N306 Study Guide - Finals PDF

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4 N306 Study Guide – Final Spring I This guide includes all content that is important to understand in each chapter. A comprehensive level of understanding will ensure your success. For more focused guidance: If something is bolded/underlined, then it’s probably going to be on your exam. All page numbers refer to Durham 3rd ed. Chapter 3 Genetics o Associated terminology/definitions and classifications (genotype vs phenotype) → genotype – genes, genes of mom straight hair and dad curly hair → phenotype – curly hair (expressed, observable), tall, green eyes

o → → → →

Genetic counseling- role of the nurse offer support assess risk factors for genetic disorders assist in value clarification educate on procedures and tests

o Genetically linked disorders and associated ethnic backgrounds ● ● ● ● ● ● ●

Sickle-Cell Anemia à African American ancestry Cystic Fibrosis → European ancestry Tay-Sachs Disease → Jewish ancestry Phenylketonuria → lack of an enzyme to metabolize the amino acids phenylalanine leads to severe mental and physical retardation. Huntington’s Disease → uncontrollable muscle contractions b/w the ages of 30 and 50 y.o. Hemophilia (X-linked) → lack of factor VIII impairs chemical clotting Duchenne’s Muscular Dystrophy (X-linked) → replacement of muscle by adipose or scar tissue.

o Fetal alcohol syndrome § Causes? Fetal characteristics? Fetal characteristics ● Small eyes, flat midface, smooth philtrum, thin upper lip, eyes with wide spaced, strabismus, ptosis, poor suck, small teeth, cleft lip or palate, microcephaly ● Developmental delays, sleep disturbances, heart defects, tetralogy of fallot ● Withdrawal: jitteriness, irritability, increased tone and reflex response, seizures ● Causes: intake of alcohol while pregnant (chronic or periodic intake)

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o TORCH § Look at each and understand the mode of transmission, is there treatment for it? Do we screen for it during prenatal care? How might it affect the pregnancy and baby? ● T: Toxoplasmosis, increased risk for fetal demise, blindness, mental retardation ● O: Other (Hep B) ● R: Rubella (German measles), increased risk for heart defects, deafness and/or blindness, mental retardation, fetal demise ● C: Cytomegalovirus (CMV), increased risk for hydrocephaly, microcephaly, cerebral calcification, mental retardation, hearing loss ● H: Herpes Simplex virus (HSV), increased risk for hypoplasia of hands and feet, blindness/cataracts, mental retardation § What about viruses and placenta? ● Viruses such as rubella and cytomegalovirus can cross the placental membrane and enter the fetal system, potentially causing fetal death or defects ● NO MMR vaccine during pregnancy § How long is zika in male system for? What can zika lead to in newborn who is affected by it? ● Increased risk for microcephaly, blindness hearing defects, impaired growth, increased muscle tone, seizures

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Menstrual Cycle Consists of two cycles working simultaneously (ovarian and endometrial) what are levels and roles of estrogen and *progesterone in each cycle

*ovarian hormones – maintain endometrium, provide nutrition, aid in implantation, decrease uterine contractility, initiate breast ductal system development o Where each hormone is released from in the body? -LH and FSH (follicle stimulating hormone) o Know the role and function of the corpus luteum (think hormones) -makes estrogen and progesterone (to prepare uterus for fertilization also to inhibit LH and FSH from maturing eggs) Conception - when a sperm nucleus enters the nucleus of the oocyte o Where does fertilization occur? -fallopian tubes (ovum released to the peritoneal cavity then swept by the fimbriae towards the fallopian tubes. -fertilization occurs – CL stays in place -> embryo releases HCG (human chorionic gonadotropin) which prevents CL from dying -corpus luteum stays in place until Placenta takes over (about 8 weeks)

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When does implantation occur? What part of the blastocyst is involved in implantation? Where does implantation usually happen? What will happen if implantation occurs too early? - Implantation, the embedding of the blastocyst into the endometrium of the uterus, begins around day 5 or 6 - the trophoblast, which assists in implantation and will become part of the placenta. ● Endometrium → Endometrial lining Embryonic and Fetal Development When to expect to see fetal cardiac activity on ultrasound → expected 3 weeks after conception, heartbeat at 5 weeks, 2 days Summary of fetal development - table 3-4, p. 49.

heart forms at 3 weeks Hear the heart by 5 weeks, 2 days

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What is considered a term pregnancy? -

38 weeks

Difference between identical and fraternal twins Identical vs fraternal twins ● Identical: also known as Monozygotic result from a fertilized ovum that splits during the early stages of cell division to form two identical embryos that are genetically the same ● Fraternal: Known as Dizygotic result from two separate ova fertilized by two separate sperm they are not genetically identical. Fetal circulations (ductus venosus, foramen ovale, ductus arteriosus) ● Ductus venosus: connects the umbilical vein to the inferior vena cava. This allows the majority of the highly oxygenated blood to enter the right atrium. ● Foramen ovale: opening between the right and left atria. After delivery the foramen ovale closes in response to increase blood returning to the left atrium . ● Ductus arteriosus: Connects with the pulmonary artery with the descending aorta. After delivery, the ductus arteriosus constricts in response to the higher blood oxygen levels and prostaglandins. Basic concepts of placenta physiology and its purpose o Hormones produced by the placenta (what roles do these hormones play? Which is used to diagnose pregnancy? Which hormone is responsible for regulating glucose availability in the newborn? The major hormones the placenta produces are progesterone, estrogen, hCG, and hPL. ● Progesterone: facilitates implantation and decreases uterine contractility ● Estrogen: stimulates the enlargement of the breast and the uterus. ● hCG: secrets estrogen and progesterone until the placenta is mature enough to do so. *Hormone in pregnancy tests, rises in the first trimester and then decreases ❖ hPL: promotes fetal growth by regulating available glucose and stimulates breast development in the preparation for lactation. Purposes of amniotic fluid ❖ Amniotic fluid: contains proteins, carbs, lipids, electrolytes, fetal cells, lanugo. ➢ Cushion the fetus from sudden maternal movements ➢ Allows freedom of fetal movement ➢ Thermal environment Normal structure of the umbilical cord ❖ Baby AVA ➢ Two arteries, one vein Infertility Definition of infertility → Inability to conceive and maintain pregnancy after 12 months

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Common causes of infertility → Common causes: ⅓ men factors. Low levels of LH, FSH, testosterone, drugs, infections, prolonged heat exposure, radiation, obesity, eating disorders Basic work up for infertility ○ Basic work : Screening for STIs--CDC estimates that undiagnosed STIs cause 24,000 women to become infertile each year. ○ Assessment of hormonal levels ○ Semen analysis ○ Assessing for ovulatory dysfunction ○ Hysterosalpingogram ○ Endometrial biopsy Chapter 4 Prenatal Care What is the goal and purpose of prenatal care? ● ● ● ● ●

Regular assessment of health of pregnancy Regular screening of risk factors for potential complications Education on health promotion & disease prevention or complications Implementation of interventions based on risk status or actual complications Inclusion of significant others/family in care & education to promote pregnancy adaptation

Diagnosing pregnancy o Most likely cause of amenorrhea? (Pregnancy) → increased levels of estrogen and progesterone (pregnant) o Know presumptive, probable and positive signs of pregnancy § Definition of Goodell’s Sign, Chadwick’s sign, Hegar’s sign, quickening Probable – objective signs: Chadwick’s sign: Bluish-purple coloration of the vaginal mucosa, cervix, and vulva seen at 6 to 8 weeks ● Ballottement: rebounding of the fetus against the examiner’s fingers on palpation ● Braxton hicks contractions: irregular painless contractions that may occur intermittently throughout pregnancy ● Goodell’s sign: Softening of the cervix and vagina with increased leukorrhea discharge; palpated at 8 weeks ●

Skin hyperpigmentation:

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● Melasma (chloasma), also referred to as the mask of pregnancy: Brownish pigmentation over the forehead, temples, cheek, and/or upper lip ● Linea nigra: Dark line that runs from the umbilicus to the pubis § Know what symptoms could possibly attributed to something else versus what actually gives you the diagnosis of pregnancy: -

N/V Breast changes Urinary frequency Amenorrhea

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When can I hear baby’s heartbeat with an ultrasound, with a hand held Doppler - Heart formed – 3rd week, and begins to beat and circulate blood during the 4th week - Heartbeat at 5 weeks, 2 days →Auscultation of the fetal heart, by 10 to 12 weeks gestation with a Doppler

o When can mom feel quickening? (baby moving)…is there a difference b/w 1st and 2nd time pregnancies? →14- 22 weeks varies - A woman’s first awareness of fetal movement; occurs around 18 to 20 weeks’ gestation in primigravidas (between 14 and 16 weeks in multigravidas) o Where am I expecting to find the fundus during different gestational ages?…Where would I palpate the fundus at 24 weeks? At 28 weeks? What is normal deviation from this finding? -

Estimating fetal growth: o # of cm = # of weeks – starting from 20 weeks Fundal height: symphysis to top of fundus - Milestones: - 12 weeks: fundus above symphysis - 20 weeks: fundus at umbilicus - 36 weeks: fundus at xiphoid

§ IF I have finding larger than expected, what might be reasons? -

Macrosomic baby

§ IF I have finding smaller than expected, what might be reasons? -

Baby isn’t growing bc of poor nutrition/iugr

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Nutrition- prevention of neural tube defects- ie. spina bifida -

Folic acid Folic Acid: prevents neural tube defects (400 - 800mcg)

Weight gain in pregnancy ● Recommended weight gain for underweight, normal, overweight and morbidly obese (box 4-2, pg 83) ○ Underweight: 28-40 lbs ○ Normal weight: 25-35 lbs ○ Overweight: 15-25 lbs ○ Obese: 11-20 lbs ● Basic nutritional requirements (calories needed and what extra vitamins and minerals are needed) ○ Folic acid → prevent neural tube defects ○ Iron → increase it during pregnancy ○ Protein → increases to 60g/day ○ Increase calorie intake by 2000-2500 daily ○ Increase fiber → prevent constipation ○ Up to 3 L of water needed ○ Minerals: calcium, phosphorus, iodine, iron, fluoride, sodium, zinc. ● Maternal weight gain distribution (box 4-3, pg 83) ○ Baby → 7.5 lbs ○ Placenta → 1.5 lbs ○ Amniotic fluid → 2 lbs ○ Breasts → 2lbs ○ Uterus → 2 lbs ○ Body fluids → 4 lbs ○ Blood → 4 lbs ○ Maternal stores of protein, fat, and other nutrients → 7 lbs

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Schedule of prenatal visits o Know what is done in first trimester, 2nd trimester, 3rd trimester during visits (what tests are done? What is screened for? What vaccines can be given, and which can’t?) ● ● ● ● ● ● ●

28 weeks – Tdap 28 weeks – rh- (rhogam) 35 - gbs 24 - glucose Flu vaccine- ANYTIME MMR and varicella are generally considered to be contraindicated in pregnancy Rubella, blood type, HIV, hep b, syphilis – done in the first trimester

1st trimester: ● ● ● ● ● ● ● ●

Hx of current pregnancy Obstetrical hx Physical & pelvic exam Assessment of uterine growth Assessment of fetal heart tones Lab & diagnostic studies Pt education & anticipatory guidance ***DENTAL HEALTH à should make & keep dental check ups

2nd trimester: ● ● ● ● ● ● ●

Confirm established due date Administer Rhogam (if indicated) Glucose screening → 1 hr Triple or quad screen → 15-20 wks screening for neural tube defects and trisomy 21 H&H b/w 28-32 wks → anemia Syphilis serology if indicated Antibody screen for Rh negative

3rd trimester: ● ● ● ● ● ● ●

Fundal height Fetal kick counts Assessment of fetal well being Pelvic exam Leopold’s maneuver Nutritional follow-up GBS screening → 35-37 wks

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What happens at a first prenatal visit- procedures and work up (know all the prenatal labs that need to be drawn) -

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Labs - CBC, H&H, Rh factor, Blood type - Rubella, Varicella - STI - Chlamydia - Gonorrhea - Diabetes Naegele’s Rule in calculating a due date (need LMP)

o What is the most accurate dating of gestational age? -

First trimester ultrasound (looking for growth of fetus)

What to expect the fundal height to be based on the number of weeks gestation= McDonald’s Rule -

After 20 weeks of gestation, the fundal height should be the same as the gestational age

· Definitions of gravida and para, and the TPAL system of term, preterm, abortions and living. Gravida: total number of times a woman has been pregnant, including the current pregnancy. Para: number of births after 20 wks gestation whether live or stillbirth. T: # of infants born after 37 wks P: # of preterm births born b/w 20 and 37 wks A: # of abortions L: # of living children Physiological changes of pregnancy (table 4-1, pg 58-62) & Self-Care/Relief Measures (Table 45, pg. 88-93) · Go through EACH system and look at the right side of the table with clinical s/s and know what those are and then make sure you know WHY you are seeing those s/s … as in, what change is happening physiologically that is resulting in the clinical s/s the client will be reporting? THEN once you know/understand this, be able to tell the client that what they report is normal and what they can do about it (table 4-5). o N/V during pregnancy, fatigue, insomnia, emotional lability, tender/enlarged breasts, Braxton Hicks contractions, increased cervical/vaginal secretions (yeast infections),

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dyspareunia, supine and orthostatic HTN, anemia, dependent edema, varicosities, hyperventilation and dyspnea, nasal and sinus congestion, bleeding gums, flatulence, heartburn, constipation, hemorrhoids, low back pain, round ligament spasms and pain, leg cramps, stretch marks, skin hyperpigmentation, acne, headaches. o Make sure you understand physiological adaptations of pregnancy especially CARDIAC (how does the body prepare to prevent PPH, physiologically). Re-read pg. 63, 64, 65, 66 and 67. -

Hypercoagulable - cardiac output is high ● Plasma fibrin increase of 40% ● Fibrinogen increase of 50% ● Coagulation inhibiting factors decrease Cardiac increase blood volume to help combat potential for blood loss

Chapter 5 Overview of the transition the woman goes through into her new maternal role Common psycho-social changes that accompany pregnancy ● Intendedness ● Ambivalence: normal response ● Acceptance: quickening (20 wks) → baby is real Special needs regarding specific patient populations o Teenagers § Specific concerns regarding teenage parents ● May not seek prenatal care ● Not future oriented ● Acceptance of pregnancy hindered 

Older mothers, lesbian mothers, single parents

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Chapter 6 Antepartal tests § Indications for first trimester ultrasound ● Indications for first trimester ultrasound ○ Confirms the intrauterine pregnancy ○ Fetal cardiac activity ○ Multiple gestation ○ Gestational age ○ Detects missed abortion, ectopic pregnancy ○ Evaluate vaginal bleeding ○ Nuchal translucency o Best indicator of accurate dating -

Ultrasound

o Why is accurate dating of pregnancy so important? -

To ensure the fetus is growing properly throughout the pregnancy

§ What does nuchal translucency screen for? -

Can detect about 80% of fetuses w/ trisomy 21 and other major aneuploidies for a false positive rate of 5%

§ Anatomy ultrasound o When is it performed? - typically done in 2nd trimester b/w 18-22 wks o What does it look for? - down syndrome/trisomy 21 - fetus increase fluid base of neck (nuchal fold) § Indication for umbilical artery Doppler flow -

Assess fetal heart tones

§ CVS o Indication: detects fetal abnormalities caused by genetic disorders

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o Procedure: catheter inserted either transvaginally through cervix or abdominally through a needle under ultrasound guidance o Timing in pregnancy: typically performed b/w 10-12 wks o Risks: fetal loss due to bleeding, infection, and rupture of membranes o Pros and cons for parents § Amniocentesis o Indication ● Amniocentesis indication: Commonly performed for genetic testing, fetal lung maturity, hemolytic disease in fetus or for intrauterine infection, NOT a routine test ○ “To detect genetic defects” o Procedure - genetic testing, assessment of fetal lung, intrauterine infection, therapy for POLYHYDRAMNIOS ·needle inserted thru maternal abdominal into uterine cavity to obtain amniotic fluid (fetal cells) looking for chromosomal abnormalities o Timing in pregnancy -performed at 14-20 weeks gestation, positive alpha-fetoprotein (protein made by baby) or suspected hemolytic disease o Risks - trauma to fetus/placenta, bleeding (hemorrhage), leak, preterm labor, infection o Pros and cons for parents - the test can give you and your partner extra time to work out the details of your child's future health care — or make the difficult decision whether to continue the pregnancy -

risk of miscarriage is believed to be very small

§ PUBS - Fetal Blood Sampling – Percutaneous Umbilical Blood Sampling o Indication: detects chromosome abnormalities & certain blood disorders w/ high levels of accuracy o Procedure: needle inserted into umbilical vein, fetal blood aspirated, ultrasound guides the needle to aspirate fetal blood o Timing in pregnancy o Risks: malformations of the fetus, fetal infection, fetal platelet count in the mother, fetal anemia, isoimmunization o Pros and cons for parents

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§ NIPT (Non-Invasive Prenatal Testing) o Indication: estimates whether risk of having certain conditions is increased or decreased. Analyzes both fetal & maternal DNA. o Procedure o Timing in pregnancy o Risks: may detect a genetic condition in the mother o Pros and cons for parents § California Prenatal Screening Program (Quad Screen or Multiple Markers Screen) o Indication: o Procedure o Timing in pregnancy: most accurate results when done 16-18 wks (but can be done b/w 15-22 wks) o Risks o Pros and cons for parents § Fetal Kick Counts o Patient teaching on how to perform -

10 Movements in 2hrs or 4 in 1 hr. ← if not detected contact HCP Best to count before bed time

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§ NST 

Indications - done to assess fetal well-being under NO stress (no labor)

- FHR increases 15 beats above baseline for 15 seconds twice or more in 20 minutes - done to assess fetal well being, just looking at fetal hr - Non-invasive test that measures the FHR response to fetal movement. Performed during third trimester.

o Procedure - performed twice a week, outpatient -

put toco on top of fundus or back of baby you can do 20-40 (max) minutes

o Interpretation-Be sure to consider normal baseline and moderate variability in addition to accels § Reactive Normal baseline, 2 accelerations within 20mins, NO decelerations, moderate viability = Reactive (baby is good) What does moderate variability indicate? ● → BEST indication of good oxygenation What do accelerations indicate? ● 2 accelerations, FHR increases 15 above baseline for 15 seconds or more in 20 minutes ● GOOD OXYGENATION What teaching do we give when an NST is reactive? ● Send mom home, have them count kick counts ○ 10 kicks/2hrs § Non Reactive ● Vibroacoustic Stimulation ● Next steps for ...