Exam 2 Study Guide PDF

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Exam 2 Study guide...

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OB study guide exam 2 Newborn Transitioning and Nursing Management Fetal to neonatal circulation - a murmur can be heard due to the fetal shunts being opened but should close and be resolved by 24 hours o 3 structures: o Ductus venosus -allows the majority of the umbilical vein blood to bypass the liver and merge with blood moving through the vena cava, bringing it to the heart sooner-closes within a few days after birth  constricts after birth when cord is cutbecomes a ligament o foramen ovale -Allows more then half the blood entering the right atrium to cross directly over to the left atrium bypassing the lungs  Breathing begins, pressure in the L side of heart increases & formen ovale is held closed o ductus arteriosus -connects the pulmonary artery directly to the aorta bypassing the pulmonary circuit-closes within a few hours after birth - when the umbilical cord is clamped, the first breath is taken and lungs begin to function o systemic vascular resistance increases and blood return to the heart via the inferior vena cava decreases - Heart Rate o immediately after birth: 110- 160 o it begins to decrease since the birth: 120-130 - Blood Volume o depends on the amount of blood transferred from the placenta at birth o Benefits of delayed cord clamping (3mintues after birth)  improving the newborn’s cardio-pulmonary adaptation  preventing iron-deficient anemia in full term newborns without increasing hypervolemia-related risks and increased iron stores  increasing blood pressure  improving oxygen transport  increasing red blood cell flow o low blood volume= low oxygenation, poor perfusion - Blood components o large red blood cells but few in number  RBC will increase as cell size decreases  larger cells can carry more oxygen o WBC increase related to birth trauma Respiratory System - Initiation of breathing triggered by 4 types of stimuli o Mechanical- squeezing during birth help get the fluid out of the lungs  may need help by removing fluid from mouth (clearing airway)  c-section babies do not have that squeeze to help remove fluidmay need more suctioning  transient tachypnea of newborn may occur (60 breaths per minute) o Chemical- CO2 in the air triggering to breath o Thermal- warmth

o Sensory- rubbing baby, auditory, visual stimuli - Surfactant is necessary for breathing o a surface tension reducing lipoprotein found in the newborns lungs, prevents alveolar collapse, lines the inside of alveoli o premature babies without surfactant will receive synthetic surfactant - Positive pressure by crying at birth helps keep the alveoli open/ maintains expansion of the lungs Heat Loss - Thermoregulation is the process of maintaining a balance between heat loss and heat production - temperature ranges from 97.9 to 99.7 (36.6 to 37.6) - Characteristics: o thin skin and blood vessels close to surface o Lack of shivering ability to produce heat until 3 months old o Limited stores of metabolic substances (glucose, glycogen, fat) o Limited use of voluntary muscle movement or movement to produce heat o Large body surface relative to body weight o Lack of sub q fat, no insulation o little ability to change position to conserve heat o inability to communicate that they are too cold or too warm - Types of heat loss o Convection- do not have cool air blowing on baby  air drafts, air conditioning, and air outside of an incubator o Radiation- the area around the baby cold therefore warm the room  walls of the room or windows not covered by drapery o Evaporation- important to keep the baby dry  amniotic fluid evaporates from the skin causing heat loss o Conduction- do not lay directly on a cooler surface  unheated mattresses or blankets, scales and caregiver’s hands - Premature babies especially struggle with regulation it temperature but also 36 weeks o size and gestation age have a factor with temperature regulation - Prevention o cribs and examining tables placed away from outside windows middle of room o care is taken to avoid air drafts o pre-warming blankets and hats o keeping the infant transporter heated at all times o drying the newborn completely after birth o encouraging skin to skin o promoting early breastfeeding to provide fuels for nonshivering thermogenesis o increasing temperature of room before birth of baby o deferring bathing until stable temp is maintained Over heating - Newborn can be prone to overheating due to inability to sweat. - maintain a neutral thermal environment - Overheating can cause increased fluid loss, RR and metabolic rate. Cold stress- heat loss through all four mechanisms

excessive heat loss that requires a newborn to use compensatory mechanisms to maintain core body temperatures o nonshivering thermogenesis o tachypnea - newborns will increase temp by increasing their metabolic rate this will therefore their glucose will decrease - As the body temp. decreases the newborn becomes less active, lethargic, hypotonic, and weaker - preterm newborns are at greatest risk - can lead to: o depleted brown fat stores o increased oxygen needs o respiratory distress o increased glucose consumption >hypoglycemia o metabolic acidosis o jaundice o hypoxia Hepatic System - Liver- takes over the functions of the placenta has been doing o blood coagulation (vit. K+), iron storage, conjugation of bilirubin o most enzymatic pathways are present in the newborn, but are inactive at birth and generally become fully active at 3 months of age - Iron Storage o as the red blood cells are destroyed after birth, their iron is released and stored by the liver until new red cells need to be produced o if the mother’s iron intake was adequate during pregnancy, sufficient iron has been stored in the newborn’s liver for use during the first 6 months of age - Carbohydrate metabolism -Cord is cut, maternal glucose supply is cut off o Initially newborns serum glucose decline o Initiating feedings help maintain adequate glucose levels which is the main source of energy for the first several hours o Newborns must learn to regulate their blood glucose concentration and adjust to an intermittent feeding schedule o Hypoglycemia is one of the most frequent problems - Bilirubin conjugation- a yellow-to-orange bile pigment produced by the breakdown of red blood cells o In utero the placenta and the moms liver handle the excretion of bilirubin o toxic to the body and must be excreted o Bilirubin is released unconjugated (fat soluble), enzymes and proteins process the unconjugated into conjugated (water soluble) which can then be excreted o Newborns produce bilirubin at twice the rate of adults  due to polycythemia and increased red blood cell turnover  production will decline to adult level within 10 to 14 days afterbirth o Due to immature liver cannot conjugate as quickly=jaundice  increased amount of bilirubin in the blood stream - when a baby is cold then the baby will use its glucose/energy to stay warm - Hypoglycemia -

o Maternal glucose supply is now gone in utero the baby would get glucose from the placenta and it was as if receiving sugar packets o Work of breathing and thermoregulation require use of glucose o Glucose declines in the first 2 hours after birth, then rises then reaches a steady state by 3 hours! o commonly seen in babies that are small or heavy, moms with gestational diabetes, temperature is an issue, a baby working hard to breath

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o signs and symptoms  jittery  expect greater than 40 glucose level o important to get baby to breast as soon as possible o Using glucose stores very quickly due to the regulation of breathing and thermoregulation Hyperbilirubinemia (jaundice) o The fetus has never conjugated bilirubin (made it excretable) before mom took care of this. o This process starts after birth o Conjugated bilirubin is excrete by stool and urine  the more the baby pees and poos the better it is getting rid of the bilirubin o Unconjugated bilirubin (likes fatty tissues) forms when RBC’s are destroyed  conjugated bilirubin=excretable o Decreased ability to clear bilirubin occurs in breastfed babies and in delayed bacterial colonization of the gut (use of antibiotics)  Early and frequent feedings necessary o severe jaundice could mean that the bilirubin could be in the brain lots of fatty tissue o if there is bruising there are destroyed RBC’s increased risk for bruising o babies are expected to have some jaundice when first born but should resolve o Jaundice progresses from head to toe (cephalocaudal)  if yellow skin begins to creep down to lower extremities then should worry  test bridge of the nose or chest to see if it yellow after applying pressure  get blood test to test for hyperbilirubinemia Risk Factors for Jaundice o East Asian Race o Sibling with jaundice o High transcutaneous readings o Cephalohematoma o Prematurity o Asphyxia at birth o Neonatal and maternal medications  Pitocin, valium o Hypothermia o Hypoglycemia o ABO incompatibility (RH – and O blood type women) o infrequent feedings

o maternal gestational diabetes o trauma during birth - Coagulation- placenta does the job in utero o Coagulation factors made in the liver o Vitamin K is needed to activate these factors (prevent bleeding) o Vitamin K is synthesized in the intestine o Normal flora is not present to make vitamin K o Vitamin K given as an injection at birth to prevent bleeding- injection in the vactus lateralis o If infant platelets are low-ask yourself what were maternal platelet levels. Gastrointestinal and renal changes - The term newborn can swallow, digest, metabolize and absorb food shortly after birth - Stomach and digestion o The stomach of the newborn is small, the size of a small marble at birth o small frequent feedings o For the first 24 hours the newborns stomach does not stretch to hold more.  Why newborns are spitty o Normal term newborns lose approximately 5%-10% of birth weight due to small feedings, insensible water loss, shifting of intracellular water to extracellular spaces - Bowel elimination o Meconium is first bowel movement, tarry consistency o After feedings are initiated, stools turn to greenish brown to yellowish brown, guldens' mustard. - Renal system- Kidneys are able to handle excretion and maintenance of acid base balance o limit in ability to concentrate it until 3 months of age Immune System Adaptations - Natural immunity- skin o responses that do not require previous exposure to microorganism: o physical barriers such as intact skin and mucous membranes, chemical barriers such as gastric acid and digestive enzymes - Acquired immunity- 28 to 36 weeks mom receive DiTAP shot so some of it will transfer to baby o Development of circulating antibodies and formation of activated lymphocytes. o Hep B is usually the 1st immunization the baby receives Neuro Sensory - Can see 8 to 15 inches - Can select their mother by smell - Can distinguish between sweet and sour - Reflexes- an involuntary muscular response to a sensory stimulus o gag o Babinski- feet fanning out o moro (startle)- arms and legs will flare out o rooting- stroking side of face, looking for breasts o sucking o grasp- baby’s fingers curling around o stepping

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o Very sensitive, enjoy touch-encourage skin to skin o mom should be awake and alert, keep blanket on baby, head tilted to the side, mom should be able to kiss baby

Pregnancy Complications: Gestational Hypertensive Disorders Chronic Hypertension - BP exceeding 140/90 or higher before pregnancy or before the 20th week of gestation or when hypertension persists 12 weeks postpartum Gestational Hypertension- BP starts to rise during pregnancy - Onset of hypertension without proteinuria after week 20 of pregnancy and resolving by 12 weeks postpartum - Systolic BP >140, diastolic BP >90 - on two occasions at least 6 hours apart after the 20th week of gestation in women who have been normotensive - The difference b/t chronic and gestational is that gestational began after 20 weeks of pregnancy Preeclampsia – increase BP but effects other organs systemically - Etiology o A condition unique to human pregnancy o Signs and symptoms develop during pregnancy and disappear after birth o Common risk factors:  Primigravidity or new partner in this pregnancy  Extremes of maternal age 40  Multifetal pregnancy  Obesity  Preexisting medical condition- diabetes and hypertension, migraine headaches, type 1 or type 2 diabetes, kidney disease, a tendency to develop blood clots, or lupus - The diameters of the vessels will shrink o decreased placental perfusion and hypoxia occurs o skinny blood vessels= poor blood flow - Maternal Effects-can occur anytime from 20 weeks until 6 weeks postpartum - Elevated Blood pressure > 140 systolic or > 90 diastolic - Proteinurea -300 mg in a 24 hour urine or in the absence of proteinuria the patient (protein in urine) o Excess protein in your urine (proteinuria) and Decreased urine output--> decreased kidney perfusion - May have o Visual Disturbances o Headache, oliguria, blurred vision, epigastric pain decreased liver perfusion from liver function o Epigastric pain related to elevated liver enzymes o Hyperreflexia (Clonus)- foot would beat back quickly, can beat back more than once o Seizures (Eclampsia) o Pulmonary Edema, mild facial edema, sudden weight gain o Epigastric Pain related to elevated liver enzymes

o Evaluate kidney function o temporary loss of vision - Fetal/Neonatal Effects o Poor Growth o Prematurity o Childhood high blood pressure o Stillbirth o Low Apgar scores o Abruption- placenta blowing off the wall Eclampsia- effecting organs systemically but now is having seizures - Onset of seizure activity or coma in a woman - with preeclampsia - No history of preexisting pathology - 70% of eclamptic women develop the condition while pregnant - 30% develop eclampsia in the immediate - postpartum period - occurs when preeclamapsia is not controlled - preceded by worrying signs of persistent headache, blurred vision, severe epigastric pain, or right upper quadrant abdominal pain and altered mental status - convulsions can appear suddenly and without warning - Nursing Interventions o Quiet o Low stimulus o Side rails up o Limit phone calls and visitation o Oral airway near by o Monitor fetal heart tones o Monitor DTR’s o Monitor vital signs o Support family o Assess level of consciousness o Medication to stop seizures o What are they for this patient? o What kind of decelerations might you see in this patient related to the preeclampsia? o Long term health issues-what education can we provide these women? o Who is at risk? HELLP (Hemolysis Elevated Liver Enzymes and Low Platelets- extreme form of eclampsia - VERY SERIOUS-can be complicated by DIC Magnesium Sulfate Therapy - Drug of choice o Prevention & treatment of seizures o “loading dose-initial bolus of 4-6 g over 15 to 30 min; maintenance dose, 1-2 g/hr, according to unit protocol or specific physician’s order” o Therapeutic serum magnesium level of 4-7 mEq/ml - anticonvulsant - Almost always administered IV via an infusion control device or pump.

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“loading dose-initial bolus of 4-6 g over 15 to 30 min; o maintenance dose-2 g/hr, according to unit protocol or specific physician’s order May see oxytocin and mag given simultaneously Always have calcium gluconate at bedside (antidote) Nursing assessments: toxicity o Respiratory rate: < 12 o Deep tendon reflexes: absent o Urinary output: < 30 per hour o Serum magnesium levels: > 8mEq/dl o Also assess for clonus-related to nervous system irritability does not treat BP decreases risk of seizure monitor reflexes Magnesium is exerted through the kidneys- watch UO

Pregnancy Complications: Bleeding in Pregnancy High risk conditions - Bleeding during pregnancy - Spontaneous abortion - Ectopic pregnancy - Gestational trophoblastic disease (GTD) - Cervical insufficiency - Placenta previa - Abruptio placentae - Placenta accreta - Hyperemesis gravidarum - Hypertensive disorders of pregnancy - Blood incompatibility - Amniotic fluid issues Risk factors - Biophysical factors-Genetic conditions, Chromosomal abnormalities, multiple’s pregnancy, ABO incompatibality, inherited disorders, LGA, medical conditions of the mom, nutritional status, preterm labor and birth, diabetes, HTN - Psychosocial factors smoking, caffeine, SA & AA, maternal obesity, hx of IPV, - Sociodemographic factors Poverty, no prenatal care, age 35, accessibility to health care - Environmental factors Infections, radiation, second hand smoke, stress Spontaneous Abortion - An abortion is the loss in early pregnancy prior to 20 weeks. - The most common cause is genetic fetal abnormalities. o Chromosomal abnormalities > 1st trimester. - Disease conditions of the mother or uterine anomalies of the uterus >2nd trimestercervical insufficiency, DM, Cocaine, severe HTN, PCOS, acute infections - A= Threatened abortion- The cervix is not dilated and the placenta is still attached to the uterine wall, but some bleeding occurs. Initially beginning as scant bleeding and usually bright red in color. No passage if fetal tissue

o Some bleeding but still a fetal heart rate. A little worried. No tissue has passed. Emotional support needed because there are not any medical interventions to stop it, some cramping o Management> conservative supportive treatment.

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B=Inevitable, Vaginal bleeding greater than in threatened, Abortion cannot be stopped. Possible passage of products of conception. The membranes rupture and cervix dilates. Possible D & C or use of misoprostol (cytotec) to empty uterus o Cervix has dilated, lots of bleeding, D&C= delineation corintinge. Some passing of the products of conception. Cramping

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C=Incomplete, A portion of the products of conception are expelled and a portion are retained most often the placenta is retained. Heavy vaginal Bleeding and intense cramping, cervical dilation , D & C o did not pass all the products of conception and is continuously bleeding, will need a D&C

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D=Complete, All products of conception are expelled, and the uterine bleeding and cramping cease. No medical or surgical intervention necessary o passed all products of conception

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E=Missed, Absent uterine contractions, a pregnancy becomes nonviable. Fetus dies in uterobut is not expelled; irregular bleeding, fetus is retained beyond 6 weeks, Evacuation if products not expelled o no fetal heart rate. Will use D&C or will use medication to bring on contractions so she can pass products of conception -

Habitual abortion: Hx of 3 or more consecutive SAB’s Nursing management: Continual monitoring and psychological support. All of these occur less than 20 weeks in gestational age Will draw labs (HcG hormone) to see the level and how the pregnancy is doing. Levels should be increasing

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Ectopic Pregnancy

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EP or tubal pregnancies=is the implantation of the fertilized ovum in a site other than the endometrial lining of the uterus Usually results from conditions that obstruct or slow the passage of the fertilized ovum #1 leading cause of maternal death in the 1st trimester Get pregnancy test to confirm Fallopian tube implantation can cause the tube to rupture and will cause internal bleeding, unilateral lower abdominal pain. Change in vital signs if it ruptures: BP decreases, HR increases hypovolemic shock Priority for ectopic pregnancy is fluid volume causes o tubal damage from pelvic inflammation disease (PID) o previous tubal surgery o congenital anomalies of the tube o endometriosis o previous EP o presence of an IUD Clinical manifestations o Initially symptoms of pregnancy may be present, including amenorrhea, breast tenderness and nausea. o The hormone hCG is present in the blood and urine. o As the pregnancy progresses, the chorionic villi grow into the tube wall and establish a blood site.

o When the embryo outgrows this space, the tube ruptures and there is bleeding into the abdominal cavity.

o This bleeding irritates the peritoneum causing the characteristic symptoms of sharp one-sided pain, syncope and referred shoulder...