Maternal-Newborn Nursing Exam IV Review Flashcards

High-Risk Hemorrhagic Conditions in Pregnancy

• Major High-Risk Conditions:

  • Ectopic Pregnancy.

  • Placenta previa.

  • Placental abruption.

  • Gestational trophoblastic Disease (GTD).

• Risk Factors for Ectopic Pregnancy:

  • History of previous ectopic pregnancy.

  • Previous tubal surgery.

  • Endometriosis.

  • Pelvic Inflammatory Disease (PID).

  • Infertility treatment.

  • Smoking.

• Gestational Trophoblastic Disease (GTD) Recovery:

  • Patients must avoid becoming pregnant for at least $1\,\text{year}$.

  • $hCG$ levels must be closely monitored.

  • Follow-up care must continue as directed by the provider even after $hCG$ levels return to normal.

  • Contraception should be used consistently during the entire recovery period.

• Differential Diagnosis: Placenta Previa vs. Placental Abruption:

  • Placenta Previa:

    • Bleeding: Bright red.

    • Pain level: Painless.

    • Abdominal assessment: Soft abdomen.

    • Nursing Contraindication: No vaginal exams.

  • Placental Abruption:

    • Bleeding: Dark red (may also be concealed with no visible bleeding).

    • Pain level: Severe abdominal pain.

    • Abdominal assessment: Board-like abdomen.

    • Urgency: Considered an Obstetric Emergency.

• Analysis of Hemorrhage Severity:

  • True or False: If the patient isn't bleeding very much, the placental abruption probably isn't severe.

  • Answer: FALSE.

  • Rationale: Visible bleeding is not an accurate determinant of severity because blood may remain concealed behind the placenta.

• Complications of Placental Abruption:

  • Clinical Indicators: Severe abdominal pain, board-like abdomen, and fetal distress.

  • Life-threatening Maternal Complication: Disseminated Intravascular Coagulation (DIC).

• Classic Presentations at a Glance:

  • Ectopic Pregnancy: Unilateral pelvic pain, shoulder pain, vaginal bleeding, and a missed period.

  • Placenta Previa: Painless, bright red bleeding.

  • Placental Abruption: Board-like abdomen, severe abdominal pain, and dark-red bleeding (if bleeding is present).

  • Gestational Trophoblastic Disease: Grape-like clusters that may be expelled from the vagina.

 # Hypertension in Pregnancy

• Progression Continuum:

  • Normal Blood Pressure (BP) $\rightarrow$ Gestational Hypertension $\rightarrow$ Preeclampsia $\rightarrow$ Severe Features $\rightarrow$ HELLP Syndrome and/or Eclampsia.

• Categorizing Hypothetical Patients:

  • Patient A (Gestational HTN): $35\,\text{weeks}$ gestation. BP is $146/92$, repeat at $4\,\text{hours}$ is $148/90$. No headache (HA), visual disturbances, epigastric pain, or swelling. Urine dipstick is negative for protein. Deep Tendon Reflexes (DTR) are $2+$.

  • Patient B (Pre-Eclampsia): $33\,\text{weeks}$ gestation. BP is $152/96$. Reports HA unrelieved with Tylenol. Urine dipstick shows $2+$ proteinuria. DTRs are $3+$. Presence of swelling in hands and face. Denies visual disturbances or epigastric pain.

  • Patient C (Severe Pre-Eclampsia): $34\,\text{weeks}$ gestation. BP is $168/112$. Reports severe HA, blurred vision, and right upper quadrant (RUQ) pain. Urine dipstick shows $3+$ proteinuria. DTRs are $4+$. Clonus present ($3\,\text{beats}$).

• Pharmacology for Pregnancy-Induced Hypertension:

  • Hydralazine.

  • Labetalol.

  • Procardia (Nifedipine).

Magnesium Sulfate Management

• Safe Dosing Protocols:

  • Protocol Option 1: Loading dose of $4\,g$ IV over $20\,\text{minutes}$; Maintenance dose of $2\,g/hour$.

  • Protocol Option 2: Loading dose of $6\,g$ IV over $30\,\text{minutes}$; Maintenance dose of $2\,g/hour$.

  • Protocol Option 3: Loading dose of $4\,g$ IV over $20\,\text{minutes}$; Maintenance dose of $1\,g/hour$.

  • Incorrect Dose Example: Loading dose of $20\,g$ IV over $30\,\text{minutes}$ with a maintenance of $10\,g/hour$.

  • Fluid requirement: Always run with Lactated Ringers ($LR$).

• Required Hourly Assessments:

  • Urine output.

  • Deep Tendon Reflexes (DTRs).

  • Clonus.

  • Respiratory assessment and lung sounds.

  • Level of consciousness (LOC).

  • Fetal status (if applicable).

  • Action for Low Urine Output: If output is low, the nurse must notify the provider immediately.

• Nursing Care Considerations:

  • Perform hourly assessments.

  • Keep the antidote, Calcium Gluconate, at the bedside.

  • Keep environmental stimulation to a minimum.

• Magnesium Toxicity:

  • Assessment Findings:

    • Respirations: $8\,\text{breaths/min}$.

    • Reflexes: Absent DTRs.

    • Urine output: $20\,mL/hr$.

    • LOC: Patient is very lethargic.

  • First Priority Action: STOP THE INFUSION!!

• Therapeutic Parameters:

  • Therapeutic Serum Magnesium Level: $4.8–8.4\,mg/dL$.

  • Important Note: Magnesium Sulfate is administered to prevent seizures, NOT to treat high blood pressure.

HELLP Syndrome

• Syndrome Breakdown:

  • H (Hemolysis): Red blood cells are being destroyed.

  • EL (Elevated Liver Enzymes): Liver injury results in right upper quadrant (RUQ) or epigastric pain.

  • LP (Low Platelets): Leads to an increased risk for bleeding and DIC.

• NCLEX Red Flags for HELLP:

  • Right upper quadrant or epigastric pain.

  • Severe, persistent headache.

  • Nausea and vomiting.

  • Hypertension.

  • Elevated AST/ALT.

  • Platelets < 100,000.

  • Hemolysis.

Diabetes and Rh Incompatibility

• Diabetes Impacts on Pregnancy:

  • Maternal Risks: Increased risk of spontaneous abortion, Urinary Tract Infections (UTIs), polyhydramnios, pregnancy-induced HTN/Pre-Eclampsia, increased likelihood of Cesarean birth, and increased risk for postpartum hemorrhage.

  • Fetal/Newborn Risks: Congenital malformations, macrosomia, birth trauma, neonatal hypoglycemia, hyperbilirubinemia, polycythemia, and increased risk for stillbirth.

• Rh Incompatibility Management:

  • During Pregnancy: If the mother has an Rh-negative factor ($A-, B-, AB-, \text{or } O-$), she receives Rhogam (typically around $26\,\text{weeks}$).

  • After Birth: If the baby is Rh-positive ($A+, B+, AB+, \text{or } O+$), the mother receives a second Rhogam injection within $72\,\text{hours}$ of delivery.

• Diagnostic Screening (Coombs Tests):

  • Indirect Coombs Test:

    • Target: Maternal blood.

    • Purpose: Detects free Rh antibodies to determine if the mother is sensitized.

  • Direct Coombs Test:

    • Target: Neonatal blood.

    • Purpose: Detects antibodies attached to RBCs to determine if the baby has been affected.

Infectious Diseases in Pregnancy

• Toxoplasmosis:

  • Can cause congenital defects if contracted during pregnancy.

  • Associated with cat litter and contaminated gardening soil.

• Group Beta Strep (GBS):

  • Occurs in approximately $25\%$ of pregnancies.

  • Usually asymptomatic in the mother.

  • Requires IV antibiotics during labor.

  • Untreated GBS can lead to neonatal sepsis.

• Evaluating GBS Treatment Adequacy:

  • Criteria for Adequate Treatment: Must receive at least $2\,\text{doses}$ of IV antibiotics, and the second dose must be administered at least $4\,\text{hours}$ prior to delivery.

  • Scenario A (Adequacy Check): GBS positive; received IV penicillin; 2nd dose at $15:20$; delivered at $19:32$. Result: Adequate.

  • Scenario B (Adequacy Check): GBS positive; received IV penicillin; 1st dose at $09:27$; 2nd dose at $13:52$; delivered at $16:47$. Result: Inadequate (Less than $4\,\text{hours}$ from 2nd dose to delivery).

Labor Induction and Augmentation

• Key Definitions:

  • Induction: Creating labor when labor is not already in progress.

  • Augmentation: Helping speed labor along or increasing the progressiveness of existing labor.

  • Bishop Score: Used to calculate if induction should be considered.

• Nursing Priorities:

  • The highest priority in labor is to ensure adequate maternal and fetal oxygenation throughout the labor process.

• Contraindications for Induction:

  • Placenta previa.

  • Previous Classical Cesarean (vertical uterine incision).

  • Active Genital Herpes.

  • Unknown presenting fetal part.

• Induction Agents:

  • Oxytocin (Pitocin): High-risk drug; must be administered on a pump for specific titration ($1-20\,mu/min$).

  • Cytotec (Misoprostol): Can be given orally, vaginally, or buccally in small doses (usually $25\,\mu g$ every $2-4\,\text{hours}$). Cannot be given to Trial of Labor after Cesarean (TOLAC) patients.

  • Cervidil: Vaginal insert for $12\,\text{hours}$; patient must lie flat after insertion.

• Tachysystole Management:

  • Scenario:$6\,\text{contractions}$ in a $10\text{-minute}$ window consistently for $45\,\text{minutes}$ during induction ($10\,mu/min$). Fetal tracing shows recurrent late decelerations.

  • Diagnosis: Tachysystole.

  • Priority Action: STOP or DECREASE the Pitocin infusion immediately.

• Hypotonic Labor:

  • Pathophysiology: Contractions are too weak or infrequent to produce cervical change and fetal descent.

  • Interventions: Oxytocin infusion, amniotomy, frequent position changes, ambulation, and adequate hydration.

  • Complication Risk: Increased risk for Postpartum Hemorrhage (PPH) due to uterine atony (Weak Labor $\rightarrow$ Weak Uterus $\rightarrow$ Uterine Fatigue $\rightarrow$ Uterine Atony).

Clinical Procedures and Safety

• Amniotomy (Artificial Rupture of Membranes - AROM):

  • Documentation Requirements: Time of rupture, color of fluid, odor of fluid, and amount (scant, small, moderate, or copious).

  • Priority Nursing Assessments:

    1. Assess fetal heart rate (FHR) for signs of cord compression or umbilical cord prolapse.

    2. Obtain patient temperature every $2\,\text{hours}$.

• Operative Vaginal Delivery Risks (Forceps/Vacuum):

  • Maternal: Vaginal or perineal lacerations, increased bleeding, infection.

  • Fetal/Neonatal: Cephalohematoma, facial bruising/edema/laceration, facial nerve injury (transient), jaundice (secondary to bruising/hematoma), cerebral hemorrhage, fractured clavicle, brachial plexus injury.

• Operating Room (OR) Safety (Circulating Nurse):

  • Responsibilities: Ensure correct patient/procedure, safe positioning, count instruments and sponges with the scrub nurse, record times and procedures.

  • PRIORITY Responsibility: WATCH THE STERILE FIELD TO MAINTAIN STERILITY.

Preterm Labor (PTL) and Chorioamnionitis

• Risk Factors for Preterm Labor:

  • Previous preterm birth (the strongest predictor).

  • Infection (especially UTIs or chorioamnionitis).

  • Multiple gestation.

  • Polyhydramnios.

  • Gestational diabetes.

  • Assisted reproductive technology (IVF).

  • Dehydration.

• Priority Nursing Interventions for PTL:

  • Place patient on fetal monitor.

  • Assess contraction pattern and cervical change.

  • Encourage hydration.

  • Notify provider and prepare for Betamethasone, Magnesium sulfate, or tocolytic therapy.

• Preterm Labor Medications:

  • Betamethasone: Accelerates fetal lung maturity.

  • Terbutaline: Temporarily relaxes the uterus to slow contractions. Contraindication: Do not administer if patient's Heart Rate (HR) is above $120\,\text{bpm}$.

  • Nifedipine (Procardia): Calcium channel blocker that decreases uterine contractions.

  • Magnesium Sulfate: Used for short-term tocolysis and fetal neuroprotection (commonly before $32\,\text{weeks}$).

• Chorioamnionitis:

  • Major Risk Factor: Prolonged rupture of membranes.

  • Chorio Triad: Maternal Fever, Maternal Tachycardia, and Fetal Tachycardia.

  • Other Findings: Tender uterus, foul-smelling amniotic fluid.

  • Interventions: Notify provider, administer broad-spectrum IV antibiotics, continue monitoring, and prepare for delivery if indicated.

• Post-term Pregnancy (> 42\,\text{weeks}):

  • Major Concern: Placental Insufficiency (Old Placenta $\rightarrow$ Hypoxia).

  • Complications: Oligohydramnios, variable/late decelerations, meconium-stained amniotic fluid, fetal distress, and stillbirth.

Obstetrical Emergencies

• Shoulder Dystocia:

  • Identification: "Turtle sign" (head delivers but shoulders do not); difficulty delivering the anterior shoulder.

  • Nurse's Priority Action: CALL FOR HELP! Implement McRoberts maneuver and apply suprapubic pressure.

  • Critical Warning: NEVER apply fundal pressure.

  • Maternal Concerns: 3rd/4th degree lacerations, PPH.

  • Neonatal Concerns: Brachial plexus injury (Erb’s Palsy), fractured clavicle/humerus, and hypoxia (especially if the cord is cut prematurely).

• Umbilical Cord Prolapse:

  • Description: Cord slips below the presenting part, leading to compression and decreased oxygen/blood flow (fetal bradycardia).

  • Risk Factors: Polyhydramnios, high unengaged presenting part, premature ROM, AROM, breech, transverse lie, multiple gestation.

  • Interventions:

    1. Elevate presenting part off the cord with a gloved hand and CALL FOR HELP.

    2. DO NOT remove hand until delivery or relief by a qualified provider.

    3. Reposition (Trendelenburg or knee-chest).

    4. Administer oxygen (nonrebreather), stop oxytocin, and administer Terbutaline.

    5. Prepare for emergency C-section ("splash and dash").

• Uterine Rupture:

  • Signs: Sudden loss of fetal station, sudden fetal bradycardia, sudden severe abdominal pain, cessation of contractions, vaginal bleeding, and maternal shock (tachycardia/hypotension).

  • Action: Stop oxytocin, call for help/notify provider, reposition laterally, oxygen, increase IV access/fluids/blood, and prepare for emergency C-section.

• Amniotic Fluid Embolism (AFE):

  • Hallmark Signs: Sudden respiratory distress (after ROM), hypotension, cardiovascular collapse, hypoxia, altered mental status, followed by DIC and massive hemorrhage.

  • Pathophysiology: Amniotic fluid triggers a massive inflammatory response, depleting clotting factors (DIC).

  • Priority Actions: High-flow oxygen, call rapid response, support airway (intubation), support circulation (IV fluids, vasopressors), CPR if needed, and prepare blood products to treat DIC/PPH.