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OB ATI Study Guide Initial Prenatal Visit: ↑  

Estimated date of delivery based on LMP. Vaginal ultrasound may be done to establish DOD Medical & nursing hx including past med health, family hx, social supports, social hx, & review of systems (to determine risk factors) & past OB hx

Physical assessment: baseline weight, vitals, pelvic exam Initial lab work: o Blood type o RH factor o HIV status o Hep B o VDRL o Rubella status Ongoing Prenatal Visits:  

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Urinalysis Pap Indirect Coomb’s test will determine if client is sensitized to RH+ blood

Monitor weight, BP, & urine for glucose, protein, & leukocytes Present of edema Fetal development: o FHR heard by Doppler at 10-12 wks o Heard with ultrasound stethoscope at 16-20 wks. Listen at the midline, right above the symphysis pubis, holding stethoscope firmly on abd o Measure fundal height after 12 wks. Between 18 & 30 weeks, fundal height measured in cm should equal the week of gestation. Have pt empty bladder & measure from the level of the symphysis pubis to the upper border of the fundus o Begin assessing for fetal movement between 16 & 20 weeks gestation

Routine Lab Tests in Prenatal Care & Their Purpose Blood type, Rh factor, presence of irregular Determines risk for maternal-fetal blood incompatibility (erythroblastosis fetalis) or neonatal antibodies hyperbilirubinemia. For clients are are Rh(-) & not sensitized, the indirect Coombs’ test will be repeated b/t 24-28 weeks gestation CBC w/ differential, Hgb, Hct

Detects infection & anemia

Hgb electrophoresis

Identifies hemoglobinopathies (sickle cell anemia & thalassemia) Identifies DM, gestational HTN, renal disease, & infection

Urinalysis: pH, gravity, color, sediment, protein, glucose, albumin, RBCs, WBCs, casts, acetone, & HCG

2 1 hr Glucose Tolerance (oral/IV admin of concentrated glucose w/ venous sample taken 1 hr later. Fasting not necessary)

Identifies hyperglycemia; done at initial visit for atrisk clients, & at 24-28 wks for all pregnant women (>140 requires follow up)

3 hr Glucose Tolerance (fasting overnight prior to oral or IV admin of concentrated glucose with a venous sample taken at 1, 2, & 3 hrs later)

Used in clients w/ elevated 1-hr glucose tst as a screening tool for DM. A dx of GD requires 2 elevated blood-glucose readings

Pap Test

Screens for cervical cancer, HSV II, &/or HPV

Vaginal/Cervical Culture

Detects streptococcus B-hemolytic, Group B (routinely done at 35-37 wks), BV, STDS (gonorrhea, chlamydia)

Rubella Titer

Determines immunity to rubella. If non-immune, give shot!

PPD, chest screening after 20 weeks w/ + purified protein derivative Hep B Screen

Identifies exposure to TB

VDRL

Syphilis screening mandated by law

HIV

Detects HIV infection: recommended for all clients who are pregnant unless client refuses testing

TORCH (Toxoplasmosis, other infections, rubella, cytomegalovirus, & herpes) when indicated

Screening for group of infections capable of crossing the placenta & adversely affecting fetal development

Maternal serum alpha-fetoprotein (MSAFP)

Between 15-22 wks

Identifies carriers of hep B

Rhogam Administration:  

IM around 28 weeks for clients who are Rh (-) For amniocentesis, car wreck, or any instance of possibility of fetal/maternal blood mixture

Health Promotion:    

Avoid all OTC meds, supplements, & rx meds unless OB who is supervising care has knowledge of this practice Alcohol (birth defects) & tobacco (low birth weight) contraindicated during pregnancy Substance abuse of any kind is to be avoid during pregnancy & lactation Encourage flu vaccine during the fall months

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Treat current infections Ascertain maternal exposure to hazardous materials Avoid use of hot tubs/saunas Consume at least 2-3 L of h20 daily from food & beverage sources Exercise: moderate exercise (walking/swimming) consisting of 30 minutes; no new exercise during pregnancy

Third Trimester Childbirth Prep: 

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Breathing & relaxation techniques o Deep cleansing breaths at ½ the usual respiratory rate during ctxns can promote relaxation of the abd muscles, which lessens the discomfort of uterine ctxns. discussion regarding pain management during labor & birth (natural child birth, epidural) Fetal movement/kick counts to ascertain fetal well-being. Client should be instructed to count & record fetal movements or kicks daily o It is recommended that mothers count fetal activity 2-3 x/day for 60 mins each time o Fetal movements 35 years or congenital anomaly of fetus o Previous birth w/ chromosomal o Alpha fetoprotein level for fetal anomaly abnormalities o Parent who is carrier of o Lung maturity assessment chromosomal anomaly o Fetal hemolytic disease dx o Family hx of neural tube defects o Meconium in amniotic fluid Interpretation of finding:

6 AFP (protein produced by fetus) can be measured from the amniotic fluid between 1618 weeks & may be used to assess for neural tube defects in fetus or chromosomal disorders. May be evaluated to follow up a high level of AFP in maternal serum:  High level: associated w/ neural tube defects such as anencephaly (incomplete development of fetal skull & brain), spina bifida (open spine), or omphalocele (abd wall defect). May also be present with normal multifetal pregnancies  Low levels: chromosomal disorders (Down syndrome) or gestational trophoblastic disease (hydratiform mole) o Tests for fetal lung maturity may be performed if gestation < 27 weeks in event of rupture of membranes, preterm labor, or for complication indicating C-section. Amniotic fluid tested to determine if the fetal lungs are mature enough to adapt to extrauterine life or if the fetus will likely have respiratory distress. Determination is made whether the fetus should be removed immediately or if the fetus requires more time in utero w/ the admin of glucocorticoids to promote fetal lung maturity  Fetal lung tests  Lecithin/sphingomyelin (L/S) ratio- a 2:1 indicating fetal lung maturity (2.5:1 or 3:1 for a client who has DM)  Presence of phosphatidylglycerol (PG)- absence of PG is associated w/ respiratory distress Preprocedure for Amniocentesis o Explain procedure & obtain informed consent o Instruct client to empty bladder to reduce risk of inadvertent puncture Intraprocedure: o Assist client in supine position & place a wedge or rolled towel under right hip to displace uterus off vena cava & place drape over client exposing only abd o Prepare for ultrasound to locate placenta o Obtain baseline vitals & FHR & document prior to procedure o Cleanse abd w/ antiseptic solution prior to administration of a local anesthetic given by the PCP o Advise client that she will feel slight pressure as the needle is inserted for aspiration. However, she should continue breathing because holding her breath will lower the diaphragm against the uterus & shift intrauterine contents\ Postprocedure: o Monitor vitals, FHR, & uterine ctxns throughout procedure & 30 mins following o Have client rest for 30 mins o Administer Rhogam if Rh (-) o Advise client to report to PCP if she experiences fever, chills, leakage of fluid/bleeding from insertion site, ↓d fetal movement, vaginal bleeding, or uterine ctxns after the procedure o Drink plenty of fluids & rest for next 24 hours post procedure Complications: o

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7 Amniotic fluid emboli o Fetal death Maternal or fetal hemorrhage o Inadvertent maternal intestinal Fetomaternal hemorrhage w/ or bladder damage Rh isoimmunization o Miscarriage or preterm labor o Maternal or fetal infection o Premature rupture of o Inadvertent fetal damage or membranes anomalies involving limbs o Leakage of amniotic fluid Nursing Actions: o Monitor vitals, temp, respiratory status, FHR, uterine ctxns, vaginaly discharge o Provide med admin as prescribed, client education, & support o o o

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Alpha-Fetoprotein Screening   

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Abnormal finding should be referred for a quad marker screening, genetic counseling, ultrasound, & an amniocentesis Indications: all pregnant clients between 16 & 18 weeks Interpretation of findings: o High levels: neural tube defect or open abd defect o Low levels: Down syndrome Nursing actions: o Discuss testing w/ client o Draw blood sample o Offer support & education as needed

Time

Summary of Causes of Bleeding during Pregnancy Complication S/S Spontaneous abortion

Vaginal bleeding, uterine cramping, & partial or complete expulsion of products of conception

Ectopic pregnancy

Abrupt unilateral lower-quad pain w/ or w/out vag bleeding

Gestational trophoblastic disease

Uterine size increasing abnormally fast, abnormally high levels of hCG, nausea & ↑ emesis, no fetus present on ultrasound, scant/profuse dark brown or red vag bleeding

Placenta previa

Painless vaginal bleeding

First Trimester

Second Trimester

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Abruptio placenta

Vaginal bleeding, sharp abd pain, & tender rigid uterus

Vasa previa

Fetal vessel cross over the cervix abrupt red vaginal bleeding following ROM

Third Trimester

Other Causes of Bleeding:  

Incompetent cervix o Painless bleeding w/ cervical dilation leading to fetal expulsion Preterm Labor o Pink-stained vaginal discharge, uterine ctxns becoming regular, cervical dilation & effacement

Spontaneous Abortion    

When a pregnancy is terminated before 20 weeks of gestation or a fetal weight 35 y.o

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Family hx of DM

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Previous delivery of infant that was large or stillborn

Subjective data o Hypoglycemia (nervousness, HA, weakness, irritability, hunger, blurred vision, tingling of mouth or extremities) o Hyperglycemia (thirst, nausea, abd pain, frequent urination, flushed dry skin, fruity breath) Objective Data o Hyperglycemia o Hypoglycemia o Vomiting o Shaking o Excess weight gain during o Clammy pale skin pregnancy o Shallow respirations o Rapid pulse Lab tests o Routine urinalysis w/ glycosuria o Glucola screening test/1 hour GTT  Positive: 140 mg/dL or greater  Additional testing w/ 3 hr GTT is indicated o 3-hr GTT  Avoidance of caffeine & abstinence from smoking for 12 hour prior to testing  100 g glucose load given o Ketones tested to assess the severity of ketoacidosis Dx procedures o Biophysical profile to ascertain fetal well-being o Amniocentesis w/ alpha-fetoprotein o Nonstress test to assess fetal well-being Nursing Care: o Monitor client’s blood glucose o Monitor fetus o Instruct client to perform daily kick counts o Administer insulin as prescribed  Most oral hypoglycemic agents are contraindicated for GDM, but there is limited use of glyburide at this time. The provider will need to make the determination if these meds can be used o Educate client about diet, exercise, & self-administration of insulin o Desired client outcomes: effectively manage & control blood glucose level throughout her pregnancy to ensure maternal/fetal well-being

Gestational Hypertension/ Pregnancy Induced Hypertension (PIH)

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Hypertensive disease in pregnancy is divided into clinical subsets of the disease based on endorgan effects & progresses along a continuum from mild gestational hypertension, mild & severe preeclampsia, eclampsia, & HELLP syndrome Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the s/s of pregnancy hypertensive disorders Gestational hypertension (GH), which begins after the 20th week of pregnancy, describes hypertensive disorders of pregnancy whereby the woman has: o an elevated BP at 140/90 or greater o or a systolic ↑ of 30 o or a diastolic ↑ of 15 from the prepregnancy baseline o no proteinuria or edema o client’s bp returns to baseline by 12 weeks postpartum Mild preeclampsia: o GH w/ addition of proteinuria of 1 to 2+ o Weight gain of more than 2 kg (4.4 lbs) per week in the 2nd & 3rd trimesters o Mild edema will appear in the upper extremities or face Severe preeclampsia: o Hyperreflexia w/ possible ankle o BP >160/100 clonus o Proteinuria 3 to 4+ o Pulmonary or cardiac o Oliguria involvement o Elevated serum creatinine >1.2 o Extensive peripheral edema mg/dL o Hepatic dysfunction o Cerebral or visual disturbances o Epigastric & RUQ pain (HA & blurred vision) o Thrombocytopenia Eclampsia is severe preeclampsia symptoms along w/ onset of seizure activity or coma. o Usually preceded by HA, severe epigastric pain, hyperreflexia, & hemoconcentrations, which are warning signs of possible convulsions HELLP syndrome is a variant of GH in which hematologic conditions coexist w/ severe preeclampsia involving hepatic dysfunction. Diagnosed by lab tests, not clinically: o H- hemolysis resulting in anemia & jaundice o EL- elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, n/v o LP- low platelets (< 100,000), resulting in thrombocytopenia, abn bleeding & clotting time, bleeding gums, petechiae, & possibly DIC Gestational hypertensive disease & chronic hypertension may occur simultaneously Gestational hypertensive diseases are associated w/ placental abruption, acute renal failure, hepatic rupture, preterm birth, & fetal & maternal death Risk Factors o No single profile identifies risks for GH disorders, but some high risks include:

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 Maternal age 40  First pregnancy  Morbid obesity  Multifetal gestation  Chronic renal disease Chronic hypertension Assessment of Gestational Hypertensive Disorders

Familiar hx of preeclampsia DM Rh incompatibility Molar pregnancy Previous hx of GH

Subjective Data

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Severe continuous HA Nausea

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Blurred vision Flashes of lights or dots before the eyes

Objective

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HTN Proteinuria Periorbital, facial, hand, & abd edema Epigastric pain RUQ pain Dyspnea Seizures Jaundice Scotoma Diminished breath sounds ↓ Hgb ↑ Creatinine Thrombocytopenia Liver enzymes CBC Clotting studies Dipstick urine for proteinuria 24 hr urine collection for protein & creatinine clearance

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Pitting edema of lower extremities Vomiting Oliguria Hyperreflexia Rapid weight gain (2 kg [4.4 lb]) per week in 2nd & 3rd trimesters Signs of progression of hypertensive disease w/ indications of worsening liver involvement, renal failure, worsening hypertension, cerebral involvement, & developing coagulopathies

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Lab Tests

Dx Procedures

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Nursing Care: o Assess LOC o Pulse ox o Urine output & obtain cleancatch urine sample to assess for proteinuria o Daily weights Meds:

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↑Plasma uric acid ↑ liver enzymes (LDH, AST) Hyperbilirubinemia Serum creatinine, BUN, uric acid, & Mg ↑ as renal function ↓ Chemistry profile Nonstress test, ctxn stress test, biophysical profile, & serial ultrasounds to assess fetal status Doppler blood flow analysis to assess fetal well-being

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Vitals Lateral positioning Perform NST & daily kick counts as prescribed Instruct client to monitor I&O

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Mag Sulfate  Anticonvulsant  Med of choice for prophylaxis or treatment.  Lowers BP & depresses CNS  Use infusion control device to maintain regular flow rate  Inform client she may initially feel flushed, hot, & sedated w/ MgSO4 bolus  Monitor BP, pulse, RR, DTRs, LOC, urinary output (indwelling cath for accuracy), presence of HA, visual disturbances, epigastric pain, uterine ctxns, & FHR & activity  Fluid restriction of 100 to 125 ml/hr, maintain urinary output of 30 ml/hr or greater  Monitor for signs of mag toxicity:  Absence of patellar DTR  Urine output 38 weeks gestation o Umbilical cord compression r/I fetal hypoxia that stimulates the vagal nerve in mature fetuses o Hypoxia stimulate vagal nerve, which induces peristalsis of fetal GI tract & relaxation of the anal sphincter, which r/I release of meconium as well as fetal bradycardia Objective Data: o Presence of meconium via visual inspection o Fluid may vary in color from black to greenish, yellow or brown, w/ thick fresh consistency o Criteria for evaluation of meconium-stained amniotic fluid:  Consistency that is thick & fresh: indicates fetal stress  Meconium is 1st passed in later labor w/ variable or late FHR decelerations (ominous sign)  Meconium alone in the amniotic fluid isn’t sign of fetal distress; it must be accompanied by variable or late FHR decelerations w/ or w/out acidosis, which is confirmed by scalp blood sampling to be considered ominous o Dx Procedures  Intrapartal meconium requires further careful evaluation if birth is not imminent  Electronic fetal monitoring  Fetal scalp blood sampling Nursing Care: o Document meconium-stained amniotic fluid & its color o Amnioinfusion of 0/9% NaCl or LR should be instilled into the amniotic cavitiy through a transcervical cavity into the uterus to thin meconium-stained fluid o Nurse should be prepared to suction the nasopharynx of neonate o Suctioning reduces the incidence & severity of meconium aspiration syndrome in the neonate

Postpartum Period  

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Greatest risks: hemorrhage, shock, & infection Oxytocin coordinates & strengthens uterine contractions o May be administered postpartum to improve quality of uterine ctxns o Firm & contracted uterus prevents excessive bleeding & hemorrhage o Uncomfortable uterine cramping: afterpains Assessments immediately following delivery: o Vitals

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o Uterine firmness & location relative to umbilicus o Uterine position in relation to midline of the abd o Amount of vaginal bleeding Postpartum chill: occurs in first 2 hr puerperium. Uncontrollable shaking chills possibly r/t nervous system response, vasomotor changes, shift in fluid, &/or work of labor. o Normal occurrence unless accompanied by elevated temperature o Provide client w/ warm blankets & fluids Fundus: o Immediately after delivery: firm, midline w/ umbilicus, at level of umbilicus o At 12 hr postpartum: 1 cm above umbilicus o Q 24 hr, descends approximately 1-2 cm  Should be halfway b/t symphysis pubis & umbilicus by 6th day o By day 10, uterus should lie within true pelvis & not palpable Comfort measures: o Apply ice packs to perineum for 1st 24-48 hrs to reduce edema & provide anesthetic o Encourage sitz baths at temp of 38-30 (100-104 F) or cooler at least BID o Admin analgesia such as nonopioids, NSAIDS,& opioids as prescribed o Opioid analgesia may be admin via PCA after c-section. Continuous epidural infusions may also be used for pain control after c-sections o Apply topical anesthetics to perineal area prn or witch hazel compresses to rectal area for hemorrhoids Immune System: o Review the Rh status  All Rh(-) mothers w/ newborns who are Rh(+) must be given Rhogam administered w/in 72 hrs of delivery to suppress antibody formation in mother o Test client who receives both rubella vaccine & RhoGAM after 3 months to determine if immunity to rubella has been developed

Bonding & Integration of Infant into Family System 
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