Contraceptive use
a water soluble lubricant should be used with condoms
Oral contraceptive danger indications
Shortness of breath can indicate pulmonary embolism or myocardial infarction
IUD (intrauterine device)
Check for presence of IUD strings following each menstruation to ensure the device is still present. A change in the length of the strings should be reported to the provider
Implantable progestins adverse effects
Irregular vaginal bleeding
weight gain
breast changes
medroxyprogesterone
clients should take calcium and vitamin D o prevent loss of bone density
can cause irregular bleeding
Signs of pregnancy: Presumptive
changes might be subjective or objective:
amenorrhea (no periods)
fatigue
nausea and vomiting
urinary frequency
breast changes
quickening (fluttering movements of a fetus 16 to 20 weeks gestation)
abdominal enlargement
Signs of Pregnancy: Probable
changes that make the examiner suspect pregnancy:
uterine enlargement
Hegar’s sign (soft lower uterus)
chadwick’s sign ( bluish cervix)
goodell’s sign ( softening cervix tip)
ballottement
braxton Hickscontractions
positive pregnancy test
fetal outline felt by examiner
Signs of Pregnancy: Positive
those explained only by pregnancy:
fetal heart sounds
visualization of fetus by ultrasound
fetal movement palpated by experienced examiner
hCG blood / urine test
Human chorionic gonadotropin:
can start as early as day of implantation and can be detected about 8 days after conception.
peaks about day 60-70, declines til day 100-130 then incline until term
raised levels=multifetal, ectopic, hydatidiform mole
low level= miscarriage, ectopic
Gravidity
Nulligravida: never been pregnant
Primigravida: this is first pregnancy
Multigravida: two or more
Parity
Number of pregnancies which fetus reached 20 weeks ( includes stillborn)
Nullipara: no pregnancy
primipara: one
Multipara: two or more
Viability
Point at which a fetus can survive outside the womb.
GTPAL
Gravida,
Term – 38 weeks and more
Preterm – 37 weeks and under
Abortions,
Living
Physiological changes
stretch marks
hyperpigmentation
Supine hypotensive syndrome
Low blood pressure resulting from compression of the inferior vena cava by the weight of the pregnant uterus when the mother is supine.
lie on left side with head elevated on a pillow
pulse during pregnancy
increases 10 to 15/min around 32 weeks until term
FHR
110-160 beats/min
Cardiovasuclar changes
Output increases
blood volume increases
heart rate increases
uterine changes
by 36 weeks the top of the uterus and the fundus will reach the xiphoid process, causing shortness of breath as uterus pushes against the diaphragm
Skin changes
chloasma: an increase of pigmentation on face
linea nigra: dark line (happy trail)
striae gravidarum: stretch marks
April 1st was first day of last period. what is her due date
january 8
G3 T1 P0 A1 L1
what does this mean
gravida-3 (3 pregnancies including her being pregnant now)
term-1 baby delivered at term (38 wks and more)
preterm-0 (no preterm deliveries)
abortions-1
living-1
which of these are probable signs of pregnancy? select all that apply
Enlarged montgomery glands
goodell’s sign
ballottement
chadwicks sign
quickening
enlarged montgomery glands- presumptive
goodell’s sign- probable
ballottement- probable
chadwicks sign- probable
quickening- presumptive
explain causes episodes of hypotension?
this is due to the weight of the uterus on the large blood vessels. Supine hypotensive syndrome, uterus places pressure on the vena cava decreasing venous blood flow to the heart
taking a pregnancy test should include
take urine from first morning void
prenatal visits
monthly until 28 weeks
every 2 weeks until 36 weeks
every week until born
Fetal heart can be heard when
late in the first trimester
listen at the midline, right above the symphysis pubis, by holding the doppler firmly on the abdomen
fundal height is the same as age of gestation in weeks…
18-30
begin checking for fetal movement between weeks….
16-20
Rh negative clients receive Rho(D) immune globulin IM around…
28 weeks
Cbc with differential (types of wbc’s analyzed)
Hgb and Hct
detect infection and anemia
Hgb electophoresis
identifies hemoglobinopathies (sickle cell and thalassemia)
rubella titer
determines immunity to rubella
hep B screen
identifies carriers of hep b
group B streptococcus
obtain a vaginal/anal culture at 35-37 weeks to check for group b strep infection
urinalysis with exam of pH, specific gravity, color, sediment, protein, glucose, albumin, RBC’s, WBC’s, casts, acetone, and hCG
identify pregnancy, diabetes, gestational hypertension, renal disease, preeclampsia,
one hour glucose tolerance
Identifies hyperglycemia; done at initial visit for at-risk clients, and at 24 to 28 weeks of gestation for all pregnant women ( greater than 140 mg/dL requires follow up).
Papanicolaou (Pap) test
Screening tool for cervical cancer, herpes simplex type 2, and/or human papillomavirus.
PPD test
tuberculosis test at 20 weeks gestation
gestational hypertension signs
severe persistent headaches
blurred vision
edema of face and hands
epigastric pain
relieve backache during pregnancy
perform the pelvic rock exercise every day (bend back forward then backwards)
use proper body mechanics
which is a complication that should be promptly reported?
a. vaginal bleeding
b. swelling ankles
c. heartburn after eating
d. lightheadedness when lying on her back
vaginal bleeding- could indicate placental problems
what do you do for nausea and vomiting in the morning
eat crackers or plain toast 30-60 minutes before rising from bed
6 weeks pregnant: signs/symptoms
breast tenderness
urinary frequency
epistaxis ( nose bleed)
8 weeks and says she isnt too happy about being pregnant. your response:
feelings of ambivalence about pregnancy are normal during the first trimester
Nurtrition
calories:
340 extra during 2nd trimester
452 extra during 3rd trimester
450-500 extra for breastfeeding mothers
increasing protein intake
folic acid: 400-600 mcg a day
iron: given with OJ, extra fluids decrease constipation from iron
calcium: 1000g/day
limit caffeine 200mg/day
good sources of calcium other than milk
dark green leafy vegetables
weight gain during pregnancy
3-4 lbs in first trimester
1 lb per week in second (total 12 lb just in 2nd)
25-30 lbs By 3rd trimester
what can these lead to:
iron deficiency anemia
calcium deficiency
maternal obesity
folic acid deficiency
iron deficiency
poor bone and teeth
macrosomic fetus
neural tube defects
What aids iron absorption?
Vitamin C ( Orange Juice)
a postpartum woman who is breastfeeding and doesnt like milk needs….
calcium supplements
Biophysical Profile (BPP)
Assessment of five variables in the fetus with a score of 2 for each normal finding and 0 for each abnormal finding
FHR- reactive 2, nonreactive 0
FETAL BREATHING MOVEMENTS- at least on episode of greater than 30 seconds duration in 30 min =2
GROSS BODY MOVEMENTS- at least three body or limb extensions with return to flexion in 30 min=2
FETAL TONE- at least one episode of extension with return to flexion = 2
QUALITIVE AMNIOTIC FLUID VOLUME- at least one pocket of fluid that measures at least 2 cm in two perpendicular planes =2
Biophysical profile scoring
8-10: Normal
4-6: Suspect chronic asphyxia
0-4: Strongly suspect asphyxia
Nonstress test (NST)
antepartum evaluation of fetal well being performed during third trimester. monitors response of FHR to fetal movement
accelerates 15/min for at least 15 seconds
amniocentesis
aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client’s uterus and amniotic sac under direct ultrasound guidance
a nurse is reviewing findings of a client’s biophysical profile with the charge nurse. Which of the following variables should the nurse expect the test to include? (select all that apply)
a. fetal weight
b. fetal breathing movements
c. fetal tone
d. fetal position
e. amniotic fluid volume
B. Fetal breathing movements
C. Fetal Tone
E. Amniotic Fluid Volume
what test is part of an amniocentesis to determine fetal lung maturity?
Lecithin/sphingomyelin (L/S) ratio
before having an amniocentesis, instruct client to…..
empty bladder
causes of bleeding during pregnancy
first trimester:
spontaneous abortion: before 20 wks
ectopic pregnancy: outside of uterus
second trimester:
gestational trophoblastic disease: trophoblast cells
third trimester:
placenta previa: placenta lies low in uterus
abruptio placentae: placenta seperates
vasa previa: fetal vessels are implanted into membrane rather than the placenta
kleihaauer-betke test
used to detect fetal blood in maternal circulation
ectopic pregnancy signs
unilateral lower quadrant pain with or without bleeding
abruptio placentae risk factors
blunt abdominal trauma
cocaine
cigarette use
32 weeks and has placenta previa. actively bleeding. what medication is prescribed?
Betamethasone is given to promote lung maturit if delivery is anticipated
indomethacin
nifedipine
for the client in preterm labor
methylergonovine
for the client experiencing postpartum hemorrhage
Hydatiform Mole (Molar Pregnancy)
Abnormal development of the trophoblast, a placenta develops, but no fetus
exhibits increased fundal height that is inconsistent with the week of gestation and excessive nausea and vomiting
HIV infection is a contraindication to…
episiotomy forceps, internal fetal monitoring
*blood exposure
TORCH symptoms
joint pain, malaise, rash, tender lymph nodes
cervical insufficiency
cervix opens too early and expulsion of the products of conception occurs.
blood glucose level during pregnancy
70-110 mg/dL
risk factors of hyperemesis gravidarum
obesity
multifetal pregnancies
lab results for a suspected hyperemesis gravidarum.
ketones in urine
the presence of ketones in the urine is associated with the breakdown of protein and fats
signs of magnesium sulfate toxicity
BURP
Blood pressure decrease
Urine output decrease
Respiratory rate decrease
Patella reflex absent (deep tendon reflexes)
-and flushing/sweating
magnesium sulfate antidote
calcium gluconate
heparin antidote
protamine sulfate
iron antidote
Deferoxamine (Desferal)
pyridoxine
Vitamin B6
preterm labor lab tests
fetal fibronectin (FFN)
cervical cultures
CBC
Urinalysis
management of a client who is in preterm labor
activity restriction
ensuring hydration
identifying and treating an infection
chorioamnionitis
monitor FHR and contraction pattern
fetal tachycardia
Nifedipine
Calcium channel blocker to Suppress contractions
monitor for headache, flushing, dizziness, and nausea
Don’t administer with Magnesium Sulfate
Magnesium Sulfate
Tocolytic to Suppress uterine contractions
monitor for edema, toxicity, antidote Calcium Gluconate
Indomethacin
NSAID suppresses preterm labor by blocking production of prostaglandins Suppress contractions
Dont exceed 48 hrs
Only for weeks LESS THAN 32
Betamethasone
enhance fetal lung maturity and surfactant production in fetuses between 24 and 36 weeks
ampicillin
antibiotic for infection (chorioamnionitis)
Risk factors for Preterm Labor
urinary tract infection, multifetal, diabetes, uterine abnormalitie, hydramnios (excessive amniotic fluid)
what medication hastens fetal lung maturity
betamethasone
Nifedipine for preterm labor, monitor for…
a. blood sputum
b. dizziness
c. pallor
d. somnolence
b. dizziness and lightheadedness
contraindications for magnesium sulfate
Acute fetal distress
Vaginal bleeding
Cervical dilation greater than 6 cm
Severe pregnancy-induced hypertension
26 weeks, PROM, what should the nurse instruct at discharge
keep a daily record of fetal kick counts
physiologic changes preceding labor
Backache, low, dull
Weight loss 1-3 lbs
Lightening, head descends into true pelvis 14 days before labor
Contractions
increased vaginal discharge/blood show
energy burst called nesting
GI changes
Cervical ripening- becomes soft, effaced
Rupture of membranes- labor usually occurs within 24 hours
Amniotic fluid is alkaline
Urine is slightly acidic
Five P’s
Passenger (fetus and placenta)
Passageway (birth canal)
Powers (contractions)
Position of mother
Psychologic response
Position of Fetus
Right (R) or Left (L)- first letter
Occiput (O), Sacrum (S), Mentum (M), Scapula (Sc)- 2nd letter
Anterior (A), Posterior (P), Transverse (T)- 3rd letter
preferrably Occiput
Station
measurement of fetal descent in centimeters
Station 0 at level of ischial spines
Station negative (-1, -2) superior to ischial spines
Station + inferior to ischial spines
Inducing labor
Cervical ripening
Oxytocin- monitor vitals 30-60 min, FHR every 15 min. STOP if hyperstimulation occurs
Nonreassuring FHR
- Notify provider
- Turn pt on their side
- Keep IV open and increase fluids 200ml/hr
- administer O2 face mask
- administer Tocolytic terbutaline
- monitor, document, prepare for cesarean
Prolapsed umbilical cord
umbilical cord is displaced, preceding the presenting part of fetus, protruding through cervix, results in cord compression and compromised fetal circulation
- call for assistance immediately
- notify prescriber
- the RN or provider will use a sterile gloved hand to lift fetus off of cord
- pt in a knee chest , trendelenburg
stages of labor
STAGE 1 – onset of uterine contractions till dilation of cervix is complete (6-24 hours).
STAGE 2 – maximal cervical dilation until baby passes thru the vagina (few minutes – one hour). STAGE 3 – expulsion of the placena (15 mins).
Stage 1 labor
Latent phase dilates 0-3 cm
Active phase dilates 4-7 cm
transition phase dilates 8-10 cm
a pt experiences a large gush of fluid from her vagina while walking in hallway, what should the nurse do first
monitor FHR for distress
40 weeks, contractions every 3-5 min, dilated 3 cm, 80% effaced, -1 station.
client asks for pain meds, what should nurse do
encourage use of patterned breathing techniques
administer opioid analgesic medication
suggest application of cold
before performing an amniotomy, what should the nurse ensure during a vaginal exam
fetal engagement at a 0 station to prevent umbilical cord prolapse
if a pt’s water breaks and the nurse sees the umbilical cord coming out, what should the nurse do first
call for assistance
Monitoring FHR
- count for 30-60 seconds for a baseline
-auscultate immediately following rupture of membranes
-count FHR between contractions for a baseline
-auscultate FHR:
latent phase 30-60 mins
active phase 15-30 mins
2nd Stage 5-15 mins
Benefits of Internal Fetal Monitoring
can detect abnormal fetal heart tones early
allows for accurate readings despite maternal movement
can measure uterine contraction intensity
Fetal tachycardia can be caused by
maternal fever, infection, chorioamnionitis
late decelerations in FHR, what should the nurse do IN ORDER
- assist client to left lateral position
- apply oxygen face mask
- increase rate of maintenance IV
- prepare for vaginal exam
An external monitor cannot measure what
uterine contraction intensity
Fundus Postpartum
Involution- uterus returns to its prepregnant state
-Immediately after delivery ,the fundus should be firm midline with umbilicus
-should descend 1-2cm every 24hrs, halfway between symphis pubis and umbilicus by day 6
-after 2 wks the uterus should lie within the true pelvis and should not be palpable
Lochia rubra
dark red to brown discharge
1-3 days after delivery
Lochia serosa
Pinkish/brown, serosanguineous. Lasts day 4-10 postpartum
Lochia Alba
Yellowish-white creamy discharge on Day 11-8 weeks postpartum
Cardio changes in postpartum
decrease in blood volume related to :
blood loss during birth (300-500mL)
diaphoresis and diuresis of the excess fluid ( loss occurs within 2-3 days postdelivery)
pulmonary embolus
when fragments or an entire cot dislodges and moves into circulation
is a complication of DVT that occurs if the embolus moves into the pulmonary artery or one of its branches and lodges in a lung, occluding the vessel and obstructing blood flow to the lungs
thrombolytic therapy
Oxytocin
Uterine Stimulant
-to promote uterine contractions
Postpartum hemorrhage
occurs if client loses more than 500 mL of blood after a vaginal birth or more than 1,000 mL of blood after a cesarean birth
Uterine Atony
inability of uterine muscle to contract adequately after birth, can lead to postpartum hemorrhage
give oxytocin, methylergonovine, misoprostol, or Carboprost tromethamine
Methylergonovine, Misoprostol, Carboprost tromethamine
uterine stimulant
-to control postpartum hemorrhage
Subinvolution of the uterus
uterus remains enlarged with continued lochia discharge and can result in postpartum hemorrhage
give oxytocin or methylergonovine
Inversion of the uterus
uterus is turning inside out
can be partial or complete
results in hemorrhage; emergent situation
give tocolytic
Terbutaline
Tocolytic
-relax uterus prior to the provider’s attempt at replacement of the uterus into the uterine cavity and uterus repositioning
Retained placenta
Placenta or fragments of the placenta remain in the uterus preventing the uterus from contracting which leads to uterine atony or subinvolution
Med given: oxytocin….if unsuccessful then tocolytic for d&c
Lacerations
occur during labor and birth consist of the tearing of soft tissues in the birth canal and adjacent structures including the cervical, vaginal, vulvar, perineal, and rectal areas
-episiotomy can extend and become a third- or fourth- degree laceration
Hematoma
collection of 250-500 mL of clotted blood within tissues that can appear as a bulging bluish mass.
Can occur in pelvic region or higher in vagina or broad ligament
ice packs to treat small hematomas
pain meds
sitz baths and frequent perineal hygiene
Endometritis
uterine infection
usually 2nd to 5th day postdelivery
meds: clindamycin, cephalosporins, penicilins, gentamicin (all antibiotics)
mastitis
breast infection involving connective tissue
-most common in breastfeeding mothers
for thrombophlebitis, what intervention should the nurse recommend?
measure leg circumferences to monitor changes
teaching on a breastfeeding mother with mastitis, what to include?
completely empty each breast at each feeding or use a pump
which of the following risk factors should the nurse include for UTI’s ?
epidural anesthesia
urinary bladder catheter
frequent pelvic exams
history of UTI’s
cesarean births
postpartum client who is exhibiting tearfulness, insomnia, lack of appetite,and a feeling of sadness
what do these symptoms indicate
postpartum blues
postpartum psychosis; what is the nurses priority
ask the client if she has thoughts of harming herself or her infant
expected reference range for newborns
2,500 g – 4,000 g / 5.51 lb-8.81 lb
45 cm – 55 cm / 17.7 in – 21.6 in
head circum: 32 cm – 36.8 cm/ 12.6 in – 14.5 in
chest circum: 30 cm – 33 cm/ 11.8 in – 12.9 in
vital signs reference
RR 30-60/min with short apnea (less than 15 secs)
HR 110-160
BP 60-80 systolic/ 40-50 diastolic
T 97.7-99.5 F/ 36.5 – 37.5 C
milia
small raised white spots on face
mongolian spots
bluish purple spots of pigmentation
telangiectatic nevi
Flat, pink or red marks that easily blanch and are found on the back of the neck, nose, upper eyelids, and middle of forehead
nevus flammeus
a port wine stain on face or neck that is permanent birthmark of newborn
erythema toxicum
pink rash that appears suddenly anywhere on the body of a term newborn during the first 3 weeks.
small white nodules on the roof of the newborn’s mouth
epstein perals
In checking for the Moro reflex in a newborn, the nurse should perform which of the following to assess it?
hold newborn in a semi sitting position, then allow the newborn’s head and trunk to fall backward
bluish marking across newborn’s lower back
this is frequently seen in newborns of african american, asian, or native american origin
a nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which medication will the nurse administer
Erythromycin
a nurse is returning a newborn to his mother following circumcision. Which of the following actions should the nurse take to ensure safety of the newborn
match the mothers identification band with the newborns identification band
teaching about breastfeeding
when latched on, the infants nose, cheek, and chin are touching the mother’s breast
teaching about proper techniques for bottle feeding with a new mother
keep the nipple full of formula when feeding to prevent infant from sucking air
readiness to feed sign
attempts to place his hand in his mouth
circumcision contraindications
hypospadias (foreskin used to repair defect)
family history of hemophilia
episadias (defect in urethral opening)
42 weeks in labor, what should she expect because her baby is postmature
leathery, cracked, and wrinkled skin
high bilirubin level and is receiving phototherapy
what is a priority finding
Sunken fontanels (injury from dehydration)
32 week newborn weighing 1,100 g, findings expected include
Lanugo
weak grasp reflex
translucent skin, thin, smooth, shiny
postterm newborn
thin, loose skin, wasted appearance
meconium staining of umbilical cord
long finger nails
Neonatal Abstinence Syndrome
a continuous high pitched cry
father appears nervous when the mother asks him to help care for the newborn,