NUR 201 Maternity/Peds Exam 2_Latest,100% CORRECT

NUR 201 Maternity/Peds Exam 2_Latest Gestational Diabetes (6 questions on exam) • Metabolism o Metabolism  Digest Absorb Transport o Glucose is transported inside he cell by Insulin o #1 see if not transporting ...

NUR 201 Maternity/Peds Exam 2_Latest Gestational Diabetes (6 questions on exam) • Metabolism o Metabolism  Digest Absorb Transport o Glucose is transported inside he cell by Insulin o #1 see if not transporting glucose into cell = No energy for patient, Fatigue o Glucose used by the cells for energy o Type I & Type II glucose cannot get inside the cell o Glucose does not want to be in blood stream it wants to be in cell, too much glucose in the blood = Hyperglycemic o Can lack Insulin or have problems with function of Insulin (can’t bring into the cell) • Gestational Diabetes Pathophysiology o Two-part complication o One complication ▪ Anti-insulin effect of hPL (insulin antagonist) in the maternal circulation so glucose can go to baby ▪ hPl blocks effect of insulin going into mothers cell because it wants the insulin to go to baby’s cells ▪ Then Hyperglycemia in Mom—too much glucose in the blood ▪ After delivery of the placenta, insulin requirements usually decreases abruptly with the loss of hPL in the maternal circulation o 2nd Complication that can happen ▪ Pancreas doesn’t produce enough insulin to meet the demand of the pregnancy (need enough insulin for mama & baby) ▪ So Insulin requirements rise in Second trimester because baby is growing more ▪ Leads hyperglycemia in mom---too much glucose in blood • Glucose Metabolism o The nurse and patient must be able to recognize when it is impaired o Both must know signs of hyperglycemia & hypoglycemia o Moms start symptoms of gestational diabetes at 20-24 weeks (2nd trimester) • Signs & Symptoms o Hypoglycemic BG (blood glucose) less than 70 ▪ Reduced cognition ▪ Tremors ▪ Diaphoresis ▪ Weakness ▪ Hunger ▪ Headache ▪ Irritability ▪ Seizure o Euglycemic BG 70-140 ▪ Pre and post prandial (after mom has eaten) o Hyperglycemic Post prandial greater than 140 BG ▪ Polyuria ▪ Polydipsia (thirsty) ▪ Dehydration ▪ Fatigue ▪ Fruity odor to breath ▪ Kussmaul breathing ▪ Weight loss ▪ Hunger ▪ Poor wound healing o What assessment tool does the RN use in practice to determine the efficiency of practice of insulin to transport glucose into the cell? ▪ Accu-check ▪ Too high of result=glucose not be transported into the cell o Risk Factors GB ▪ Advanced Maternal Age – 35 older ▪ BMI greater 29 overweight ▪ Previous episode of GD—at risk but does not mean will get it again ▪ High fat diet/high glycemic—food has to be both not just one • (example bacon is not both it is not high glycemic only high fat) • Use whole wheat pasta & low fat pasta sauce ▪ Sedentary lifestyle ▪ Women with gestational diabetes are at risk for type II diabetes later on in life ▪ Hydramnios--- or an increase in the volume of amniotic fluids, result of excessive fetal urination b/c of fetal hyperglycemia o When mother has hyperglycemia how is the growth of the baby affected? ▪ Baby has increasing tissue & fat deposits (because high levels of insulin production stimulated by the high levels of glucose crossing the placenta) ▪ So baby is often larger than expected gestational age • Called Macrosomia-- >4,000g or more than 8ibs & 13oz ▪ Increased risk for birth defect including problems with formation of the heart, brains, spinal cord, urinary tract, & gastrointestinal system • Sacral agenesis—appears only in mothers with diabetes, the sacrum & lumbar spine fail to develop and the lower extremities develop incompletely ▪ Possibility not enough surfactant so problems breathing o How does hyperglycemia influence delivery? ▪ Baby being larger could mean baby gets wedged in birth canal ▪ Could cause lacerations of maternal perineal tissue during birth ▪ Baby could have birth injuries ▪ Hyperbilirubin • (Bilirubin is orange- yellow pigment formed in the liver by the breakdown of hemoglobin and excreted in bile—leads to jaundice in baby) • Baby becomes hypoglycemic when cord is cut during birth • A newborn with a Bilirubin level greater than or equal to 8mg/dL needs phototherapy Tx o Interrelate Concepts ▪ Nutrition • Diet high in fat & high glycemic increases blood glucose • Can’t decrease calories b/c pregnant ▪ Acid/Base balance • Can go into ketoacidosis & alkalosis—sugar hanging in vascular area • Blood becomes acidic • Pregnant women go into ketoacidosis much faster at 300BG where as normal people is in 600 ▪ Perfusion • Kussmaul breathing • Decreased perfusion to extremities toes & fingers • Increased vascular resistance • Most of perfusion takes place in placenta, hyperglycemia damages the placenta ▪ Elimination • Polyuria • Go to bathroom to flush glucose out (kidneys) • Baby is also peeing more which goes into amniotic fluid & gets bigger & bigger till it can pop—called Hydramnios (leads to premature labor) ▪ Sensory perception • Blocks nerves leading to neuropathies • Pins & needles • Especially affects eyes, toes, & fingers ▪ Mobility • If glucose can’t get in the cell then mom has no energy • Exercise decreases glucose in the blood ▪ Infection • Neuropathies in lower extremities—less able to feel cuts • Decreased healing • Increased UTI’s & yeast infections (b/c love glucose) ▪ Teaching & learning • #1 teach how to recognize when blood sugar is too high or too low • Teach meds • Teach how to take blood sugar ▪ Reproduction • If had GD (Gestational Diabetes) before does not mean will have next pregnancy but increases the risk ▪ Growth and development • Babies are bigger with GB mothers o Risks to Mom ▪ Increased amniotic fluid (from baby’s increased urination)—called hydramnios ▪ Vascular disease ▪ Ketoacidosis— too much glucose in blood, not good for baby, usually born as still born ▪ Difficult labor—baby is bigger ▪ Yeast and urinary tract infections ▪ Neuropathy and retinopathy o Treatment Plan ▪ During birth mom’s glucose levels are measured hourly to determine if glucose is needed (need more energy for birth so need insulin to let glucose in the cells ) ▪ During Birth long-acting insulin should be reduced or stopped and regular insulin should be used to ▪ Intravenous insulin (5% dextrose solution used with a saline solution) is discontinued with the completion of the third stage of labor (placenta) ▪ Monitor mom 4-6 times a day b/c trouble with lower levels BG ▪ No oral insulins ▪ Introduce exercise & counseling esp. if wants to be pregnant again ▪ Dietary Regulation: increase caloric intake ▪ Glucose Monitoring: more frequently ▪ Insulin Administration: mixture of intermediate and regular • NPH- Intermediate acting. Do not use if its an emergency • DO NOT use oral insulins because don’t know how it affects the baby • ▪ Evaluation of fetal status o Oral glucose challenge Test (GCT)---Current practice women at low risk ▪ Toward end of 2nd trimester ▪ Using 1-hr, 50-g oral glucose ▪ Oral glucose load is administered without regard to time of day or time of last meal ▪ Venous plasma glucose is measured 1 hr later ▪ A plasma level that is equal to or greater than 130-140mg/dL indicates a need for further diagnostic test ▪ If fail tis test have to do 3-hr 100g OGTT o 2 hr Oral Glucose tolerance Test (OGTT)---Maybe new practice soon for low risk Moms ▪ Recommended at 24 to 28 weeks gestation ▪ It is a 2 hr 75g oral glucose tolerance test ▪ Is done on all women not previously diagnosed with overt diabetes ▪ Are diagnosed with GB is met or exceed • Fasting 92 mg/dL • 1 hr 180 mg/dL • 2 hrs 153mg/dL o 3 hr Oral Glucose Tolerance Test (OGTT) ▪ 3hrs;s using 100-g glucose ▪ Women eats an unrestricted diet, consuming at least 150g of carbohydrates per day for at least 3 days before her scheduled test ▪ She then consumes 100-g oral glucose in the morning after an overnight fast (no eating after midnight) ▪ Plasma glucose is measured fasting and at 1 hr, 2hr, and 3hrs ▪ Women should remain seated and not smoke throughout the test ▪ Gestational diabetes is diagnosed if two or more of the following values are met or exceeded • Fasting 95mg/dL • 1 hr 180 mg/dL • 2 hrs 155mg/dL • 3 hrs 140mg/dL o Problems & solutions ▪ A gestational diabetic arrives for a scheduled doctor’s appointment and her blood sugar is 300 • Ask when her last meal was • Ask what she ate • Get urine ketones to look for acidosis • Give fast acting Insulin ▪ A client is contemplating a second pregnancy. She was a gestational diabetic in her previous pregnancy. She is now 50 pounds overweight with a BMI of 31 • Recommend to eat healthy & exercise • Teach her she has risk factors she did not have in first pregnancy • Encourage intake journal or app or weight watchers ▪ A gestational diabetic at 34 weeks gestational calls the clinic to report that she thinks she is feeling decreased fetal movement • #1 check moms blood sugar—sick babies do not move • Drink something cold= baby moves • Eat something spicy or eat something= baby should move • Music or press on belly see if baby moves • Have mom lay back and pay close attention to movements ▪ A gestational diabetic arrives at the clinic. She reports that on several occasions during the past week she has felt shaky & sweaty • Ask if she has been checking her blood sugar regularly • How often does she eat—may not be eating enough for amount of insulin needed with baby growing • 24hr diet check • Ask if she has been around anyone sick—if mom is sick blood sugar goes up o Levels of Sickness Model gestational Diabetes ▪ Sick • Elevated fasting glucose <96 (fasting should be less than 96) • Tired • Dizzy/vertigo • Trouble concentrating • UTI/yeast infection ▪ Sicker • Increased thirst • Increased urination • Increased hunger • Dry mucous membranes (tongue, gums) • Fatigue • Weight loss • Sweaty • Increase in amniotic fluids— (called Hydramnios) find out when Dr measures moms belly ▪ Sickest • Ketoacidosis • Prolonged decreased fetal movement (sick babies do not move) • High high BG—300 to 500 • Premature labor • Coma if in--ketoacidosis Reproduction Part 2 (20 question son Exam) • Antepartum Care (time between conception & onset of labor. Before active true labor contractions) o Female Reproductive Cycle ▪ Placenta functions • Fetal respirations, nutrition, and excretion • Corpus Luteum (when egg is fertilized): Produces hormones- estrogen & progesterone • Progesterone effects o Primary source for nutrition for first 11 weeks until placenta big enough to take over o Allows pregnancy to be maintained o Decreases uterine motility & contractility • Estrogen effect o Increases secretions- females secondary sex characteristics (wide hips, breasts, hair) o Thickens cervical mucosa o Mucosa plug  white and acidic, prevents bacterial infections, but likes yeast infections o UTI can send mom into preterm labor o Relaxes connective tissue when labor becomes near & cervix can dilate • Miscarriages can be from hormone imbalance. Progesterone not keeping uterus closed • Vagina o Muscular membranous tube o Estrogen lets vagina become loose so mom can push the baby out (relaxes connective tissue) o Development & functions of the Placenta ▪ The placenta means of metabolic and nutrient exchange ▪ Two parts of the Placenta: • Maternal Portion o Reddish portion attached to uterus o Consist of decidua basalis with a red flesh like surface • Fetal Portion o Chorionic villi covered by the amnion o Gives a shiny gray appearance o Chorion Frondosum ▪ The Umbilical Cord • 3 vessels • 2 arteries • 1 vein o Physical & psychological Changes of Pregnancy ▪ Uterus • Provides protective environment for the baby to grow during pregnancy (pear size when start pregnancy) • Enlarges • Increased blood supply—can hold 1/6th of mothers blood supply to apply to growth of baby • Braxton Hicks Contractions—mild cramping that do not help the cervix to dilate, so they are not true contractions. Can be from dehydration. Why Moms need to drink 8-10 glasses every 24hrs ▪ Cervix • Effacement- thinning out of uterus, needs to be paper thin to deliver, have to be 100% effaced to deliver • Mucus Plug- can lose at 5 weeks before baby is due. Pinkish/Orangish. Okay as long as bag of water does no break because cord could collapse which is a true emergency, moms are than hospitalized till delivery • Mucorrhea- increase in cervical discharge for 3-4 days during ovulation—normal is egg white • Increased vascularity- normal because part of 1/6th of blood goes to uterus • Increased cervical vascularity also causes both the softening of the cervix (Goodell sign) and bluish discoloration of cervix or vagina (Chadwick sign) • Hegar sign—softening of the isthmus of the uterus, the area between the cervix & the uerus • McDonald sign- is an ease in flexing the body of the uterus against the cervix ▪ Cardiovascular System • Increased cardiac output- 1/6th mother blood supply- placenta, fetus, & uterus, & breasts • Decreased blood pressure- lowest point is 2nd trimester, decrease is only slightly o Mom can have postural hypotension- baby puts pressure on SVC when lying flat pushing for delivery. Mom often complains of feeling light headed clammy • Increased total erythrocytes: o RBC 30% o Plasma 50% o Mom may have pseudoanemia pregnancy if H&H low get iron sup. Because plasma is greater than RBC’s • Increased leukocytes: o 15,000/mm3 • Increased clotting factors 7,8,9,10 o Mom can develop DVT’s o If leg is red or hot do not rub them, point toes to ceiling and nose to prevent o Signs of Pregnancy ▪ Subjective (presumptive)—Symptoms the woman experiences and reports that can be caused by other conditions not just from pregnancy • Breast changes • Gaining weight • Amenorrhea—no period • Nausea & vomiting • Urinary frequency • Quickening—movement of the baby occurs 20 weeks (2nd trimester) this is because it could just be gas ▪ Objective (probable) changes: changes perceived by the examiner that can be caused by other causes • Pregnancy test • Changes in pelvic organs (diff. signs like Mcdonalds sign, Goodell sign) • Uterine & Funic soufflés- is a blowing sound heard in synch with fetal heart sounds, and may originate from the umbilical cord • Enlargement of the abdomen • Skin changes (darkening) ▪ Diagnostic (positive) changes: proves conclusively that the woman is pregnant • Fetal heart beat • Fetal movement • Visualization of fetus o Prenatal Care ▪ Nursing assessment & education • Identify is mom just pregnant or does she have HTN or gestational diabetes ▪ Identify education needs ▪ Anticipate the course of pregnancy • Complete client medical Hx • Routine lab tests: CBC, Rubella titer, Hep B, GBS, UA (urine analysis), 1 hr glucose and if fail then 3 hr glucose, HIV, PAP, STI’s o Some moms normal flora flip & become positive GBS (group B strep), they have to be treated 4hrs before delivery with IV penicillin • Emotional status—Hx depression • Past health care • Disease states—lupus, diabetes o Determining Number of Pregnancies ▪ TPAL Method • Gravida- all pregnancies, twins count as 1 pregnancy, includes if they are pregnant now & if they had an abortion • Para: Number of infants born (alive or dead), births after 20 weeks gestation o T=term greater than or equal to 37 weeks o P=Preterm (before 37th weeks) o A=Abortion (before the 20th wk gestation) ▪ Includes induced (mom decided) ▪ Spontaneous (miscarriage) ▪ Ectopic pregnancy o L-Living children ▪ Calculating the Delivery Date • EDD (expected date of delivery) • EDC (expected date of confinement) • EDB (expected date of birth) • Nagele’s Rule: o Most common method of determining the due date o Begin with date of last menstrual period subtract 3 months and add 7 days o 30 days in September, April, June, and November all the rest have 31 except February • Uterine Assessment o Fundal Height ▪ Measure fundus ▪ At 20 weeks should be at belly button o Promoting Health & Pregnancy ▪ Prenatal Education • Developmental Challenge • Role changes • Caring interventions o Prenatal education Classes ▪ Pelvic tilt- helps turn posterior facing babies forward facing by pushing uterus forward and back ▪ Kegel exercises • Do not stop urine mid flow for Kegel exercise because increases UTI ▪ Other Self-Care Measures • Sexual activity o Abstinence if cervix is weak, Hx of preterm deliveries, Hx STI, or multiple gestation • Dental Care o Is key because increased vascularity to the mouth o Bleeding gums increases risk for infection o Know word for bleeding gums—pregnancy gingivitis? o Periodontal disease is a contributing factor to preterm labor o Ptyalism—excessive, often bitter salivation o Increase in heartburn • Immunizations o Rubella vaccine not given when pregnant b/c it is a live virus. Titer <1:8 means susceptible. Have to have after baby delivers o TDAP- whooping cough vaccine given 3rd trimester o Varicella- chicken pox vaccine contraindicated while pregnant (live-virus) o Influenza Vaccine- given when pregnant o Teratogenic Substances ▪ Tobacco ▪ Alcohol- No alcohol b/c fetal alcohol syndrome ▪ Caffeine- decrease intake b/c stimulant an decreases iron absorption in mom so become anemic ▪ Medication (OTC) • Can only take Tylenol for pain • No marijuana o NAS (Neonatal Abstinence Scoring)- if find marijuana or drugs in mom urine screen. Observed very carefully o Assessment of Fetal Well Being ▪ Maternal Assessment of Fetal Activity • Vigorous fetal activity- measures uterus & palpate the stomach o Quickening- when baby moves o Fetal heart rate monitored • Decreased or cessation of movement o Stillbirth, fetal hypoxia, growth restriction, preterm birth, fetal death • Fetal activity monitoring o Mom and babies HR are on screen (babies is higher than mothers) watch o Order of Assessment Tests ▪ Ultrasound ▪ Nonstress Test (if fail then next test below) ▪ BPP (if fail then next test below) ▪ CST [Contraction Stress Test] o Ultrasound- One of the tests for fetal activity ▪ Abdominal Ultrasound • Allows early diagnosis of complications • High frequency sound waves • Safe and noninvasive • Need a full bladder to do Abd ultrasound- have mom drink 1-2 quarts of water • Left lateral tilt to prevent gestational Hypotension ▪ Transvaginal U/S (ultra sound) • Invasive probe inserted vaginally • Detect ectopic pregnancy, abnormalities • Nurses Role o Tell mom to empty bladder before ultrasound o Fetal Biophysical Profile (BPP) ▪ Any physical characteristics of baby ▪ Scored as good=2; nonreactive or not meeting qualifications=0 ▪ 5 responses of baby to stress either • Fetal HR- is done first, reactive to non stress= 2; nonreactive=0 • Fetal Breathing- 1 or more episodes of breathing lasting 30 secs or more in 30 minutes =2, No movement is 0 • Fetal Movement- more than 3 episodes of movement=2, less than 3 episodes of movement=0 • Fetal Tone- rapid flexion & extension=2, slow flexion & extension=zero • Amniotic fluid volume- need to score at least a 2 o Also need at least one pocket of fluid measuring 2cm to=2 o Zero pockets=0 o Amniotic fluid cushions the baby ▪ Scoring 8-10: Good unless 0 on amniotic fluid which is most important ▪ Do if mom fails Nonstress test o Nonstress Test (NST) ▪ Most widely used Tx for antepartum well being done 3rd trimester of pregnancy ▪ Evaluates fetal well being ▪ Electronic fetal monitoring: 2 belts measure fetal activity and FHR (fetal HR) ▪ Monitors responses of the FHR to fetal movement • FHR increases with fetal movement ▪ Start 30 to 32 weeks ▪ Advantages: easy to interpret & no harm ▪ Disadvantages: Mom has to lie still 20min; tracing ▪ Reactive NST/nonreactive NST • Need two accelerations of FHR with or without fetal movement • 15 bpm for 15 seconds in a 20 minutes interval ▪ Nurse’s Role • Put patient in flat in left lateral position(cushion on right side) and tell them to remain still for 20 minutes as much as possible • Tell mom to push button when she feels baby move ▪ Looks for risk of fetal death o Reactive Non Stress Test ▪ Contraction Stress Test (CST) • Do if mom fails NST, then fails BPP (biophysical profile) • Is Oxytocin (Pitocin) challenge test—makes mom contract • When mom is contracting analyze the FHR • Negative (normal finding)- a pattern of at least 3 contractions in 10 min period and no late decelerations of FHR • Positive (abnormal fining/not good)- persistent and consistent late decelerations with 50% of contractions o Because HR of baby keeps decelerating it means baby will not survive the stress of labor so have to do STAT C-section o Amniocentesis ▪ Determines gene abnormalities ▪ Aspiration of amniotic fluid analysis ▪ Done early pregnancy & 3rd trimester [29 or 30 weeks] (is baby thought to be LBW/stopped growing) ▪ Chance test could lead to infection or lose baby ▪ Evaluation of fetal health ▪ Alpha-fetoprotein (AFP)- protein made by baby’s liver • Can be measured from amniotic fluid • High levels associated with neural tube defects • Low levels associated with chromosomal defects (down syndrome, 13, & 18) ▪ Fetal lung maturity: Surfactant • Lecithin/Sphingomyelin ration 2:1 • If low or does not match 2:1 ratio may need Betamethasone shot to improve babies lung capabilities • Betamethasone given IM, 2 doses 24hrs part • Intrapartum Care (time from onset of true labor until birth of baby & explosion of placenta) o Complications of pregnancy ▪ Torch Acronym for a group of infections: • Can negatively affect women who are pregnant o Cross the placenta o Causing teratogenic effects to the fetus • Does NOT include all the major infection risks to mother/fetus • Test the blood for these infections: o T-Toxoplasmosis o O-Other viruses (measles) o R-Rubella o C-Cytomegalovirus (Herpes Virus) o H- HIV o Risk Factors ▪ Toxoplasmosis • Consumption of raw/undercooked meat o No sushi • No handling of cat feces • S&S Baby: o Fever o Malaise o Muscle aches (flulike symptoms) ▪ Cytomegalovirus • Common virus (herpes viruses) • Person to person through body fluids • Very contagious, spread through unprotected sex, & blood fluid exchange • S&S Baby: o Asymptomatic or o Mononucleosis-like symptoms-“Kissing disease” debilitating disease (causes fatigue, fever, rash, & swollen glands) o Babies with congenital CMV+ o Yellow Skin and eyes o Purple skin splotches or a rash o SGA (small gestational age), enlarged spleen & liver o Pneumonia, seizures, hearing loss, vision impairment ▪ Rubella • Spread by direct contact with nasal or throat secretions (mask) • Contracted through infected children • Newborns who are born to positive rubella mothers • Positive Rubella or Mom’s who get rubella shot should NOT get pregnant for 6 months b/c it is a live virus • S&S Baby: o Fever o Rash o Mild lymphedema o Joint and muscle pain • Antepartum (Fetus): Congenital anomalies, miscarriage, death o Care of the Women at Risk ▪ Bleeding during pregnancy • First & second trimester o Spontaneous abortion o Ectopic pregnancy • Second half of pregnancy o Placenta Previa o Placenta abruptio ▪ Ectopic Pregnancy • Abnormal implantation of ovum in fallopian tube—very painful • Do not do hCG pregnancy test if come in with pain • Stabbing pain and tenderness • Delayed/irregular menses • Scant dark red or brown vaginal spotting • Do vaginal exam/pap smear palpate are—can see very inflamed • Salpingostomy/salpingectomy— salpingostomy- removal of where egg got implanted to save the tube, salpingectomy-have to remove whole tube, • Methotrexate- Tx of choice, inhibits cell growth and prevents ovum to continue to grow ▪ Placenta Previa • Placenta abnormally implants- should implant way up uterus but instead implants low in the cervix • Painless bright red vaginal bleeding • Go to Dr. if any vaginal bleeding • Types of placenta previa:-- if first trimester deliver may deliver vag b/c can move o Marginal/Low- lying: placenta attached in lower segment but doesn’t reach the cervical os (The opening of the uterine cervix)—Need C-section o Incomplete/partial: os is only partially covered o Complete/Total: cervical os completely covered o ▪ Placenta Abruptio • True emergency • Premature separation of the placenta from the uterine wall—very painful • Sudden onset • Rushed to C-section- not even husband is allowed in have to get baby right out • Pain severe & steady • Vaginal bleeding o Bright red or dark • Board-like abdomen • Firm rigid uterus with CX o Preterm Labor ▪ Labor that occurs between 20 and 36 weeks gestation • Before 37 weeks gestation or 3 wks before the due date ▪ Preterm labor can be stopped if identified early ▪ Treatment of choice uterine relaxant= Ritodrine Hydrochloride o Risk factors ▪ Things that may put women at risk include: • Previous preterm birth • Twin or triplet pregnancy • Medical problems such as high blood pressure, diabetes, kidney or lung disease • Infections of the uterine tract (UTIs) o If mom complains of burning when peeing could go into preterm labor • Age below 17 or above 35 • Smoking and substance abuse • Hx of multiple miscarriages or abortions • Uterine abnormalities o True labor VS False Labor ▪ True Labor Contractions: • Get closer together, last longer, and increase in intensity • Discomfort in back and/or lower abdomen • Do not stop with walking—instead contraction intensifies, strengthens, & consistency of contractions increase • Dilate the cervix ▪ False Labor Contractions: • Do not get closer together or increase in intensity • Discomfort primarily in lower abdomen • May be relieved with walking, resting, or hydration • Does not dilate cervix o Pharmacological Therapies ▪ Induce labor & stop preterm labor • Uterine Stimulants (Oxytocics) o Oxytocin (Pitocin) o Puts mom into labor o IV access for all moms to help progress through labor o Makes uterus contract • Uterine relaxants (tocolytics, beta 2 adrenergic agonist) o Ritodrine Hydrochloride—Tx of choice for preterm labor o Terbutaline Sulfate o Magnesium sulfate o Nifedipine (Procardia, Adalat)—also used for heart issues ▪ Adverse effects • HA (headache) • Flush • Nausea • Orthostatic hypotension • Light headed o Indomethacin (Indocin)—bocks prostaglandins to suppress contractions o Betamethasone (Celestone)—glucocorticoid, help mature babies lungs. IM 2 injections 24 hrs apart if lungs surfactant not 2:1 ratio • Vitamin and mineral supplement o Fetal Assessment during Labor ▪ Assessment of contractions • External monitoring—most moms start. See on screen when contraction will occur • Internal monitoring—see strength of contraction. Done by physician. FSE (fetal scalp electrode) in lays next to babies head o Baseline fetal HR o Fetal tachycardia o Fetal bradycardia ▪ Types • Early Deceleration—HR have early decelerations. Not negative is OK • Late Decelerations—contraction come & HR decreases—BAD • Variable decelerations—contraction & have variable HR changes could be complication of baby • If baby’s cord comes out of mom= compressed cord and makes baby hypoxic, Put hand in mom & push baby’s head off of the cord/ push cord back in ▪ Leopold Maneuvers: • Consist of performing external palpations of the maternal uterus through the abdominal wall to determine: o Number of fetuses o Presenting parts, fetal lie, and fetal attitude o Degree of descent of the presenting part into the pelvis o Expected location of the point of maximal impulse (PMI) ▪ Optimal location where fetal heart tones are auscultated the loudest in the mom’s abdomen o Assessment Of Contractions ▪ Leopold Maneuvers- RN’s do always B4 measurements • First maneuver (Upper pole) o Head or buttocks or legs o Determine what fetal part is at the uterine fundus • Second Maneuvers (Sides of maternal Abdomen) o Palpate with one hand on each side of abdomen o Palpate fetus between two hands o Assess which side is spine and which is extremities • Third Maneuvers (Lower pole) o Palpate just above symphysis pubis o Palpate fetal presenting part between two hands o Assess for fetal descent (where baby is in pelvic cavity) • Fourth Maneuver (Presenting part evaluation) o Apply downward pressure on uterine fundus o Hold presenting part between index finger and thumb o Assess for cephalic versus breech (buttocks) presentation • Nursing considerations for Leopold Maneuver: o Have mom empty bladder before o 45 degree angle with knees bend slightly o Have mom in left lateral position (on left side) o Then palpate Mom ▪ o Physical Changes ▪ Pre-labor Warning Signs • Lightening- mom can breathe better cuz baby drops • Contractions o Braxton Hicks • Cervical Changes: Dilation & effacement o Determine by palpating o Paper thin 100% o Need 10cm dilated & 100% effacement before the mom can push o If mom pushes before 10cm & 100% she will get a hematoma & a lot of swelling • Bloody Show: mucus plug • Rupture membranes • Nesting- burst of energy to get baby room ready • Weight loss of 0.5 to 1.4kg (1-3 ibs) • Increased backache and pressure • G.I. upset o Stages of Labor ▪ First stage—takes the longest • Early Phase—contractions aren’t that bad • Active Phase--want mom to come to hospital if contractions 3-5 minutes apart • Transitional Phase—most discomfort mom will have. Contractions are very intense 1-2 minutes apart 5-7cm dilated ▪ Second Stage • Pushing—some moms push for 1 hr or 45 minutes fast birth called precipitous delivery. Others are normally 2-3 hrs • Delivery of the baby ▪ Third stage • Delivery of the placenta • Do skin and skin with baby & do one last push to get placenta out o The Five P’s ▪ Passage: Birth canal ▪ Passenger: Fetus & placenta ▪ Position: Fetal head ▪ Power: Contractions ▪ Psyche: Confidence ▪ And interaction between the passage (canal) and the passenger is most important o 1) Passage: Birth Canal ▪ Bony Pelvis • 4 bones • Support and protect pelvic contents • Form relatively fixed axis of birth passage ▪ Four Bones: • 2 inominate bones, sacrum, coccyx • Sacroiliac bones have degree of mobility (hips) ▪ False Pelvis: • Portion above the pelvic brim, or linea terminalis • Supports weight of enlarged pregnant uterus • Directs presenting part into true pelvis (base) • ▪ True Pelvis: • Portion that lies below linea terminalis • Made up of the sacrum, coccyx, &innominate bones & represents the bony limits of the birth canal • The relationship of the true pelvis & fetal head is very important o The size and shape of the true pelvis must be adequate for normal fetal passage during labor & birth • Determines passage of the fetal head o Pelvic inlet ▪ Upper border of true pelvis ▪ Typically rounded o Pelvic cavity o Pelvic outlet (baby comes out the outlet) ▪ Lower border of true pelvis ▪ The anteroposterior diameter of the pelvic outlet increases during birth as the presenting part pushes the coccyx posteriorly ▪ The Pubic arch is of great importance b/c fetus must pass under it during birth • If arch is narrow baby’s head may be pushed backward toward the coccyx, making extension of the head difficult • May require the use of forceps or a cesarean birth • The shoulders of a large baby also may become wedged under the pubic arch making birth difficult ▪ Pelvic Types: • Gynecoid- most common & best for vaginal delivery o Wide and round pubic arch • Android—male type pelvis, heart inlet, small inlet o Narrow, sharp, deep pubic arch o Not favorable for a vaginal birth o Descent into pelvis is slow • Anthropoid- baby born face up because of oval shape o Normal or moderately narrow pubic arch • Platypelloid- more oval-ish, flat female pelvis results in baby being born transverse- needs to have C-section o Has extremely wide pubic arch, transverse diameter is wide, but anteroposterior diameter is short o Outlet inadequate for vaginal birth ▪ ▪ Soft Tissue: • Cervix & vagina form birth canal • Effacement 100% • Dilation of cervix 10cm o 2) Passenger Fetus: ▪ Head: Fetal Skull (cranium) ▪ Most important to labor and birth—Head Size ▪ Molding is overlap of bones ▪ Sutures (membranous) ▪ Fontanels o Fetal Lie ▪ Relationship of the cephalocaudal axis of fetus to cephalocaudal axis of mother • Longitudinal/parallel- vertebra lined up with mother • Transverse—baby is in transverse or horizontal position and has to have C-section to be born • Oblique—head at 45 degree angle head going toward inlet, when baby’s head is in the mother’s hip. Baby’s head & body are diagonal not vertical or horizontal (transverse lie) • Baby should be facing down ▪ o Fetal Attitude: ▪ Relationship of fetal parts to one another ▪ Fetal flexion: chin flexed to chest—completely flexed • Smallest head diameter passes through birth canal ▪ Fetal extension: chin extended • More difficult—presenting part chin, called mentum o Station ▪ The relationship of the presenting baby part to the ischial spines ▪ Engagement: head passes through pelvic inlet ▪ For a baby to be delivered has to be +4 or +5 to pelvic inlet ▪ Negative numbers are before Ischial spines & positive numbers are after the Ischial spines ▪ Inlet= -5cm ▪ Floating over false pelvis= -4 ▪ Ischial spines=0 (Engaged baby will not go back after hitting this mark, means baby has entered True pelvis) • Correct Term is the baby is Engaged when charting • Station Zero= when the fetal vertex is at the level of the Ischial spines ▪ +1, +2, +3 mean baby is headed toward the cervix ▪ +3 = Baby beginning to emerge from Birth canal ▪ Outlet= +5 (means he baby is crowning) ▪ o Fetal Presentation ▪ Fetal part entering the pelvis first ▪ Three main ways a fetus can present • Head—cephalic • Feet or buttocks—breech • Shoulder presentation—scapula o Fetal Position ▪ Relationship of the fetal presenting part to the front, side, or back of maternal pelvis ▪ Noted by 3 letters (example ROP,LOP) • Maternal pelvis (which way is baby’s spine is): right (R) or left (L) • Fetal presenting part: Occiput (O), Sacrum (S), Mentum-chin not tucked in (M), Scapula (Sc) • Maternal Pelvic Aspect (baby’s spine to pelvis)- anterior (A) baby is facing down, posterior (P), or transverse (T) • • o 3) Powers ▪ Uterine contractions • Primary power—frequency, duration, intensity • Effacement and dilation • Each contraction has 3 phases: o Frequency—should be hospitalized if 5 minutes, beginning of one contraction to beginning of next contraction o Duration—beginning to end of some contraction o Intensity—ACME how high on the graph contraction goes o 4) Maternal Position (look in book at positions) ▪ Frequent position changes: • Comfort • Relieve fatigue • Promote circulation • Determine by maternal preference • Health care provider • Condition of mother & fetus • Level of anesthesia received • Peanut (birthing bowl)—when mom has an epidural and squats in bed to push out baby into bowl • o 5) Psyche ▪ Factors Affecting Psyche • Mental & physical preparation for childbirth • Sociocultural values & beliefs • Previous childbirth experiences • Support from significant others • Emotional status ▪ Nursing Tip • Provide emotional support to laboring women so she is less anxious and fearful • Excessive anxiety or fear can cause greater pain, inhibit the progress of labor, & reduce blood flow to the placenta o Pain Management ▪ Pain Threshold and Tolerance • Threshold • Tolerance ▪ Source of Pain during Labor • Dilation and stretching of cervix • Reduced uterine blood supply during ctx (ischemia) • Pressure of fetus on pelvic structure • Stretching of vagina and perineum o Non-pharmacological pain management: ▪ Child education: breathing & relaxation ▪ Imagery: use of focal points ▪ Changing positions, emptying bladder, walking o Pharmacologic Pain management: ▪ Analgesics: decrease pain • Butorphanol (Stadol) and Nalpbuphine o Don’t use Demerol anymore b/c respiratory depression • Nalaxone (Narcan) o Used if baby has depressed resp. rate ▪ Anesthetics: decrease sensation • Epidural/spinal anesthethesia: Marcaine and fentanyl • Local: for episiotomy: lidocaine and bupivacaine—if have a tear • General anesthesia—c/s emergency for placenta abruption ▪ Pudental: local anesthetic, pudental nerve if no epidural so not as much pain o Procedure for Anesthetics ▪ Epidural anesthesia • Bolus of IV before procedure • Monitor BP • Sit on side of bed • Injected into epidural space • Takes 20-30 minutes • Biggest problem is hypotension • Waste down is numb • Give 100mL IV fluid to prevent hypotension • Test dose Lidocaine ▪ Spinal Anesthesia • Sit on side of bed • Administer directly into the spinal sac • Works immediately • Does not do hypotension • Chest down is numb Fluid & Electrolytes (6 question on Exam) • Fluid Volume Deficit o Common o Decrease in intravascular, interstitial &/or intracellular fluid in the body o Alone or in combination with electrolyte or acid base imbalances o Dehydration—loss of fluid alone o Happens faster in pregnant women & moms recover slower • How infants & Younger children Differ from Older Children & Adults o Infants more vulnerable to alterations in fluid & electrolyte balance ▪ Because infants have highest proportion of water, accounting for 70%- 80% of their body weight (water% decreases with age) o Greater fluid intake & output related to size o Happens fast o Slower adjustments o Amount of body fat (muscle holds fluids better) • Why do Infants differ from Adults & older children o Lose greater proportion of fluids each day o Children may not feel thirsty and so fail to drink even when dehydrated o Kidneys are immature and inefficient ▪ Infants lose more fluid through the kidneys because immature kidneys are less able to conserve water than adult kidneys ▪ Kidneys are immature until 2 years old o Little reserve o Infants have high daily fluid requirement o Extracellular fluid (ECF) compartment is larger & constitutes greater proportion of body weight—greater insensible loss o Greater body surface area ▪ Gain more heat in hot weather and lose more in cold weather o Higher basal metabolic rate (BMR) because growing ▪ Also increase when they have a fever o Preemies have most body water, than an infant, than an adolescent o Lose a lot of water during birth o Water goes through GI faster • Implications of feeding o Newborn can be overhydrated if formula diluted too much or undehydrated if concentration of formula is not right • Dehydration o Common fluid imbalances: ▪ Total output> total intake ▪ Infants more susceptible to infection—rotavirus (rotavirus causes gastroenteritis) ▪ Insensible losses • Heat lamp=more water lost (phototherapy used to Tx hyperbilirubinemia) • Wounds or burns • GI losses • Types of Dehydration o Isotonic dehydration —primary form in children electrolyte and water deficits equal o Hypotonic dehydration—electrolyte deficits (Na) greater than water deficits (diarrhea & vomiting, burns & renal disease) ▪ Fluid shifts from extracellular (outside cell) to intracellular (inside the cell) in attempt to establish normal proportions ▪ Cells swell rapidly as water rushes in them o Hypertonic dehydration—water loss greater than electrolyte loss, electrolytes are above normal levels [mostly Na] (NG feedings, intravenous fluids, or diabetes insipidus) ▪ Intracellular (inside cell) shifts to extracellular (outside the cell) ▪ Cells lose water & shrink o • Elevated Electrolyte Level o Hypernatremia (increased Na) and Hyperkalemia (increased K) are the most common and significant extracellular findings o Manifestations ▪ Hyperkalemia • Fatigue • Nausea • Muscle weakness • Cardiac irregularities • Tx- administer glucose and insulin to lower K by driving K into intracellular space. Diuretics will increase K & Na loss but also remove fluid ▪ Hypernatremia • Swelling • Irritability • Muscle spasms • Thirst • Confusion • Coma ▪ Hypercalcemia • Nausea & vomiting • Excessive thirst • Frequent urination • Constipation • Muscle pain • Low Electrolyte Level o Hypokalemia (Low K) is most common result of diuretics unless K sparing o Manifestations ▪ Hypokalemia • Cardiac arrhythmias • Nursing assessment o General appearance o Weight measurements o Level of consciousness (crying? Sleeping? Unresponsive?) o Vital signs ▪ Change in v/s may indicate or in some cases precede fluid, electrolyte and acid-base imbalance balance ▪ Elevated temp may be result of dehydration or a cause of increased body fluid losses ▪ Tachycardia is an early sign of hypovolemia ▪ Pulse volume will decrease if a fluid volume deficit is present and increase in the case of fluid volume excess ▪ BP decrease for fluid volume deficit and hypovolemia or increase with FVE ▪ Orthostatic hypotension may also occur with FVD and hypovolemia o Intake & output o Skin turgor, mucous membranes o Fontanel—sunken in? o Extremities (capillary refill) • Severity of clinical Dehydration (Deff Know for Exam) o Mild <5% o Moderate 6-9% o Severe >10% o Chart in book • Dehydration Severity o Mild (hard to detect) ▪ Infants irritable & older children thirsty ▪ Blood pressure, pulse, & resp. are normal ▪ Mucous membranes moist ▪ Urine normal ▪ Capillary refill and tears normal o Moderate ▪ Restlessness and irritability (infants) ▪ Alert, thirsty, & restless (older children & adolescents) ▪ Skin turgor poor ▪ Urine dark and decreased output ▪ Pulse rate & RR normal but BP is normal or low ▪ Mucous membranes dry ▪ Thirst increased ▪ Fontanelle sunken in ▪ Capillary refill increases & tears decreased o Severe ▪ Lethargic to comatose (infants & young children) ▪ Decreased consciousness or apprehensive (older children & adolescents) ▪ Blood pressure low to undetectable ▪ Pulse tachycardia or bradycardia ▪ Respirations changing rate & pattern ▪ Skin turgor very poor ▪ Mucous membranes parched ▪ Urinary output decreased or absent ▪ Thirst greatly increased ▪ Fontanelle sunken in ▪ Capillary refill (greater than 3-4 seconds ) o Weight ▪ Each Kg of weight is equal to 1 L of fluid ▪ Rapid weight loss is a good indicator of fluid volume deficit ▪ Subtract the child’s current weight from the original weight ▪ Divide loss by original weight=% of dehydration ▪ 1 L of fluid= Approx 1KG ▪ Example 14kg original weight ▪ 14 kg original weight of infant ▪ Now weighs 13.6kg 14-13.6kg=0.4kg ▪ 0.4/ 14=0.0028 rounded to 0.03 ▪ Express as percent (x100)=3% which is mild dehydration o Oral Rehydration ▪ Major worldwide health care advances ▪ More effective, safer, less painful, & less costly than IV hydration ▪ Enhance & promote reabsorption of sodium & water ▪ Greatly decreases vomiting, volume loss from diarrhea & duration of illness ▪ Keeps kid out of emergency room ▪ D5 1/2NS--hypertonic ▪ 5-10mL every 5 to 10 minutes o Administer of Parenteral Therapy ▪ Fluid deficit severe ▪ Unable to take fluids ▪ Administer IV fluids ▪ Hypertonic dehydration (rapid fluid replacement contraindicated because of risk of cerebral edema) ▪ Avoid Potassium replacement until renal function verified ▪ H&H, BUN, CR, and electrolyte labs ▪ Lab vales similar to adults o Daily Maintenance Fluid Requirements (ORT therapy equation) (Know equation not given on Exam) ▪ 1) know how much the child weighs ▪ 2) Allow 100ml/kg/day for first 10kg (1000ml/day) ▪ 3) Allow 50ml/kg/day for second 10kg (500m/day) • (+ 1000ml from first category) ▪ 4) allow 20ml/kg/day for remainder of kg above 20 • (+1500ml from first 2 categories) ▪ 5) divide total amount by 24 hrs to obtain rate in milliliters/hour ▪ Example 1: • If child weighs 7.2 kg • 7.2kg * 100ml/kg/day=720ml/day • Then 720ml/day/24hrs= 30ml/hr ▪ Example 2: • If child is 22kg • 1000ml/day+ 50ml/day+20ml/day+20ml/day= • 1540ml/day / 24hrs = 64.17ml/hr ▪ Example 3: • If child is 15kg o 1st 10—100ml/day o 2nd 10—250ml/day (because 5kg*50ml/day=250ml/day) o Add them together= 1250ml/day o 1250 / 24hrs = 52.08ml/hr Perfusion (7-9 questions on exam) • Preeclampsia—hypertension disorder of Pregnancy o Perfusion (heart) then to central then to tissues o With Preeclampsia central and tissue perfusion is impaired or absent o Preeclampsia starts 20 weeks & ends when the baby is born • Definition of Preeclampsia o Pregnancy—specific syndrome o Occurs 20 weeks gestation—ends when baby is born o Hypertension + Proteinuria ▪ NEED both to be diagnosed with Preeclampsia ▪ These symptoms to look for ▪ Varying degrees on a scale • Mild Severe Preeclampsia • Mom can fall anywhere on the scale but can only get more severe cannot go back to mild o Etiology of Preeclampsia ▪ Etiology is unknown ▪ Theory: • Starts with implantation of placenta ▪ Research has demonstrated abnormal placental development or placental damage from diffuse microthrombosis as playing a role in the development of maternal hypertension ▪ An altered maternal immune response to fetal/placental tissue may also contribute to preeclampsia o Pathophysiology ▪ Pregnancyincreased blood volume Release of prostacyclin and endothelium relaxing factors (tells the blood vessels o dilate & accommodate the extra fluid)blood vessels dilate (vasodilation)  Defective placentaIncreased sensitivity to Angiotensin II (vasoconstrictor) blood vessels constrict Increased blood volume + vasoconstriction = Hypertension ▪ There is hyper responsiveness to angiotensin II and epinephrine in moms with preeclampsia ▪ BP are liable (can change quickly) in preeclampsia, normal circadian rhythms may be reversed or blunted (weakened) o Risk Factors for Preeclampsia ▪ Teenagers and women over 35 especially if Primigravida (first baby) ▪ Family Hx—genetic component ▪ Multiple gestations—twins, triplets ▪ Obesity—causes placenta not to implant properly ▪ Medical Hx of hypertension or kidney disease o Mild Preeclampsia (Sick) ▪ Few if any symptoms ▪ Elevated BP (140/90mmHg) ▪ Protein in urine (1+ or 2+ dipstick) • Protein should not come through kidneys, it should be held onto ▪ Slight Edema is present • Puffy face • Puffy hands • Ankles • Periorbital edema ▪ Third spacing • Fluid pushed into third space by edema • Occurs when too much fluid moves from the intravascular space (blood vessels) into the interstitial or "third" space-the nonfunctional area between cells o Severe Preeclampsia (Sicker) ▪ BP greater than or equal to 160/110mmHg • On 2 occasions at least 6 hrs apart while on bedrest ▪ Proteinuria >5g found in 24hrs urine • Dipstick 3+, 4+ on 2 samples at least 4hrs apart ▪ Increased BUN & CR • Acute Kidney failure b/c kidneys getting hit with high BP ▪ Oliguria (UO <500mL/24hrs) • Kidneys start to fail so produce less urine ▪ Deep tendon reflex +3 or +4 ▪ Weight gain ▪ CNS Symptoms (affecting all vessels in the body) • Headache • Blurred Vision • Tinnitus • Hyperreflexia o Has Eclampsia (no more pre) [sickest] ▪ Kidney failure ▪ Emergency C-section ▪ No urine output at all ▪ CNS Symptoms • Seizure (most babies do not survive seizures) • Altered consciousness caused by cerebral edema or cerebral vasospasm ▪ Fetal demise or abruption o Maternal Risks for Severe Preeclampsia ▪ Increased risk for renal failure ▪ Abruptio-placentae • Placenta detaching self from uterine wall • If placenta abrupt’s & detaches baby dies b/c cut off from 02 & nutrients ▪ CNS: seizure (CNS so jacked up mom has a seizure) ▪ Rupture Liver—from the pressure ▪ Pulmonary edema—fluid forced into lungs ▪ May develop hypertension later in life o Fetal/Neonatal Risks (Severe Preeclampsia) ▪ Small for gestational age (SGA) • Baby is scrawny and skinny ▪ Over sedated at birth • From Mg sulfate ▪ Decreased Placental Perfusion • Decrease in 02 (B/C placental defect decrease in 02, vitamins, electrolytes) • Chronic hypoxia • Fetal distress o Nursing care ▪ Bedrest • If mom sent home on bedrest will have to be taught to assess BP, weight, protein in the urine and log fetal movement daily • Mom should report absence of movement ▪ B/P every few hrs—want V/S to go down ▪ Edema daily weights • Increase in ibs=more edema, or water ▪ Deep tendon reflexes (+1,+2,+3,+4) • Checking CNS B/C is jacked up and Mom can have seizure ▪ Fetal monitoring—want baby to survive ▪ Intake & output—kidney function ▪ Dipstick urine for protein—kidneys, how much protein is lost ▪ High protein diet/low sodium diet • High Na foods should be limited to 6g/day ▪ Bedrest: Mom should be on left side/low stimuli • Get uterus off vena cava • No TV, NO cellphone, low lights so she does not have seizure ▪ If edema elevate extremities • Daily labs o BUN & CR ▪ BUN 7 to 20mg/dL ▪ Cr 0.6-1.2 mg/dL o Medical Therapies for Severe Preeclampsia ▪ Anticonvulsants • Magnesium Sulfate (Drug of choice) o Given IV ▪ Fluid and electrolyte management • Clients are hypovolemic due to edema (shift into third spacing) ▪ Pharmacology • Valium—to calm down Mom • Apresoline—If BP is too high o Magnesium Sulfate IV ▪ Acts as CNS depressant by blocking neuromuscular transmission ▪ Also acts as smooth muscle relaxant to help reduce blood pressure ▪ Excreted by kidneys • Monitor mom for toxicity by watching BUN& Cr • Do not want Mg to build up in Moms blood • Can increase fluid intake to flush out Mg but watch for fluid overload ▪ Vesicant—kills tissue & can be necrotic if gets in intestinal tissue • If Mom is in any pain after administration she needs to use call bell immediately ▪ HIGH ALERT DRUG • Need two nurses to verify patient, drug, amount and IV site before administration • We use drug no more than 5-7 days because of toxicity ▪ First Test Dose • Makes patient act drunk • Can have slurred speech or flushed skin ▪ Magnesium Blood Levels • Therapeutic range for Mom: 4-8 (if lower than 4 not helping moms preeclampsia ) • Reflexes (deep tendon) will start to disappear at 9-13 o Stop Mg & get stats Mg blood check o Should have Calcium Gluconate (antidote) at bedside at all times 10mL in 10mL syringe • Respiratory depression at 14 • Death at 30 ▪ Nursing considerations for Mg Sulfate • Signs to watch for if Toxicity o Drowsiness o Decreased RR, Decreased HR, Decreased BP o Flushing of skin, sweating o Diarrhea o Bad headache—(monitor neuro-status) o Muscle weakness o Loss of tendon reflexes • Toxicity in the Baby after birth o Difficulty breathing immediately after birth can be reversed with medication • If notice toxicity what does Nurse do? o Stop IV o Administer Calcium Gluconate IVP (IV push) • Contraindications o Do not use more than 5-7 days for preterm labor (risk of decreased Ca, bone changes in baby) o Avoid continuous use during active labor or within 2hr of delivery (Mg toxicity) • Implications o Have to have two Nurses verify order, drug, patient, & IV site before administering Mg sulfate o Monitor newborn for decreased BP, hypoflexia, decreased RR (Fetal Monitoring) o Monitor I &O, output should be greater than or equal to 100mL/4hrs o Monitor Neuro-status and tendon reflexes before & during Mg therapy ▪ If patella reflex is absent STOP drug o RR should be >16 before Mg is given o Pt should be side lying on left side with dim lights, no TV, No phone—low stimuli o Antidote Calcium gluconate should be at bedside at all times with 10ml syringe and needle to draw med up o Make sure room is set up with emergency breathing equipment-- 02 tubing, nonrebreather mask, ambu • Eclampsia Definition bag, suction equipment (tubing & catheter)-- incase mom does have seizure o Preeclampsia that has progressed to seizures or coma o Characterized by grand mal convulsion or coma ▪ May occur before the onset of labor, during labor, or in early postpartum period o Mom will have immediate C-section if progresses to seizure or coma • Only cure for preeclampsia is birth of the child o Client with preeclampsia usually improves rapidly after giving birth o After birth seizures can still occur up to 48hrs postpartum o Physician may order hydralazine or magnesium sulfate after delivery in severe cases of preeclampsia • Nursing Considerations o BP should be assessed at least every 1-4 hrs, more frequent monitoring is needed with changes in client status o Client should be weighted daily at the same time o Temp, pulse, & resp. should be monitored every 4 hrs o Fetal HR-- is assessed with maternal vital signs ▪ A late deceleration or a decrease or absence in variability indicates fetal distress o Urinary output—I & O should be checked monitored and recorded every shift or more frequently per physician order. ▪ Output should be at least 30mL/hr o Urine Specific gravity—findings over 1.040 correlate with oliguria and proteinuria o Deep tendon reflexes—assess for evidence of hyperreflexia ▪ The patellar reflex is the easiest to assess ▪ Clonus should also be asses by dorsiflexing the foot while the knee is held in a fixed position ▪ Normally no Clonus is present o Level of consciousness—any change is level of consciousness or mental status should be reported o Pt should be on left side (left lateral position) even when giving birth, if Pt can’t push while on left side she should be encouraged to move into a semi sitting position o Non stimulating environment o Oral contraceptives may be used if the woman’s blood pressure has returned to normal by the time they are prescribed (usually 4-6 weeks) Antenatal Lab Notes o Loading dose: infuse 4 grams of Mg Sulfate IV in 250mL of NS to run over 30 minutes and then follow with the maintenance dose. What rate would you set the infusion pump? o 250mL/ 30minutes * 60min/ 1hr = 500mL/hr o Maintenance dose: 40 grams of Mg sulfate in 1 L of D5W to infuse at 2 grams per hour X 24hrs. What rate would you set the infusion pump o 40gram/ 1L (1000mL) * 2 grams per hr/ X= 50mL/hr o Learning Activity 1 o Define mucous plug ▪ Blocks cervical opening to protect baby from outside environment slightly pink/egg white before delivery ▪ Can be pushed out a few hrs before birth or 2 weeks priot o What are some of the Pre labor warning signs ▪ Warm-up contractions—Braxton Hicks, mild contractions, builds strength before labor, relived by walking, emptying bladder, or drinking fluids ▪ Lightening—movement of baby dropping to pelvic cavity, mom can breathe easier but more lower back aches ▪ Flu-like symptoms—loose bowel, diarrhea, nausea ▪ Sporadic backaches—uterine contractions ▪ Nesting instinct—urge to prepare for baby, burst of energy ▪ Passing of mucous plug o At onset of labor, what are the two most common signals/physical factors that indicate that labor is near ▪ Breaking of waters (amniotic fluid)—know discharge amount, color, & timing ▪ Stronger, longer contractions that are more closely together—don’t go away with walking, or emptying the bladder, or drinking fluids ▪ Bloody show (losing mucous plug)--is a mucusy discharge tinged pink or brown with blood. It means the blood vessels in the cervix are rupturing as it begins to efface and dilate o Define 3 stages of Labor ▪ Stage 1—Labor ▪ Stage 2—Pushing & delivery of baby ▪ Stage 3—Delivery of Placenta o Which stage of labor is divided into 3 phases and what are they named? ▪ Stage 1 • Early • Active • Transitional Fluid & Electrolytes: Hyperemesis Gravidarum(HG)—(2-4 questions on Exam) o Fluid + Electrolyte • Review fluid volume deficit • Review electrolyte imbalance • Dehydration leads to fluid electrolyte imbalance & Alkalosis loss of hydrochloric acid • Hypovolemia—not enough fluid • Hypotension • Tachycardia • Increased Hct & BUN • Decreased urine output ▪ Average daily urine output for an adult 1.5L (1500mL) • Puking HCl acid so becomes alkaline • Electrolytes come through dietary intake & excreted by urine • Na & Cl not stored in he body so have to have them everyday • K & Ca stored in cells & bones, shift in bld out of storage to maintain normal level o Normal Plasma Ranges of Electrolytes (know ranges) • Cations ▪ Mg 1.5- 2.5 mEq/L ▪ K 3.5-5.0 mEq/L ▪ Ca 8.0 10.5 mEq/L ▪ Na 135-145 mEq/L • Anions ▪ Sulfate1.0 mEq/L ▪ Organic Acids (Lactate) 2.0 mEq/L ▪ Phosphate  2.5-4.5 mEq/L ▪ Total Protein6.0-8.4 mEq/L ▪ Bicarbonate 24-30 mEq/L ▪ Cl 95-105 mEq/L o Hyperemesis Gravidarum (HG) • Uncontrolled vomiting ▪ 0.3-2% of pregnant women end up with HG • Pathophysiology begins with dehydration: ▪ Dehydrationleads to fluid electrolyte imbalance & Alkalosis from loss of hydrochloric acid (HCl) • Symptoms ▪ Dehydration ▪ Weight loss >5% of weight LBW & SGA infants ▪ Ketosis • Raised levels of ketone bodies in the body, associated with abnormal fat metabolism and diabetes mellitus ▪ Nutritional deficiency ▪ Electrolyte abnormalities ▪ Mom can’t keep anything down not even water o Nausea & Vomiting • Pregnancy frequently causes nausea & vomiting ▪ 80-85% of pregnancies • Usually occurs in the morning but can occur at any time of day • Vomiting usually develops at 5 weeks • Disappearing at 16 to 20 weeks (2nd trimester) o Pathophysiology • Evolution protective responsevomits  remove potentially toxic or teratogenic chemicals ▪ Body thinks its toxic so vomit to keep baby safe • Psychosocial factors ▪ Emotional response to stress ▪ Displacement of the GI track o Theories & Risk Factors • Theories ▪ Increased HCG ▪ Thyroid function (not funct. properly) ▪ Adrenocorticotrionic hormone production ▪ Mineral &vit. B6 deficiency • Mom’s with non-balanced diet from vomiting ▪ Helicobactor Pylori infection • Risk Factors ▪ Primigravida (first pregnancy) ▪ Multiple pregnancies (twins, triplets, etc) ▪ Hx of previous HG o Laboratory Tests • Urinalysis for ketones and acetones checked ▪ Excess ketones when body is using an alternative form of energy • Elevated urine specific gravity—means concentrated urine (normal range is 1.0053 to 1.030) • Chemistry profile ▪ Decreased Na, K, and Cl (from low intake) ▪ Elevated liver enzymes—ALT& AST ▪ Thyroid test—for hyperthyroidism • Even if no Hx of hyperthyroidism • Due to elevated HCG • Fluid & electrolytes thoughts to effect the thyroid • Can get gestational Hyperthyroidism or Hypo & after birth of baby goes back to normal (synthroid—drug to fix hypo) ▪ Elevated Hematocrit concentration (hemoconcentration) • HCt due to not being able to keep food down o Signs & Symptoms • Physical assessment findings • Excessive vomiting and diarrhea (both ends) • Dehydration with possible electrolyte imbalance • Weight loss >5% • Increased pulse rate (tachycardia), weak pulse • Decreased BP (hypotension) • Poor skin turgor and dry mucous membranes o Pregnancy Unique Quantification of Emesis and Vomiting score(PUQEscore) • Helpful in early pregnancy and takes 2 minutes to preform • 4 questions, 4th is about Moms welling being • Score <6 mild discharge to out-patient management from GP and community midwife • Score 7-11 Moderate consider admission depending on woman’s preferences • Score >12 severe Recommend admission • 15 is highest Score a Mom can have for grading, 4th question not included in score, just how mom is generally feeling • Question 1 in last 12 hrs, for how long have you felt nauseated or sick to your stomach ▪ Not at all score 1 ▪ 1 hour or less score 2 ▪ 2-3 hrs score 3 ▪ 4-6hrs score 4 ▪ More than 6 hrs-score 5 • Question 2 In the last 12 hrs have you vomited or thrown up? ▪ 7 or more times score 5 ▪ 5-6 score 4 ▪ 3 to 4 score 3 ▪ 1 to 2 score 2 ▪ I did not throw up score 1 • Question 3 In the last 12 hrs, how many times have you had retching or dry heaves without bringing anything up? ▪ No time score 1 ▪ 1 to 2 score 2 ▪ 3 to 4 score 3 ▪ 5 to 6 score 4 ▪ 7 or more score 5 • Question 4 On a scale 1-6 how would you rate your nausea and/or vomiting today, if 1 is acceptable and 6 is extremely debilitating? • 1 2 3 4 5 6 o Management Hyperemesis Gravidarum • Administer pyridoxine (Vitamin B6) IV and other supplemental vitamins that are added to the IV • Administer antiemetic medication for uncontrollable nausea and vomiting ▪ Ondanseron (Zofran)—have to monitor closely ▪ Metoclopramide (Reglan) o Nursing Care • NPO for 48hrs • IV fluids LR (Lactated Ringers) for Rehydration • Monitor I & O ▪ Measure emesis & diarrhea • Assess skin turgor and mucous membranes • Monitor vital signs (hypotension &tachycardia) • Monitor Moms weight—weigh moms daily o Teaching • Moms should rest as much as possible; get some help if you can ▪ A support group is very beneficial • Small, frequent snacks, high carbohydrate and lower fat protein foods, e.g. cereal, pasta, rice potatoes, lean meat, eggs and fish. Avoid strong flavors and smells • Don’t drink and eat at same time, leave a gap of 30 minutes • If you can’t tolerate hot food try cold and vice versa • Have a snack before going to bed and try to eat before getting up in the morning e.ge plain biscuits/crackers. Get out of bed slowly and don’t make any sudden movements • Try travel sickness wristbands, available by chemists • Take ginger—biscuits, tea, root, stem, capsules, ginger beer • Try Lucozade, sprite, 7-up, coke (not diet versions), and also ice pops/lollies which help to give fluid and sugar slowly o Patient Education • Discharge Instructions ▪ Clear fluids after for 24hrs if not vomiting ▪ Soft diet ▪ Advance diet as tolerated • Dry toast, crackers or cereal ▪ Normal diet as tolerated ▪ If vomiting returns • Feeding tube or Total Parenteral nutrition (TPN) Ethical & Legal Standards (5-6 questions on Exam) • Ethical Principles o Respect for person—moral worth o Autonomy—self-determination, patient expresses their wishes o Veracity—telling the truth o Nonmaleficence—to do no harm o Justice—fair treatment o Fidelity—loyal, keep promises o Beneficence—do good to the patient • How is our Moral Comfort Zone formed? o Culture o Family (biggest influence) o Religion o Life experience o Peers (adolescents, high school) • Professional Ethics o Ethical Dilemma ▪ When personal and professional ethics clash ▪ ANA code of ethics based on professional Ethics ▪ A problem for which in order to do something right you have to do something wrong o Top 3 Ethical Problems Nurses see: ▪ Staffing issues ▪ Having to report an impaired colleague (drug or alcohol) ▪ Quality Life—keeping doing treatments when patient should be left alone to pass • Ethical Decision Making in Practice o Asking the right questions the “Four Topic Approach” ▪ Question One: Do I have a duty or obligation to tell the truth? • Veracity (tell the truth) ▪ Question Two: What are the best interests of my patient? • Beneficence (to do good to patient) ▪ Question Three: To whom is My Primary Loyalty? • Fidelity (loyalty, keep promises) ▪ Question Four: What is the greater harm? • Nonmaleficience (do no harm) • Delaware Mandatory Reporting Requirements Regarding Children o Who must report (MANDATORY)? ▪ Any physician or other person in the healing arts, including any person licensed to render services in medicine ▪ Osteopathy, dentistry, any intern, resident, nurse, school employee, social worker, psychologist, medical examiner, or any other person who knows or in good faith suspects child abuse or neglect ▪ The Delaware Attorney General has indicate that any person with knowledge suggesting that everyone is a potential mandated reporter ▪ However Delaware State court decision suggested that only those in enumerated positions above are mandatory reporters ▪ Because the law is unclear on this issue everyone should report all instances of suspected child abuse or neglect to avoid any criminal or civil liability o Standard Knowledge ▪ Knowledge of or good faith suspicion of child abuse or neglect ▪ “Abuse” occurs when a person • Causes or inflicts sexual abuse on a child • Or has care, custody, or control of a child & causes or inflicts physical injury through unjustified force o Emotional abuse o Torture o Exploitation o Maltreatment o Mistreatment ▪ “Neglect” occurs when a person • Is responsible for the care, custody, and/or control of a child, and has the ability and financial means to provide for the care of the child and: o Fails to provide necessary care with regard to food, clothing, shelter, education, health, medical, or other necessary care o Chronically and severely abuses alcohol or controlled substances, is not active in Tx for such abuse, and the abuse threatens the child’s ability to receive necessary care o Fails to provide necessary supervision appropriate for a child when the child unable to care for the child’s own basic needs o Definition of Applicable Victim ▪ A child is any person under 18 years of age o Reports Made to ▪ Reports must be made to the Division of Child Protective Services of the Department of Services for Children, Youth and Their Families ▪ Reports can also be made to law enforcement, though not in lieu (instead) of the report made to the Division o Contents of Report ▪ Reports and the contents thereof including a written report, if requested, shall be made in accordance with the rules and regulations of the Division of Child Protective services ▪ The Divisions reporting form available at http://Kids.delaware.giv/fs/fs_cai.shtml ▪ Form requires • Childs name, address, date of birth/age, race, and sex • The name, address, date of birth/age, race, and sex of the child’s parents or custodians • Languages spoken by the child and the parents or custodians • A description of the child’s current injuries and reasons for suspecting abuse or neglect and • Any evidence of prior abuse or neglect o Timing/Other Procedures ▪ An oral report shall be made immediately and can be made through the 24hr state-wide toll-free hotline (1-800-292-9582) ▪ A written report must be made if requested o Other ▪ A mandated reported who fails to report shall be liable for a civil penalty not exceed $5,00 for the first violation, and not exceed $50,000 for any subsequent violation ▪ No legally recognized privilege, except that between attorney and client and that between priest and penitent in a sacramental confession, shall apply to situations involving known or suspected child abuse, neglect, exploitation or abandonment and shall not be constitute grounds for a mandated reporters failure to report