ZW

166 Final Exam

Exam Preparation

General Information

  • The Zoom video will be shared with all campus instructors.

  • Instructors will send the link to students for repeated viewing.

  • PowerPoint slides will not be distributed; only the Zoom recording.

  • Dean Lawson approved the distribution of the Zoom video.

How to Prepare for the Exam

  • Study the workbook from front to back.

  • Separate information into smaller chunks.

  • Use the syllabus to break down topics by week.

Syllabus Breakdown

  • Weeks 1-2: Antenatal care (prenatal care of the mother).

  • Weeks 3-4: Intrapartum care (childbirth).

  • Weeks 4-5: Postpartum care.

  • Week 5: Newborn assessment (Pediatrics).

  • Remainder of term: Growth and development, congenital anomalies.

Antepartum Care

Key Nutritional Elements
  • Four key nutritional elements for pregnant women to consume daily:

    • Protein: At least 60 grams per day.

    • Iron: 30 milligrams per day (for mother and newborn's iron stores).

    • Folic Acid: 0.4 micrograms per day (prevent spina bifida).

      • Start 3-6 months before pregnancy and continue throughout.

    • Calcium: 1200 milligrams per day.

  • Calcium and iron compete for absorption. Take separately.

    • Iron in the morning on an empty stomach with orange juice.

    • Calcium later in the day.

Pelvis Size and Shape (Textbook page 28, Figure 2.5)
  • Four types of pelvises:

    • Gynecoid: Most favorable, widest opening.

    • Platypoid

    • Android: Male pelvis, narrow hip.

    • Anthropoid

  • Cesarean section may be needed for non-gynecoid pelvises due to cephalopelvic disproportion.

Definition of Terms (Textbook page 51)
  • Gravida: Pregnant uterus. Count every pregnancy, including current one.

  • Para: Births after 20 weeks gestation (age of viability).

  • Abortion: Delivery of a fetus prior to 20 weeks, spontaneous or induced.

  • Age of viability: 20 weeks gestation.

  • Term deliveries: 37 completed weeks gestation.

  • Preterm baby: Born after 20 weeks but prior to 36 weeks and 6 days.

GTPAL

G: Gravida (total number of pregnancies)
T: Term births (37 weeks or more)
P: Preterm births (20-36 weeks, 6 days)
A: Abortions (prior to 20 weeks)
L: Living children

Nagel's Rule (Textbook page 51)
  • Calculating the estimated date of delivery.

  • If the last normal menstrual period was in January, February, or March, the delivery will be in the same year.

  • If the last menstrual period was after March, the delivery will be in the following year.

  • Calculate based on 28-day cycles.

Signs of Pregnancy (Textbook page 52, Box 4.3)
  • Presumptive Signs: Physiologic changes consistent with pregnancy but not definitive.

    • Amenorrhea (missed period).

    • Nausea and vomiting.

  • Probable Signs: Objective signs identified by obstetricians (Gidells, Chadwick's, Hagar's, Braxton Hicks, McDonald's) that may mistakenly indicate pregnancy based on physiological changes in the woman’s body.

    • Goodell's sign (softening of the cervix).

    • Chadwick's sign (bluish-purple cervix).

    • Hegar's sign (softening of the lower uterine segment).

    • Braxton Hicks contractions (irregular uterine contractions).

  • Positive Signs: Only three definitive signs.

    • Hear a baby (fetal heartbeat via Doppler, 110-160 bpm).

    • See a baby (ultrasound of fetal sac).

    • Feel a baby (practitioner feels fetal sac sloshing).

Prenatal Testing (Textbook page 50, Table 4.1)
  • Trimester blood work: Determines anemia, Rh incompatibility, and infections.

  • CBC: Check for anemia (hemoglobin below 12, or below 10 requires higher iron supplements).

  • Blood type and Rh: Check for ABO incompatibility or Rh-negative mother with a potentially Rh-positive baby.

  • Infections: VDRL (syphilis), Rubella titer, HIV, Hepatitis B (TORCH panel).

    • Chlamydia and Gonorrhea are bacterial infections treatable with penicillin.

    • Rubella, HIV, and Hepatitis B are viral (no cure).

  • Second trimester:

    • Oral Glucose Tolerance Test (24-28 weeks): Assess risk for gestational diabetes.

      • If blood glucose is over 140 mg/dL after one hour, a two or three-hour test is required. Over 140 afterward means they are diagnosed as gestational diabetic.

      • Treated with insulin if carbohydrate intake can't be managed.

    • Alpha-Fetoprotein (AFP): Part of quad screen for Down syndrome.

      • Low AFP indicates Down syndrome.

    • Ultrasound (around 16 weeks): Confirm delivery date and assess fetal anomalies (Down syndrome).

  • Third trimester:

    • Vaginal and rectal swab for Group Beta Strep (GBS).

      • Treat with antibiotics during labor and ruptured membranes.

Fetal Diagnostic Tests (Page 88, Table 5.1)
  • Kick count: Count fetal movements after a meal, lying on the side (left preferable) for 30 minutes to an hour.

    • Decreased fetal movement indicates a non-stress test.

  • AFP: High levels indicate spina bifida, low levels indicate Down syndrome or hydatidiform mole.

  • Non-Stress Test (NST): Fetal monitor for 20 minutes; assess fetal well-being.

    • Reactive/positive test: Fetal heart rate elevates 15 bpm above baseline for 15 seconds within 20 minutes (15x15x20 rule).

  • Biophysical Profile (BPP): Includes NST plus ultrasound.

    • NST (reactive = 2 points, nonreactive = 0 points).

    • Amniotic fluid pocket measurement.

    • Fetal movement (arms and legs).

    • Fetal tone (arms and legs flexed).

    • Fetal breathing movement (chest rising and falling).

    • Score of 8-10 is good, below 7 is retested, 4 indicates distress and likely C-section.

Discomforts of Pregnancy (Page 70, Table 4.6)
  • Nausea and vomiting: Avoid an empty stomach, eat dry toast/crackers.

  • Heartburn: Sit up for 30 minutes after eating, avoid gas-forming and greasy foods.

  • Constipation: Increase fluid intake, avoid caffeine, walk for 30 minutes a day.

  • Hemorrhoids: Witch hazel.

  • Varicose veins: Avoid prolonged standing/sitting, avoid restrictive clothing, walk frequently.

  • Edema of feet and ankles: Elevate legs when sitting.

Early and Late Bleeding Disorders

Early Pregnancy
  • Hydatidiform mole, ectopic pregnancy, and abortion.

  • Previa: Placenta over or within 2 cm of cervical opening. Bright red, painless bleeding.

  • Abruption: Placenta separates from the uterine wall. Dark red blood, severe pain.

  • Hydatidiform mole: Brown discharge (chorionic villi), rapid uterine growth, hyperemesis gravidarum, high hCG, no fetal heartbeat.
    *Care for patients after D&C or D&E:
    *Report continued bleeding to health provider.
    *Do not use tampons.
    *Check temperature every 8 hours for three days. Notify if it's over 100.4^{\circ}F.
    *Report foul or brownish vaginal discharge.
    *Continue to take iron pills.
    *Prevent pregnancy for 6 months to a year after hydatidiform mole.

Late Pregnancy
  • Ectopic Pregnancy: hCG levels are lower than normal.

Gestational Hypertension and Preeclampsia

  • Occurs after 20 weeks gestation. Blood pressure at or above 140/90, assessed four hours apart or on separate occasions.

  • Preeclampsia: Hypertension plus edema (above the waist) and proteinuria.

  • Worsening signs: CNS and eye involvement (headache and visual disturbances).

  • Treatment: Oral labetalol (Trandate), IV labetalol in the hospital.

    • Labetalol is contraindicated in patients with asthma or heart failure.

    • Avoid diuretics.

  • Preeclampsia worsening:

    • Decreased urine output (less than 50 mL per hour).

    • Respiratory issues (fluid in lungs, crackles).

    • Epigastric pain (right side), indicating HELLP syndrome.

HELLP Syndrome
  • Hemolysis, Elevated Liver enzymes (ALT & AST above 20 mg/dL), Low Platelets (below 100,000).

Rh Factor (Pages 103-104)

  • Rh positive: Has rhesus protein on red blood cells.

  • Rh negative: Does not have rhesus protein.

  • Rh-negative mother with Rh-positive baby: Mother's body creates antibodies against baby's blood.

  • Give RhoGAM at 28 weeks and within 72 hours of birth.

  • Only a problem if mother is Rh negative and baby is Rh positive.

Childbirth (Intrapartal Care)

Contraction Pattern
  • Resting period of at least 30 seconds between contractions for placental blood flow.

  • Count contractions from the beginning of one to the beginning of the next.

Four Stages of Labor
  • Stage 1: Dilatation and effacement of the cervix.

  • Stage 2: Pushing the baby out through the vagina.

  • Stage 3: Delivery of the placenta.

  • Stage 4: 2-4 hour recovery period.

Impending Signs of Labor
  • Braxton Hicks contractions: Uterine muscles getting ready for birth.

  • Lightening: Baby falls into the pelvic rim.

  • Increased vaginal discharge (clear, may have bloody show).

  • Cervical changes: Softening.

  • Bloody show (may include mucus plug).

  • Rupture of membranes: If no contractions after 18 hours, induce labor.

  • Energy spurt (nesting desire).

  • Weight loss (3-5 pounds).

Leopold Maneuvers
  • Determine fetal position and presentation.

  • Palpate fundus for butt or head.

  • Palpate sides for fetal spine.

  • Rock fingers above symphysis pubis for head or butt.

Fetal Heart Rate Patterns (VIL CHOP MIND)

V: Variable decelerations (cord compression).
E: Early decelerations (head compression).
A: Accelerations (okay).
L: Late decelerations (placental insufficiency).

Management:
V and L require POISON (change Position of mother, Oxygenate, Increase IV fluids, Stop pitocin, Notify practitioner).

Postpartum Care

  • Assess fundus: Goes down one fingerbreadth/cm per day. Massage to make firm.

  • Assess lochia: Blood, mucus, and debris from birth.

  • Lochia Rubra: 72 hours post-birth, mainly blood.

  • Lochia Serosa: Pinkish discharge.

  • Lochia Alba: Site healed, no more bright red bleeding.

Postpartum Hemorrhage
Early Hemorrhage
  • Occurs anytime after placenta delivery.

  • Four Ts: Tone, Trauma (lacerations or tears), Tissue (retained placental fragments), Thrombin (coagulation disorders).

  • Most Common Cause: Uterine atony (loss of muscle tone in uterus due to too much Pitocin or large baby (70%)

  • Assess fundus in relation to bladder every two hours

Late Hemorrhage
  • Retained placental fragments.

  • Subinvolution of the uterus

Treatment
  • Massage the fundus.

  • Medications:

    • Oxytocin (IV or IM).

    • Methergine (IM or PO), Contraindicated in preeclampsia or gestational hypertension.

    • Cytotec (rectally).

    • Hemabate/CarboHose (IM), Contraindicated in asthma.

Pediatrics (Newborn Assessment)

Systems Assessment
  • Neurologic

    • Rooting reflex

    • Sucking reflex

    • Palmar grasp reflex

    • Moro reflex

    • Plantar grasp reflex

    • Babinski reflex

  • Eyes

    • Outer canthus at the top of the baby's ear

  • Spine
    *Two fingers from the nape of of the neck to gluteus maximus and then spread gluteus.

Newborn Hypoglycemia
  • At-risk babies: Mothers with gestational diabetes or preeclampsia.

  • Check heel stick every hour for three hours postpartum.

  • Feed if blood sugar is below 44 mg/dL.

  • Breastfeed within one hour, formula feed after three hours.

  • Symptoms:

    • Hypo Symptoms: Flaccid, poor muscle tone, respiratory distress (nasal flaring, grunting, sternal retractions), low temperature, poor suck, lethargy.

    • Hyper Symptoms: Jittery, sweating, high pitched cry, seizures.

  • Nursing interventions:

    • Ensure the baby is warm.

    • Prevent evaporation from amniotic fluid.

    • Convection: Laying on wet surface.

      • Conduction: Close to an Air Vent or cold blanket.

    • Radiation

      • Remove wet blankets.

      • Keep away from air vent.

Apgar Score
  • Done at 1 minute and 5 minutes after birth.

  • Cardiac, respiratory, and neuro assessment:

    • Heart Rate: Above 100 bpm.

    • Reflex Irritability: Tickle nose to induce the baby to move their head.

    • Color: Cardiac.

      • Respiration: Torso turns pink upon crying.

      • Respiration Effort.

    • Cry/respiration Baby cries more to exchnage lungs.

    • Respiration.

    • Color (acrocyanosis, blue fingers and feet, is normal for 12 -24 hours).

    • Respiration

      • Lound cry can increase oxygen levels in the lungs.

      • See baby breathing more.

Congenital Anomalies
Hydrocephalus

When anterior fontanel fills with water and Bulge.
* Put in a tube to drain excess in the abdomen.

Cleft Lip
  • Musculoskeletal.
    *Open cut in area of the lip.
    *Before 6 months surgery is perfomed in the area.

Cleft Palate
The palate is combined will effect speech tooth and family to ensure correct practice and speech theraphy.
Down Syndrome
  • The Chromosomal problem is low Alpha Fetal Protein test if mother has.

  • Eyes close together.

  • Small Finger.

  • Small neck.

  • More likely to develop heart defects.

Inborn Errors of Metabolism
  • Genetic defects where baby has difficulty with breakdown of amino acids or sugars.
    Phenylketonuria (PKU)
    Over build up of the amino acid Phenylalanine. 2-10mg per deciliter. Monitor with monthly monthly monitoring blood tests and food formula

    • Cannot be broken down. 10mg per deciliter. Different Foods,Different Milk,Different meals.
      Maple Syrup Disease
      Leusineisoluceine and Valine (LIV)
      Babys Smells like maple Syprup
      LIV baby cant break down L, I, V
      Galactosemia
      Baby is unable to break down lactose and cant breast feed and will need specialy made formula

      Develpmental Hip Dysplasia

      The hips we, during the newborn assessment, we check the hips to make sure that it, the head of the femur is inside the socket.

If it's not, thing we'll try is this Pavlik harness where we're forcing the femur head into the pelvis.
If that doesn't work, then we're gonna put the baby in a Spica cast, and this is gonna be for a much longer period of time to maintain the femur head in the pelvis.

Hemolytic Disease

*This test will let us know if mother has (o blood + a or b.
Baby start to turn yellow (JANDACE)
mother has (high bilirubin level). Treat the baby most likely with photophraphy. 24 hours, typically, it's because of ABO incompatibility. Give Baby diapers and special goggles over the eyes. Turn baby overy 2 hours so treatment can work around body, 2-3 feedings with bilibrum

School Age Vital Signs

Start to look like adult vital signs

growth Chapter 15

Toddlers work in parallel in play.
Preschoolers are coopertive in play
sccool Age kids are competitive play
Teen are teen

emergency Treatment Chpater 15

if tooth is knocked out it to be picked up by crown avoid damage do root then it has to be palced in milk. Kid has to go to doc to see if tooth has to be put back in
adHD has 7 symtoms but kid has to exabit 5 out 7 in order to be identified as ADHD (test not needed)
pet overship after the year age of 7 years
pace- to talk to parents on how to talk to kids safty or drugs. start discustion with adisoltns

prescriptions

Folic acid: Used for Prevention for Spinal biffinda
Colace: Is used Pretnally to have Softer Stool Elimanation
Preeclampsia and labetalol in Pretnatal period and then also magnasium sulfate is used booth for pertum labor or proclamsps. Aconvusant/Smooth Muscle Relaxtion = GOOD BOTH
calcium calculate has to be by the bed side in order to use antidote if mother gest too much magsulfat. The pt may have burp

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