OB.PEDS Final Exam PDF

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OB/PEDS

FINAL EXAM STUDY GUIDE

OB REVIEW: 66 questions total  10% will be select all that apply, so 6 select all that apply  No math questions  99 minutes for the exam o Exam will be like the Kaplan exam o Not open book More newborn and postpartum question only 4-5 intrapartum Heat loss  What are the ways?  How do they use heat? o Characteristics predisposing newborns to heat loss:  Thin skin, blood vessels close to the surface  Lack of shivering ability  Limited stores of metabolic substrates such as glucose, glycogen, and fat  Lack of subcutaneous fat  Little ability to conserve heat by changing posture  Their flexed posture decreases the exposed surface area  No ability to adjust their own clothing or blankets to achieve warmth  They cannot pull the blanket up as needed like an adult or child could  Infants cannot communicate that they are too cold or too warm o Thermoregulation of the newborn:  Thermoregulation is the balance b/w heat loss and heat production  Heat production in the newborn is primarily through non-shivering thermogenesis (NST) o NST uses stores of brown adipose tissue (AKA brown fat) to provide heat o This is unique to newborns  Heat loss occurs via four mechanisms leading to cold stress. The four mechanisms of heat loss are: o Convection – loss of heat from warm body surface to cooler air currents like airconditioned rooms o Radiation – transfer of heat from heated body to cooler surfaces like walls o Evaporation – water is converted to vapor amniotic as in the amniotic fluid and in a bath o Conduction – heat loss to cooler surfaces such as chilled hands or cold weigh scales  Newborns need a neutral thermal environment  Neutral thermal environment of 32 to 34 C  Overheating can occur as a result of:  Large body surface area  Limited insulation  Limited sweating ability  Babies are not given a bath until they have at least 2-3 regular temperatures  Temperature of the newborn:  Their temperature stabilizes within 8-12 hours  Monitor their temperature via: o Axillary skin mode  Axillary temperature range is 36.5 to 37.2 C (97.7 to 98.6 F) o Skin probe o Rectally o Tympanically Transient tachypnea (TTN) o

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 What to do when it happens o Transient tachypnea of the newborn (TTN) is a self-limiting condition involving a mild degree of respiratory distress that requires minimal intervention and resolves over 24 to 72 hours o It is described as retention of lung fluid or transient pulmonary edema o Risk factors:  Lower gestational age  Cesarean birth  Male sex o Pathophysiology:  During fetal life, the lungs are filled with serous fluid b/c the placenta, not the lungs, is used for gas exchange.  During and after birth, this fluid must be removed and replaced with air  Passaged through the birth canal during a vaginal birth compresses the thorax, which helps remove the majority of the fluid. Pulmonary circulation and the lymphatic drainage system remove the remaining fluid shortly after birth.  An infant born by c-section is at risk of having excessive pulmonary fluid as a result of not having experienced all the stages of labor  TTN occurs when the liquid is removed slowly or incompletely o Nursing assessment:  Maternal sedation or birth by cesarean  Did she have a c-section or was she sedated?  Assess the newborn for:  Withing the first few hours: o Tachypnea o Expiratory grunting o Retractions o Labored breathing o Nasal flaring o Mild cyanosis  Mild to moderate respiratory distress is present by 6 hours of age  Respiratory rate possibly 100-140 breaths per minute  Assess the chest for hyperextension or barrel shape  Breath sounds may be diminished  Lab and diagnostic testing:  Chest x-ray may show mild symmetric lung over-aeration (think like something you would see in a COPD pt with barrel chest), prominent perihilar interstitial marks and streaking o Nursing management:  Supportive care  Oxygenation  IV fluids and gavage feedings  Provide IV fluids and/or gavage feedings until the respiratory rate decreases enough to allow safe oral feedings  Supplemental oxygenation  Provide supplemental oxygenation via nasal cannula or oxygen hood to maintain adequate oxygen saturation  Neutral thermal environment  Maintain a neutral thermal environment with minimal stimulation to minimize oxygen demand Hyperbilirubinemia o Jaundice (icterus neonatorium) is the most common physical finding in the newborn 2

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 Jaundice is the yellowing of the body tissues and fluids Hyperbilirubinemia refers to elevated serum blood levels Hyperbilirubinemia is a total serum bilirubin level above 5 mg/dL resulting from unconjugated bilirubin being deposited in the skin and mucous membranes Clinical manifestations:  After birth, the infant must conjugate their own bilirubin  The rate of conjugation depends on the rate of hemolysis, bilirubin load, maturity of liver, presence of albumin binding sites Predisposing factors:  Prenatal:  DM  Torch (toxoplasmosis, hepatitis B, rubella, cytomegalovirus [CMV], herpes simplex virus)  Rh and ABO incompatibilities  Neonatal:  Prematurity  Polycythemia  Bowel obstruction o A lot of times babies get rid of bilirubin in their stool, so, if there is a bowel obstruction then they cannot get rid of it o Delayed meconium passage, which increases the amount of bilirubin that returns to the unconjugated state and can be absorbed by the intestinal mucosa Pathologic jaundice:  Criteria for diagnosis:  Bilirubin > 4 mg/dl in blood cord  Total serum bilirubin increasing by more than 5 mg/dl over 24 hours or 0.5 mg/dl or more over 4-8 hours  Physiologic jaundice is an unconjugated hyperbilirubinemia that occurs after the first postnatal day and can last up to 1 week. Total serum bilirubin concentrations peak in the first 3 to 5 postnatal days and decline to adult values over the next several weeks.  Serum bilirubin levels reach up to 10 mg/dL and then decline rapidly over the first week after birth  Physiologic jaundice differs between breast-fed and bottle-fed newborns in relation to the onset of symptoms. Breast-fed newborns typically have peak bilirubin levels on the fourth day of life; levels for bottle-fed newborns usually peak on the third day of life. The rate of bilirubin decline is less rapid in breast-fed newborns compared to bottle-fed newborns because bottle-fed newborns tend to have more frequent bowel movements. Clinical jaundice:  Occurs within 24 hours of birth  In preterm newborns, bilirubin levels will be over 10 mg/dl at any time  In term newborns, bilirubin levels will be > 15 mg/dl that persists over 10 days  Visible jaundice that continues for more than 21 days in a preterm or more than 10 days in a term infant: unless breastfeeding  Pathologic jaundice is manifested within the first 24 hours of life when total bilirubin levels increase by more than 5 mg/dL/day and the total serum bilirubin level is higher than 17 mg/dL in a full-term infant.  Conditions that alter the production, transport, uptake, metabolism, excretion, or reabsorption of bilirubin can cause pathologic jaundice in the newborn. A few conditions that contribute to red blood cell breakdown and thus higher bilirubin levels include polycythemia, blood incompatibilities, and systemic acidosis. These altered conditions can lead to high levels of unconjugated bilirubin, possibly reaching toxic levels and resulting in a severe condition called kernicterus or bilirubin encephalopathy. 3

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Hyperbilirubinemia complications:  Kernicterus  Kernicterus is permanent brain damage. Deposits of unconjugated bilirubin in the brain especially the basal ganglia and subsequent symptoms of neurologic damage.  Associated with high levels of bilirubinemia. 25 mg/dl is considered upper limits  Permanent brain damage  Motor abnormalities  Deafness  Mental retardation  Seizures  Death Assessment of hyperbilirubinemia:  Prematurity, family hx, ethnic background, birth trauma, illness  Often see jaundice in the East Asian background o Also, Mediterranean, or Native American ethnicities  Birth trauma such as cephalohematomas which increase bilirubin production  Correlation onset of jaundice with gestational age  Gestational age of 34 to 36 weeks  Differentiate b/w physiologic and pathologic  Pathologic begins within 24 hours of birth and we really need to be worried about this one  Physiologic/clinical occurs 2-3 days after birth  Feeding behavior and alertness  Inadequate breast-feeding leading to dehydration, decreased caloric intake, weight loss, and delayed passage of meconium  Dietary problems and lethargy  They will be lethargic, not very active, do not feed well, are irritable Interventions  Laboratory monitoring  Fluids  Monitoring intake and output  Monitor stool for consistency and frequency. Unconjugated bilirubin excreted in the feces will produce a greenish appearance, and typically stools are loose. Lack of frequent green stools is a cause for concern.  Phototherapy  Phototherapy is the first line treatment for hyperbilirubinemia  When providing phototherapy, make sure the genitals are covered by a diaper and the eyes are also covered. Also ensure to turn and reposition the baby frequently (turn every 2 hours)  Exchange transfusion  This is where they replace the baby’s blood with donor blood  We will need a venous line and arterial line  The doctor does this, it is not a task of the nurse  We need to check the bilirubin and glucose levels q15 minutes  Parental education  Promote and support successful breast-feeding.  Encourage early initiation of feedings to prevent hypoglycemia and provide protein to maintain the albumin levels to transport bilirubin to the liver.  Ensure newborn feedings (breast milk or formula) every 2 to 3 hours to promote prompt emptying of bilirubin from the bowel.  Encourage the mother to breast-feed (8 to 12 feedings per day) to prevent inadequate intake and thus dehydration. 4

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Supplement breast milk with formula to supply protein if bilirubin levels continue to increase with breast-feeding only. Emphasize the need to seek treatment from their pediatrician should any of the following occur: o Lethargy, sleepiness, poor muscle tone, floppiness o Poor sucking, lack of interest in feeding o High-pitched cry

APGAR o Document the infant’s response to birth at 1 minute and 5 minutes after birth  A: appearance (color)  Cyanosis, acrocyanosis, central cyanosis  P: pulse (HR)  G: grimace (reflux irritability)  A: activity (muscle tone)  R: respiration (respiratory effort) o Scoring:  A score of 8 to 10 reflects normal adaptation  A score of 4 to 7 is moderate difficulty adjusting to extrauterine life. Need for stimulation  Sometimes just drying the baby is enough stimulation  A score of 0 to 3 is difficulty adjusting to extrauterine life and requires immediate intervention  resuscitation

o Other conditions she talked about - Small-for-gestational-age newborns o Conditions affecting fetal growth  28 weeks, intrauterine malnutrition (normal growth potential with optimal postnatal nutrition) o IUGR for some SGA newborns (asymmetric versus symmetric)  IURG is a baby that is not as big as it should be for their gestational age. They are not where they need to be on the growth chart.  They are born at term but are small for where they should be gestationally  Asymmetric is when the brain and head are normal size, but the rest of the body is small  Symmetric is when all the organs are symmetric, similar sized o Contributing factors (see Box 23.1) o SGA Newborns: Assessment: Typical Characteristics  Head disproportionately large compared to rest of body  Wasted appearance of extremities, loose, dry skin 5

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Reduced subcutaneous fat stores  Don’t have a lot of fat on them  Decreased amount of breast tissue  Scaphoid abdomen (sunken appearance)  Wide skull sutures  Poor muscle tone over buttocks and cheeks  Thin umbilical cord  They have a thin umbilical cord which means they are not getting much oxygen through the placenta o SGA Newborns: Common problems  Perinatal asphyxia  Deprivation of oxygen  Difficulty with thermoregulation  Have a hard time regulating the body temperature. So, you put a temperature probe on the baby, this will help adjust the temperature in the incubator so that it keeps the baby at the right temperature  Hypoglycemia  Polycythemia  Meconium aspiration  Hyperbilirubinemia  Birth trauma (see Table 23.1) o SGA Newborn: Nursing management  Weight, length, and head circumference measurements  As they continue on, you want to make sure they grow appropriately and catch up to their size  Serial blood glucose monitoring  Treat hypoglycemia as needed  Vital sign monitoring  At least every 3 hours  Early and frequent oral feedings; IV infusion of dextrose 10%  Monitoring for signs and symptoms of polycythemia  They will be very red if they have polycythemia  HCT and HGB will be very high  Anticipatory guidance  Educate the parents what they should expect Preterm newborn o Preterm – born before 38 weeks independent of birth weight o Very preterm – born before 30 weeks o Modern equipment has increased the survival rate for newborns 23-25 weeks gestation o Often may have vision, hearing, chronic lung disorder and cognitive impairments o Preterm newborns have fewer plantar creases, soft pliable ear cartilage (meaning if you fold their ears then they will stay folded) fused eyelids (if the eyelids are fused, do not try, and open them. They will open on their own. You can wipe them every 6 hours though), poor muscle tone, breast, and nipple area barely visible, minimal rugae on scrotum, prominent labia, and clitoris. o Assessment: Common characteristics  Weight < 5.5 lb.  Scrawny appearance  Poor muscle tone  Minimal subcutaneous fat  Undescended testes  Plentiful lanugo  Lanugo is soft, fine hair that sheds as the baby grows 6

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Poorly formed ear pinna Fused eyelids Soft spongy skull bones Matted scalp hair Absent to few creases in soles and palms Minimal scrotal rugae; prominent labia and clitoris Thin, transparent skin Abundant vernix  Which, cheesy substance you see on babies Preterm newborn assessment  Cry is weak and whimpering  Respirations are rapid, irregular, diaphragmatic with periods of apnea  Irregular is considered normal in a baby  Respiratory distress – sternal retractions, inspiratory lag, flared nostrils, grunting  If they have respiratory distress then put them on a c-pap and if they keep having respiratory distress, then intubate them  Posture is limp, they have weak muscles  Behavior – averting gaze, tremors, flaccid  Reflexes – poor suck and gag reflex  Physiologic indicators – poor tolerance to stress (tachycardia, periods of apnea, color changes) Complications: preterm newborn  Birth asphyxia  May develop from inadequate oxygen transfer during labor and birth  Interventions o Positive pressure ventilations for HR 140/90) without proteinuria after 20 weeks’ gestation resolving by 12 weeks’ postpartum  Mild preeclampsia management  Bed rest, daily BP monitoring, and fetal movement counts  Hospitalization; IV magnesium sulfate during labor  Severe preeclampsia management  Hospitalization; oxytocin and magnesium sulfate; preparation for birth  Eclampsia management  Seizure management, magnesium sulfate, antihypertensive agents; birth once seizures controlled o MgSO4 is given for prevention and treatment of eclamptic seizures  Nursing assessment: risk factors, BP, nutritional intake, weight, edema; urine for protein; other laboratory tests if indicated  Risk factors include family hx, primigravida status, multiple gestation, African American descent, and preexisting conditions like renal disease, collagen disorders, chronic HTN, and DM.  Nursing management  Home management for mild preeclampsia  Hospitalization for severe preeclampsia; quite environment, sedatives, seizures, seizure precautions, antihypertensives, DTR testing, assessing for magnesium toxicity and labor  Diminished or absent reflexes occur when a client develops magnesium toxicity. Elevated liver enzymes are unrelated to magnesium toxicity and may indicate the development of HELLP syndrome. The onset of seizure activity indicates eclampsia. A serum magnesium level of 6.5 mEq/L would fall within the therapeutic range of 4 to 7 mEq/L.  Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic. o Maintain the client on complete bed rest in the left lateral lying position. Ensure that the room is dark and quiet to reduce stimulation. o The client is at risk for seizures if the condition progresses. Therefore, institute and maintain seizure precautions, such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury. o Closely monitor the client’s blood pressure. Administer antihypertensives as ordered to reduce blood pressure o Assess the client’s vision and level of consciousness. Report any changes and any complaints of headache or visual disturbances. o Assess for evidence of end-organ damage by palpating the left upper quadrant (LUQ) of the abdomen for tenderness or pain; ask the patient whether she has been experiencing LUQ abdominal or epigastric pain. o Assess for evidence of cerebral involvement by testing deep-tendon reflexes, assessing mental status, and obtaining a history from the patient. o Assess for pulmonary edema by auscultating for abnormal breath sounds; observe the patient for signs of respiratory o Quiet, dimly lit room 23

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With Mg toxicity  Normal Mg levels: 1.5-2.5  Toxicity is above 2.5 Educate for s/s of Mg toxicity if she is being given Mg Sulfate  Decreased urinary output, change in RR rate so if it falls below 12, absent deep tendon reflexes are signs you tell her to look for P. 714

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Seizure management for eclampsia; fetal monitoring; uterine contraction monitoring; preparation for birth o The cure for eclampsia is giving birth!! Vaginal birth is preferred over c-section Biophysical profile  KNOW WILL BE ON TEST  A BPP is consists of ultrasounds and nonstress tests. Includes an ultrasound monitoring of fetal movements, fetal tone, and fetal breathing as well as ultrasound assessment of amniotic fluid volume with a or w/o assessment of fetal heart rate  Helps identify infants who may be at risk of poor pregnancy outcome  Primary objective of BPP is to reduce stillbirth and to detect hypoxia early enough to allow delivery in time to avoid permanent fetal damage resulting from fetal asphyxia  The BPP is a scored test with five components, each worth 2 points if present. A total score of 10 is possible if the NST is used. Thirty minutes are allotted for testing, although less than 10 minutes is usually needed.  8-10 indicates normal score  A score of 6 or below is suspicious, possibly indicating a compromised fetus; further investigation of fetal well-being is needed.  Nursing management focuses primarily on offering the client support and answering her questions. Expect to complete the NST before scheduling the BPP and explain why further testing might be needed. Tell the woman that the ultrasound will be done in the diagnostic imaging department. Hydatidiform mole  The grapes looking thing in the uterus  High HGC levels  Gestational trophoblastic disease  Two types o Hydatidiform mole  A common sign is vaginal bleeding...