RNSG 1538- Exam 1

Reproduction

Pathophysiology

what is the formula for Naegel’s Rule

current month - 3 months + 7 days

Pathophysiology

According to GTPAL, what is considered a viable pregnancy

when fetus is 22 weeks or older

(G)	Gravidity =
(T)	Term =
(P)	Preterm Births  =
(A)	Abortion =
(L)	Living Children =

(G)	Gravidity = all pregnancies (miscarriages, current pregnancy and abortions included)
(T)	Term = term births (37 weeks and above)
(P)	Preterm Births  = pregnancies that ended where the fetus was greater than 20 weeks, but less than 37 weeks completed
(A)	Abortion = abortion or miscarriages prior to 20 weeks
(L)	Living Children = all living children 5

Manifestations

what are the presumptive signs of pregnancy

Presumptive (Subjective signs) 

• Amnorrhea 

• Nausea 

• Vomiting 

• Fatigue 

• Breast tender 

• Urinary frequency 

• Hyperpigmentation 

• quickening (not a positive sign of pregnancy) → it can be gas

Manifestations

What are the probable signs of pregnancy

Probable Signs of Pregnancy 

• Softing of the cervix 

• Chadwick’s sign - blue cervix 

• Hagar signs 

• Positive pregnancy test → to check for increased levels of HCG levels 

• Uterine enlargement 

Manifestations

What are the positive signs of pregnancy

Positive Signs (only providers can diagnose pregnancy) 

• Ultrasound 

• Associations of fetal heart tones 

• Palpitations of fetal movement

Complications

How is Gestational Hypertension defined

• Gestational Hypertension 

  • Greater than 140 /90 after 20 weeks of pregnancy

  • Can cause pre-term labor

Complications

What manifestations care indicative of pre-eclampsia

• Pre-eclampsia 

  • Elevated BP

  • Proteinuria (+3 or >) 

  • Severe headache 

  • Can cause pre term labor

Manifestations

A nurse is assessing a 2nd trimester patient and observes bright red blood. The patient reports no pain

• Vaginal Bleeding, decreased fetal movement, cramps in the 2nd Trimester 

  • Indicate placenta previa 

    • Placenta previa is painless and there is bright red blood 

    • Emergency c-section needs to be done 

Nurse Interventions

A nurse is caring for a patients who reports intense pain and dark red blood leakage. What should the nurse do first?

Rationale:

Assess via an ultrasound

Rationale:

S/S indicate placenta abruption. The baby is being cut off from O2. A C-section must be done. Late decels appear on the FHR

Diagnostic

A pregnant person is being educated on how weeks gestation is determined. What can the nurse tell the patient

measuring from the symphysis pubis to the uterine fundus gives an estimate of gestational age

• cm = gestational weeks

Diagnostic

What is the relationship between Rh Factors and Pregnancy

Mom is RH negative and Dad and baby is RH positive → up to 20 weeks or less gestation, the mom’s body can kill the baby and cause an abortion. → future pregnancies will be at risk of death due to the antibody build up.

Diagnostic

In the intrapartum phase of pregnancy, what is the

Normal heart rate:

Tachycardia:

Bradycardia

The heart rate in relationship with contractions 

Normal: 110-160 

Tachycardia: >160 for 10 mins

Bradycardia: <110 for 10 mins 

Nurse Interventions

A nurse observes the FHR monitor and observes uterine tachysystole. What should the nurse do first

Rationale:

stop IV oxytocin

Rationale:

when there is 5 or more contractions in 10 mins. it can lead to fetal distress and low O2

Nurse Interventions

A nurse notices the FHR strip. What should the nurse do first

Rationale:

Place mother in the left lateral position

Rationale:

The strip shows variable decels. the cord is being compressed. O2 needs to be restored

Nurse Interventions

A nurse notices the FHR strip. What should the nurse do first

Rationale:

Nothing theses are normal FHR. These are called accelerations

Nurse Interventions

A nurse notices the FHR strip. What should the nurse do first

These are late decelerations. The placenta is not getting enough O2. An emergency C section is needed

Nurse Interventions

A nurse notices the FHR strip. What should the nurse do first

Nothing. These are early decels. The head is just compressing the placenta

Nurse Interventions

A patient is showing signs of pre-eclampsia. What should the nurse do

• take vitals (BP)

• Get a urinalysis

• assess strength

• place the TOCO machine below the fundus

• place an ultrasound in-between the babies shoulder blades

Treatment 

Metformin →

Terbutaline →

Betamethasone →

Treatment 

Metformin → used to prevent miscarige 

Turbutoline → to stop the contractions in pre-term labor 

Betamethasone → if the baby is born pre term >34 weeks → helps with lung maturity 

Treatment 

A nurse is explaining when a mother with get the RhoGAM shot. What should the nurse say

Rationale:

RhoGAM shot 

• Will be given between 26 - 28 weeks and again 72 hours after delivery

Rationale

to reduce future pregnancies of death due to the antibody build up. 

Name:  Magnesium Sulfate  Class:  CNS Depressant  MOA: Nurse Consideration:  Be cautious if Magnesium Toxicity    Monitor Mg levels every 4-6 hours when given   Watch for low resp rates <12 Nurse Education:

Name:  Magnesium Sulfate  Class:  CNS Depressant  MOA:  increasing the levels will sedate mom and reduce the risk of seizures Nurse Consideration:  Be cautious if Magnesium Toxicity  absent DTR   resp depression / sedation  low urine output  Turn off the IV drip when mom is going to start pushing → reduce the sedation effects of Mag Sulfate and give her the strength to push  Admin calcium gluconate → magnesium levels can rise and cause toxicity Obtain Mg level before giving Mag Sulfate → on Mag for 24-48 hours  Monitor Mg levels every 4-6 hours when given   Watch for low resp rates <12 Assess for a <30 ml of urine output → magnesium levels can rise and cause toxicity Place them on a foley cath if urine output is <30 mL  Nurse Education:  Tell the pt that the dug can causes a warm flushing feeling

Nurse Education

A nurse is educating a patient about fetal movement during pregnancy. What can the nurse explain to the patient

Movement of the Baby → educate that baby can be felt around 16-20 weeks gest. And is called quickening and can be felt in the second trimester 

Pathophysiology

• Primagavida-

• Multipera-

• Granmultiperida-  

• False contractions-

• Lightning-

• Bloody show-

• Quickening-

• Primagavida- first pregnancy 

• Multipera- multiple birth under 20 weeks

• Granmultiperida- has had many children 

• False contractions- braxton hicks 

• Lightning- happens at 38 weeks → baby is settling and getting ready to be delivered. 

• Bloody show- cervical mucus acts as protective plug (happens around 38 weeks) → baby ready to be delivered 

• Quickening- first movement of baby at 16-20 weeks

Pathophysiology

Explain the first stage of labor (include cm dilation)

First Stage (Latent) “Cervical Dilation phase”  (Active) Contraction occurs at the fundus

Dilation size: 4-6 cm Dilation size: 6-10 cm

Pathophysiology

Explain the third stage of labor

Third Stage  “Placenta stage”

Delivery of the placenta  Starts: birth of the baby Ends: delivery of the placenta

Pathophysiology

Explain the second stage of labor (include cm)

Second Stage  “Pushing stage”

Dilation size: full dilation (10 cm)  (the baby is pushed out and baby is born)  Starts: baby is pushed out  Ends: delivery of baby

Pathophysiology

Explain the fourth stage of labor

Fourth Stage  Recovery stage

Moms vitals stabilize  Occurs for 4 hours  Best time for bonding

What are the most ideal fetal positions a fetus can be in to have a successful delivery

ROA- Right occiput anterior /  LOA- Left occiput anterior 

• The baby’s face is facing towards the spine of mom 

• The most optional → ensures a smoother delivery 

At what station must the fetus be at for optimal delivery

Zero Station = the baby is engaged (good) → the baby is born in seconds  

+5 = the head is crowning 

The higher the baby, the longer mom has to push 

If the head is higher than 0 station there is a risk for cord prolapse 

Nurse Interventions

A patient comes into the ED and has ruptured membranes. What should the nurse do to protect the mom and the baby

Rationale:

1. Place on monitor (fetal scalp electrode)→ to see how baby responded to rupture → the longer mom is ruptured and not delivered the risk for infection rises → c-section has to be done if infection occurs (24 hrs post rupture) 

2. Monitor for temperature 

   • Check every 2 hours 

   • Mom feels warm 

3. Reposition mom → movement can help promote baby to move into the correct position 

4. Assess mom’s GTPAL → The more babies she has had, the easier it is to determine how smoothly the delivery will be 

5. Admin Oxytocin for a poor dilation ( aka augmented labor) → to help move along the labor 

6. Place mom in froggy position or lower the bottom of the bed → open up the pelvis to help with delivery

Complications

Why is fetal distress a complication during birth

• Fetal distress 

  • Will show fluctuations from the baseline. The heart rate starts to drop and doesn't come back up  → leads to a late decel → emergency c section needed 

Complications

A nurse is caring for a patient with a prolapsed cord. What interventions should the nurse perform

• Prolapsed Cord 

  • Medical emergency 

  • Remove pressure from the cord 

  • Knee chest position or Trendelenburg position → moves uterus to the side to relieve compression 

  • Give O2 → compression of the head → low o2 to baby → poor perfusion

Complications

A nurse is helping deliver a baby. The nurse notices that the arm is coming out of the vaginal canal. What interventions should the nurse do

• Shoulder Dystocia  → it can break the baby’s clavicle 

  • Shoulder stuck under the symphysis pubis  

  • An emergency 

  • Mc Roberts Movement- legs are held to help move the babies shoulder 

  • Suprapubic Pressure- nurses hands over the suprapubic area 

  • C-section needed if all measures fail 

Treatment

A nurse is helping a patient during the active stage of labor. The patient is given anesthesia. The patient started to push. What interventions should be done and why

Anesthesia Epidural 

• Given in the active stage of labor 

• Epidural shuts off when it's time to push → so mom can feel contractions 

• A 500-1L of Normal Saline Bolus given prior to epidural → epidural can cause hypotension → leads to poor perfusion of baby

  • Left lateral position with wedge → to relieve support on vena cava and improve blood flow and hypotension 

Pathophysiology

What are differences between vaginal blood loss and c-section

vaginal- 500 ml

C-section- 1000ml

Early Postpartum Hemorrhage-

Late Postpartum Hemorrhage-

Early Postpartum Hemorrhage- within 24 hours of birth 

Late Postpartum Hemorrhage- 1-2 weeks after birth OR 3-6 weeks after birth 

Nurse Interventions

A nurse is caring for a post partum patient and wants to know how much blood the patient lost. What can the nurse use to calculate the loss

• Measured in grams (1gram of weight = 1 ml of blood) 

• All blood soaked material - dry pre-weighed material = quantified blood loss amount → this assessment helps nurses determine normal signs of bleeding or potential hemorrhage 

Nurse Interventions

A nurse is helping a postpartum patient. What interventions can the nurse do to to reduce the risk of hemorrhage

• Massage the Fundus of the uterus and track the amount of blood loss

• 2 hours post  birth, admin Oxytocin IV after the placenta is delivered → detachment of the placenta leads to an increase in blood loss. 

• Do not give the oxytocin until after the placenta had come out → oxytocin will cause uterus to contract and prevent the placenta from being delivered

Nurse Interventions

A nurse is helping a postpartum patient.

• What interventions can the nurse do to to reduce the risk of hemorrhage when the uterus is boggy upon assessment

• where is the uterus located

• Location: halfway between the umbilicus and the symphysis pubis MIDLINE 

• Position: non dominant hand at the pubic symphysis and dominant hand right under umbilicus → massage will help expel as much blood as possible via 

• If the uterus is boggy, you must massage the fundus→ causes contractions → reduce blood flow

Nurse Interventions

A nurse is caring for a post partum patient. Upon assessment the nurse notices that the fundus is not midline

• what us suspected

• what interventions can the nurse perform to have the fundus midline

• The fundus is not in the midline position → she has a full bladder → it makes it hard for the uterus to contract 

  • Assist her to the bathroom → to empty the bladder and return the fundus to midline position 

  • Use a foley catheter if mom cant get up to urinate 

  • Do another fundal massage

Assessment of Lochia Days
Days 1-3
Days 4-10
Days 11-21

Assessment of Lochia Days
Days 1-3	Lochia Rubia  A red brown color  Has small spares clots  If you see many small little clots or golf ball size clots contact the PCP
Days 4-10	Lochia Psorosa  Pink color w/ brown tinge  Serosanguoneus  Assess for darker color changes → it can indicate a hemorrhage due to left over placenta, lacerations in vaginal canal, cuts to the uterus  Weigh pads → to determine blood loss
Days 11-21	Lochia Alba  Yellow white color that has no odor  Assess for odor scent → a sign of infection of endometrium (needs antibiotics

Nurse Interventions

A nurse is caring for a post partum patient. Upon assessment the patient states i have not bled for a week and now im bleeding really bright red blood. What should the nurse do

• If the mother has not had lochia bleeding for a week, then begins to bleed bright red, she needs to go to the emergency room → she is either hemorrhaging or have retained placenta 

• Know the amount  

  • Scant 

  • Moderate 

  • Copious 

• Assess for clots (golf size or bigger) → she is either hemorrhaging or have retained placenta 

Oxytocin →

Methergine → 

Nurse Considerations: 

 

Hemabate 

Nurse Considerations: 

Cytotec 

Tranexamic acid (TXA) 

Oxytocin → first line drug postpartum

Methergine →  the second line drug given if they can't use Oxytocin

Nurse Considerations: 

• Contraindicated for patients with hypertension 

 

Hemabate 

Nurse Considerations: 

• Contraindicated with asthma pts 

Cytotec 

Tranexamic acid (TXA) 

Keeps the clots bunched together → to prevent the hemorrhage