NS2P1 OB: EXAM 4 SG

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Radhika316
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NS2P1 OB: EXAM 4 SG
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2015-03-14 00:37:10
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Final OB Elizabeth Exam4 NS2 NS2P1
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FINAL OB SG.
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  1. How to Read Fetal Strips w/ Late Decels.
    (OB TEST 2)
  2. Appropriate Questions after mom's stillborn.
  3. Eye Ointment For Baby (Reason for eye antibiotic ointment (pg 603) for newborns)
    􀂾 Antibiotics ointments prophylaxis are applied to the newborn within 1-2 hrs to protect against contracting infection from gonorrhea and Chlamydia from passage through the mother’s birth canal

    􀂾 Use erythromycin or Tetracycline ophthalmic ointments
  4. 4. Phototherapy
    phototherapy and appropriate nursing intervention (pg 607)
    Use to reduce the level of circulating unconjugated bilirubin or keep it from increasingby changing the shape and structure and convert it to molecules that can be excreted.

    Interventions:􀂃 Cover eyes to prevent exposure (uncover when feeding and PRN to check eyes)􀂃 Monitor temperature of infant (light can cause fluid loss/dehydration)􀂃 Monitor urination (fluid loss)􀂃 Number and consistency of stools
  5. Care of Circumcised Infant􀂙 Instructions to give mom for newly circumcised infant (pg 616)
    􀂾 Observe for bleeding and infections

    􀂾 Check to see if infant is urinating with no difficulties

    􀂾 Change diaper Q24H and inspect, wash with warm water and apply petroleum jelly toglands every diaper change. Apply diaper loosely over penis

    􀂾 Don’t use baby wipes (alcohol), soap until healed

    􀂾 Penis is dark red then becomes covered with yellow exudates in 24hs (this is normal andwill persist for 3-4 days).

    􀂾 Redness, swelling, discharge, or odor indicates infection.

    􀂾 If plastibell used no petroleum jelly is needed, it prevents the diaper from sticking andprevents pain with urination. Falls off in about one week
  6. 6. Hep B Vaccine (Look at what before you give HepB vaccine, mom status relative to that (physical conditions), what you look for before you give pg 613)
    􀂾 For infants of mothers with negative HepB status give vaccine before discharge

    􀂾 For infants of mothers with positive HepB, give HepB vaccine and HBIG (Hepatitis BImmune Globin) within 12 hours after birth

    􀂾 When mothers HepB status is unknown:􀂃 <2000g – give vaccine and HBIG with 12 hrs after birth􀂃

    >2000g – give vaccine ASAP, if mother is positive give HBIG within 1 week.
  7. 7. Review Preeclampsia Labs-which to look at (too high or too low) (pg 306, table on pg305)
    • 􀂾 Increased HgB and Hct
    • 􀂾 Decreased platelets
    • 􀂾 Increased liver enzymes
  8. => Pt on mg sulfate, what is the most important assessment of mom for preeclampsia (pg310-313, box 12-4)
    • 􀂾 BP > 160/110
    • 􀂾 Resp Rate < 12
    • 􀂾 Urinary output < 25-30 ml (to excrete mg)
    • 􀂾 Presence of headache, visual disturbances, decrease level of consciousness, or epigastricpain
    • 􀂾 Loss of DTRs (deep tendon reflexes), increased edema or proteinuria
    • 􀂾 Abnormal labs (mg, platelets, Cr clearance, Uric acid, AST, ALT, PT, PTT, fibrinogen
  9. 8. Care of Umbilical CordHow to care for newborn umbilical cord (pg 627)
    • 􀂾 Primary goal is to prevent/decrease risk for hemorrhage and infection
    • 􀂾 Clean with water and dry with gauze
    • 􀂾 Remove clamp when it has dried and is no longer bleeding (24-48hrs)
    • 􀂾 Assess for edema, redness, and prurlent drainage every diaper change
    • 􀂾 Keep open to air and free of clothes and diapers
  10. 3rd Stage of Labor (Review 3rd stage of labor ( pg 347) assessment, what would you find? What’s normal?) 

    SEE TEST 1 INFO
    Third stage aka placental stage – begins at birth of baby, ends with passage of placenta. Goal is prompt, complete, & safe separation/expulsion of placenta. Can last 5-30 minutes. Two stages:placental separation & placental expulsion. Oxytocin may be administered to promote uterine contractions & to prevent uterine hemorrhage. Nipple stimulation is a non-pharmaceutical alternative to oxytocin.

    SEE TEST 1 INFO
  11. 10. Oxytocin
    • => Why oxytocin given after the placenta delivered?
    • 􀂾 The hormone oxytocin (released for pituitary gland) strengthens and coordinates uterinecontractions, which compress blood vessels and promote homeostasis. This keeps theuterus firm and contracted.

    􀂾 Oxytocin decreased blood loss and reduces the risk for postpartum hemorrhage.
  12. 11. Midwife vs. Doctor: differences of roles
    􀂾 Doctors see low and high risk patients. Care includes pharmacologic and medicalmanagement of problems and use of technologic procedures

    􀂾 Midwifes see low risk patients and refer high risk patients to doctors. Care is often noninterventionist
  13. 12. Appropriate Gestational Age (box 25-1?)
    • 􀂾 AGA: anything between 10% and 90% growth curves
    • 􀂾 LBW: less then 5lb 8oz (2500g)
    • 􀂾 LGA: above 90% or >4000g
    • 􀂾 Preterm: before 37wks
    • 􀂾 Full-term: 38 to 42 wks
    • 􀂾 Post-term: after 42 wks
  14. 13. Infant mortality Rates (Infant mortality statistics, between ethnicities, who are more predisposed for things? pg 723)
    => Increased risks for infant mortality􀂃 African-American race have twice the rate of Caucasians􀂃

    Caucasians are lower than all other races􀂃

    LBW (low birth weight) rate is much higher for African-American infants then anyother group
  15. Review Fetal Monitoring: Late Vs. Early (OB Test 2)
  16. Signs & Sumptoms that should be reported to a doctor when pregnant
    • a.First trimester:
    • i.Severe vomiting: Hyperemesis Gravidarum

    ii.Chills, fever, Burning on urination, Diarrhea =Infection

    iii.Abdominal cramping, vaginal bleeding = Miscarriage, ectopic pregnancy.

    b.Second & Third semester:

    i.Persistent, Sever vomiting= Hyperemesis Gravidarum, Hypertension, preeclampsia

    ii.Sudden discharge of vag fluid before 37 weeks : Premature Rupture of Membranes

    iii.Vaginal bleeding, severe abdominal pain = Miscarriage, placenta previa, abruptiio placenta

    iv.Chills, fever, burning on urination, diarrhea = Infection

    v.Severe Backache or flank pain = Kidney infection or stones, Preterm Labor

    vi.Change in fental movements: absence of fetal movements after quickening, any unusual chang in pattern or amount = Fetal jeopardy or intrauterine fetal death

    vii.Uterine contractions; pressure; cramping before 37 weeks = Preterm Labor

    viii.Visual disturbances (blurring, double vision, spots) = Preeclampsia, Hypertensive.

    ix.Swelling of face, fingers, sacrum = HTN, Preeclampsia

    x.Headaches (severe, frequenct, continuous) = HTN, Preeclampsia

    xi.Musc Irritability/convulsion = HTN, Preeclampsia

    xii.Epigastric or abdominal pain (severe stomache) - HTN, Preeclampsia, abruption placentae

    xiii.Glycosuria, positive glucose tolerance test reaction = Gest Diabetes Mellitus
  17. Grading Placentas: a) Placeta previa
    – placenta attaches/implants in the lower segment of the uterus &encroaches on internal cervical os. Characterized by bright red vaginal bleeding,painless, soft & relaxed uterus.

    i) Placenta spreads out becoming thinner & larger than normal (seeking additional bloodsupply; blood supply is limited in the lower segment of uterus)

    • ii) Causes bright red bleeding after the 20th week gestation (painless); can be scantinitially & increase in volume as each incident occurs; placental villi are torn fromuterine wall during normal uterine contractions (B-H)
    • iii) Causes fetal malpresentations & poor fetal descent (determined w/ Leopold maneuvers)

    iv) Palpation reveals soft, non-tender uterus􀂾 v) Confirmed by ultrasound; vaginal exam in not done unless emergency caesarianequiment is on hand—may trigger hemorrhage or stimulate contractions.

    vi) Rarely delivered vaginally (must be real low risk for bleeding & previa is  marginal);usually delivered c-sect.
  18. vii) Grading of placenta & interpretation – placenta previa
    (1) Grade I: placenta is in lower segment of uterus but does not reach the internal os 

    (2) Grade II (aka low implantation): The lower edge of the placenta reaches the internalos but does not cover it

    (3) Grade III (aka partial placenta previa): placenta partially covers the internal os

    (4) Grade IV (aka total placenta previa): placenta completely covers os
  19. b) Placental abruptia
    – premature separation of placenta from uterine wallcharacterized by dark red vaginal bleeding, uterine pain &/or tenderness and uterinerigidity.

    􀂾 i) Usually occurs after 20-24 weeks gestation but can occur during first/second stage of labor

    􀂾 ii) More common in multigravidas who are > 35 years; common cause of bleeding in 2ndhalf of pregnancy.

    􀂾 iii) May result in termination of pregnancy—fetal prognosis (gestational age) & bloodloss; maternal prognosis is good if blood loss is controlled.

    􀂾 iv) Increase in fundal height indicates potential placental abruptia

    􀂾 v) Maternal mortality 6%, depending on severity; greater risk for vascular spasm,intravascular clotting/hemorrhage, or renal failure from shock post partum.
  20. vi) Grading of placental separation:
    •  (1) Mild separation – < 50% placental separation; possible vaginal delivery or c-sectdelivery
    • (a) Gradual onset; mild to moderate bleeding

    • (b) Dull, vague, lower back pain
    • (c) Mild-mod tenderness to abd/uterus
    • (d) Fetal heart tones strong & regular


    • (2) Moderate separation – 50% placental separation; c-sect delivery
    • (a) Gradual/abrupt onset; dark red moderate vaginal bleeding
    • (b) Continuous abdominal pain
    • (c) Tender uterus; possible signs of shock
    • (d) Spontaneous labor onset within 2 hours that is rapidly progressing
    • (e) Barely audible or bradycardic irregular fetal heart tones

    • (3) Severe separation – 70% placental separation; c-sect delivery
    • (a) Moderate external hemorrhage, shock & fetal cardiac distress (absence of fetal hearttones)
    • (b) abrupt onset of pain (tearing or knife-like)
    • (c) tender uterus
  21. 17. HIV Testing
  22. 19. Alcohol and Using Drugs During Pregnancy: How to educate Patient 
    => Alcohol while pregnant, how would you answer if it’s ok to consume (pg 208)
    􀂾 Completely abstain from alcohol

    􀂾 Can have powerful effects on a developing fetus
  23. Gathering Health History
  24. When a woman comes to you and is not pregnant but wants to be in three months, whatprep do you tell her to do?
    • Folic acid, stop smoking, drinking, etc.
    • 􀂾 Take folic acid to prevent neural tube defects
    • 􀂾 No smoking or alcohol
    • 􀂾 Good nutrition and healthy weight, prevention of STI’s
  25. Calorie intake recommendation during pregnancy
    a) Average weight gain: 25-35# for women w/ normal pre-pregnancy weight

    b) 300 cal/day increase (from 2,200 kcal/day to 2,500 kcal/day) – pregnancy

    • c) 500 cal/day increase – lactationd) Foods/supplements high in folic acid (800 mcg/day)to
    • i) prevent neural tube defects (spina bifida) & cleft palate
    • ii) prevents maternal anemia
    • iii) promotes fetal growth
    • iv) found in green, leafy veggies, eggs, milk, whole grain breads.

    • e) 8-10 glasses (8oz)/day; 4-6 glasses water to be included in total
    • f) Supplemental vitamins & minerals

    g) Increase protein to 60g/day

    h) Increase sodium intake to 2,469 mg/day

    i) Drink fluoridated water or fluoride supplement (teeth/bone)

    j) Fats w/ linoleic acid essential to new cell growth; found in veg oils (corn, olive,peanut, & safflower oils)
  26. 23. Apgar Scores
    • Apgar score permits rapid assessment of the newborn transition to extrauterin life basedon five signs:
    • 1. Heart rate (auscultation with stethoscope)
    • 2. Respiratory effort (movement of chest wall)
    • 3. Muscle tone (degree of flexion and extremity movement)
    • 4. Reflex irritability (based on suction of the nares or pharynx)
    • 5. Generalized skin color (pallid, cyanotic, or pink)

    • => Done at 1 and 5 minutes
    • 0 to 3 – severe distress
    • 4 to 6 – moderate difficulty
    • 7 to 10 – minimum or no difficulty adjusting
  27. 24. Symptoms of Preeclampsia
    PIH: Hypertension without proteinuria

    • =>Preeclampsia Symtoms
    • 􀂾 Headache
    • 􀂾 Protein in urine (<+1)
    • 􀂾 Blurred vision
    • 􀂾 Epigastric pain
    • 􀂾 Pulmonary edema
    • 􀂾 Changes in affect or irritability
  28. 25. Review Epidurals-Informed Consent=> Pt gets epidural and BP falls, what is the (pg 373) important assessment
    (bolus IV fluid): instilling extra fluids prevents CV collapse, decrease in B/P

     a) Assess B/P pre-admin; apply cardiac monitor, SpO2, external fetal monitor (EFM)

    •  b) Admin 500 - 1000mL Lactated Ringers crystalloid over 10-30 min. before epidural. Rationale: patient can become
    • very hypotensive post admin; instilling extra fluids prevents CV collapse, decrease in B/P

     c) Assist patient into sitting or side-lying position (sitting is preferred for instillation ofepidural)

    d) Assess B/P & bladder function (hypotension & bladder retention) post admin.
  29. Pitocin-focused on labor induction=> What is the standard protocol for oxytocin in labor induction? (pg 465)
    􀂾 Administer starting with 1 milliunit/min and increase by 1-2 units no more than 30-60min. The uterus responds to oxytocin within 3 to 5 minutes of IV administration.

    􀂾 Half life is 10-12 minutes and it takes approx 40 min to reach a steady state of oxytocinlevels (point at which IV levels = elimination)

    􀂾 Decreases risk of tachysystole and unnecessary cesarean births
  30. What causes freq. urination in early preg (page 209-211 table 8-3)
    a. Vascular engorgement and altered bladder  function caused by hormones; bladder capacity reduced by enlarging uterus and fetal presenting part.

    • b. Edu.For Self-Management: Empty bladder regularly, perform kegel exercises, limit
    • fluid intake before bedtime, report pain or burning sensation while urinating.
  31. **Erythroblastosis Fetalis
    -the destruction of red blood cells that results from an antigen antibody reaction; this disorder is characterized by hemolytic anemia or hyperbilirubinemia.

    -Exchange of fetal and meternal blood occurs primarily when the placenta sparates at birth

    -Antibodies are harmless to the mother but attach to the erythrocytes in the fetus and cause hemolysis.

    -Sensitization is rare with the first pregnancy-ABO incompatiblility is usually less severe.

    => Assessment: Anemia, jandice develops at birth and after 24 hours.

    • => Interventions:
    • 1. Admister RHo(D) immune globulin (RhoGAm) to the mother during the first 72 hours after delivery if the Rh-negative mother delives an Rh-Positive fetus but remains unsensitivzed

    • 2. Assisst with exhcange transfuion affter birth or intrauterine transfusion as prescribed
    • 3. The newborn's blood is replaced with RH-Negative blood to stop destruction of newborn's RBCs, the Rh-Negative blood is replaced with the newborns own blood graudally.
    • 4. Reassume mom that baby will experience no untoward effects from conditon.
  32. Review RH incomp. (page 679-680, chapter 25)
    • RH Incompatibility has no effect during the first pregnancy with an Rh-positive
    • fetus because the initial sensitization to Rh antigens rarely occurs before the
    • onset of labor. However, with the increased risk of fetal blood being
    • transferred to the maternal circulation during placental separation, maternal
    • antibody production is stimulated. During a subsequent pregnancy with an
    • Rh-positive fetus, these previously formed maternal antibodies to Rh-positive
    • blood cells may enter the fetal circulation, where they attack and destroy fetal
    • erythrocytes.
  33. Pt. on Mag (pre eclamptic page 310-313), what’s important to look for
    • a. Monitoring to anticipate:
    • i. Maternal: Blood pressure, pulse, respiratory rate, DTRs, level of consciousness, urine output (indwelling catheter), presence of headache, visual disturbances, epigastric pain
    • ii. Fetal: FHR and activity

    b. If magnesium toxicity is suspected, prompt actions are needed to prevent respiratory or cardiac arrest. The magnesium infusion should be discontinued immediately. Calcium gluconate or calcium chloride (antidotes for magnesium sulfate) can be given intravenously.

    • c. Vital signs and assessments are performed as ordered by the health care provider and per hospital protocol.
    • i. Monitor blood pressure, pulse, respiratory rate every 15 to 30 minutes, depending on woman's condition.
    • ii. Monitor FHR and contractions continuously.
    • iii. Monitor intake and output, proteinuria, DTRs, presence of headache, visual disturbances, level of consciousness, and epigastric pain at least hourly.
    • iv. Restrict hourly fluid intake to a total of no more than 125 mL/hr; urinary output should be at least 25 to 30 mL/hr.
  34. Insulin changes during pregnancy
    • a. glucose transported through placenta to fetus, but not insulin (fetus produces own)
    • i. maternal glucose rises -> so does fetal glucose levels -> fetal insulin secretion increases

    • b. in first trimester, insulin-dependent diabetes prone to hypoglycemia
    • i. increase estrogen & progesterone ->increase insulin -> decreased blood glucose ->also decreased glucose production

    c. little or no change in prepregnancy insulin requirements

    d. but insulin dosage may be decreased because of hypoglycemia

    • e. second & third semesters, decreased tolerance to glucose & increased insulin resistance
    • i. insulin resistance, so dosage increased to maintain target glucose levels
  35. Parent instructions after surgery for a shunt for hydrocephalus
    a. Recognize signs of infection: increased ICP (pupillary dilation and increased BP), elevated vitals, poor feeding, vomiting, decreased responsiveness and seizure activity. Incision site is inspected for leakage and any suspected drainage is tested for glucose (indication of CSF).

    b. discharge instructions on infection risks

    c. infection signs & symptoms

    d. bring in immediately if altered LOC, fever, mood change

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