Test 4 study guide second semester PDF

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NURSING 153 ADULTS & CHILDREN 1

OB STUDENT LEARNING OBJECTIVES

SPRING 2020

DR. GODFREY

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UNIT II:

ROLES OF THE NURSE IN CARING FOR THE CHILDBEARING FAMILY

TOPIC A:

Fetal Conception and Development

REFERENCES:

Durham & Chapman 3rd ed. – (Table 3-2, pp. 40-41), pp. 46-52 ATI– RN Maternal Newborn Nursing (Edition 11.0 - 2019)

BLACKBOARD AUDIO POWER POINT (LISTEN TO PRESENTATION PRIOR TO CLASS)

LEARNING OBJECTIVES: At the end of this unit, the student will be able to:

1. Identify critical components of conception, embryonic, and fetal development. 2. Explain the role of teratogenic agents in the fetus. 3. Discuss basic fetal circulation concepts. 4. Describe the development and function of the placenta, amniotic fluid, and umbilical cord. 5. Discuss the function of the foramen ovale, ductus venosus, and ductus arteriosus.

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UNIT II:

ROLES OF THE NURSE IN CARING FOR THE CHILDBEARING FAMILY

TOPIC B:

Nursing management of the laboring patient

REFERENCES:

Durham & Chapman 3rd ed. (pp. 219-254, 271-298) ATI– RN Maternal Newborn Nursing (Edition 11.0 - 2019)

AUDIOVISUALS:

Lippincott’s Maternity Nursing Video Series (Labor & Delivery: Vaginal Birth, DVD: 610.736 L765 Volume 2)

BLACKBOARD AUDIO POWER POINT (LISTEN TO PRESENTATION PRIOR TO CLASS)

LEARNING OBJECTIVES: At the end of this unit, the student will be able to:

1.

Describe the four stages of labor and the related nursing care.

2.

Identify the five Ps of labor.

3.

Discuss premonitory signs of labor in the pregnant woman.

4.

Define engagement, station, fetal presentation, and fetal position.

5.

Explain the relationship of physiologic forces of labor to include dilation, frequency, duration, and intensity of contractions.

6.

Discuss the impact of cultural awareness and support of clients in labor.

7.

Differentiate between true and false labor.

8. Apply knowledge of VEAL CHOP MINE to analyze fetal heart tracing. 9. Distinguish between Category I, II, and III fetal heart rate patterns and appropriate nursing actions based on these interpretations. Green light I Yellow light II Red light III

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UNIT II:

ROLES OF THE NURSE IN CARING FOR THE CHILDBEARING FAMILY

TOPIC C:

Nursing management of the patient receiving pain relief during childbirth

REFERENCES:

Durham & Chapman 3rd ed. (pp. 255-264) ATI– RN Maternal Newborn Nursing (Edition 11.0 - 2019)

BLACKBOARD AUDIO POWER POINT (LISTEN TO PRESENTATION PRIOR TO CLASS)

LEARNING OBJECTIVES:

At the end of this unit, the student will be able to: 1. Develop a plan of care for the client in pain during labor and delivery to include nonpharmacological and pharmacological treatment. a. Describe the classification, side effects, and nursing interventions for: - morphine sulfate - butorphanol (Stadol) *may cause respiratory depression in woman and neonate - nalbuphine (Nubain) *may cause respiratory depression in woman and neonate - sublimaze (Fentanyl) 2. Develop a plan of care for the client receiving anesthesia in labor to include: a. Regional (local, pudendal, epidural, and spinal) b. General anesthesia 3. Compare differences in cultural groups’ response to pain in the patient in labor.

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UNIT II:

ROLES OF THE NURSE IN CARING FOR THE CHILDBEARING FAMILY

TOPIC D:

Nursing management of the patient experiencing operative and assistive procedures (High-Risk Labor and Birth)

Durham & Chapman 3rd ed. (Chapter 10) ATI– RN Maternal Newborn Nursing (Edition 11.0 - 2019) __________________________________________________________________________________

REFERENCES:

BLACKBOARD AUDIO POWER POINT (LISTEN TO PRESENTATION PRIOR TO CLASS) __________________________________________________________________________________ AUDIOVISUALS: Lippincott’s Maternity Nursing Video Series: Cesarean Delivery, 610.736 L765 DVD Volume 3

LEARNING OBJECTIVES:

At the end of this unit, the student will be able to: 1.

Discuss primary causes of dystocia and the related nursing care. Dystocia- Long, difficult or abnormal labor. It is diagnosed when there is an alteration in the progress of labor related to cervical dilation and/or descent of the fetus.

Fetal dystocia *may be caused by excessive fetal size, malpresentation, multifetal pregnancy or fetal anomalies. Pelvic dystocia *is related to the contraction of one or more planes of the pelvis. Nursing care plan: Oxytocin administration, intravenous fluids, and calcium gluconate are the mainstays of medical management; however, approximately 62% of dystocia cases require surgical intervention 2.

Discuss the implications of a precipitous labor and birth. *Labor lasts fewer than 3 hours from onset of labor to birth. *Precipitous labor puts woman at risk for postpartum hemorrhage related to uterine atony or lacerations. 3.

Develop a plan of care for a woman who experiences an induction/augmentation of labor.

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Augmentation of labor- Stimulation of uterine contractions after labor has started spontaneously but progress is unsatisfactory. Common methods include infusion of oxytocin and rupture of membranes The most important predictor of successful induction of labor is cervical status. It is assessed before induction. Cervical status is assessed via the Bishop score. A score of 6 or more is considered favorable for induction.

Piggyback oxytocin solution to main I.V. per policy via controlled infusion device and commence infusion at a beginning rate of 0.5-1 mU/minute (see Appendix B for conversion tables). Remain with woman continuously for the first 20 minutes to evaluate labor pattern and fetal heart response.

4.

Discuss the nursing management of a client who has an operative vaginal delivery a. Vacuum assist- used more than forceps

b. Forceps- use when baby is at 2+ station

c. Cesarean Section Operative Vaginal Delivery is a vaginal birth that is assisted by vacuum extraction or forceps Vacuum Assisted Delivery or vacuum extraction is a birth involving the use of a vacuum cup on the fetal head to assist with delivery of the fetal head. 4.1% of deliveries Advantages of vacuum over forceps includes -easier application -less anesthesia required -less maternal soft tissue damage -fewer fetal injuries Vacuum Assisted Delivery Guidelines -the fetal head needs to be engaged and the cervix completely dilated -maximum of 3 attempts for a period of 15 minutes. THE 3 PULL RULE -cup detachment from the fetal head is a warning that too much pressure or ineffective force is being exerted on the fetal head -physician should proceed with a C-section when vacuum attempts are not successful Vacuum assisted delivery risks for woman -vaginal and cervical lacerations -extension of episiotomy -hemorrhage related to uterine atony, uterine rupture 6|Page

-bladder trauma -perineal wound infection Vacuum assisted delivery risks for newborn -Cephalohematoma (15%) and increased risk of jaundice -intracranial hemorrhage and retinal hemorrhage -scalp lacerations or bruising. (10%) Forceps assisted birth is one in which an instrument is used to assist with delivery of the fetal head, typically done to improve the health of the woman or the fetus. 1.1% of deliveries Forceps assisted birth risk for women -vaginal and cervical lacerations -extension of episiotomy -hemorrhage related to uterine atony, uterine rupture -perineal hematoma -bladder trauma -perineal wound infection Forceps assisted birth risk for newborn -cephalohematoma -nerve injuries including craniofacial and brachial plexus injuries -skin lacerations or bruising -skull fracture -intracranial hemorrhage Nursing care for C- section- have patient turn, cough, deep, breathe, early ambulation for bowel motility, assessment of the incisions for signs of infection, adequate urinary output, and absence of bladder trauma 5. Develop plan of care for the woman having a vaginal birth after a cesarean (VBAC) and trial of labor after a cesarean (TOLAC). -Monitor patient for bleeding, tachysystole if oxytocin is used, uterine rupture, or fetal death -recognize best candidates -recognize contraindications- pelvic abnormalities, previous uterine rupture, the type of induction meds, type of uterine incision that was previously made 6. Discuss the care of a woman who experiences obstetrical emergencies: Shoulder dystocia- Shoulder dystocia refers to difficulty encountered during delivery of the shoulders after birth of the head. Turtle sign is the first sign of shoulder dystocia and is the fetal head retracting Risk factors for shoulder dystocia

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-fetal macrosomia -maternal diabetes -history of shoulder dystocia -prolonged second stage -excessive weight gain -post dates pregnancy Risk associated with shoulder dystocia for newborn -compression of fetal neck by the maternal pelvis which impairs fetal circulation and results in possible increased intracranial pressure, anoxia, asphyxia and brain damage -brachial plexus injury and clavicle fracture in the neonate Risk associated with shoulder dystocia for the woman lacerations, infection, bladder injury and postpartum hemorrhage Woods corkscrew maneuver progressively rotates the posterior shoulder 180 degrees to disimpact the anterior shoulder Zavanelli maneuver is cephalic replacement i to the pelvis and then cesarean delivery, for catastrophic cases only. NURSING ACTION: Mcrobert’s maneuver or suprapubic pressure Prolapse of the umbilical cord- Prolapse of the umbilical cord is when the cord lies below the presenting part of the fetus Occult prolapse is when the cord is palpated through the membranes but does not drop into the vagina NURSING ACTION: - Recommended position to relieve pressure on the occluded cord is knee to chest position or Trendelenburg -relieve pressure off of the cord and put patient in a knee chest position Anaphylactic syndrome/amniotic fluid embolism -Amniotic fluid embolism AFE is a rare but often fatal complication that occurs during pregnancy, labor, or 24 hours after birth. An embolism forms when the amniotic fluid that contains fat cells, lanugo and vernix enters the maternal vascular system and results in cardiorespiratory collapse. -administer 02 at 8-10l -administer IV fluids -position client on her side with her pelvis tilted at a 30 degree angle to displace the uterus -administer blood products as prescribed to correct coagulation failure -insert indwelling catheter and measure output -prepare client for an emergency c section Disseminated intravascular coagulation 8|Page

-Disseminated intravascular coagulation DIC is a syndrome that occurs when the body is breaking down blood clots faster than it can form a clot. Depletes body of clotting factor and can lead to hemorrhage and maternal death.

Obstetrical emergencies are urgent clinical situations that place either the maternal or fetal status at risk for increased morbidity and mortality QUESTION: Which nursing action can improve uterine blood flow, increase umbilical cord circulation, improve maternal oxygenation, and decrease uterine activity? ANSWER: infusing IV fluids QUESTION: A laboring woman reports spontaneous rupture of membranes and you assess severe decelerations in the fetal heart rate. Examination reveals a cord in the vagina. The first nursing action is to: ANSWER: manually elevate the presenting parts

UNIT II:

ROLES OF THE NURSE IN CARING FOR THE CHILDBEARING FAMILY

TOPIC E:

Nursing management of the childbearing patient at risk (High-Risk Antepartum Care)

REFERENCES

Durham & Chapman 3rd ed. – pp. 149-196, 205-212 ATI– RN Maternal Newborn Nursing (Edition 11.0 - 2019)

BLACKBOARD AUDIO POWER POINT (LISTEN TO PRESENTATION PRIOR TO LASS) PART I AND PART II LEARNING OBJECTIVES:

At the end of this unit, the student will be able to: 1.

Develop a plan of care for the woman experiencing preterm labor and birth to include tocolytic agents. CARE PLAN: Administer Uterine Relaxants (Tocolytics) IIndomethacin (NSAID)- a nonsteroidal anti-inflammatory to manage chronic pain and induce closure of a patent ductus arteriosus in premature infants 9|Page

N- Nifedipine (CA channel blocker) M- Magnesium sulfate T- terbutaline ( Adrenergic Agonist)- used as a bronchodilator to prevent premature labor 2.

Discuss nursing management for the woman experiencing preterm premature rupture of membranes, chorioamnionitis, and multiple gestation pregnancy. PPROM NURSING CAREPriority- check for cord prolapse, be aware that if the rupture happened 24 hours ago or more there is a high risk for infection -Monitor FHR, uterine contractions and vital signs. -If mom is GBS positive, antibiotic therapy will be administered. -Antenatal steroids such as betamethasone will be administered to strengthen fetal lungs and prevent respiratory distress syndrome and neuro problems like cerebroventricular hemorrhage -Mag sulfate is administered to protect fetus neurologically- to protect hemorrhage in fetus’s brain -assess fetal well being -health care provider may order Non stress test and biophysical profile tests CHORIAMNIONITIS NURSING CARE-

Although chorioamnionitis does not always cause symptoms, some women with the infection might have the following:     

High temperature and fever Rapid heartbeat (the fetus might also have a rapid heartbeat) Sweating A uterus that is tender to the touch A discharge from the vagina that has an unusual smell

- Chorioamnionitis is a serious condition in pregnant women in which the membranes that surround the fetus and the amniotic fluid are infected by bacteria -Maternal antibiotics for chorioamnionitis. The standard drug treatment in the mother with chorioamnionitis includes ampicillin and an aminoglycoside (ie, usually gentamicin), although clindamycin may be added for anaerobic pathogens 3.

Develop plan of care for the woman with hyperemesis gravidarum.

• Severe form of nausea and vomiting – Symptoms usually resolve by week 20 * It is normal to have N/V during the first trimester but if it extends more than that, it should be reported and requires hospitalization – Weight loss > 5% of pre-pregnancy body weight 10 | P a g e

– Dehydration (assess, mucous membranes, skin turgor, etc.), metabolic acidosis, alkalosis, and hypokalemia • Therapeutic management – Conservative (diet and lifestyle changes) – Avoid N/V stimulants – Oral hygiene – Blood work – Hospitalization with parenteral therapy – NPO to rest the bowels – Then, small frequent meals, gradually increase the meals as tolerated – Antiemetics (second line of Tx) à Promethazine (Phenergan), Prochlorperazine (Compazine), Ondasetron (Zofran) • Nursing assessment – Onset, duration, course of N/V; diet history; risk factors, weight, associated symptoms, perception of situation – Liver enzymes, CBC, BUN (increased when salt and water depletion), electrolytes, urine specific gravity (increased when excessive fluid loss > 1.025), ultrasound • Nursing management – Comfort and nutrition (NPO, IV fluids to replace fluid losses, hygiene, oral care, I&O) – VS: blood pressure changes d/t hypovolemia – Support and education: reassurance; home care follow-up

4.

Discuss nursing management of pregnant patients with pre-gestational and gestational diabetes.

There are similar factors that predispose a woman to diabetes in each classification so keep this in mind. -Risk factors for the woman, fetus and newborn -include spontaneous abortion, preterm labor, and poly/oligohydramnios. -Macrosomia, hypoglycemia, and the development of type II diabetes in the future are risk factors for the newborn. NURSING CARE: It’s important to educate the mom on the importance of managing her hemoglobin A1C levels, eating nutritious meals, and self-administering insulin as needed. Oral hypoglycemic agents may be used (such as glyburide and metformin), may be used but limited random controlled trials have been performed to determine safe dosages and fetal and neonatal health outcomes. Insulin does not cross the placenta or enter breastmilk leading to a safe administration. GESTATIONAL DIABETES: Diagnosed in pregnancy 90% of diabetics in pregnancy 11 | P a g e

Routine screening 24-28 week 2-step method (1 hour 50g/3 hours 100g) Non-fasting 1-hour 135-140mg/dL(positive) Fasting 3-hour (BS drawn at 1, 2, and 3 hours) Fasting >95 mg/dL 1-hour >180 mg/dL 2-hour >155 mg/dL 3–hr >140 mg/dL

Treatment- (Diet, exercise, insulin) Requires two or more glucose levels above the levels drawn for Gestational Diabetes diagnosis

5.

Discuss nursing management for the pregnant patient with hypertensive disorders to include preeclampsia, eclampsia, and HELLP syndrome.

Hypertensive Disorders of Pregnancy • Gestational hypertension • Preeclampsia • Eclampsia • Chronic hypertension • Chronic hypertension with superimposed preeclampsia Gestational HTN: HTN > 140/90 on two consecutive occasions without proteinuria after 20 weeks of gestation resolving by 12 weeks postpartum. * HTN decreases blood flow to the placenta! * Preeclampsia refers to hypertension during pregnancy with proteinuria, may be accompanied by hyperreflexia depending on the severity. Eclampsia is a really high HTN with proteinuria, hyperreflexia and seizures. Gestational Hypertension: Management • Mild preeclampsia – s/s: HTN > 140/90, proteinuria, edema that doesn’t resolve with leg elevation, no hyperreflexia or seizure in this stage – Preeclampsia increases the risk of placental abruption – Bed rest, side lying position because it increases blood flow to the placenta and kidneys – Daily BP monitoring q. 4-6 hrs. – Fetal movement counts – Measure urine with dipsticks for protein – Daily weight (d/t possible edema, accumulation of fluids) – Diet low in sodium and increase water intake – If these measures fail to stabilize the HTN à Hospitalization may be needed – During hospitalization, strict I/O (+ everything above) – IV Magnesium Sulfate during labor to prevent seizures • Severe preeclampsia 12 | P a g e

– BP > 160/110, proteinuria, hyperreflexia, no seizures in this stage – other s/s: headache, blurred vision, pulmonary edema, thrombocytopenia (decreased platelets), cerebral disturbances, epigastric or RUQ pain – Hospitalization à oxytocin (to stimulate uterine contractions to induce labor because giving birth is the only cure) and magnesium sulfate (to prevent seizures) (watch for toxicity); preparation for birth • Eclampsia – BP > 160/110, marked proteinuria, hyperreflexia and seizure – other s/s: severe headache, generalized edema, RUQ pain, visual disturbances, cerebral hemorrhage, renal failure – Seizure management, magnesium sulfate (watch for toxicity), antihypertensive agents; birth once seizures are controlled – Seizures compromise fetal oxygenation – Seizure precaution: side lying position, protect airway, suction kit next to bed side at all times, protect from injury • Nursing assessment: risk factors, BP, nutritional intake, weight, edema, urine for protein, other laboratory tests if indicated • Nursing management – Home management for mild preeclampsia, daily BP monitoring at home, dipstick to test urine for proteins, daily weight for edema, etc. – Hospitalization for severe preeclampsia; quiet environment, sedatives, seizure precautions, anti-hypertensives DTR testing, assessing for magnesium toxicity and labor – Seizure management for...