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NU313 Exam 3 With Complete
Solution
Extremely Preterm - ANSWER Less than 28 weeks Very Preterm - ANSWER 28-32 weeks Moderate to Late Preterm - ANSWER 32-37 weeks Betamethasone - ANSWER Corticosteroid that increases development of surfactant for infant's lungs, given to Mom in 2 doses IM who is suspected of/high risk for preterm labor Post-term - ANSWER 42 weeks and beyond Post-term Maternal Risks - ANSWER - Large size of fetus at birth (Macrosomia)
- Increase risk of cesarean birth
- Shoulder Dystocia
- Birth Trauma
- Postpartum hemorrhage
- Infections Post-term Fetal Risks - ANSWER - Macrosomia
- Shoulder Dystocia: brachial plexus nerve damage/injury
- Low APGAR score
- Meconium aspiration syndrome
- Oligohydramnious Meconium Aspiration Interventions - ANSWER - Assess amniotic fluid for meconium staining with ROM
- Be prepared at delivery: Neonatologist, oxygen, suction, endotracheal tubes, stethoscope
- Assess vital signs, lung sounds, & oximetry
- Do not stimulate infant to cry/breath Physiologic Jaundice - ANSWER - Serum bilirubin levels greater than 5-
- Hyperbilirubinemia that occurs as the result of normal newborn metabolism
- Appears 2-5 days after birth Pathologic Jaundice - ANSWER - Caused by hemolytic diseases such as Rh incompatibility and ABO incompatibility
- Serum bilirubin levels greater than 5- Rh Sensitization - ANSWER - Rh- women is carrying an Rh+ fetus, leading to development of antibodies in bloodstream
- Doesn't effect first pregnancy but can effect any following
- Can lead to Pathologic jaundice
- Administer Rhogam ABO Incompatibility - ANSWER - Mom is O & baby is A, B, or AB so Mom's antibodies attack baby's
- Best results when 2 doses have been given at least 4 hrs prior to delivery
- C/S prior to labor with intact membranes does not require treatment if mom is GBS + Give GBS Antibiotics During Labor When - ANSWER - Positive screening culture
- Positive urine culture any time during preg
- Previous infant with GBS
- If labor occurs prior to screening, assume positive Toxoplasmosis - ANSWER - 1st trimester most dangerous
- At risk for SAB, 40% congenital toxoplasmosis
- Treat with sulfonamides
- Prevent by avoid changing cat litter, avoid eating raw meat, clean cutting boards, wash fruit & veggies, & wash ahnds Congenital Toxoplasmosis - ANSWER Low birth weight, enlarged liver/spleen,anemia, coagulopathy, blind, deaf, seizures, hydrocephalus Syphilis Effects on Newborn - ANSWER Premature & stillbirths Gonorrhea & Chlamydia Effects on Newborn - ANSWER - Can cause eye infections
- Apply Ophthalmia neonatorum following birth Herpes Simplex Virus (HSV) and Pregnancy - ANSWER - Suppressive viral therapy should be offered at 36 weeks for women with active recurrent genital herpes
- C/S is recommended to prevent perinatal HSV transmission in women with active genital lesions
- Not recommended for women with HSV lesions found on non-genital areas like back, thigh or buttock
- Safe to breastfeed HIV and the Infant - ANSWER In addition to perinatal transmission of the virus other risks to the fetus include: Prematurity, low birth weight, & infection Newborn Gonococcal Infections - ANSWER - Can cause Gonococcal Ophthalmia Neonatorum which may lead to blindness, arthritis, meningitis or sepsis
- Prevent with Erythromycin (0.5%) ophthalmic ointment given prophylactically to all newborns within 24 hrs after birth Spina Bifida - ANSWER - Incomplete development of brain, spinal cord & their protective covering by the failure of the fetus's spine to close properly during 1st month of pregnancy
- Surgery can repair the opening after birth, but the nerve damage is permanent Spina Bifida Occulta - ANSWER - Failure of the vertebrae to close, usually without other anomalies
- May be seen by a dimple/indentation on the back
- Defect may not be visible on inspection because it is covered with skin but sometimes a tuft of hair grows of the area
Normal Blood Loss During Labor - ANSWER - Vaginal: 300-500 mL
- C/S: 800-1000 mL
- Anything >1000 mL is considered a hemorrhage Classification of Postpartum Hemorrhage (PPH) - ANSWER - Early: within 24 hrs postpartum, most commonly in first 1-2 hrs
- Late: after 24 hrs postpartum Major Causes of Postpartum Hemorrhage (PPH) - ANSWER - Uterine atony (70-80%)
- Trauma: Cervical, vaginal, or perineal Postpartum Hemorrhage (PPH) from Uterine Atony - ANSWER - Lack of uterine muscle contraction or inability to contract effectively
- Can be from lack of tone, full bladder, retained placenta, or retained clots What size clots are normal? - ANSWER Quarter sized is okay but when it gets to golf ball sized it's concerning Uterine Atony Risk factors - ANSWER - Over-distention of uterus
- Grand multiparity
- History of PPH
- Fast or long labor
- Lengthy use of oxytocin (Pitocin)
- Magnesium sulfate
- Uterine infection
- C/S
- Retained placenta Precipitous vs Prodromal Labor - ANSWER Precipitous is fast, prodromal is long Uterine Atony Signs - ANSWER - Inability to locate fundus
- Boggy fundus
- Fundal location higher than expected
- Excessive lochia (>1 pad in 15 min)
- Large clots
- Uterus firms up with massage but then becomes boggy without massage Uterine Atony Nursing Interventions - ANSWER - Massage fundus
- Expel clots once fundus is contracted
- Ensure empty bladder
- Monitor VS
- Maintain large bore IV access Meds to treat Uterine Atony (Oxytocics) - ANSWER - Oxytocin (Pitocin) IV or IM
- Methylergonovine (Methergine) IM or PO
- Prostaglandins: Carboprost (Hemabate) deep IM or directly into uterine muscle/Misoprostol (Cytotec) rectally or orally (off label use)
Postpartum Hemorrhage (PPH) from Trauma - ANSWER - Lacerations or hematomas in the birth canal, especially cervix & vagina
- Large baby
- Rapid delivery
- Pushing before full dilation, can tear cervix
- Use of oxytocin in labor, ensure there's resting tone in between contractions
- Use of vacuum or forceps Signs of Lacerations Postpartum - ANSWER - Bright red bleeding in the setting of a well contracted fundus at the appropriate location
- May be profuse or a steady trickle
- Treat with surgical repair
Lacerations Postpartum Nursing Interventions - ANSWER Timely recognition notification of provider monitor for hypovolemic shock, low BP, high HR, pale, clammy, etc
Hematomas - ANSWER - Collection of blood enclosed by tissue, causes swelling but no visible active bleeding
- Large hematomas require incision and evacuation of blood, then ligation of bleeding vessel
Best patient position for perineum assessment? - ANSWER Side lying
Postpartum Hemorrhage (PPH) from Trauma Signs - ANSWER - Well contracted fundus
- Heavy bright red vaginal bleeding
- Steady flow of bright red blood
- Hematoma: visible (vulvar) or deep, severe pain (vaginal or abdominal), blood loss may be concealed
Postpartum Hemorrhage (PPH) from Trauma Treatment - ANSWER - Dependent on size
- Pain management, narcotic or perc
- Surgical repair of lacerations
- Surgical incision & drainage of large hematoma
Nursing Care During Hemorrhage - ANSWER - Insure IV access: fluid resuscitation, blood admin
- Med administration
- O2 via mask, 8L
- Strict I&O, including accurate blood loss, foley catheter
- Raise legs
Subinvolution Treatment - ANSWER Control of bleeding with methylergonovine (oral or parenteral), D&C if indicated, antibiotics if indicated
Endometritis Risk Factors - ANSWER - Infection of the inner lining of the uterus
- C/S
- Ruptured membranes >24 hrs
- Multiple vaginal exams after ROM
- Retained placenta
Endometritis S/S - ANSWER - Fever > 100.4 F º , usually within 36 hours of birth
- Chills & general malaise
- Uterine tenderness
- Abdominal pain/cramping
- Foul smelling lochia
- WBC elevated 15,000-30,000/mm
Endometritis Nursing Implications - ANSWER - Administer broad spectrum antibiotics as ordered, most don't cross placenta
- Fowler's position promotes drainage of lochia
- Comfort measures
- Monitor for response to therapy or worsening symptoms
- Maintain lactation
Mastitis S/S - ANSWER - Localized area of redness on one breast, progressing to heat, pain, inflammation & a tender lump or area of breast
- Enlarged lymph nodes in the corresponding axilla
- General malaise
- Fever above 102 º F
Mastitis Treatment - ANSWER - Antibiotics
- Regular & thorough emptying of the breast
- CONTINUE TO BREASTFEED
Mastitis Nursing Role - ANSWER - Prevention: correct latch, teaching to avoid milk stasis, well fitting bra, change nursing pads frequently
- Comfort: moist heat, express or pump if breastfeeding too painful, acetaminophen, rest
- Maintain lactation: moist heat/shower & massage prior to feeding every 1.
- 2 hrs, start w/unaffected side, oral fluids
Pulmonary Embolus (PE) Treatment - ANSWER - Lysis of clot
- Oxygen
- Elevate head of bed
- Narcotics
- Anticoagulation
- Monitor for compromised pulmonary oxygenation
Amniotic Fluid Embolism S/S - ANSWER - Overwhelming sense of dread by the patient
- Chills, nausea, vomiting, agitation
- Hypoxia & respiratory distress
- Cardiogenic shock Disseminated Intravascular Coagulation (DIC), causing massive internal/external bleeding
TORCH Infections - ANSWER - T: Toxoplasmosis
- O: Other (Hep B)
- R: Rubella (German measles)
- C: Cytomegalovirus (CMV)
- H: Herpes Simplex Virus (HSV)
Hepatitis B Virus - ANSWER - Hep B infection can become chronic, meaning it lasts >6 months
- Chronic hep B increases risk of developing liver failure, liver cancer or cirrhosis
Hep B Nursing Assessment - ANSWER - At the first prenatal visit, all pregnant women should be screened, even if they were vaccinated
- History of STI's
- Household contacts with HBV-infected person
- Employment as a health care provider
- Abuse of IV drugs
- Review chart for high risk: Sexual partners, or sexual partners who are HBV-infected
Highest Risk for Sexually Transmitted Infections - ANSWER - Youth ages 15-
- Women are more easily infected & at greater risk for complications than men as vaginal lining is thinner & more delicate than the skin on a penis, so it's easier for bacteria & viruses to penetrate
Bacterial Vaginosis - ANSWER - Thin, grayish-white discharge that is malodorous
- Wet mount slide, clue cells (vaginal epithelial cells show coccobacilli bacteria on microscopic examination)
- Associated with multiple male or female partners, a new sex partner, douching, & lack of condom use
Bacterial Vaginosis Treatment - ANSWER - Metronidazole (Flagyl) PO or vaginally or clindamycin, avoid alcohol use until 24 hours after completion
- Increases your chance of getting an STI, and also can cause pregnancy complications like preterm labor or low birth weight
- Avoid sexual activity & douching
Trichomoniasis - ANSWER - Purulent vaginal discharge, thin or frothy, malodorous, yellow-green or brownish-grey vulvar itching, & edema or redness
- Increases your chances of acquiring HIV
- Increases risk of preterm birth, PROM, & small for gestational age infants
Trichomoniasis Treatment - ANSWER - Metronidazole (Flagyl), avoid alcohol use until 24 hours after completion
- All sexual partners should also be treated
Chlamydia - ANSWER - Asymptomatic, may have yellowish discharge & painful urination
- Gonorrhea & chlamydia are often found together
- Diagnosed with urine sample or a vaginal swab
Chlamydia Treatment - ANSWER - Azithromycin (Zithromax), Amoxicillin (Amoxil)
- Treatment of all sexual partners during 60 days preceding onset of symptoms
- Can cause tubal scarring resulting in infertility & ectopic pregnancy if left untreated
Gonorrhea S/S - ANSWER - Infection of genitourinary tract
- Usually asymptomatic
- Men: painful urination, yellow/green tinted d/c from penis, untreated infection can lead to epididymitis (testicular swelling or pain)
- Women: symptoms appear with development of PID - purulent vaginal discharge, dysuria, dyspareunia
Gonorrhea Treatment - ANSWER - Ceftriaxone (Rocephin) 250 mg IM in a single dosePLUS Azithromycin (Zithromax) 1g orally in a single dose
