Families final review

Role of the placenta

organ that transports oxygen and nutrients to the fetus from the mother while removing waste from the fetus as well.

Risk factors for an abnormal placenta

1. high blood pressure

2. maternal age >40

3. premature rupture of membranes (PROM)

4. blood clotting disorders

5. a twin or multiple pregnancies

6. previous uterine surgery or previous placental complications

7. substance use, including tobacco and drugs, especially cocaine use

8. abdominal trauma such as a fall or motor vehicle accident

what is placenta previa

when the placenta extends too low in the uterus covering some or all of the vaginal opening.

Risk factors for placenta previa

• previous placenta previa

• previous cesarean section

• multiple pregnancies

• smoking

• cocaine use

• prior dilation and curettage

• assisted reproductive technology

how is placenta previa diagnosed

ultrasound

what precautions do we want to take in a patient with placental previa

-Never perform a vaginal exam

-no heavy lifting

-no intercourse

Why does placenta previa increase the risk of hemorrhage?

Because the placenta sits over the cervix, any dilation or contractions can tear placental vessels, causing antepartum or postpartum hemorrhage.

Is actively bleeding placenta previa an emergency?

Yes — it is an obstetric emergency requiring stabilization, monitoring, and possible blood transfusion.

Does the first episode of bleeding always require immediate delivery?

No — if the woman stabilizes, she may not need to deliver immediately.

What is the recommended mode of delivery for uncomplicated placenta previa?

c-section

Maternal risks associated with placenta previa?

• Postpartum hemorrhage

• Blood transfusion

• Hysterectomy

• ICU care after delivery

Fetal risks associated with placenta previa?

• Preterm birth

• Low birth weight

• Low APGAR scores

• Respiratory distress syndrome

what is placental abruption

is complete or partial detachment of the placenta after 20 weeks gestation but before delivery of the fetus.

The. main findings of placental abruption are

-bleeding

-abdominal pain

-hypertonic uterine contractions

-uterine tenderness

-abnormal fetal heart tracing

The risk factors for a placental abruption

·       Previous abruption not caused by trauma

·       Hypertension

·       Cocaine use during pregnancy

·       Smoking

·       Polyhydramnios

·       Multiple gestation pregnancy

·       Preeclampsia

·       Sudden uterine decompression

·       Age > 35

·       Trauma (ex. abdominal trauma)

What is the major maternal risk of placental abruption?

Maternal hemorrhage, which can progress to DIC, shock, and maternal death.

What fetal complications are associated with placental abruption?

• Preterm delivery

• Fetal growth restriction

• Low birth weight

• Hypoxemia & asphyxia

What fetal heart rate pattern suggests uteroplacental insufficiency in abruption?

• Absent variability

• Category III tracing
  (Category I is normal; anything abnormal must be reported and intervened on.)

priority actions for placenta previa

• Notify provider

• Ultrasound (possible placenta previa)

• O2 (uteroplacental insufficiency)

• Prepare for blood transfusion

• Blood type & screen

• Large-gauge IV

Why give oxygen to a placental previa patient?

To improve uteroplacental oxygenation during fetal distress or insufficiency.

Why prepare for a blood transfusion?

both abruption and previa can cause severe maternal hemorrhage.

what are all of the nursing actions for a placental previa patient

• Continuous monitoring (EFM)

• Ultrasound (omit vaginal exam)

• IV

• Left lateral positioning

• O2

• Prepare for blood transfusion

• Prepare for emergency c-section (OR, NPO)

• Give RhoGAM if needed

• If pre-term labor, give Terbutaline and Betamethasone (promote lung

development of baby)

• Narcan on standby

what are clinical findings most concerning for a patient with gestational diabetes

-maternal age (over 35)

-history of large birthweight babies

-BMI (above 30)

Which clinical findings put a 26‑week pregnant client at risk for gestational diabetes?
(Select all that apply)

Options:
• Fetal heart rate
• Multigravida status
• Pre‑pregnancy BMI
• Level of physical activity based on occupation
• Weight gain 2 lbs since last visit
• Previous children >9 lb (4 kg)
• Maternal age

• pre pregnancy BMI

• level of physical activity based on occupation

• previous children birthweight more than 9lb

• maternal age

what is the highest priority care for. a client with gestational diabetes

stabilizing blood glucose levels

what is the strongest evidence that the client may have gestational diabetes that requires further testing

1 hr glucose tolerance test

The client takes the 3 hour glucose tolerance test and receives the diagnosis of gestational diabetes. The nurse begins to develop the plan of care.

 

  What additional assessment data should the nurse obtain?

Ø  Select All that Apply

¨  Access to transportation

¨  24 hour diet recall

¨  Assessment of salt intake

¨  Economic ability to purchase healthy food

¨  Access to supermarkets

¨  Location of kitchen in residence

¨  Assess intake of foods containing vitamin K

¨  Physical activity patterns

 

24‑hour diet recall

✔ Economic ability to purchase healthy food

✔ Access to supermarkets

✔ Physical activity patterns

The nurse implements a dietary plan to manage the client’s diabetes during pregnancy.

 

¨  Encourage use of low fiber food

¨  Identify carbohydrates with low glycemic index

¨  Client should increase fat based foods while pregnant  

¨  Recommend consultation with a registered dietician

¨  Should consume 2 large meals and 3 small snacks/day

¨  Should consume 3 small – moderate meals and 4 snacks/day

¨  Discuss the importance of consuming high sodium diet

weight gain allowance for each BMI

how do we measure appropriate fundal height after 20 weeks

fundal height should be within 2cm plus or minus of the gestational age

what should the fundal height be after delivery

It should be at the level of umbilicus or 1cm above

1615. 27yo Gravida 2 now Para 2 delivered 3590 gram (7lb 9oz) term infant via cesarean at 1545.

Quantitative blood loss 850 mL. Client stable in PACU with oxytocin 30units/500mL LR IV @ 250mL/hr.

1645. Client states, “I feel dizzy” and appears pale. Additional blood loss 400 mL.

Fundus boggy, midline, and 3cm above umbilicus.

The client in the 4th stage of labor is most likely experiencing:
• Septic shock
• Cardiogenic shock
• Hemorrhagic shock

as most evidenced by:
• Total blood loss
• Blood pressure
• Pulse

hemorrhagic shock, total blood loss

what is the nursing actions for hemorrhage

-massage fundus

-weigh peri pads

-oxegen at 10L

laboratory values to look after in a hemorrhage patient

hgb and hit

what are the medications for a patient is hemorrhage

IV blood transfusion

Misoprostol

Ø  Which 4 orders should the nurse implement first, for a hemorrhage patient? Highlight selection

¨  Hemoglobin and hematocrit

¨  Massage fundus

¨  Administer misoprostol

¨  Weigh pads

¨  Oxygen 10 L/min

¨  Type and cross ¨  500 mL normal saline fluid bolus

¨  Notify surgical team

-massage the fundus

-administer misoprostol

oxygen 10L/min

500 ml normal saline fluid bolus

0900. 4g loading dose magnesium sulfate IV started, to be run over 20 minutes. Second nurse verified pump settings. Client educated on medication side effects. Client complains of headache rated 7/10, no nausea/vomiting, no epigastric pain, no visual disturbances. Current BP 159/89. Fetal monitor shows baseline heart rate 130 bpm, moderate variability, accelerations present, decelerations absent. 

0920. Magnesium sulfate loading dose complete. Magnesium rate changed to 2g/hr continuous infusions. Second nurse verified pump settings.

1100. Client noted to have cutaneous flushing and sweating.  Fan brought to bedside.

1200.Absent patellar reflex,RR 11,withcomplaints of shortness of breath. Pulse oximeter 92% on RA

Which findings in a preeclamptic client on magnesium sulfate are most significant?

✔ Absent reflexes
✔ RR 11/min
✔ Urine output 20 mL/hr
✔ Shortness of breath
These indicate magnesium toxicity (CNS depression + respiratory depression + decreased renal clearance).

primary focus of giving magnesium

prevents seizures by depressing the central nervous system

what is a side effect of magnesium effecting the vital signs

lowers blood pressure

Assessment findings for magnesium sulfate toxicity

less urine output

lethargic

respiratory depression

0900. 4g loading dose magnesium sulfate IV started, to be run over 20 minutes. Second nurse verified pump settings. Client educated on medication side effects. Client complains of headache rated 7/10, no nausea/vomiting, no epigastric pain, no visual disturbances. Current BP 159/89. Fetal monitor shows baseline heart rate 130 bpm, moderate variability, accelerations present, decelerations absent.  0920. Magnesium sulfate loading dose complete. Magnesium rate changed to 2g/hr continuous infusions. Second nurse verified pump settings. 1100. Client noted to have cutaneous flushing and sweating.  Fan brought to bedside. 1200. Absent patellar reflex, RR 11, with complaints of shortness of breath.  Pulse oximeter 92% on RA. What additional assessments should the nurse obtain STA ¨  Fetal status ¨  Breath sounds ¨  Pupils ¨  Level of consciousness ¨  Sensation ¨  Capillary refill

fetal status

breath sounds

level of consciousness

Action

Stop magnesium infusion

Administer calcium gluconate

Place client in supine position

Activate rapid response

Provide oxygen

Monitor fetus

Administer anti-seizure medication

Draw serum magnesium level

Check for medication error

Elevate extremities STA the actions that are indicated for a patient with magnesium deficiency

• stop the magnesium infusion

• administer calcium gluconate

• activate rapid response

• provide oxygen

• monitor fetus

• draw magesium level

• check for medication error

Which 3 actions should the nurse take FIRST for magnesium toxicity? Options: stop mag, monitor fetus, check med error, oxygen, calcium gluconate, draw mag level, rapid response

✔ Stop magnesium infusion

✔ Provide oxygen

✔ Administer calcium gluconate

if the magnesium toxicity is unchanged then

request an additional dose of calcium gluconate

For magnesium toxicity what 2 parameters should the nurse monitor and what actions should be taken.

monitor respiratory status and deep tendon reflexes

stop the infusion and administer calcium gluconate.

how to evaluate for compartment syndrome

-assess 6 p’s: pain, pallor, pressure, pulselessness, paresthesia, pain with passive stretch

-see if pain is unrelieved by medication

Manifestations of pyloric stenosis

-projectile vomiting

-olive shaped mass

manifestations of intersusseption

-sausage shaped abdominal mass

-sudden episodic abdominal pain

-bilious emesis

-red “current” stools

Manifestations of Hirschsprung’s disease

-ribbon like stools

-failure to pass meconium in 48 hours

A nurse is preparing to care for a child with watery diarrhea, what are the nursing actions

-oral rehydration therapy

How do we position a patient with epistaxis

sit up and lean forward

Diagnostic for sickle cell anemia

hemoglobin electrophoresis

Suspected findings for rheumatic fever

Discrete pink-red maculopapular rash on face, then trunk, then

extremities

fever

joint pain

for a patient with cystic fibrosis we give pancreatic enzymes with

snacks

Acute exacerbation of asthma

expiratory wheeze, chest tightness, and cough

we use quick relief inhalers like albuterol

Impetigo

-can be caused by staph or strep

-ages 2-5 years old

-spread through direct contact

-honey crusted lesions

-nurisng interventions: oil, antibiotics, and infection control

why would a newborn with upper respiratory infection not want to eat

newborns are obligate nose breathers

ICP interventions

-elevate head of the bed 30 degrees

-administer mannitol

hypothyroidism symptoms

lethargic, slow, jaundiced

medication for thyrotoxicosis

what is the priority assessment for regular wellness of a 6 month year old

update on vaccination status

9 month fine motor skill milestones

-pincer grasp

-grabbing a rattle

12 month year old physical milestones

-birth weight doubled

-anterior fontanelle is closed

Anticipatory guidance for toddlers

-bedtime fears are normal

-prevent giving food with caries

-negatism and ritualism is normal

-decrease in appetite is normal

method to promote sleep in children with bedtime fears

-keep a dim light in the room

Findings of nephrotic syndrome

• urine dipstick of 2+ protein

• ankle edema

• hyperlipidemia

• NOT polyuria

• anorexia?

primary cause of hypertension in pediatrics

renal dysfunction

Meningocele interventions

-keep dressing moist and use sterile technique

a failure to thrive patient will likely have

developmental delays

what so we not do for assessment of epiglottis

-use tongue depressor to inspect oral mucosa

-throat culture

what should we do for epiglottis patient

-vitals

-past medical hx

-auscultaion of the chest

-observe patient’s ability to swallow

with an acyanotic defect what finding would be reported to provider

dyspnea as it is a sign of heart failure

What is a sign of slipped capital epiphysis

-pain in a PUBERTAL child

chemotherapy patient with neutropenic precautions should not be

pulled around

vaccines due ages 4-6

1. DTaP (Diphtheria, Tetanus, Pertussis)

• 5th dose (final booster)

• Completes protection against diphtheria, tetanus, and whooping cough

2. IPV (Inactivated Polio Vaccine)

• 4th dose (final dose)

• Completes polio immunity series

3. MMR (Measles, Mumps, Rubella)

• If not already given earlier:

  • 2nd dose is completed by age 4–6

4. Varicella (Chickenpox)

• 2nd dose (final dose) by age 4–6

5. Annual Flu vaccine

• Recommended every year for all children 6 months and older

a 5 year old should be up to date on

By age 5, most children should also already be up to date on:

• Hepatitis B series

• Hepatitis A series

• Hib (Haemophilus influenzae type b) series

• Pneumococcal (PCV) series

• Rotavirus (completed in infancy)

normal temperatures in pediatrics

Normal range: 97* – 100.4*F

• Axillary: 97.6*F

• Oral or tympanic: 98.6*F

• Rectal: 99.6*F

HR range for an infant

100-160

HR range for toddler

90-140

HR for school aged

75-120

normal RR for an infant

30-60

normal RR for toddler

24-40

normal RR school aged

18-30