NURS 4441 OB Study Guide 3 Final Exam 3 Review

NURS 4441 OB Study Guide 3 Final Exam 3 Review I think now that we are covering disorders you will be more comfortable—nursing students learn early on how to study for diseases and disorders—it is the normal “stuff” ...

NURS 4441 OB Study Guide 3 Final Exam 3 Review I think now that we are covering disorders you will be more comfortable—nursing students learn early on how to study for diseases and disorders—it is the normal “stuff” that usually proves to be more difficult for them in OB. Hemorrhagic problems 1. Know the causes and types of spontaneous abortion. How can a clinician tell the difference been a threatened abortion and one that has already happened? What are the options for a missed abortion? An abortion is the loss of an early pregnancy, usually before week 20 of gestation. A spontaneous abortion refers to the loss of a fetus resulting from natural causes-that is, not elective or therapeutically induced by a procedure. Most common cause for first trimester is fetal genetic/chromosomal abnormalities, usually unrelated to the mother. Second trimester more likely related to maternal conditions, such as cervical insufficiency, congential or acquired anomaly like uterine septum or fibroids. Hypothyroidism, DM, chronic nephritis, use of crack cocaine, lupus, PCOS, severe HTN, rubella, CMV, hsv, bacterial vagniosis, toxoplasmosis. Threatened abortion: vaginal bleeding, no cervical dilation, mild abdominal cramping, no passage of fetal tissue. Inevitable abortion: vaginal bleeding, rupture of membranes, strong abdominal cramping, possible passage of products of conception. Incomplete abortion: passage of some products of conception. Intense abdominal bleeding, heavy vaginal bleeding, cervical dilation. Complete abortion: passage of all products of conception, history of vaginal bleeding and abdominal pain, passage of tissue with subsequent decrease in pain and decrease in bleeding. Missed abortion: nonviable embryo retained in utero for at least 6 weeks. Absent uterine contractions, irregular spotting, possible progression to inevitable abortion. Habitual abortion: history of 3 or more consecutive abortions, not carrying pregnancy to viability or term. 2. What are the signs and symptoms of placenta previa? (What exam should NOT be done on cases of previa? How will women with previa deliver?) Placenta previa is a bleeding condition that occurs during the last 2 trimesters of pregnancy. It literally means afterbirth first. In placenta previa, the placenta implants over the cervical os. It may cause serious morbidity and mortality to fetus and mother. It is initiated by implantation of embryo in the lower uterus. AVOID doing vaginal exams, they may disrupt the placenta and cause hemorrhage. S/S: maternal age more than 35, previous c sect, multiparity, uterine insult or injury, cocaine use, prior placenta previa, infertility treatment, Asian, mult. Gestations, previous induced surgical abortion, smoking, short interval b/t pregnancies, htn or DM. Prepare pt for possibility of a c section. 3. What are the signs and symptoms of abruption placenta? (Know the differences between previa and abruptions). Abruptio placentae is the separation of a normally located placenta after the 20th week of gestation and prior to birth that leads to hemorrhage. Significant cause of 3rd trimester bleeding, high mortality rate. Mother may need blood transfusions, DIC and renal failure can occur. Medical emergency PLACENTA PREVIA -insidious onset -visible bleeding, slight then more profuse -bright red blood -no pain, soft relaxed uterus, -FHR in normal range/Fetus may be breech or transverse lie; absent engagement ABRUPTIO PLACENTAE -Sudden onset -Can be concealed or visible blood, dark in color -Constant pain, uterine tenderness, firm to rigid tone -FH distress or absent/no relationship to fetal presentation 4. Know the meds in the Drug Guide table 19.1—especially the nursing implications. (Nearly all will show up on either exam 3 or the HESI—ount on it!) -Misoprostol (Cytotec): stimulates uterine contractions to terminate a pregnancy; to evacuate the uterus after abortion to ensure passage of all the products of conception. Side effects: diarrhea, abd pain, increased vaginal bleeding, s/s of shock, tachycardia, hypotension, anxiety. -Mifepristone (RU-486): Acts as progesterone antagonist, allowing prostaglandins to stimulate uterine contractions; causes the endometrium to slough; followed by Misoprostol. SE: headache, vomiting, diarrhea, heavy bleeding. Antiemetic prior to use to minimize n/v, encourage client to use acetaminophen to reduce discomfort from cramping. -PGE2, dinoprostone (Cervidil, Prepidil Gel, Prostin E2): stimulates uterine contractions, causes expulsion of uterine contents; to expel uterine contents in fetal death or missed abortion during 2nd semester, or to efface and dilate the cervix in pregnancy at term. Nursing implications: bring gel to room temp, avoid contact with skin, use sterile technique, remove with retrieval system after 12 hour or onset of labor -Rh(D) Immunoglobulin (Gamulin, HydroRho-D, RhoGAM, MICRhoGAM): suppresses immune response of nonsensitized Rh negative clients who are exposed to Rh-positive blood; to prevent isoimmunization in Rh-neg women exposed to Rh-positive blood after abortions, miscarriages and pregnancies. NI: give IM in deltoid area, give only MICRhoGAM for abortions and miscarriages <12 weeks unless fetus or father is Rh negative. Educate woman that she will need this after subsequent deliveries if newborns are Rh positive; also check lab study results prior to administering the drug. 5. Know the meds in Drug Guide table 19.2 (as much as it pains me to say it, 19.1 and 19.3 are more important than 19.2, however.) Promethazine (Phenergan): diminishes vestibular stimulation and acts on the chemoreceptor trigger zone (CTZ). Symptomatic relief of nausea and vomiting, and motion sickness. NI: be alert for urinary retention, dizziness, hypotension, involuntary movements. Institute safety measures d/t sedative effects. Offer hard candy and frequent rinsing of mouth for dryness. Prochlorperazine (Compazine): acts centrally to inhibit dopamine receptors in the CTZ and peripherally to block vagus nerve stimulation in the GI tract. Controls severe nausea and vomiting. NI: Neuroleptic malignant syndrome such as seizures, hyper/hypotension, tachycardia and dyspnea. Assess mental status, I/O. Caution d/t drowsiness and dizziness, orthostatic hypotension. Ondansetron (Zofran): blocks serotonin release which stimulates the vagal afferent nerves, thus stimulating the vomiting reflex. NI: possible side effects of constipation, diarrhea, abd pain, HA, dizziness, drowsiness and fatigue. Monitor liver function studies. 6. Know the first 4 meds in Drug Guide 19.3—the last 2 are not terribly important for OB because women using Nitroprusside are going to be in ICU (and you already know Lasix). Magnesium sulfate: prevention and treatment of eclamptic seizures. NI: loading dose 4-6 grams IV in 100 ml of fluid over 15-20 minutes, followed by maintenance dose of 2 grams continuous IV infusion. Check for ankle clonus, have calcium gluconate ready in case of toxicity: flushing, sweating, hypotension, cardiac and CNS depression. Hydralazine hydrochloride (Apresoline): vascular smooth muscle relaxant, improves perfusion, reduction in blood pressure. NI: Administer by slow IV bolus. Use parenteral form immediately after opening. Monitor for palpitations, tachycardia, anorexia, n/v/d. Labetelol hydrochloride (Normodyne): alpha 1 and beta blocker to reduce blood pressure. NI: lowers blood pressure without decreasing maternal heart rate or cardiac output. Possible side effects include gastric pain, flatulence, constipation, dizziness, vertigo and fatigue. Nifedipine (Procardia): Calcium channel blocker/dilates coronary arteries, reduction in blood pressure, stops preterm labor. Possible side effects such as dizziness, peripheral edema, angina, diarrhea, nasal congestion and cough. Really understand the Rh negative situation—who gets Rhogam, when and why. Here is a youtube on it: https://www.youtube.com/watch?v=kHxk6SwxDsE This is rather simplistic, but you will get the idea. You will get questions on this on the HESI, and some of you will get it on exam 3. Rh incompatibility is a condition that develops when a woman with Rh-negative blood type is exposed to Rh-positive blood cells and subsequently develops circulating titers of Rh antibodies. Most commonly arises with exposure of Rh-negative mother to Rh-positive fetal blood during pregnancy or birth. If the indirect Coombs test is negative (meaning no antibodies are present), then woman is a candidate for RhoGam. If the test is positive, RhoGam is of no value b/c isoimmunization has occurred. In this case, the fetus is carefully monitored for hemolytic disease. 7. What are the risks for ectopic pregnancy and why is it so dangerous? How do we treat it? An ectopic pregnancy is any pregnancy in which the fertilized ovum implants outside the uterine cavity. This abnormally implanted gestation grows and draws its own blood supply from the site of abnormal implantation. Can lead to massive hemorrhage, infertility or death. It is a medical emergency. Risk factors: previous ectopic pregnancy, history of STI, fallopian tube scarring from PID, endometriosis, fibroids, IUD’s, age older than 35, cigarette smoking. Hallmark is abdominal pain with spotting 6-8 weeks after a missed menstrual period. Many women have symptoms of early pregnancy: breast tenderness, nausea, fatigue, shoulder pain. Analgesics for pain management, may need surgery. Hypertensive (HTN) disorders 8. How does gestational HTN differ from chronic HTN? Characterized by hypertension without proteinuria after 20 weeks gestation resolving by 12 weeks postpartum. Differentiated from chronic HTN, which appears before the 20th week of gestation; or hypertension before the current pregnancy, which continues after woman gives birth. Temporary diagnosis wo do not meet criteria for preeclampsia. 9. (Read my guides on preeclampsia in prep for this.) What is preeclampsia— what is happening and what are the signs/symptoms? Preeclampsia is characterized by both hypertension and proteinuria. Multisystem vasopressive disorder targeting cardiovascular, renal, hepatic and central nervous systems. S/S pitting edema, bp 140/90 after 20 weeks gestation. Greater than 1+ protein, mild facial or hand edema. Weight gain 10. What are the risk factors of preeclampsia? You will be asked to select which patient has the most of them. Primigravida, chromosomal abnormalities, multifetal pregnancy, structural congential abnormalities, history of preeclampsia in previous pregnancy, excessive fetal tissue, chronic stress, use of ovulation drugs, family history of preeclampsia, lower SES, history of diabetes, HTN, renal disease, poor nutrition, African American, age extremes: younger than 20 or older than 40, obesity 11. How do we treat mild preeclampsia? Conservative strategies used if woman has no s/s of renal or hepatic dysfunction. A woman with mild bp elevation may be placed on home bed rest. Encouraged to rest in lateral recumbent position. Monitor bp every 4-6 hours. Measure urine in protein, monitor weight gain. Monitor daily fetal movement. Balanced nutritional diet with no sodium restrictions, 6-8 glasses water a day. If home management fails, may have to go to hospital. 12. How do we treat severe preeclampsia—know dosages. Birth of the baby is really the only cure. Woman in labor with severe preeclampsia receives oxytocin to stimulate uterine contractions and magnesium sulfate to prevent seizures. Can be given simultaneously via infusion pumps. Magnesium is give loading dose of 4-6 grams over 15-20 minutes. Then, a maintenance dose of 2g/hour given. 13. What distinguishes preeclampsia from eclampsia? Mild -BP >140/90 after 20 weeks gestation -Proteinuria 300 mg/24 hr or greater than 1+ protein urine dipstick -No seizures, coma, hyperreflexia -Mild facial/hand edema, weight gain Severe -BP > 160/110 -Proteinuria 500 mg/24hr, greater than 3+ protein urine -No seizures, coma -Hyperreflexia -Headache, oliuria, blurred vision, scotomata(blind spots), thrombocytopenia, cerebral disturbance, epigastric or RUQ pain, HELLP Eclampsia -BP >160/110 -Marked proteinuria -Seizures, coma, hyperreflexia -Severe HA, generalized edema, RUQ/epigastric pain, visual disturbances, cerebral hemorrhage, renal failure HELLP How is HELLP syndrome alike and different from preeclampsia? HELLP: Hemolysis, elevated liver enzymes, low platelet count, a variant of the preeclampsia/eclampsia syndrome. Women with HELLP usually have fewer signs of abnormalities consistent with the metabolic syndrome and a lower prevalence of thrombophilia as compared with preeclampsia women without HELLP. Usually diagnosed between 22-36 weeks. It can present prior to the presence of an elevated bp. 14. Absolutely KNOW all the signs of magnesium sulfate toxicity, and the blood levels. These will be on the exams. Also know that calcium gluconate is the antidote for mag sulfate—and is on all the crash carts in OB. Remember that most IV meds in OB are ordered by the clinician, but the nurse titrates them “to effect”—including mag sulfate to some extent. (There are protocols for it, with blood levels drawn at intervals.) If toxicity occurs, the nurse is expected to turn it off and go through a protocol, of course notifying the doc when it happens, but the clinician often will not be the one calling the shots—a protocol approved by the medical director/ACOG will be initiated, and then the clinician will weigh in. Respiratory rate of less than 12 bpms, absence of DTR, decrease in urinary output <30 ml/hr. Magnesium levels greater than 8 are considered toxic. Level of 10: loss of DTR’s. Level of 15: possible respiratory depression. Level of 25: cardiac arrest. 15. Know the signs and symptoms of hydatidiform mole/gestational trophoblastic disease and the treatment and the teaching that must be done to the woman experiencing it. GTD comprises a spectrum of neoplastic d/o that originate in the placenta. Gestational tissue is present, but pregnancy is not viable. Hydatidiform mole is a benign neoplasm of the chrorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscous fluid. Contains no fetal tissue and develops from an “empty egg” which is fertilized by sperm. The embryo is not viable and dies. Treatment consists of immediate evacuation of the uterine contents as soon as diagnosis is made. D&C used to empty uterus. Need extensive follow up therapy for up to 1 year. Risk of cancer. Women needs to have follow up care to improve chances of future pregnancies/quality of life. 16. What are the two reasons we give magnesium sulfate? For preterm labor, and to prevent seizures. 17. Why is HELLP syndrome such a serious problem? (Remember that among other reasons, it may occur without any visible signs and symptoms.) Clinically progressive, early diagnosis critical to prevent liver distension, rupture, and hemorrhage and the onset of DIC. If presents prenatally, morbidity and mortality can affect mother and baby. Increased maternal risk for liver hematoma or rupture, stroke, cardiac arrest, seizure, pulmonary edema, DIC, ARDS, renal damage, sepsis, hypoxic encephalopathy, death. 18. What is PPROM, and what are the goals of treatment? Preterm Premature Rupture of Membranes. Rupture of membranes prior to the onset of labor in a woman who is less than 37 weeks gestation. Risks from prenatal immaturity including respiratory distress syndrome, inraventricular hemorrhage, pda and nec. Treatment depends on gestational age. No unsterile digital cervical examination until woman enters active labor to minimize infection. If fetal lungs are mature, labor is initiated. May give corticosteroids to help mature lungs. 19. What factor drives the decision to allow delivery to occur in PPROM? If fetal lungs are mature, labor is initiated. 20. Know the patient teaching for PPROM Preventing infection and identifying uterine contractions. Monitor baby’s activity daily. Check temp and report temp increases. Watch for signs of labor. Avoid touching or manipulating breasts which could stimulate labor. Do not insert anything in to vagina: tampons, intercourse, do not swim in pools, ocean, hot tub. Maintain activity restrictions. Wash hands, take antibiotics as directed, call with changes in condition: fever, uterine tenderness, heart racing, foul smelling vaginal d/c. 21. Why should pregnant women stay away from sources of toxoplasmosis, and what are strategies for doing this? -Can pose serious risk to fetus: low birth weight, enlarged liver and spleen, jaundice IUGR, hydrocephalus, microcephaly, anemia, neurologic damage. Avid eating raw or undercooked meat especially pork. Cook meat to 160 degree temp. Clean cutting boards, utensils with hot soapy water after raw meat of fruits/vegs. Peel/thoroughly wash fruit/veg. Wash hands after touching raw meat, avoid feeding cat raw or undercooked meat, avoid emptying/cleaning cat litter box, keep cat indoors to prevent it from hunting and eating birds, rodents. Avoid uncooked eggs, raw milk, wear gloves with handling soil, avoid contact with sandboxes. 22. What makes pregnant women vulnerable to gestational diabetes? Normal pregnancy is characterized by increasing peripheral resistance to insulin and a compensatory increase in insulin secretion. 23. Know the desired fasting and 1 hour post-prandial (and post GTT) values. Fasting: 92 mg/DL. 1 hour post prandial: less than 180. 2 hour post prandial: less than 153. 3 hour post prandial: less than 140. 24. What meds can a woman with rheumatoid arthritis use if she is pregnant— and which is category X and cannot be used? During pregnancy, meds are limited to hydroxychloroquine, glucocorticoids and NSAIDS. Methotrexate is a category X and cannot be used during pregnancy. 25. Women who take illegal drugs are exposing their infants to which risks? Alcohol: IUGR, fetal alcohol syndrome Cocaine: vasoconstriction, decreased blood blow, decreased birth weight, “snow baby syndrome”, CNS defects, IUGR Marijuana: anemia, inadequate weight gain, “amotivational syndrome”, hyperactive startle reflex, newborn tremors, prematurity, IUGR Opiates/Narcotics: maternal and fetal withdrawal, abruptio placentae, preterm labor, perinatal asphyxia, newborn sepsis and death, intellectual impairment, malnutrition Sedatives: CNS depression, newborn withdrawal, newborn abstinence syndrome, delayed lung maturity 26. When are pregnant women with cardiovascular disease especially vulnerable? Uterine blood flow increases by at least 1 liter per minute, requiring the body to produce more blood during pregnancy. 50% expansion in plasma volume during pregnancy and overall hemodilution. Increase in clotting factors and platelets, hypercoagulable state during pregnancy. Cardiac output increases by 30- 50%. Decrease in SVR and PVR. Cardiac decompensation can occur. S/S include: cyanosis of lips, nail beds, swelling of face, hands feet, jvd, rapid respirations, abnormal heartbeats, palpitations, chest pain with effort or emotion, syncope with exertion, increasing fatigue, most frequent cough during labor, use invasive hemodynamic monitoring, assess for fluid overload, and s/s of heart failure. 27. How do we treat pregnant women with HIV to prevent transmission to the fetus? (You may also see a question on the HESI asking if women with HIV and with HepB can breastfeed). Early identification of maternal HIV seropositivity allows early antiretroviral treatment to prevent mother to child transmission. The risk of perinatal transmission directly correlates with the viral load. Standard treatment is oral antiretroviral drugs given twice daily from 14 weeks gestation until giving birth, IV administration during labor, and oral syrup for the newborn in the first 6 weeks of life. Reducing viral load as much as possible will reduce risk of transmission to fetus. Some reports suggest that c sect may reduce risk of HIV infection. Efforts to reduce instruments like fetal scalp electrodes, episiotomy reduce newborn exposure to body fluids. Mothers should not breastfeed. 28. What is the risk that vaginal Strep B can pose to mom and fetus? Group B streptococcus (GBS) is rarely serious in adults, but it can be life threatening to newborns. It is the most common cause of sepsis and meningitis in newborns and is a frequent cause of newborn pneumonia. - Early-onset (within a week of birth) may have pneumonia or sepsis - Late-onset (after the first week) infections often manifest with meningitis. 29. When do we check for Strep B, and how do we treat it? (There is a vSim with this.) All pregnant women should be screened for GBS at 35 to 37 weeks gestation & treated. Penicillin G is the treatment of choice for GBS because of its narrow spectrum. It is usually administered by IV 4 hours prior to birth. 30. How do we treat iron deficiency anemia, and how can women decrease unpleasant symptoms when they are being treated? Iron supplements. Encourage to take with Vit C containing fluids such as orange juice, which will promote absorption, rather than milk, which can inhibit iron absorption. Taking iron on an empty stomach improves it absorption, but many women cannot tolerate the GI discomfort it causes. Adverse effects include: Gastric discomfort, N/V/D, Anorexia, Metallic taste, constipation. Taking the iron with meals and increasing intake of fiber and fluids can help overcome the most common side effects. 31. How are chlamydia and gonorrhea treated in pregnancy? (I disagree with the textbook on treatment of chlamydia. The CDC says azithromycin 1 gram in a single dose is first-line treatment. Erythromycin is what my teachers called a “wimpy” antibiotic!) Chlamydia – Erythromycin Gonorrhea – ceftriaxone (Rocephin) 125 mg in a single dose before going home 32. Which women are at higher risk than average for having babies with congenital malformations? ?? – this is about risks in general, did not see info about congenital malformations Risks are dramatically increased for certain vulnerable populations: adolescents, women over the age of 35, women who are obese, and women who abuse substances. 33. Be able to identify the signs and symptoms a neonate presents when his mother abused heroin. The most common harmful effect of heroin and other narcotics on newborns is withdrawal, or neonatal abstinence syndrome. Symptoms may include: - Irritability - Hypertonicity - Excessive and often high-pitched cry - Vomiting - Diarrhea - Feeding disturbances - Respiratory distress - Disturbed sleeping - Excessive sneezing and yawning - Nasal stuffiness - Diaphoresis - Fever - Poor sucking - Tremors - Seizures 34. How much caffeine can a woman safely consume in pregnancy without harm to herself or fetus? Caffeine intake of no more than 300 mg/day during pregnancy does not affect pregnancy duration and the condition of the newborn. 35. Do insulin needs for type 1 diabetics go up or down during the various trimesters of the pregnancy? First trimester hormones render glucose levels slightly lower because of increased storage in the liver and there is less insulin resistance than usual. This makes first trimester diabetics more likely than usual to experience hypoglycemia. This changes with the 2nd and 3rd trimesters as a result of hormones. Hormones seem to work together to increase insulin resistance – it is as if they have the fetal best interest at heart and strive to give the fetus glucose – but of course things can go too far and blood sugar levels can go too high. DKA or HHNKS is more likely in the 2nd and 3rd trimester. The woman will need more insulin – possibly as much as double or quadruple the amount needed before pregnancy. 36. What risks will face the neonate if his diabetic mother had uncontrolled glucose levels during pregnancy? 37. What is hyperemesis gravidarum and how is it treated? Characterized by severe persistent, uncontrollable nausea and vomiting that begins in the first trimester and causes dehydration, electrolyte imbalance, ketosis, and weight loss of more than 5% of prepregnancy body weight. 1st line treatment – in the home, focuses on dietary and lifestyle changes Hospitalization may be necessary if conservative mgmt. fails: blood tests are ordered to assess the severity of the client’s dehydration, ketosis, electrolyte imbalance, and malnutrition. - Parental fluids (D5 in LR with vitamins and electrolytes - Oral food and fluids are withheld for the first 24 to 36 hours to allow GI tract rest - Drugs: antiementics rectally or IV until stabilized o Promethazine (Phenergan) o Prochlorperazine (Compazine) o Ondansetron (Zofran) Labor and birth risks 38. What is the management of prolapsed cord? Prevention is the key to managing cord prolapse by identifying clients at risk for this condition, to reduce the risk of fetal hypoxia. - When membranes are artificially ruptured, assist with verifying that the presenting part is well applied to the cervix and engaged into the pelvis - If pressure or compression of the cord occurs, assist with measures to relieve the compression. Typically the examiner places a sterile glove hand into the vagina and holds the presenting part off the umbilical cord until delivery - Changing the woman’s position to a modified Sims, Trendelenburg, or knee-chest position also helps relieve cord pressure - Monitor FHR, maintain bed rest, and administer oxygen if ordered - If the mother’s cervix is not fully dilated, prepare the woman for stat C-section 39. Using a vacuum extractor during birth puts the baby at risk for which problems? The use of forceps or a vacuum extractor poses the risk of tissue trauma to the mother and the newborn. Maternal trauma may include lacerations of the cervix, vagina, or perineum; hematoma; extension of the episiotomy incision into the anus; hemorrhage; and infection. Potential newborn trauma includes ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum. 40. What if forceps are used in delivery—what are risks to the baby? Depressed skull fractures (rare) may result from the pressure of a forceps delivery. 41. What is the difference between caput succedaneum and cephalhematoma? Cephalhematoma – subperiosteal collection of blood secondary to the rupture of blood vessels between the skull and periosteum – occurs in 2.5% of all births and typically appears within hours after birth. Suture lines delineate its extent; usually located on one side, over the parietal bone. Usually resolves gradually over 2-3 weeks without treatment. Caput succedaneum – is a soft tissue swelling caused by edema of the head against the dilating cervix during the birth process. Swelling is not limited by suture lines: it extends across the midline and is associated with head molding. It does not usually cause complications other than a misshapen head. Swelling is maximal at birth and then rapidly decreases in size. 42. Why would betamethasone be given in pregnancy, and what precautions will be needed? Promotes fetal lung maturity by stimulating surfactant production; prevents or reduces risk of respiratory distress syndrome and intraventricular hemorrhage in the preterm neonate less than 34 weeks’ gestation. - Monitor for maternal infection or pulmonary edema - Educate parents about potential benefits of drug to preterm infant - Assess maternal lung sounds and monitor for signs of infection 43. KNOW how to administer oxytocin—know the reasons it is given, why we might stop it, the benefits and risks. Oxytocin is a potent endogenous uterotonic agent used for both artificial induction and augmentation of labor. It stimulates contractions of the uterus. Administer as an IV infusion via pump, piggybacked into the main IV line at the port most proximal to the insertion site. - Typically 10 unites of oxytocin is added to 1L of isotonic solution - The dose is titrated according to protocol to achieve stable contractions every 2-3 minutes lasting 40 to 60 seconds. - The uterus should relax between contractions. If the resting uterine tone remains above 20 mm Hg, uteroplacental insufficiency and fetal hypoxia can result. Assess baseline vital signs and FHR and then frequently after initiating oxytocin infusion Determine frequency, duration, and strength of contractions frequently Notify HCP of any uterine hypertonicity or abnormal FHR patterns Maintain careful I&O, being alert for water intoxication Keep client informed of labor progress Monitor for possible adverse effects such as hyperstimulation of the uterus, impaired uterine blood flow leading to fetal hypoxia, rapid labor leading to cervical lacerations or uterine rupture, water intoxication (if oxytocin is given in electrolyte-free solution or at a rate exceeding 20 mU/min) and hypotension. Oxytocin has many advantages: it is potent and easy to titrate, it has a short half-life (1-5 min), and it is generally well tolerated. Because the drug does not cross the placental barrier, no direct fetal problems have been observed. 44. What is a ripe cervix? Which methods can be used to ripen a cervix? What precautions should be taken when doing it? Cervical ripening is a process by which the cervix softens via the breakdown of collagen fibrils. It is the first step in the process of cervical effacement and dilation so that, on average, the cervix is approximately 50% effaced and 2 cm dilated at the onset of labor, although wide differences do exist. A ripe cervix is shortened, centered (anterior), softened, and partially dilated. Non-pharmacologic methods – used less frequently today but may include herbal agents such as evening primrose oil, black hawk, black and blue cohosh, and red raspberry leaves. In addition, castor oil, hot baths, and enemas are used. Sexual intercourse with breast stimulation is another method (promotes release of oxytocin). Mechanical methods – all share a similar action of mechanism, application of local pressure stimulates the release of prostaglandins to ripen the cervix Surgical methods – stripping of the membranes and performing an amniotomy Pharmacologic agents – this has revolutionized cervical ripening; dinoprostone (Cervidil insert, Prepidil gel); misoprostol (Cytotect) Precautions: ability to induce excessive uterine contractions, which can increase maternal and perinatal morbidity. Major adverse effect: Cytotec – hyperstimulation of the uterus, which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy, or amniotic fluid embolism. 45. What does a high vs. low Bishop’s score mean? The Bishop’s score helps identify women who would be most likely to achieve a successful induction (table 21.2 pg. 728). The duration of labor is inversely correlated with the Bishop score. - A score of over 8 indicates a successful vaginal birth - Scores of less than 6 usually indicate that a cervical ripening method should be used prior to induction 46. What is prolonged ROM and what risks does it pose? Release of membranes greater than 24 hours – the woman’s risk for infection (chorioamnionitis, endometritis, sepsis, and neonatal infections) increases and this risk continues to increase as the duration of rupture time increases. 47. Which assessment must be carried out immediately when the membranes rupture? 48. VBAC—which women should be cautious about it? Vaginal Birth After Cesarean – contraindications of to VBAC include a prior classic uterine incision, prior transfundal uterine surgery (myomectomy), uterine scar other than low-transverse cesarean scar, contracted pelvis, and inadequate staff or facility if an emergency cesarean birth in the event of uterine rupture is required. 49. What is amnioinfusion and what precautions must be taken when women have this procedure done? A technique in which a volume of warmed, sterile, normal saline or Ringer’s lactate solution is introduced into the uterus through an intrauterine pressure catheter to increase the volume of fluid when oligohydramnios is present. It is used to change the relationship of the uterus, placenta, cord, and fetus to improve placental and fetal oxygenation. Instilling an isotonic glucose-free solution into the uterus helps to cushion the umbilical cord to prevent compression or dilute thick meconium. Overdistention of the uterus is a risk, so the amount of fluid infused must be monitored closely. Should reach therapeutic result in 30 minutes. 50. A woman comes to the hospital because she says she is 42 weeks and wants to be induced. What would the admitting clinician want to establish first? (Think about this carefully!) A good health history to determine actual estimated due date. 51. Be able to select tocolytic medications out of a list of drugs. - Magnesium sulfate – reduces the muscle’s ability to contract - Terbutaline (brethine, a beta-adrenergic) - Indomethacin (Indocin, a prostaglandin synthetase inhibitor) - Nifedpine (Procardia, a CCB) 52. How can we teach women to treat their own preterm labor (teaching guidelines 21.1). Remember, dehydration will start preterm labor “from scratch” even in women who are at low risk. They MUST drink a lot of water! - Avoid traveling for long distances in cars, train, planes, or buses - Avoid lifting heavy objects, such as laundry, groceries, or a young child - Avoid performing hard, physical work, such as yard work, moving of furniture, or construction - Visit a dentist in early pregnancy to evaluate and treat periodontal disease - Enroll in a smoking cessation program if you are unable to quit on your own - Curtail sexual activity until after 37 weeks if experiencing preterm labor symptoms - Consume a well-balanced nutritional diet to gain appropriate weight - Avoid the use of substances such as marijuana, cocaine, and heroin - Identify factors and areas of stress in your life, and use stress mgmt. techniques to reduce them - If you are experiencing intimate partner violence, seek resources to modify the situation Recognize the signs and symptoms of preterm labor and notify your birth attendant if any occur: - Uterine contractions, cramping, or low back pain - Feeling of pelvic pressure or fullness - Nausea, vomiting, and diarrhea - Leaking of fluid from vagina If you are experiencing any of these signs or symptoms do the following: - Stop what you are doing and rest for 1 hour - Empty your bladder - Lie down on your side - Drink two to three glasses of water - Feel your abdomen and make note of the hardness of the contraction. Call your health care provider and describe the contraction as: o Mild if it feels like the tip of the nose o Moderate if it feels like the tip of the chin o Strong if it feels like your forehead Newborns 53. How can we promote good developmental care for premies? Developmentally supportive care is defined as care of a newborn or infant to support positive growth and development. Developmental care focuses on what newborns or infants can do at that stage of development; it uses therapeutic interventions only to the point that they are beneficial; and it provides for the development of the newborn-family unit. Developmental care includes these strategies: - Clustering care to promote rest and conserve the infant’s energy - Flexed positioning to simulate in utero positioning - Environmental management to reduce noise and visual stimulation - Kangaroo care to promote skin-to-skin sensation - Placement of twins in the same isolette or open crib to reduce stress - Activities to promote self-regulation and state regulation: o Surrounding the newborn with nesting rolls/devices o Swaddling with a blanket to maintain the flexed position o Providing sheepskin or a waterbed to simulate uterine environment o Providing non nutritive sucking (calms the infant) o Providing objects to grasp (comforts the newborn) - Promotion of parent-infant bonding by making parents feel welcome in the NICU - Open, honest communication with parents and staff - Collaboration with the parents in planning the infant’s care 54. How do premies differ from term babies? Preterm newborns are at high risk for numerous problems and require special care. Common physical characteristics of preterm infants may include: - Birth weight of less than 5.5 lb - Scrawny appearance - Head disproportionately larger than chest circumference - Poor muscle tone - Minimal subcutaneous fat - Undescended testes - Plentiful lanugo (soft, downy hair), especially over the face & back - Poorly formed ear pinna, with soft, pliable cartilage - Fused eyelids - Soft and spongy skull bones, especially along suture lines - Matted scalp hair, wooly in appearance - Absent to few creases in the soles and palms - Minimal scrotal rugae in male infants; prominent labia & clitoris in female infants - Thin, transparent skin with visible veins - Breast and nipples not clearly delineated - Abundant vernix caseosa 55. How should nurses promote bonding in parents of premies? Early interruptions in the bonding process and concern about the newborn’s survival can create extreme anxiety and interfere with attachment. Nursing interventions aimed at reducing parental anxiety include: - Reviewing with them the events that have occurred since birth - Providing simple relaxation and calming techniques (visual imagery, breathing) - Exploring their perceptions of the newborn’s condition and offering explanations - Validating their anxiety and behaviors as normal reactions to stress and trauma - Providing a physical presence and support during emotional outbursts - Exploring the coping strategies they used successfully in the past and encouraging their use now - Encouraging frequent visits to the NICU - Addressing their reactions to the NICU environment and explaining all equipment used - Identifying family and community resources available to them 56. What are risk factors for RDS? a. Risk factors: • preterm birth, perinatal asphyxia regardless of gestational age, neonatal sepsis, cesarean birth in the absence of preceding labor (due to the lack of thoracic squeezing), male gender, and maternal diabetes. It is believed that each of these conditions has an impact on surfactant production, thus resulting in RDS in the term infant. 57. What are normal blood sugars in neonates, and how do we treat hypoglycemia? a. Blood glucose levels <40 mg/dL for term newborns b. <20 mg/dL for preterm newborns c. At birth the newborn’s glucose level is 70% of the mother’s serum glucose. 58. What are S/S of hypoglycemia in neonates? a. Neonates: weak cry, seizures, hypotonia b. Most newborns experience transient hypoglycemia and are asymptomatic. Symptoms when present are nonspecific and include: jitteriness, lethargy, cyanosis, apnea, seizures, high-pitched or weak cry, hypothermia, and poor feeding. c. If hypoglycemia is prolonged or is left untreated, serious, long-term adverse neurologic sequelae such as learning disabilities and intellectual disabilities can occur. d. Treatment- administration of a rapid-acting source of glucose such as a sugar/water mixture or early formula-feeding. In acute, severe cases, IV administration of glucose may be required. 59. What is retinopathy of prematurity and how can it be prevented? a. major cause of blindness in preterm newborns b. ROP is a potentially blinding eye disorder that occurs when abnormal blood vessels grow and spread through the retina, eventually leading to retinal detachment. c. The incidence of ROP is inversely proportional to the preterm baby’s birth weight. d. 50% to 70% in infants whose weight is less than 1,250 g at birth. e. Predisposing factors for the development of ROP include: • preterm birth • low birth weight • level of oxygen saturation • genetics • severity of underlying illnesses present at birth • Additionally, the level of oxygen saturation and genetics seem to play a role in the severity of ROP. f. ROP typically develops in both eyes secondary to an injury such as hyperoxemia due to prolonged assistive ventilation and high oxygen exposure, acidosis, and shock. g. Patho: an infant born at term has retinal vessels that are almost completely developed. However, when the infant is born preterm, normal blood vessel development is interrupted. In terms of the developing retina, preterm birth interrupts the normal development of the vascular bed that will nourish the eye. The lack of blood vessels in the retina initiates anaerobic metabolism, further increasing the already existing hypoxia. Without blood flow through the eye, the retina is deprived of oxygen and its metabolic needs go unmet. h. ROP is classified in five stages, ranging from mild (stage I) to severe (stage V). The grades are based on three criteria: (1) severity, (2) location by zones in the retina, and (3) extent or proportion of the retinal circumference. i. The key to treating ROP is prevention, by minimizing the risk of preterm birth through providing quality prenatal care and health counseling to all pregnant women. j. Typically, stages I and II resolve on their own and require only periodic evaluation by the ophthalmologist. For more advanced stages, surgical intervention such as laser photocoagulation therapy or cryotherapy can be done. Laser photocoagulation is the most common treatment modality. 60. Be able to pick out signs and symptoms of SGA out of a line-up of possible symptoms. a. Newborns are considered SGA (small for gestational age) when they weigh less than 2,500 g (5 lb 8 oz) or fall below the 10th percentile on a growth chart for gestational age. b. Characteristics of SGA: • Head disproportionately large compared to rest of body • Wasted appearance of extremities • Reduced subcutaneous fat stores • Decreased amount of breast tissue • Scaphoid abdomen (sunken appearance) • Wide skull sutures secondary to inadequate bone growth • Poor muscle tone over buttocks and cheeks • Loose and dry skin that appears oversized • Thin umbilical cord c. Newborns who experience nutritional deficiencies in utero and are born SGA are at risk for cognitive deficits that can undermine their academic performance throughout their lives. SGA infants are associated with increased neonatal morbidity and mortality as well as short stature, cardiovascular disease, insulin resistance, diabetes mellitus type 2, dyslipidemia, and end-stage renal disease in adulthood. In addition, SGA children have decreased levels of intelligence and cognition, although the effects are mostly subtle. d. Assessment of the SGA infant begins by reviewing the maternal history to identify risk factors such as smoking, drug abuse, chronic maternal illness, hypertension, multiple gestation, or genetic disorders. 61. How are postpartum women whose babies have died in birth (or are stillborn) different from those who have living babies? • Provide accurate, understandable information to the family. • Be knowledgeable about the grief process and comfortable in sharing another’s grief. • Utilize active listening to provide needed encouragement to the family members to open up to their feelings. • Create a warm, receptive, accepting, and caring environment conducive to dialogue. • Encourage discussion of the loss and venting of feelings of grief and guilt. • Provide the family with baby mementos and pictures to validate the reality of death. • Allow unlimited time with the stillborn infant after birth to validate the death; provide time for the family members to be together and grieve; offer the family the opportunity to see, touch, and hold the infant. • Use appropriate touch, such as holding a hand or touching a shoulder. • Inform the chaplain or the religious leader of the family’s denomination about the death and request his or her presence. • Assist the parents with the funeral arrangements or disposition of the body. • Provide the parents with brochures offering advice about how to talk to other siblings about the loss. • Refer the family to the support group SHARE Pregnancy and Infant Loss Support, Inc., which is designed for those who have lost an infant through abortion, miscarriage, fetal death, stillbirth, or other tragic circumstances. • Make community referrals to promote a continuum of care after discharge. 62. Where does drying the newborn fit into resuscitation efforts when there is a problem at birth? a. Dry the newborn quickly with a warm towel and then place him or her under a radiant heater to prevent rapid heat loss through evaporation. Handling and rubbing the newborn with a dry towel may be all that is needed to stimulate breathing. If the newborn fails to respond to stimulation, then active resuscitation is needed. 63. What are signs and symptoms of neonatal overstimulation? a. overstimulation may have negative effects by reducing oxygenation and causing stress. b. A newborn reacts to stress by flaying the hands or bringing an arm up to cover the face. c. When overstimulated (e.g., by noise, lights, excessive handling, alarms, and procedures) and stressed, heart and respiratory rates decrease and periods of apnea or bradycardia may follow. 64. How can do neonates display over and under-hydration? a. Monitor hydration status (weight, specific gravity of urine and urine output). b. signs of dehydration: decrease in urinary output, sunken fontanels, temperature elevation, lethargy, and tachypnea 65. What is nursing care for an infant with omphalocele? a. An omphalocele is a defect of the umbilical ring that allows evisceration of the abdominal contents into an external peritoneal sac. b. they may be limited to bowel loops or may include the entire gastrointestinal tract and liver. c. Nurse management: • preventing hypothermia • maintaining perfusion to the eviscerated abdominal contents by minimizing fluid loss • protecting the exposed abdominal contents from trauma and infection. • These objectives can be accomplished by placing the infant in a sterile drawstring bowel bag that maintains a sterile environment for the exposed contents, allows visualization, reduces heat and moisture loss, and allows heat from radiant warmers to reach the newborn. d. An orogastric tube attached to low suction is used to prevent intestinal distention. e. IV therapy is administered to maintain fluid and electrolyte balance and provide a route for antibiotic therapy. f. Monitor the newborn’s fluid status frequently. g. Closely observe the exposed bowel for vascular compromise, such as changes in color or a decrease in temperature, and report these immediately. 66. What is the cause of club foot? a. Clubfoot, or talipes equinovarus, is a congenital deformity that typically has four components: inversion and adduction of the forefoot, inversion of the heel and hind foot, limitation of extension of the ankle and subtalar joint, and internal rotation of the leg. b. Clubfoot is a complex, multifactorial deformity with genetic and intrauterine factors. Heredity and race seem to factor into the incidence, but the means of transmission and the etiology are unknown. Most newborns with clubfoot have no identifiable genetic, syndromal, or extrinsic cause. c. It is bilateral in about half of the cases and affects boys twice as often as girls. 67. Be able to select the nursing care for extrophy of the bladder out of a line- up of interventions. a. the bladder protrudes onto the abdominal wall because the abdominal wall failed to close during embryonic development. b. Wide separation of the rectus muscles and the symphysis pubis accompanies this defect. c. Virtually all affected male infants have associated epispadias. d. Nursing care: • Identify the genitourinary defect at birth so that immediate treatment can be provided. • Cover the exposed bladder with a sterile clear nonadherent dressing to prevent hypothermia and infection. • Irrigate the bladder surface with sterile saline after each diaper change to prevent infection. • Assist with insertion and monitoring of a suprapubic catheter to drain the bladder and prevent obstruction. • Administer antibiotic therapy as ordered to prevent infection. • Schedule diagnostic tests to assess for additional anomalies. • Assess the newborn frequently for any signs of infection. • Inspect skin surfaces frequently to ensure skin integrity. • Maintain modified Bryant traction for immobilization after surgery. • Administer antispasmodics, analgesics, and sedatives as ordered to prevent bladder spasm and provide comfort. • Educate the parents about the care of the urinary catheter at home if applicable. • Support the parents throughout. • Promote bonding by encouraging the parents to visit and touch the newborn. • Refer the parents to a support group to enhance their coping ability. • Be a therapeutic listener to the family 68. What effects do the different illegal drugs cause to fetuses and neonates? a. Alcohol- birth defects, such as structural anomalies and behavioral and neurocognitive disabilities, brain, craniofacial, and heart defects, neurotoxicity, and immune systems dysfunction, IUGR, leading cause of intellectual disability. b. Cocaine- Vasoconstriction, gestational hypertension, abruptio placentae, abortion, “snow baby syndrome,” CNS defects, IUGR. Cocaine use produces vasoconstriction, tachycardia, and hypertension in both the mother and the fetus. Low birth weight, the most common effect of cocaine. increased the risk of preterm labor, intrauterine fetal distress and demise, seizures, withdrawal, and cerebral infarcts. Cocaine may increase the risk of uterine rupture and congenital anomalies. Fetal anomalies associated with cocaine use in early pregnancy involve neurologic problems such as neural tube defects and microcephaly; cardiovascular anomalies such as congenital heart defects; genitourinary conditions such as prune belly syndrome, hydronephrosis, and ambiguous genitalia; and gastrointestinal system problems such as necrotizing enterocolitis. Some infants exposed to cocaine in utero show increased irritability and are difficult to calm and soothe to sleep. c. Marijuana- Anemia, inadequate weight gain, “amotivational syndrome,” hyperactive startle reflex, newborn tremors, prematurity, IUGR. Although marijuana is not considered teratogenic, many newborns display altered responses to visual stimuli, increased tremulousness, and a high-pitched cry, which might indicate CNS insults. d. Opiates and Narcotics- (opium, heroin, morphine, codeine, hydromorphone, oxycodone, meperidine (Demerol, demise), and methadone) Maternal and fetal withdrawal, fetal withdrawl or neonatal abstinence syndrome includes a collection of symptoms such as irritability, hypertonicity, excessive and often high-pitched cry, vomiting, diarrhea, feeding disturbances, respiratory distress, disturbed sleeping, excessive sneezing and yawning, nasal stuffiness, diaphoresis, fever, poor sucking, tremors, and seizures. Other effects of opiates and narcotics are abruptio placentae, preterm labor, premature rupture of membranes, perinatal asphyxia, newborn sepsis and death, intellectual impairment, IUGR, and preeclampsia. Use of heroin during pregnancy is believed to affect the developing brain of the fetus and may cause behavioral abnormalities in childhood. e. Sedatives- CNS depression, newborn withdrawal, maternal seizures in labor, newborn abstinence syndrome, delayed lung maturity, more prone to respiratory problems, feeding difficulties, disturbed sleep, sweating, irritability, and fever. Also behavior problems and birth defects. f. Methamphetamine - increased risk for preterm births, placental abruption, fetal growth restriction, and congenital anomalies. g. Nicotine- Vasoconstriction, reduced uteroplacental blood flow leading to fetal hypoxia, decreased birth weight, abortion, prematurity, abruptio placentae, fetal demise. Smoking has also been considered an important risk factor for low birth weight, SIDS, and cognitive deficits, especially in language, reading, and vocabulary, as well as poorer performances on tests of reasoning and memory. Researchers have also reported behavior problems, such as increased activity, inattention, impulsivity, opposition, and aggression. 69. What are signs and symptoms of Down’s syndrome, and how are these different from hypothyroidism and fetal alcohol syndrome? a. S&S: Down syndrome- • Small, low-set ears • Hyperflexibility • Muscle hypotonia • Wide-spaced eyes • Ulnar loop on the second digit • Deep crease across palm (termed a simian crease) • Flat facial profile • Small white, crescent-shaped spots on irises • Open mouth with protruding tongue • Broad, short fingers b. Fetal alcohol syndrome- thin upper lip, small head circumference, and small eyes, low nasal bridge, short palpebral fissures, short nose, flat face, receding jaw, epicanthal folds. c. Hypothyroidism- Large protruding tongue, slow reflexes, distended abdomen, large, open posterior fontanel, constipation, hypothermia, poor feeding, hoarse cry, dry skin, coarse hair, goiter, and jaundice. 70. What are dietary restrictions of infants with galactosemia and PKU? a. PKU: Dietary restriction of phenylalanine, with regular monitoring of serum phenylalanine levels. b. Galactosemia: Lifelong lactose-restricted diet is needed to prevent intellectual disability, liver disease, and cataracts. 71. How is RDS manifested and treated? a. expiratory grunting, nasal flaring, chest wall retractions, seesaw respirations, and generalized cyanosis. b. Auscultate the heart and lungs, noting tachycardia (rates above 150 to 180), fine inspiratory crackles, and tachypnea (rates above 60 breaths per minute). c. Use the Silverman-Anderson index assessment tool to determine the degree of respiratory distress. A score over 7 suggests severe respiratory distress. d. The diagnosis of RDS is based on the clinical picture and x-ray findings. A chest x-ray reveals hypoaeration, underexpansion, and a “ground glass” pattern. e. Treatment: conventional mechanical ventilation, continuous positive airway pressure (CPAP), or positive end-expiratory pressure (PEEP) to prevent volume loss during expiration, and surfactant therapy, treatment with high-frequency oscillatory ventilation, use of exogenous surfactant replacement therapy to stabilize the newborn’s lungs until postnatal surfactant synthesis matures has become a standard of care. f. For newborns with RDS to experience the best outcomes, it is essential that they have optimal supportive care, including maintenance of a normal body temperature, proper fluid management, good nutritional support, and support of the circulation to maintain adequate tissue perfusion. g. Nursing management: • Administer broad-spectrum antibiotics if blood cultures are positive. • Administer sodium bicarbonate or acetate as ordered to correct metabolic acidosis. • Provide fluids and vasopressor agents as needed to prevent or treat hypotension. • Test blood glucose levels and administer dextrose as ordered for prevention or treatment of hypoglycemia. • Cluster caretaking activities to avoid overtaxing and compromising the newborn. • Place the newborn in the prone position to optimize respiratory status and reduce stress. • Perform gentle suctioning to remove secretions and maintain a patent airway. • Assess level of consciousness to identify intraventricular hemorrhage. • Provide sufficient calories via gavage and IV feedings. • Maintain adequate hydration and assess for signs of fluid overload. 72. What are S/S of NEC? a. Necrotizing enterocolitis (NEC) is a serious gastrointestinal disease. S/S: • Abdominal distention and tenderness • Bloody or hemocult positive stools • Diarrhea • Temperature instability • Feeding intolerance, characterized by bilious vomiting • Signs of sepsis • Lethargy • Apnea • Shock b. As the disease worsens, the infant develops signs and symptoms of septic shock (respiratory distress, temperature instability, lethargy, hypotension, and oliguria). c. Note respiratory distress, cyanosis, lethargy, decreased activity level, temperature instability, feeding intolerance, diarrhea, bile-stained emesis, or grossly bloody stools. Assess blood pressure, noting hypotension. Evaluate the neonate’s abdomen for distention, tenderness, and visible loops of bowel. Measure the abdominal circumference and if there is an increase or not. Determine residual gastric volume prior to feeding; when it is elevated, be suspicious for NEC. 73. How is pulmonary hypertension diagnosed? a. characterized by marked pulmonary hypertension that causes right-to-left extrapulmonary shunting of blood and hypoxemia. b. Measure oxygen saturation via pulse oximetry and report low values. Prepare the newborn for an echocardiogram, which will reveal right-to-left shunting of blood that confirms the diagnosis. 74. How is intraventricular hemorrhage manifested? a. It is a common problem in preterm infants, especially in those born before 32 weeks. b. Bleeding occurs initially in the immediate periventricular areas causing a “periventricular” hemorrhage or “PVH.” If the bleeding persists, the expanding volume of blood dissects into the adjacent lateral ventricles leading to an “intraventricular” hemorrhage or “IVH.” c. unexplained drop in hematocrit, pallor d. poor perfusion as evidenced by respiratory distress and oxygen desaturation e. Note seizures, lethargy or other changes in level of consciousness, weak suck, high- pitched cry, or hypotonia. f. Palpate the anterior fontanel for tenseness. Assess vital signs, noting bradycardia and hypotension. g. Evaluate laboratory data for changes indicating metabolic acidosis or glucose instability. h. Changes in the level of consciousness, bulging fontanel, seizures, apnea, and reduced activity level. 75. What are epispadius and hypospadias? a. Hypospadias is an abnormal positioning of the urinary meatus on the underside of the penis. • Hypospadias- can lead to urination and erection problems and infertility in adulthood. b. Epispadias is a rare congenital genitourinary defect. • In boys the urethra generally opens on the top or side rather than the tip of the penis. • In females, the urinary meatus is located between the clitoris and the labia. • This anomaly often occurs in conjunction with exstrophy of the bladder. • Surgical correction is necessary, and affected male newborns should not be circumcised. 76. Be able to select the signs and symptoms of an infant whose mother had gestational diabetes from a line-up of manifestations. a. Gestational diabetes is associated with either neonatal complications such as macrosomia, hypoglycemia, and birth trauma or maternal complications such as preeclampsia and cesarean birth. b. Fetal S&S: • Cord prolapse secondary to hydramnios and abnormal fetal presentation • Congenital anomaly due to hyperglycemia in the first trimester (cardiac problems, neural tube defects, skeletal deformities, and genitourinary problems) • Macrosomia resulting from hyperinsulinemia stimulated by fetal hyperglycemia • Preterm birth secondary to hydramnios and an aging placenta, which places the fetus in jeopardy if the pregnancy continues • Fetal asphyxia secondary to fetal hyperglycemia and hyperinsulinemia • Intrauterine growth restriction secondary to maternal vascular impairment and decreased placental perfusion, which restricts growth • Respiratory distress syndrome resulting from poor surfactant production secondary to hyperinsulinemia inhibiting the production of phospholipids, which make up surfactant • Polycythemia due to excessive red blood cell (RBC) production in response to hypoxia • Hyperbilirubinemia due to excessive RBC breakdown from hypoxia and an immature liver unable to break down bilirubin • Neonatal hypoglycemia resulting from ongoing hyperinsulinemia after the placenta is removed • Subsequent childhood obesity and carbohydrate intolerance 77. When is ECMO used? What sort of diagnoses are treated by it? a. ECMO is a modified type of heart–lung machine. Extracorporeal membrane oxygenation (ECMO), a process that mimics the gas exchange process of the lungs. b. used in- Congenital diaphragmatic hernia (CDH), Meconium aspiration syndrome (MAS), persistent pulmonary HTN 78. What are S/S of sepsis in the neonate? a. signs and symptoms of septic shock: respiratory distress, temperature instability, lethargy, hypotension, and oliguria 79. What are nursing interventions in the care of an infant with neural tube defects? a. Spina bifida occulta- is primarily supportive b. Most newborns with anencephaly are stillborn; those born alive die within a few days. c. Meningocele- closely monitor the skin covering the area for evidence of CSF leakage. Prepare the newborn and parents for surgery. d. Myelomeningocele: • Use strict aseptic technique when caring for the defect to prevent infection. • Avoid trauma to the sac (to prevent leakage of CSF or damage to the nerve tissue) through prone or side-lying positioning. • Avoid placing a diaper over the sac to prevent rupture or infection by fecal contamination. • Apply a sterile dressing or protective covering over the sac to prevent rupture and drying, with frequent changes to prevent the dressing from adhering to the defect. • Frequently monitor the sac for signs of oozing fluid or drainage. • Preserve skin integrity on and around the spinal defect. • Meticulously clean the genital area to avoid contamination of the sac. • Infants with myelomeningocele are at increased risk for latex allergy due to their repeated and numerous exposures to products containing latex during surgery and other necessary treatments. e. All NTD: • neutral thermal environment and avoid hypothermia • Assess movement and sensation below the defect; also assess urinary and bowel elimination, which may be affected based on the level of the lesion. • Measure head circumference daily to observe for hydrocephalus. 80. What are S/S of hyperbilirubinemia? How is it treated, and how do nurses administer phototherapy? a. Jaundice is the visible manifestation of hyperbilirubinemia. b. In most infants, an increase in bilirubin production (e.g., due to hemolysis) is the primary cause of physiologic jaundice. c. S&S: Elevated serum bilirubin levels • Jaundice • Tea-colored urine • Clay-colored stools d. treat newborns with phototherapy or exchange transfusion to prevent acute bilirubin encephalopathy. e. Phototherapy involves exposing the newborn to ultraviolet light, which converts unconjugated bilirubin into products that can be excreted through feces and urine. • The serum level of bilirubin at which phototherapy is initiated is a matter of clinical judgment by the physician, but it is often begun when bilirubin levels reach 12 to 15 mg/dL in the first 48 hours of life in a term newborn. • phototherapy has generally been administered with either banks of fluorescent lights or spotlights • for phototherapy to be effective, the rays must penetrate as much of the skin as possible. Thus, the newborn must be naked and turned frequently to ensure maximum exposure of the skin and eye pads are worn by the infant. • When caring for newborns receiving phototherapy for jaundice, nurses must do the following: • Closely monitor body temperature and fluid and electrolyte balance. • Document frequency, character, and consistency of stools. • Monitor hydration status (weight, specific gravity of urine and urine output). • Turn frequently to increase the infant’s skin exposure to phototherapy. • Observe skin integrity (as a result of exposure to diarrhea and phototherapy lights). • Provide eye protection to prevent corneal injury related to phototherapy exposure. • Encourage parents to participate in their newborn’s care to prevent parent–infant separation. f. Recently, fiber-optic pads (Biliblanket or Bilivest) have been developed that can be wrapped around the newborn or on which the newborn can lie. • The pads do not produce appreciable heat like the banks of lights or spotlights do, so insensible water loss is not increased. Eye patches also are not needed; thus, parents can feed and hold their newborns continuously to promote bonding.