displace it from above mothers symphysis pubis ▪ Fundal pressure should not be used - Assess infant’s clavicles for crepitus, deformity, or bruising ▪ Erb’s Palsy : nerve injury to brachial plexus
- Flaccid muscle tone on affected side
- Most resolve in few weeks
- Exercise and PT can start immediately after birth
- Swelling of leg
- Erythema - Heat - Tenderness - Reflex arterial spasms cause: Cool to touch, pale w/ decreased peripheral pulses - Add’l S/S: pain w/ambulation, chills, general malaise, and stiffness of affected leg Risk Factors: - Inactivity - Prolonged bed rest - Obesity - Cesarean birth - Sepsis - Smoking - History of previous thrombosis - Varicose veins - Diabetes mellitus - Trauma - Prolonged labor - Prolonged time in stirrups in second stage of labor - Maternal age older than 35 years - Increased parity - Dehydration - First-degree relative with thrombosis - Use of forceps - Antiphospholipid antibody syndrome - Inherited thrombophilia’s - Air travel **Interventions: pg 607
- Monitor for bleeding** ▪ Inspect for bruising or petechiae BID ▪ Report signs of bleeding (bruises, bloody nose, blood in urine or stools, bleeding gums, or increased vaginal bleeding ▪ Signs of hemorrhage:
- Tachycardia
- ↓ BP ▪ Observe for excessive or bright red lochia ▪ **Assess fundus for uterine atony ▪ Perform fundal massages
- Maintain daily fluid intake of 12 or more 8 oz glasses
- Stop smoking
- Pad stirrups
- Avoid prolonged time in stirrups (< 1 hour)**
11. Differentiate the signs/symptoms of baby blues, postpartum depression and postpartum psychosis. Baby blues: Transient, self-limiting mood disorder; Lasting < 2 weeks - Insomnia - Fatigue - Irritability - Tearfulness - Mood instability - Anxiety Postpartum Depression: - Feelings of sadness - Loss of pleasure in usual activities - Anxiety, agitation, irritability - Feelings of guilt - Fatigue, sleep disturbances - Difficulty concentrating or making decisions - Depression - Suicidal thoughts Postpartum Psychosis: ability to recognize reality, communicate, and relate to others is impaired - Agitation - Irritability - Rapidly shifting moods - Disorientation - Disorganized behavior - Delusions abt baby - Hallucinations - Suicidal thoughts - Infanticide 12. What are the signs/symptoms of infection in a newborn? Ch. 30 pg 651 General: main s/s - Temperature instability Respiratory: - respiratory distress: nasal flaring, retractions, grunting - tachypnea - apnea Cardio: - cyanosis or pallor - tachycardia - hypotension - edema GI: - poor^ feeding - vomiting - diarrhea - abdominal^ distention - hypo or hyperglycemia CNS:
- Lethargy - Irritability - Decreased/increased muscle tone - Full^ fontanel - High-pitched^ cry 13. What are the steps of neonatal resuscitation? Chapter 30 a. Warm: place in radiant warmer b. Position: neck in sniffing position; avoid hyperextension c. Suction: mouth and nose; endotracheal tube to suction meconium d. Dry infant: remove wet linens, stimulate by rubbing or flicking bottom of feet **e. Evaluate:
- Respirations
- Heart rate
- Color
- What are the major concerns/issues when caring for a preterm infant in NICU? Chapter 29
- Schedule care
- Reducing stimuli
- Promote rest
- Promote motor development
- Individualize care
- Communicate infant needs
- Nutrition
- What are the nursing considerations when caring for an infant experiencing neonatal abstinence syndrome? Ch. 30 pg 653 - 55 Neonatal abstinence syndrome:** disorder in which neonates demonstrates signs of drug withdrawal from in utero exposure to maternal drugs **S/S:
- Behavioral ▪** Irritability ▪ Tremors, jittery, seizures ▪ Increased muscle tone ▪ Restless ▪ Exaggerated startle reflex ▪ High pitched cry ▪ Poor sleep patterns ▪ Yawning - Feeding ▪ Excessive sucking ▪ Uncoordinated sucking and swallowing ▪ Frequent regurgitation and vomiting ▪ Diarrhea ▪ Weight loss - Respiratory ▪ Nasal stuffiness or sneezing
