EXAM 1 STUDY GUIDE

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Fetal heart tones and contractions assessment: Baseline fetal HR

• Baseline 

  • 110-160

  • Preterm

    • Heart rate at the upper end of normal

  • Tachycardia

    • Baseline FHR >160 bpm

  • Bradycardia

    • <110 bpm

Fetal heart tones and contractions assessment: 4 types of variability

• Absent

• Minimal

• Moderate

• Marked

Fetal heart tones and contractions assessment: absent variability

• Amplitude range undetectable

• BAD

Fetal heart tones and contractions assessment: minimal variability

• <5 bpm

• No change?

• 5 or less 

• 20 minute sleep period per hour

Fetal heart tones and contractions assessment: moderate variability

• 5-25 bpm

Fetal heart tones and contractions assessment: marked variability

>25 bpm

Fetal heart tones and contractions assessment: preterm variability

• Heart rate at the upper end of normal

  • Can go up to 175

What is an acceleration?

• 15 up 15 across

• this is okay, means baby is happy

Early vs late deceleration

• Early

  • Same as contraction

    • Mirrors

    • Does not mean fetal accel happens BEFORE contraction

• Late

  • As contraction starts, deceleration starts

Accels and Decels: VEALCHOP

• V: variable deceleration → Cord Compression

• E: Early deceleration → Head Compression

• A: Acceleration → Ok… not worried

• L: Late deceleration → Placental Insufficiency

Accel/Decel Interventions: MINE

• Variable deceleration → Move mom, change maternal position

• Early deceleration → Intervention NOT NECESSARY

• Acceleration → None

• Late deceleration → EVERYTHING

Late deceleration interventions

• Change maternal position

• Increase IV fluid

• start/increase oxygen

• Stop pitocin if infusing

Uterine contraction pattern includes

• Frequency

• Duration

• Intensity

• Tachysystole

• Toco

Uterine contraction pattern includes: Frequency

• How often

  • Normal - 5 or less in 10 minutes averaged over 30 minutes

• Beginning of one to the beginning of the next

  • In minutes

• Take shortest and longest, then its between that

Uterine contraction pattern includes: Duration

• How long

  • Measures in seconds

Uterine contraction pattern includes: Intensity

• How strong

  • Mild

  • Moderate

  •  Strong

  • MVUs

Uterine contraction pattern includes: Tachysystole

• More than 5 contractions in 10 minutes, average over 30 minutes regardless of whether FHR declarations are present or absent

  • Bolus fluids can help slow down

  • Oxytocin to automent ??/ their labor

Uterine contraction pattern includes: toco

• Might need to adjust if necessary

  • Not picking up but theres fetal movement

vaginal bleeding

Molar pregnancy aka

gestational trophoblastic disease

What is a molar pregnancy?

• Tumor that develops in the uterus as result of a nonviable pregnancy.

• There may or may not be an embryo or placental tissue in some cases of molar pregnancy.

• If there is an embryo, it is not properly formed and cannot survive.

• The exact cause of this is unknown.

the two types of molar pregnancies include

• hydatidiform mole

• choriocarcinoma

molar pregnancy therapeutic management

• immediate evacuation of uterine contents (D&C)

• Long term follow up & morning of serial hCG levels

• Strong recommendation to avoid pregnancy for the 1 year because the pregnancy can interfere with the monitoring of HCG level

• Serial levels of hCG are used to detect residual trophoblastic tissue, if tissue remains, levels will to regress.

molar pregnancy etc

• Can recur in subsequent pregnancies

• It is possible for the molar to develop into choriocarcinoma, a virulent cancer with metastasis to other organs

  • Most commonly the lungs

• Choriocarcinoma is highly responsive to chemotherapy with an overall remission rate greater than 90%

• Tendency to affect older women more often than younger women

• Asian american, african american, and native american women are at increased risk for developing choriocarcinoma after a molar pregnancy

What is RhoGam

• RhoGAM is for every Rh negative nonimmunized woman at 28-32 weeks gestation and again at 72 hours after giving birth and also

  • Ectopic pregnancy hemorrhage

  • Molar pregnancy

  • Fetal death

  • Chrionic villus sampling

  • Aminocentesis

  • Maternal trauma

  • Fetal surgery

  • Prenatal

  • Abortion

  • Umbilical sampling

  • Give for miscarridge

    • Protects the following pregnancy

RhoGam Nursing Assessment

• First prenatal visit determine the woman’s blood type & Rh status

• If mother’s history reveals and Rh-negative pregnancy with an Rh positive fetus, prepare the client for an antibody screen (Indirect coombs test) to determine whether she has developed isoimmunity to the Rh antigen.

How does rhogam occur

• Develops when a woman with Rh-negative blood type is exposed to Rh-positive blood cells and subsequently develops circulating titers of Rh antibodies. Individuals with Rh positive blood type have the D antigen present on their red cells, while individuals with an Rh-negative blood type do not. The Presence or absence of the Rh antigen on the red blood cell membrane is genetically controlled.

RhoGam Nursing Management

• If direct coombs is negative (no antigen present) the woman is a candidate for RhoGAM.

• If the test is positive, RHoGAM is of no valve because isoimmunization has occurred.

RhoGam for babies v mom

• If we have a negative type mom, theyre always going to need to get a rhoGAM injection to protect her blood form making antibodies against a baby that has a positive blood type

  • Give RhoGAM for mixing of maternal and baby blood

What is Hyperemesis Graviadarum

• A complication of pregnancy characterized by persistent, uncontrollable nausea and vomiting that veins before 9 weeks’ gestation and

• causes

  • dehydration

  • nutritional deficients

  • ketosis

  • electrolyte imbalances

  • weight loss of more than 5% prepregnancy body weight.

Hyperemesis Graviadarum risk factors

• previous pregnancy with hyperemesis

• molar pregnancy

• history of

  • H pylori infection

• multiple gestation

• prepregnancy history of GU disorders

• clinical hyperthyroid disorders

• Prepregnancy psychiatric diagnosis

Hyperemesis Graviadarum therapeutic management

• Conservative

  • diet

  • lifestyle changes

• hospitalization with parental therapy

Hyperemesis Graviadarum nursing assessment

• onset, duration

• diet history

• risk factors

• weight

• perception of situation

Hyperemesis Graviadarum nursing mangement

• comfort and nutrition

• NPO

• IV fluids

• Hygiene

• oral care

What is Preeclampsia

• new onset of HTN accompanied by proteinuria and/or, maternal organ dysfunction that targets the CV, hepatic, renal, and CNS

Symptoms of preclampsia

• Elevated BP

• Reduced blood flow to the brain, liver, kidneys, placenta, and lungs

• Decreased liver perfusion leads to impaired liver fucntion

• Epigastric pain

• Elevated Liver enzymes

• headaches

• visual disturbances

• blurred vision

• Neuro

  • A & O

• Hyperactive deep tendon reflexes

  • Irritated reflexes due to preeclampsia

  • may be +3 +4

  • Treat with magnesium to bring neural irritation

  • Decrease risk of seizures

• decreased urinary output

• increased serum levels of sodium, BUN, uric acid, and creatinine

• Pulmonary edema

• Generalized edema

• IUGR

• Placental abruption, persistent hypoxia

Preclampsia nursing management

• vital signs

• fetal well being

• Home management for mild preeclampsia

• hospitalization for severe preeclampsia

• quiet environment

• sedatives

• seizure precautions

• DTR testing

• assessment for magnesium toxicity and labor

• seizure management for eclampsia; fetal monitoring uterine contraction monitoring; prepare for birth

• follow up care

preeclampsia management: mild preeclampsia

• bed rest

• daily BP monitoring

• metal movement counts

• hospitalization; IV mag sulf during labor

preeclampsia management: severe preeclampsia

• hospitalization

• oxytocin

• mag sulfate admin

• prepare for birth

preeclampsia management: eclampsia

• Seizure management

• Mag sulfate

• Antihypertensive agents

• Birth once seizures continue

Gestational hypertension

• Higher than 140/90

• In a previously normotensive woman without proteinuria after 20 weeks’ gestation resolving by 12 weeks postpartum.

• Can be differentiated from chronic hypertension, which appears before the 20th week of gestation, or HTN before the current pregnancy, which continues after the woman gives birth.

• Higher risk for developing chronic HTN

S/S of gestational HTN

• Headache

• blurred vision

• Double vision

the 2 phases of labor include

• Latent phase

• Active phase

the 2 phases of labor include: Latent phase

• Excited behaviors

  • Talkative

  • Chit chat

• 0-5 cm dilation

• Mild contractions

the 2 phases of labor include: active phase

• Intense behavior

  • Not fun anymore

  • Oh my god what's coming out of where

  • Get this goddamn baby out

• 5/6-10 cm dilation

• Stronger contractions 

What is placenta previa

• Placenta is interested wholly or partly into the lower uterine segment of the uterus, partially or completely covering the internal cervical opening.

• Usually occurs in the last two trimesters of pregnancy.

placenta previa: therapeutic management

• Bleeding

• Amount of placenta

• Over the cervix

• Fetal development and position

• Maternal parity

• Labor signs and symptoms

placenta previa: nursing assessment

• Risk factors

• Vaginal bleeding

  • Painless

  • Bright red 2nd or 3rd trimester

  • Spontaneous cessation then recurrence

placenta previa: nursing management

• Monitoring of maternal fetal status

• Monitoring of vaginal bleeding

  • Pad count

• Avoidance of vaginal exams

• Monitoring FHR per MD order

• Support and educate

  • Fetal movement counts

  • Effects of prolonged bed rest if necessary

  • s/s to report

If the placenta covers the cervix…

• have to have c section, contractions can cause rupture

what is an ectopic pregnancy?

• Implantation of a fertilized egg in a location outside of the uterine cavity, including the fallopian tubes, cervix, ovaries, and abdominal cavity

• Occurs because of an obstruction to or slowed passage of the ovum through the fallopian tube to the uterus

ectopoic pregnancy: therapeutic management

• drug therapy

  • Commonly methotrexate

• Surgery if the tube should rupture

• Rh immunoglobulin if the woman is Rh negative

ectopic pregnancy: risk factors

• Scarring of the tube from infection

• Inflammation

• Surgery

• Appendicitis

• Endometriosis

• Failed tubal ligation

• Previous ectopic 

• Assisted reproduction

• IUD

• Delayed or premature ovulation

• Multiple induced abortions

ectopic pregnancy: goal

• Intervention early to avoid rupture of the tube or surgical intervention, either of which can result in the patient being unable to get pregnant from ovulation on the affected side.

what is a biophysical profile

• A BPP is a scored test with five components each worth 2 points.

• A total score of 10 is possible if the NST is used.

• Thirty minutes are allotted for testing, though less than 10 minutes are usually needed.

• The following criteria must be met to obtain a score of 2, anything less is 0.

How is a BPP done?

• A BPP uses an ultrasound and NST results to allow assessment of various parameters of fetal well-being that are sensitive to hypoxia

BPP : scoring is based on

• body movements

• fetal tone

• fetal breathing

• amniotic fluid volume

• NST

BPP scoring: body movements

• at least three or more distinct limb or trunk movements

BPP scoring: fetal tones

• at least one episode of active extension with return to flexion of the fetal limb or trunk

• opening and closing of the hand is deemed normal tone

BPP scoring: fetal breathing

• at least one breathing (swallowing) episode lasting a minimum of 30 seconds

BPP scoring: amniotic fluid volume

At least one pocket of amniotic fluid that measures aat least 2 cm in two perpendicular planes

BPP scoring: NST

• Normal NST = 2 points

• Abnormal NST = 0 points

maternal tachycardia

what is maternal serum alpha fetoprotein

• Is a …

• AFP then enters the maternal circulation by crossing the placenta, and the level in maternal serum can be measured

AFP purpose

• AFP can detect neural tube defects or Down Syndrome/Trisomy 21 issues

What is the optimal time for AFP testing?

• Second trimester multiple marker screening

• 16-18 weeks gestation

Situations that can lead to evaluation of maternal serum AFP

• Open neural tube defects

• Underestimation of gestational age

• Presence of multiple fetuses

• GI defects

• Low birth weight

• Oligohtdramios

• Maternal age

• Diabetes

• Decreased maternal weight

• Fetal death

Situations that can lead to lower than expected AFP

• Molar pregnancy

• Increased maternal weight

• Maternal type 1 diabetes

• Down syndrome

• Trisomy 18

AFP analysis

A glycoprotein produced initially by the yolk sac and fetal gut, and later predominantly by the fetal liver

operative vaginal birth

What is cord prolapse?

• Partial or total occlusion of cord with rapid fetal deterioration

• Occlusion of oxygenation to the fetus

Cord prolapse nursing assessment

• Prevention

• risk factors

• Continuous assessment of client and fetus

Cord prolapse nursing management

• Prompt recognition

• Measured to relieve compression through vaginal exams

What is chronic villus sampling?

• Prenatal diagnostic test; usually done 10-13 weeks to diagnose

• Do under ultrasound guidance through a sterile procedure

  • Transvaginally

  • Transabdominally

• Samples chorionic villi from placenta

• Helps diagnose down syndrome

What is CVS used for?

• Used for genetic testing for chromosomal abnormalities such as down syndrome

CVS: educate on unexpected signs

• Heavy bleeding

• Uterine cramping/contractions

• Leaking amniotic fluid

• Immediately contact physicians

  • Signs of miscarriage 

• Avoid exercise for 24 hours after the procedure

• No sexual intercourse

fetal demise

What is gestational diabetes

• Diabetes due to pregnancy

• Any degree of carbohydrate intolerance first diagnosed

gestational diabetes - risk factors

• Overweight

• Maternal age older than 23 years

• Previous GDM pregnancy

• Abnormal glucose tolerance test

• Diabetes is an immediate relative

• Member of high risk ethnic group such as hispanic, african america, native american, asian, & pacific islander

• History of prediabetes

• History of polycystic ovary syndrome (PCOS)

gestational diabetes - screening

• Glucose challenge test

• Administered between 24-28 weeks

• Woman drinks 50g of oral glucose solution

• Blood sample is taken 1 hour later

• If glucose concentration is 140 mg/dL or greater a 3-hour test is recommended

gestational diabetes - maternal, fetal, and neonatal effects

• Uncontrolled glucose levels in the third trimester can result in increased neonatal morbidity and mortality

• Macrosomia

• Birth injuries or cesarean birth due to macrosomia

• Neonatal hypoglycemia

• Hypocalcemia

• Hyperbilirubinemia

• Respiratory distress

Shoulder dystocia risk factors

• Epidural analgesia

• Excessive analgesia

• Multiple pregnancy

• Hydramios

• Maternal exhaustion

• Ineffective maternal pushing technique

• Occiput posterior position

• Liner first stage of labor

• Nulliparity

• Short maternal satire

  • less than 5ft

• Fetal birth weight

  • More than 8.8 lbs

• Shoulder dys

Epidural anesthesia

• WATCH OUT FOR HYPOTENSION

  • can increases baby’s HR

  • ephedrine

• surrounds spinal cord

• works with gravity

  • rotate mom

• continous medication

• lidocaine to numb

• not in preeclampsia due to low platelets, spinal problems such as scoliosis, or surgery

• cant feel bladder

  • insert foley

• need for a bolus of fluid prior tot he administration of epidural medication

FHR variability: category 1

• Normal and are strongly predictive or normal fetal acid base status at the time of observation

• Fetal heart rate baseline

  • 110 to 160 beats per minutes

  • Moderate variability

  • Accelerations present or absent

  • Variable or late deceleration absent

  • Early decelerations present or absent

    • Cna have earlys, earlys are ok

FHR variability: category 2

• Indeterminate and fetal acid-base status is uncertain

FHR variability: category 3

• Abnormal and predictive of abnormal fetal acid base status at the time of observation

• C SECTIONNNN

• Absent variability with something else

  • Absent variability AND recurrent late decelerations

  • Or

    • Recurrent variable decelerations,

  • Or

    • Bradycardia

    • Sinusoidal pattern

Fetal development

HIV therapeutic management

• Oral antiretroviral drugs

• retrovirals for the newborn after birth when available from pharmacy

HIV nursing assessment

• History and physical

• HIV antibody testing

• Testing for STIs

HIV nursing management

• Support

• Elective c/ section is recommended prior to rupture of membranes to minimize the risk of passing HIV to infant

• Education

  • Breastfeeding is not suggested to minimize risk of passing HIV to infants

Presumptive signs of pregnancy

• Fatigue

  • From changes in hormones such as progesterone levels

• Breast and tenderness

• Nausea/vomiting

• Amenorrhea

• Urinary frequency

• Hyperpigmentation of skin

• Quickening

• Breast enlargement

• Chadwick sign (ch 6 pg 107-108)

  • Cervix changes color from pink to blue/purple due to increased blood flow and vascularity to the cervix from pregnancy

Probable signs of pregnancy

• Braxton hicks contractions

• Positive pregnancy test

  • Can be inaccurate

• Abdominal enlargement

• Ballottement

• Goodell sign (ch 6 pg 107-108)

  • Lower segment of cervix have become soft tissue due to increased hormones in that area

• Hegar sign (ch 6 pg 107-108)

  • Softening of the lower segment of the uterus between the cervix and uterus and where they meet due to hormonal changes

• Palpation of fetal outline

• Uterine souffle

Positive signs of pregnancy

• Ultrasound image of fetus

• Fetal movement felt by clinician

• Auscultation of heart tones by doppler

The stages of labor include

• first stage

• second stage

• third stage

• fourth stage

The stages of labor include: first stage

• begins with onset of true labor contractions and ends with complete cervical dilation (10cm) and effacement (100%)

• longest stage for nulliparous an dparous clients

• cervical effacement and dilation

The stages of labor include: second stage

• complete dilation and full effacement ending with birth of the baby

• duraiton

  • nullipara without epidural

    • 2.8 hours

  • nullipara with epidural

    • 3.6 hours

  • multipara without epidural

    • 1.1-1.3 hours

  • multipara with episural

    • 1.6-2 hours

• contractions

  • strong, 2-3 minutes apart, 60-80 second duration

The stages of labor include: second stage assessment

• pressure of presenting part of rectum

• pelvic floor causes involuntary pushing response

• “i need to have a bowel movement”

• " the baby is coming”

• “I have to push”
  vulva distends with crowning, client may feel stretching or splitting sensation

The stages of labor include: third stage

• beings with birth of baby and ends with expulsion of placenta

• shortest stage with average length of 6 minutes

• no duration difference between nulliparas and parous clients

The stages of labor include: third stage assessment

• uterus must contract firmly after placental expulsion to prevent hemorrhage