Exam 4 semester 2

OB

What is spontaneous Abortion

Often called a miscarriage, this is the natural loss of pregnancy before 20 weeks gestation

What is gestational hypertension?

New hypertension ≥140/90 after 20 weeks without proteinuria or severe features.

• Monitor BP, urine protein, labs, fetal status

• Watch for progression to preeclampsia

• Report headache, vision changes, RUQ/epigastric pain

Gestational hypertension (GH) treatment

Antihypertensive medications only for blood pressure exceeding 160/100

Magnesium sulfate may be prescribed for severe preeclampsia or eclampsia to prevent seizures

Delivery is the only means to interrupt the condition,

What is disseminated intravascular coagulation (DIC)

Abnormal widespread clotting uses up platelets/clotting factors → severe bleeding.

• S/S: oozing from IV sites, petechiae, bruising, uncontrolled bleeding

• ↓ platelets/fibrinogen; ↑ PT/PTT and D-dimer

• Treat underlying cause + blood products

• Obstetric emergency

What are classic signs of placental abruption?

Premature separation of placenta.

• Painful, usually dark vaginal bleeding

• Sudden abdominal/back pain

• Rigid/tender “boardlike” uterus

• Fetal distress

• Bleeding can be concealed

• Priority: stabilize mother and fetus

Who’s at risk for DIC

• Sepsis from gram-negative bacteria

• Cancer (particularly leukemia)

• Traumatized or necrotic tissue

• Retained dead fetus

• Acute promyelocytic leukemia

What are classic signs of placental abruption?

Premature separation of the placenta.

• Sudden, severe pain accompanied by uterine rigidity

• Uterus may increase in size due to hemorrhage

• Strong, constant contractions (tetany) during labor

• Variable vaginal bleeding: If blood is trapped in the uterus (concealed abruption), little to no vaginal bleeding may be visible despite significant hemorrhage

Placental abruption treatment

• Immediate delivery, often via cesarean birth

• Blood replacement therapy

• Modified side-lying position with wedge under right hip to facilitate uterine-placental perfusion

• Retention catheter to monitor urinary output

• Continuous fetal monitoring

• Immediate delivery if signs of fetal compromise (hypoxia) or excessive bleeding (obvious or concealed) are present

High risk for placental abruption

• History of abruption in a previous pregnancy (not trauma-related)

• Hypertension and advancing maternal age

• High gravidity (more than five pregnancies)

• Smoking and cocaine use

• Blunt external abdominal trauma (motor vehicle accidents or maternal battering)

• Trauma

What anticoagulant is generally preferred during pregnancy?

Heparin/LMWH (enoxaparin) because they do not cross the placenta.

• Monitor for bleeding

• Avoid IM injections when possible

• Heparin antidote = protamine sulfate

• Warfarin is generally avoided during pregnancy

Common Anticoagulation types

Heparin

Low molecular weight heparin

Unfractionated Heparin (UFH)

What should I know about mastitis?

Breast infection commonly causing:

• Unilateral red, hot, painful breast

• Fever/flu-like symptoms

• Antibiotics may be prescribed

• Continue breastfeeding/pumping

• Empty breast frequently

• Warm compresses, fluids, rest

Common causes of mastitis

Clogged duct

Inadequate cleanliness of the breast nipple

infection in the infant

What is important for gestational diabetes?

Pregnancy-induced glucose intolerance.

• Monitor blood glucose

• Diet/exercise first; insulin may be needed

• Increased risk of macrosomia

• Newborn risk: hypoglycemia

• Maternal glucose usually improves after delivery

High risk for Gestational diabetes

Age 25 or older

Family history of diabetes

Non-white race

Obesity

Hypertension

What is a cervical cerclage?

Sutures are placed around the cervix for cervical insufficiency to help prevent premature dilation.

• Monitor for contractions, bleeding, infection, and rupture of membranes

• Report fluid leakage or contractions

• Usually removed near 36–37 weeks or earlier if labor begins

• Refrain from intercourse

• Avoid prolonged standing and heavy lifting

• Report warning signs: cramping, bleeding, rupture of membranes, or elevated temperature

What is the classic sign of placenta previa?

Painless, bright-red vaginal bleeding.

• Placenta lies near/over the cervical opening

• NO digital vaginal examination

• Ultrasound confirms location

• Monitor bleeding and fetal status

• C-section may be necessary

Risk factors for Placenta Previa

• Cesarean birth (possibly related to endometrial scarring)

• Multiple gestation (larger placental area)

• Closely spaced pregnancies

• Advanced maternal age (older than 35 years)

What is the priority assessment for postpartum hemorrhage?

Check fundus and lochia.

• Boggy uterus → massage fundus

• Most common cause = uterine atony

• Empty bladder

• Give oxytocin as ordered

• Monitor VS and blood loss

• Maintain IV access/fluids

Classifying postpartum hemorrhage

• Early PPH: Blood loss >500 mL after vaginal birth or >1000 mL after cesarean birth, occurring within the first 24 hours 1

• Late PPH: Occurs after the first 24 hours postpartum

Medications for postpartum hemorrhage

• Magnesium sulfate

• Nifedipine

Which obstetric problems can trigger DIC?

Think severe obstetric complications such as:

• Placental abruption

• Severe preeclampsia/eclampsia

• Amniotic fluid embolism

• Sepsis

• Major hemorrhage

Key clue = bleeding/oozing from multiple sites.

When is Rho(D) immune globulin (RhoGAM) given?

Prevents Rh sensitization in an Rh-negative, unsensitized mother.

• Commonly around 28 weeks

• Within 72 hr after delivery if newborn is Rh-positive

• May also be needed after miscarriage, bleeding, trauma, amniocentesis

• Does not help if already sensitized

What is eclampsia?

Preeclampsia with seizures.

• Magnesium sulfate prevents/treats seizures

• Protect airway and prevent injury

• Side-lying position

• Reduce stimulation

• Do NOT restrain or put anything in mouth

• Delivery is definitive treatment after stabilization

What are normal newborn vital signs?

Approximately:

• HR: 120–160/min

• 60 to 80/40 to 50 mm Hg

• RR: 30–60/min count for 1 minute

• Temp: Axillary: 97.6°F to 98.6°F

• Count respirations for a full minute

• Periodic/irregular breathing can occur

How should the newborn’s umbilical cord be cared for?

• Keep clean and dry

• Fold diaper below stump

• Usually falls off in about 1–2 weeks

• Report redness spreading onto skin, foul drainage, or bleeding

• Sponge bath until stump falls off/heals

What is acrocyanosis in a newborn?

Bluish hands and feet with a pink trunk.

• Common shortly after birth

• Usually normal due to immature circulation

• Central cyanosis of lips/tongue is NOT normal

What should I know about Methergine (methylergonovine)?

Uterotonic used for postpartum hemorrhage/uterine atony.

• Causes strong uterine contractions

• Check BP before giving

• Do NOT give with hypertension/preeclampsia

• Monitor fundus and bleeding

Precautions with Methergine

• Hypertension

• History of seizures (may precipitate seizures in hypertensive women)

• Liver or renal disease

• Cardiac disease

What teaching is important for the rubella vaccine postpartum?

Give to nonimmune mothers after delivery.

• Live vaccine → NOT given during pregnancy

• Avoid pregnancy for at least 28 days

• Breastfeeding is generally okay

• Helps protect future pregnancies

• Make sure get consent

What indicates an effective breastfeeding latch?

• Wide-open mouth

• Lips flanged outward

• More than nipple in mouth

• Audible swallowing

• Minimal/no nipple pain after initial latch

• Breast-fed babies do best on "on demand" schedule, generally nursing at 2- to 3-hour intervals

What does meconium-stained amniotic fluid indicate?

May indicate fetal maturity or fetal stress.

• Green/brown fluid

• Assess fetal status

• Prepare neonatal support if needed

• Risk = meconium aspiration syndrome

• Routine deep suctioning is not automatically performed

What does the nitrazine test detect?

Helps determine if fluid is amniotic fluid by testing PH of vaginal fluid.

• Amniotic fluid is alkaline → paper turns blue

• Used when rupture of membranes is suspected

• Blood/semen/infection can cause false-positive results

What are the 5 parts of APGAR?

• Appearance

• Pulse

• Grimace

• Activity

• Respiration

Each = 0–2 points. Usually assessed at 1 and 5 minutes.

How do I calculate the estimated due date using Naegele’s Rule?

From the first day of the LMP:
Subtract 3 months + add 7 days + add 1 year

What does GTPAL stand for?

• G = Gravida: total pregnancies

• T = Term births

• P = Preterm births

• A = Abortions/losses

• L = Living children

Twins = one pregnancy/birth event but two living children.

What nursing care is important with amniocentesis?

Needle removes amniotic fluid from the abdominal wall for testing.

• Ultrasound guides procedure

• Monitor fetal heart rate before/after

• Report contractions, bleeding, fever, or fluid leakage

• Rh-negative mother may need RhoGAM

What should I know about HIV during pregnancy?

• Use antiretroviral therapy (ART)

• Treatment greatly reduces transmission to infant

• Avoid invasive fetal monitoring when possible if maternal viral load is not suppressed

• Newborn receives antiretroviral prophylaxis based on risk

• Avoid breastfeeding

What are severe warning signs of preeclampsia?

• Make sure producing more than 30mL of urine per hour

• Hypertension after 20 weeks

• Severe headache

• Visual changes

• RUQ/epigastric pain

• Hyperreflexia/clonus

• Proteinuria may occur

• Severe disease → magnesium sulfate for seizure prevention

Magnesium toxicity: ↓ reflexes, respiratory depression, ↓ urine output.

What should I know about cardiac disease in pregnancy?

Pregnancy increases cardiac workload.

• Avoid excessive exertion

• Monitor for heart failure: dyspnea, crackles, tachycardia, edema

• Rest and oxygen as indicated

• Postpartum period can increase cardiac stress due to fluid shifts

The most common cardiac problems in pregnant patients result from

• Rheumatic heart disease

• Congenital heart defects

• Mitral valve prolapse

• Peripartum cardiomyopathy - may occur in the last month of pregnancy or postpartum in patients with no cardiac history, presenting with symptoms similar to congestive heart failure

How do I recognize abruptio placentae?

Think: PAINFUL bleeding.

• Dark-red bleeding

• Abdominal/back pain

• Tender/rigid uterus

• Fetal distress

• Concealed hemorrhage possible

• Risk of DIC

How do I distinguish placenta previa from abruption?

Previa: painless, bright-red bleeding; soft/nontender uterus.
Abruption: painful bleeding; tender/rigid uterus.

Previa = NO digital vaginal exam.

What are the 4 stages of labor?

1st: onset of true labor → 10 cm dilation
2nd: 10 cm → birth of baby
3rd: birth → delivery of placenta
4th: immediate postpartum recovery, usually first 1–4 hr

What do late decelerations mean and what should the nurse do?

Indicate uteroplacental insufficiency.

Interventions:

• Turn patient side-lying

• Stop oxytocin

• IV fluid bolus as ordered

• Correct hypotension

• Notify provider if persistent

• Prepare for further intervention/delivery if unresolved

What causes variable decelerations?

Umbilical cord compression.

Think: Variable = Cord

Interventions:

• Reposition mother

• Stop oxytocin if appropriate

• Consider amnioinfusion if ordered

• Assess for cord prolapse if sudden/severe

What is the priority after an amniotomy (AROM)?

Assess fetal heart rate immediately.

• Artificial rupture of membranes

• Check fluid color, odor, amount

• Risk: cord prolapse

• Monitor temperature/infection risk

What should the nurse do for an umbilical cord prolapse?

Emergency!

• Call for help

• Insert gloved hand and lift presenting part off cord

• Knee-chest or Trendelenburg/hips elevated

• Stop oxytocin

• Prepare for emergency C-section

• Keep exposed cord moist with sterile saline gauze

What should be included in a postpartum assessment?

Think BUBBLE-HE:

• Breasts

• Uterus/fundus

• Bladder

• Bowel

• Lochia

• Episiotomy/perineum

• Homan’s/DVT assessment without performing Homan’s sign

• Emotions

Fundus should be firm and midline.

What are signs of a pulmonary embolism postpartum?

Sudden:

• Dyspnea

• Chest pain

• Tachycardia

• Hypoxemia

• Anxiety

Emergency: oxygen/support ABCs and notify rapid-response/provider.

What are early signs of significant postpartum hemorrhage?

• Excessive vaginal bleeding

• Boggy uterus if uterine atony

• Tachycardia

• Pallor/dizziness

• Falling BP may be a later sign

Priority: assess fundus + bleeding, massage boggy uterus, then treat cause.

Why is newborn hypothermia dangerous?

Cold stress increases oxygen and glucose use → hypoglycemia + respiratory distress.

Prevention:

• Dry immediately

• Skin-to-skin

• Hat/warm blankets

• Radiant warmer if needed

• Delay bathing until temperature stable

What should I know about neonatal RDS?

Usually caused by surfactant deficiency, especially in premature infants.

S/S:

• Tachypnea

• Grunting

• Nasal flaring

• Retractions

• Cyanosis

Treatment may include CPAP/oxygen + surfactant

What should I know about newborn hyperbilirubinemia?

Excess bilirubin causes jaundice.

• Monitor bilirubin

• Encourage frequent feeding

• Severe untreated levels → kernicterus

• Treatment = phototherapy

What are signs of neonatal abstinence syndrome (NAS)?

Withdrawal after prenatal substance exposure.

Common:

• High-pitched cry

• Tremors

• Irritability

• Poor feeding

• Vomiting/diarrhea

• Sweating

• Sleep problems

Care: low stimulation, swaddle, small frequent feeds, medication if ordered.

Why is erythromycin eye ointment given to newborns?

Prevents gonococcal ophthalmia neonatorum.

• Given shortly after birth

• Apply to both eyes

• Do not rinse out

• Temporary blurred vision may occur

What nursing care is needed during phototherapy?

• Protect eyes

• Expose as much skin as appropriate

• Reposition periodically

• Monitor temperature and hydration

• Encourage frequent feeding

• Monitor bilirubin

• Expect loose/greenish stools

How does HIV affect the delivery plan?

Delivery method depends largely on maternal viral load near delivery.

• Continue ART

• Avoid unnecessary invasive procedures

• Scheduled C-section may be recommended with high/unknown viral load

• Newborn receives antiretroviral medication

What is the most important nursing care with oxytocin?

Stimulates uterine contractions.

Monitor:

• Contraction frequency/duration

• Fetal heart rate

If tachysystole or concerning FHR:

• STOP oxytocin

• Reposition side-lying

• IV fluids as indicated

• Notify provider

What is the key safety rule for methylergonovine (Methergine)?

Used for postpartum hemorrhage due to uterine atony.

🚨 CHECK BLOOD PRESSURE FIRST.

Do NOT give with hypertension/preeclampsia because it can cause severe hypertension.

What is the biggest test-day rule for placenta previa?

Painless, bright-red bleeding = think placenta previa.

🚨 NEVER perform a digital vaginal exam until placenta previa has been ruled out.

Ultrasound confirms diagnosis; monitor mother/fetus and prepare for C-section if indicated.