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The Obstetrical Client

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The Obstetrical Client Nursing Management Nursing Roles in Maternal-Newborn Nursing Professional Nurse Certified Registered Nurse Clinical Nurse Specialist Certified ... – PowerPoint PPT presentation

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Title: The Obstetrical Client


1
The Obstetrical Client
  • Nursing Management

2
Nursing Roles in Maternal-Newborn Nursing
  • Professional Nurse
  • Certified Registered Nurse
  • Clinical Nurse Specialist
  • Certified Nurse Midwife
  • Certified Professional Midwife

3
Concepts in Contemporary Childbirth
  • Alternative Complementary Therapies
  • Homeopathic and herbal remedies
  • Community-Based Nursing Care
  • Outpatient clinics, public health departments,
    doctors offices, birthing centers
  • Home Care

4
Legal Considerations
  • Scope of Practice
  • Standards of Nursing Care
  • Informed Consent
  • Right to Privacy

5
Terms Used Maternal-Child Health
  • Leukorrhea Vaginal secretions may increase
    during pregnancy.
  • Morning sickness Nausea and vomiting, a symptom
    of pregnancy.
  • Gravida A pregnant woman
  • Chadwicks sign When the cervix takes on a
    bluish hue due to increased vascularity during
    pregnancy.
  • Parity the number of born, viable offspring of
    a woman.

6
Terms Used Maternal-Child Health
  • T.O.R.C.H. infections toxoplasma, other (HIV,
    syphilis), rubella, cytomegalovirus, herpes all
    of these, except toxoplasma can cause abortion,
    fetal death, teratogenesis, or congenital
    disease.
  • Quickening the first perceivable movement of
    the fetus, usually at weeks 17-19 a presumptive
    sign of pregnancy.

7
Terms Used Maternal-Child Health
  • Teratogenesis Development of deformity in the
    developing embryo.
  • Braxton-Hicks contractions Irregular, painless,
    intermittent contractions during pregnancy.
  • Colostrum White-yellow fluid expressed from the
    nipples after childbirth.
  • Threatened abortion bed rest and pelvic rest.

8
Terms Used Maternal-Child Health
  • Abruptio placentae bed rest, monitor fetal
    well-being and assess signs and symptoms of
    shock.
  • Placenta previa bed rest and perineal pad count
    and monitor fetal well-being.
  • D.I.C. administer fresh frozen plasma
  • GPTAL-Gravida-Parity-Term-Abortions-Living

9
Reproductive Anatomy Physiology(Female)
  • External Genitals
  • - Mons Pubis
  • - Labia Majora
  • - Clitoris
  • - Uretral Meatus Skenes Glands
  • - Vaginal Vetibule
  • - Perineal Body
  • Internal Reproductive Organs
  • - Vagina
  • - Uterus
  • - Uterine Corpus
  • - Cervix
  • - Uterine Ligaments
  • - Fallopian Tubes
  • - Ovaries
  • - Bony Pelvis
  • - Bony Structure
  • - Pelvic Floor
  • - Breasts

10
Female Reproductive Cycle
  • Effects of Female Hormones
  • Neuro-humoral Basis of the Female Reproductive
    Cycle
  • Ovarian Cycle (ovulation)
  • Uterine Cycle (menstruation)

11
(No Transcript)
12
Conception
  • Pregnancy requires
  • Maturation of gametes (sperm ova)
  • Menstrual cycle with ovulation preparation of
    uterus for implantation
  • Intact female and male reproductive system that
    allows passage of sperm and ova
  • Fertilization of sperm ova ( zygote created)
  • Implantation of ovum in secretory endometrium

13
Maternal Nutrition
  • Maternal Weight Gain
  • Underweight woman 28 -40 lbs (12.5 -18kg.)
  • Normal-weight woman 25-35 lbs (11.5-16kg.)
  • Overweight woman 15-25 lb (7 - 11.5kg.)
  • Obese woman less than 15 lbs. (less than or
    greater than 7.0 kg.)

14
Maternal Nutrition
  • Nutritional Requirements
  • The recommended daily allowance for calories
    increase 300 kcal/day during the second and third
    trimesters.
  • The RDA for fat is less than 30 of daily caloric
    intake, of which less than 10 should be
    saturated fat.

15
Maternal Nutrition
  • Other Factors Influencing Nutrition
  • Vegetarianism
  • Lifestyle
  • Culture
  • Lactose Intolerance
  • Eating Disorders
  • Pica
  • Age

16
Fetal Development
  • Stages of fetal development
  • Pre-embryonic stage (the first 14 days of human
    development starting at the time of
    fertilization)
  • Embryonic stage (from day 15 after fertilization,
    or the beginning of the third week, until
    approximately 8 weeks)
  • Fetal stage (from 8 weeks until birth, at
    approximately 40 weeks after the last normal
    menstrual period).

17
Fetal Development
  • Amniotic Sac and Fluid
  • The fetal membranes (Amniotic Sac) composed of
    the amniotic and chorionic membranes cover the
    fetal surface of the placenta and contain and
    support the fetus and the amniotic fluid.
  • Amniotic fluid cushions and protects the fetus,
    controls temperature, permits symmetrical
    external growth of the embryo, prevents adhesion
    of the embryo and developing fetus to the amnion
    sac/membranes and allows for freedom of movement

18
Fetal Development
  • Umbilical Cord
  • Contains blood vessels (one large vein and two
    smaller arteries) that extend into the chorionic
    villi.
  • The blood vessels are surrounding by Whartons
    Jelly which assists in prevention of compression
    of the cord.
  • There is no nerve innervation to the cord.
  • The cord serves a circulatory function.

19
Fetal Development
  • Placenta
  • Provides for metabolic and nutrient exchange
    between the embryo/fetus
  • Provides for fetal respiration and excretion

20
Fetal Development
  • Fetal Circulatory System and Heart
  • The ductus venosus empties directly into the
    fetal vena cava ? enters the right atrium via the
    foramen ovale ?into the left atrium ? left
    ventricle ? aorta.
  • Some blood returning from head and upper body via
    superior vena cava empties into right atrium ?
    through tricuspid valve ? right ventricle ?
    pulmonary artery ( small amount goes to the lungs
    to provide nourishment only) ? ductus arteriosus
    ? descending aorta ? placenta

21
Stages of Labor
  • First Stage
  • Divided into 3 phases, latent phase, active phase
    and transitional phase.
  • Latent Phase
  • Dilation of the Cervix measures 0 to 3 cm.
  • Contractions are irregular, short, and last 20 to
    40 seconds.
  • Last about 6 hours for primipara and 4 ½ hours
    for a multipara

22
Stages of Labor
  • First Stage
  • Active Phase
  • Cervical dilation measures 4 to 7 cm
  • Contractions are 5 to 8 minutes apart and last 45
    to 60 seconds.
  • Last about 3 hours for a primipara and 2 hours
    for a multipara

23
Stages of Labor
  • First Stage
  • Transition Phase
  • Cervical dilation measures 8 to 10 cm
  • Contractions are 1 to 3 minutes apart and 60 to
    90 seconds.
  • A feeling of loss of control commonly occurs
    during this phase
  • At the end of this phase, the patient feels the
    urge to push.

24
Stages of Labor
  • Second Stage
  • Cervical Changes
  • Extends from complete cervical dilation to
    delivery of the neonate
  • Crowning
  • Occurs when the fetal head is encircled by the
    external opening of the vagina and this means
    birth is imminent.

25
Stages of Labor
  • Second Stage
  • Positional Changes of the Fetus
  • Descent - Occurs because of four forces (1)
    pressure of the amniotic fluid, (2) direct
    pressure of the uterine fundus on the breech, (3)
    contraction of the abdominal muscles, and (4)
    extension and straightening of the fetal body.

26
Stages of Labor
  • Second Stage
  • Positional Changes of the Fetus
  • Flexion - Occurs as the fetal head descends and
    meets resistance from the soft tissues of the
    pelvis, the muscles of the pelvic floor, and the
    cervix. As a result of the resistance, the fetal
    chin flexes downward onto the chest.

27
Stages of Labor
  • Second Stage
  • Positional Changes of the Fetus
  • Internal Rotation The fetal head must rotate to
    fit the diameter of the pelvic cavity, which is
    widest in the anteroposterior diameter
  • Extension The resistance of the pelvic floor
    and the mechanical movement of the vulva opening
    anteriorly and forward assist with extension of
    the fetal head as it passes under the symphysis
    pubis.

28
Stages of Labor
  • Second Stage
  • Positional Changes of the Fetus
  • Restitution - Once the head is born and free of
    pelvic resistance, the neck untwists, turning the
    head to one side (restitution), and aligns with
    the position of the back in the birth canal.

29
Stages of Labor
  • Second Stage
  • Positional Changes of the Fetus
  • External Rotation As the shoulders rotate to
    the anteroposterior position in the pelvis, the
    head turns farther to one side (external
    rotation).
  • Expulsion - anterior shoulder meets the
    undersurface of the symphysis pubis and slips
    under it. As lateral flexion of the head and
    shoulders occurs, the anterior shoulder is born
    before the posterior shoulder and the body
    follows quickly.

30
Stages of Labor
  • Third Stage
  • Placenta Separation
  • Occurs after the uterus resumes contractions.
  • As the placenta pulls away from the uterine wall,
    bleeding begins and aids expulsion of the
    placenta. The placenta then falls to the upper or
    lower segment of the vagina.
  • Signs include umbilical cord lengthening, gush of
    vaginal blood, and change in uterine shape.

31
Stages of Labor
  • Third Stage
  • Placenta Delivery
  • Accomplished by natural bearing down or Credes
    maneuver.
  • Remember to avoid possible eversion of the
    uterus which results in gross hemorrhage,
    pressure should never be applied to a
    non-contracted uterus.

32
Stages of Labor
  • Fourth Stage
  • Recovery
  • Encompasses the first hour after delivery. The
    focus of this period is stabilizing the status of
    the neonate and helping him or her get acclimated
    to extra-uterine life. Then the focus is on
    promoting maternal-neonatal bonding.

33
Client with Prenatal Danger Signs
  • Report any of the following immediately
  • Vaginal bleeding in any amount- May indicate
    placenta previa
  • Rupture of membranes Predisposed to infection
  • Severe, persistent headaches Pregnancy induced
    hypertension pre-eclampsia
  • Visual disturbances PIH or pre-eclampsia

34
Client with Prenatal Danger Signs
  • Report any of the following immediately
  • Edema of face or hands, abdominal pain,
    epigastric pain PIH or pre-eclampsia
  • Elevated temp(above 101),chills, painful
    urination
  • Persistent vomiting (over one day)
  • Change in, or absence of fetal movement for 6-8
    hrs.

35
Ectopic Pregnancy
  • Any gestation outside the uterus
  • Most frequently in fallopian tube (tissue
    incapable of growth, cannot accommodate
    pregnancy, rupture of site occurs within 12
    weeks)
  • Any condition that diminishes the tubal lumen may
    predispose a woman to an Ectopic pregnancy

36
Ectopic PregnancyAssessment
  • History of missed periods symptoms of early
    pregnancy
  • Abdominal pain, may be localized to one side
  • Rigid, tender abdomen sometimes abnormal pelvic
    mass
  • Bleeding if severe may lead to shock
  • Low hemoglobin, hematocrit, rising white cell
    count
  • HCG usually lower than in intrauterine pregnancy

37
Ectopic PregnancyNursing Intervention
  • Prepare client for surgery.
  • Institute measures to control bleeding/treat
    shock if hemorrhage severe continue to monitor
    postoperatively.
  • Allow client to express feelings about loss of
    pregnancy and concerns about future pregnancies.

38
Client with Hyperemesis Gravidarum
  • Persistent, uncontrollable vomiting, unknown
    cause
  • Requires medical attention because of risk of
    dehydration, fluid/electrolyte imbalance and
    metabolic alkalosis
  • May require hospitalization for IV hydration,
    nutritional supplements and prevention or
    correction of electrolyte imbalance.

39
Premature Rupture of Membrane(PROM)
  • Membrane rupture 1 or more hours before onset of
    labor
  • Spontaneous break in the amniotic sac before
    onset of regular contractions
  • Results in progressive cervical dilation
  • Mother at risk for chorioamnionitis if the time
    between rupture of membranes and onset of labor
    is longer than 24 hours
  • Risk of fetal infection, sepsis and perinatal
    mortality increase with every hour of ruptured
    membrane and labor and every vaginal examination
    or other invasive procedure.

40
PROMSigns of Infection
  • Maternal Fever
  • Fetal Tachycardia
  • Foul-smelling Vaginal Discharge

41
PROM Detecting Amniotic Fluid
  • Turn nitrazine paper (PH paper) the color blue
  • Place a smear of fluid on a slide and allow to
    dry
  • Check results. If fluid takes on a fernlike
    pattern. Its amniotic fluid.

42
PROM Treatment
  • Depends on fetal age and risk of infection
  • In a term pregnancy, within 24 hours of membrane
    rupture, labor is usually induced with oxytocin
    cesarean delivery is performed if induction
    fails.
  • In a preterm pregnancy (28 -34 weeks), patient is
    hospitalized and observed for signs of infection
    while awaiting fetal maturation. If an infection
    is detected, labor is induced and an antibiotic
    is administered.

43
PROMNursing Interventions
  • Explain all diagnostic tests
  • Assist with examination and specimen collection
  • Administer IV Fluids
  • Observe for initiation of labor (monitor VS
    frequently)
  • Offer emotional support
  • Teach patient with a history of PROM how to
    recognize it and to report it immediately

44
Client with Pregnancy Induced Hypertension
  • PIH occurs in less than 10 of pregnancies
  • Major cause of maternal and fetal death.
  • Complications
  • Fetal Intrauterine growth retardation and fetal
    distress from hypoxia
  • Maternal hemorrhage, cardiac or other organ
    failure, pul edema, cerebral hemorrhage, DIC
    HELLP syndrome

45
Client with PIH
  • HELLP Syndrome
  • Hemolysis
  • Elevated
  • Liver enzymes
  • Low
  • Platelets

46
Client with PIH.
  • Classified as preeclampsia or eclampsia depending
    on symptoms
  • Preclampsia
  • BP 140/90 or ?30mm Hg systolic or 15mm diastolic
  • 1 pitting edema after bedrest for 12 hrs
  • Wt gain more than 5 lbs/wk
  • Proteinuria (1-2 ? than 3g/L in 24 hr specimen

47
Client with PIH..
  • Severe Preeclampsia
  • BP 160/110 or ?
  • Extensive edema including pulmonary
  • Cyanosis
  • Decreased urine output
  • Continued wt gain, more than 2 s/wk
  • N V
  • Headache and epigastric pain
  • ?proteinuria (3-40 ?hematocrit)

48
Client with PIH
  • Eclampsia
  • Grand mal seizure
  • Coma preceded by further increase in BP,
    headache, blurred vision, epigastric pain, nausea
    and vomiting

49
Client with PIH.
  • Eclampsia contd
  • Mag Sulfate is used to control seizures
  • Toxic effects
  • Depressed reflexes
  • Depressed respirations
  • Oversedation
  • Circulatory collapse
  • Ca Gluconate antidote

50
Nursing Management of Client with PIH
  • VS, esp BP, frequently Assess edema
  • Position (L) side
  • Test urine for protein, I O, Foley
  • Assess deep tendon reflexes
  • Implement seizure precautions
  • Have oral airway, O2, suction available
  • Assess FHT and movement
  • Decrease environmental stimuli

51
Client with Placenta Previa
  • Occurs when the placenta implants near or over
    the cervical os Vag exams prohibited
  • Painless vag bldg occurring in 3rd trimester
  • Complications
  • Hemorrhage
  • Fetal distress/demise related to in utero hypoxia
  • Intrauterine growth retardation
  • Preterm birth or Premature rupture of membranes

52
Nursing Management of Client with Placenta Previa
  • Assess amt and character of bleeding
  • Monitor FHT and activity continuously
  • VS and output
  • Bedrest
  • IV fluid replacement

53
Client with Abruptio Placenta
  • Premature separation of part or all of the
    placenta from uterine wall
  • Medical emergency because of the risk of maternal
    hemorrhage and fetal demise
  • 10-30 develop DIC
  • Hospitalization almost always necessary
  • Vag birth often feasible

54
Abruptio Placenta..
  • Divided into 3 grades
  • Grade 1 Mild vaginal bldg, mild uterine
    tetany neither mother or fetus in distress
  • Grade 2 Mod Uterine tenderness/tetany with or
    without ext bldg mother not in shock but fetal
    distress present
  • Grade 3 Severe uterine tetany maternal
    shock, fetus dead

55
Abruptio Placenta.
  • Precipitating Factors
  • Blunt trauma to abdomen
  • Drug abuse, esp cocaine
  • PIH
  • Premature rupture of membrane
  • Smoking
  • Multifetal pregnancies

56
Nursing Management of Abruptio Placenta
  • Assess amt and character of bldg, abdomen
    rigidity, degree of abdominal pain
  • Assess FHT and activity
  • Measure fundal height concealed bldg may be
    present
  • Monitor for shock
  • Provide emotional support
  • Prepare for possible stat C-Section

57
Client with Exposure to Infections
  • TORCH place mother and fetus in jeopardy due
    to associated complications
  • T toxoplamosis
  • O othergonorrhea, syphilis, varicella, hep B,
    group B strep, HIV
  • R rubella
  • C cyomegalovirus
  • H herpes

58
Infections.
  • TORCH related complications include
  • Congenital heart defects
  • Physical fetal anomalies
  • Intrauterine growth retardation
  • Mental retardation
  • Brain dysfunctions encephalitis, hydrocephalus

59
Infections.
  • Gonorrhea
  • Spontaneous abortions, preterm delivery, PROM
  • Blindness of infant Erythromycin ung _at_ birth
  • Congenital Syphilis
  • Spontaneous abortion, preterm, stillbirth, fetal
    demise
  • Disorders of CNS, teeth and cornea
  • Chlamydia
  • PROM, preterm labor, low birth weight, fetal
    conjunctivitis and chronic OM
  • Herpes
  • Neonate highly contagious ISOLATE antiviral
    drugs used during pregnancy are given

60
Infections
  • Fetal/Newborn HIV/AIDS
  • Destroys immune system
  • Hep B
  • Causes newborn fever, jaundice, liver enlargement
  • Cytomegalovirus
  • May result in mental retardation, hearing loss or
    learning disabilities
  • Death occurs shortly after birth
  • Toxoplasmosis a protozoan
  • Spontaneous abortion
  • Hydrocephalus, blindness, deafness or mental
    retardation

61
Infections..
  • Rubella
  • Congenital cataracts, congenital heart disease,
    deafness, IUGR, extreme malformations
  • Strep B
  • Preterm labor, PROM, stillbirth, resp distress
    syndrome, apnea and shock, maternal postpartum
    sepsis

62
Client with Substance Abuse
  • Addiction to or continued use of illegal or
    prescribed substance/drug
  • Substance abuse during 1st trimester places fetus
    at greatest risk
  • Risk increases with strength, amount, frequency
    and route of administration
  • Alcohol abuse during pregnancy is leading cause
    of mental retardation in US

63
Client with Prolapsed Cord
  • Prolapsed cord is an EMERGENCY!
  • Occurs after rupture of membranes
  • Key interventions
  • Relieve pressure on cord
  • Trendelberg or knee chest and alternate
    side-lying
  • Oxygen to increase maternal oxygen sat
  • Expedite delivery
  • FHTs q 15 mins
  • Call for help, but do not leave mother

64
Client with Gestational Diabetes
  • Untreated diabetes in pregnancy may lead to
    polyhydramnios (excessive amniotic fluid) or
    macrosomia (large fetus, can be 9 lbs. or more).
    These conditions may lead to dystocia (difficult
    labor and delivery).
  • Uncontrolled glucose metabolism is also
    associated with an increased incidence of
    preeclampsia, stillbirth, neonatal hypoglycemia,
    respiratory distress syndrome, and premature
    delivery.

65
Client with Gestational Diabetes
  • Risk Factors
  • Family history of diabetes in first-degree
    relatives.
  • Poor obstetric history
  • Previous macrosomic infant
  • Previous newborn with congenital abnormalities
  • High parity
  • Nursing Considerations
  • Continually monitor fetal well-being.
  • Monitoring to maintain glucose in normal range.
  • Frequent antepartum visits
  • Educate client on blood glucose monitoring, diet
    guidelines, and about the effects of high blood
    sugar on the mother and the fetus.
  • Measure urine protein and ketones

66
Fetal DistressAssessment
  • Ominous FHR pattern
  • Fetal acidosis
  • Meconium-stained Amniotic Fluid
  • Decrease in cessation of fetal movement

67
Causes of Fetal Distress
  • Prematurity
  • Utero-placental insufficiency
  • Congenital malformation
  • ABO or Rh incompatibility
  • Maternal Complications, such as diabetes, heart
    disease or PIH
  • Prolonged Labor
  • Post Maturity
  • Oxytocin Infusion
  • Vaginal Bleeding

68
Key Nursing Interventions for Fetal Distress
  • Monitor FHR, fetal activity and fetal heart
    variability
  • Notify MD Immediately
  • Prepare for placement of internal monitor and
    fetal scalp pH sampling
  • Position patient on left side to enhance
    utero-placental blood flow
  • Administer oxygen via face mask as ordered
    (usually 6 8 liters/minute)
  • Expect to discontinue oxytocin infusion if in use
  • Treatment depends on the underlying cause

69
Common Complications of Pregnancy, Labor and
Delivery
  • Endometriosis
  • Condition where there is endometrial tissue
    outside the uterine cavity
  • Tissue responds to hormonal changes and bleeds
    which results in inflammation, scarring of
    peritoneum and adhesions in peritoneum
  • Common symptoms pain, abnormal bleeding and
    painful intercourse
  • Treated medically with combined oral
    contraceptives or surgical removal of the
    implants

70
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • Toxic Shock Syndrome (TSS)
  • Caused by Staphylococcus aureus
  • Thought to be related to tampon use of cervical
    cap or diaphragm left in place more than 48 hrs.
  • SS Early signs
  • Fever gt 38.9C or 102F
  • Rash on trunk
  • Hypotension, dizziness, vomiting, watery diarrhea
  • Treatment Hospitalization, IVs, Antibiotics

71
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • Pelvic Inflammatory Disease (PID)
  • More common with multiple sexual partners
  • Inflammatory disorders of upper female genital
    tract endometritis, salpingitis, tubo-ovarian
    abscess, pelvic abscess, pelvic peritonitis
  • Frequent organisms chlamydia and gonorrhea
  • Closely associated with infertility
  • Treatment IVs, pain medication, IV antibiotics,
    bedrest, antipyretics.

72
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • Urinary Tract Infections
  • Shortness of female urethra facilitates the
    passage of bacteria into the bladder
  • Cystitis (Lower UTI)
  • 80 caused by E coli
  • Dysuria, urgency and frequency, suprapubic or low
    back pain with low-grade fever
  • Treatment depends on causative organism

73
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • Urinary Tract Infections
  • Pyelonephritis (Upper UTI)
  • Often preceded by lower UTI
  • More common in latter pregnancy or early
    postpartum
  • S S
  • Chills, high temperature, costovertebral angle
    tenderness or flank pain, nausea, vomiting,
    cystitis
  • Treatment IV antibiotics, urinary analgesics,
    pain management, IV hydration, bed rest

74
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • Domestic Violence
  • Estimates of approximately 1.3 million women are
    physically assaulted by an intimate partner
    annually in US. This does not stop because the
    women become pregnant.
  • 3 Categories psychological, physical, and
    sexual abuse
  • There should be universal screening at every
    health care encounter for symptoms of abuse

75
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • Domestic Violence (continued)
  • Signs to look for
  • Headaches especially those after trauma
  • STDs, frequent vaginal infections, pelvic pain
  • Late onset of prenatal care, premature labor,
    excessive concern over fetal well-being
  • Irritable bowel syndrome
  • Painful joints, chronic musculoskeletal pain
  • Anxiety, panic, mood disorders, depression,
    suicide attempts, eating disorders, substance
    abuse
  • Trauma
  • Missed appointments

76
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • Premature Labor
  • Rhythmic uterine contraction producing cervical
    changes before fetal maturity
  • Onset of labor 20 37 weeks gestation
  • Increases risk of neonate morbidity or mortality
    from excessive maturational deficiencies

77
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • Maternal Causes of Premature Labor
  • Cardiovascular and Renal diseases
  • Diabetes Mellitus
  • Pregnancy-Induced Hypertension
  • Infection
  • Abdominal Surgery or Trauma
  • Incompetent Cervix
  • Placental Abnormalities
  • Premature Rupture of the Membranes

78
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • Fetal Causes of Premature Labor
  • Infection
  • Hydramnios
  • Multiple pregnancy
  • Assessment Findings
  • Onset of rhythmic uterine contractions
  • Possible rupture of membranes, passage of
    cervical mucous plug, and a bloody show
  • Cervical effacement and dilation on vaginal
    examination

79
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • Treatment for Premature Labor
  • Designed to suppress preterm labor when tests
    show premature fetal lung development, cervical
    dilation of less than 4 cm, absence of factors
    that contraindicate continuation of pregnancy.
  • Bed rest, drug therapy (if indicated) with a
    tocolytic
  • Tocolytic are contraindicated if
  • - gestation is less than 20 weeks
  • - cervical dilation is more than 4 cm
  • - cervical effacement is more than 50

80
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • First labor must be stopped
  • Magnesium Sulfate
  • - CNS depressant-prevents reflux of calcium
    into myometrial cells causing uterine
    relaxation
  • - Contraindications include severe abdominal
    pain of unknown origin and oliguria.
  • Adverse effects on the mother
  • - drowsiness, flushing, Warmth, nausea,
    headache, slurred
  • speech and blurred vision
  • - Drug is associated with toxicity manifested
    by CNS
  • depression in the mother
  • Terbutaline (Brethine), a beta-adrenergic
    blocker, is the most commonly used tocolytic

81
Common Complications of Pregnancy, Labor and
Delivery (continued)
  • Nursing Intervention in Premature Labor
  • Observe for signs of fetal or maternal distress
  • Administer medications as ordered and Oxygen to
    prevent fetal hypoxia.
  • Monitor the status of contractions, and notify
    the physician if they occur more than 4 times per
    hour.
  • Encourage patient to lie on left side to prevent
    vena caval compression, supine hypotension and
    fetal hypoxia
  • Provide guidance about hospital stay, potential
    for delivery of premature infant and possible
    need for neonatal intensive care

82
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Initial Assessment Immediately following birth
  • Need for resuscitation
  • APGAR scoring
  • If newborn is stable, place with mother or
    parents for initial attachment/bonding

83
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment Within the first to four
    hours of life
  • Weight and measurements weight, length, head
    circumference, chest circumference
  • Temperature (axillary)

84
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment
  • Skin characteristics
  • Acrocyanosis Mottling
  • Jaundice Milia
  • Skin turgor Birthmarks
  • Vernix caseosa Forceps marks
  • Erythema toxicum Newborn rash

85
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment
  • General appearance of the head
  • Fontanels
  • Cephalhematoma
  • Caput succedaneum

86
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment
  • General appearance of the face
  • Symmetry
  • Eyes
  • Nose
  • Mouth
  • Ears

87
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment
  • Neck Short neck creased with skin folds
    characteristic
  • Chest Cylindrical and symmetrical with flexible
    ribs
  • Cry Strong and lusty

88
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment
  • Respiration Normal 30 60 and predominately
    diaphragmatic
  • Heart Normal 120 160. Examine for rate,
    rhythm and intensity. Fairly common to hear a
    low-pitched musical murmur just to the right of
    apex of the heart. Also check peripheral pulses.

89
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment
  • Abdomen Slightly protuberant and move
    symmetrically with respirations. Auscultate for
    presence of bowel sounds in all four quadrants
    should be present after 1 hour of life
  • Umbilical cord Check for two umbilical arteries
    and one vein. Begins drying 1-2 hours after
    birth and should be shriveled and black by 2nd or
    3rd day

90
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment
  • Genitals
  • Examine female for labia majora, minora and
    clitoris. During the 1st week may have thick
    white mucousy vaginal discharge
  • Examine position of male urinary orifice, scrotum
    for size and symmetry

91
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment
  • Anus Verify patency
  • Arms and Hands Number of fingers, normal palmar
    creases, positions of the arm
  • Legs and Feet Number of toes, legs of equal
    length, check for hip dislocation,
  • Back Spine straight

92
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment
  • Estimation of gestational age through assessment
    of physical maturity characteristics - resting
    posture, lanugo, plantar creases, ear, vernix,
    hair, nails, skull firmness

93
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment
  • Neurologic Status
  • Alertness
  • Resting posture
  • Cry
  • Quality of muscle tone and muscle activity

94
Nursing Assessment of the Normal Newborn
Utilizing the Nursing Process
  • Second Assessment
  • Reflexes
  • Tonic neck Fencer position
  • Grasp Stimulate the palm with finger or object
  • Moro Startle reflex
  • Rooting Touch side of mouth or cheek and
    newborn will turn and open lips
  • Sucking - Place object in mouth suck even when
    asleep
  • Babinski Plantar reflex fanning and
    hyperextension of all toes when lateral aspect of
    sole is stroked from heel up

95
The Postpartum Period
  • Systems
  • Uterus
  • Urinary tract
  • Change
  • The fundus should not be palpable after the 9th
    postpartum day. Involution process results in a
    healed birth canal. Uterus returns to
    pre-pregnant state.
  • May become edematous and lose tone and sensation.
    Anesthesia may cause urine retention. If the
    fundus is above the umbilicus, the probable
    reason is bladder distention, and the client
    should be catheterized.

96
The Postpartum Period
  • Immediate nursing interventions during the
    postpartum period include
  • Monitoring for infection and signs of hemorrhage
  • Evaluating the lochia (vaginal discharge after
    childbirth) for flow Heavy clots or spurts of
    bleeding indicate uterine hemorrhage or cervical
    tear.

97
The Postpartum Period
  • Immediate nursing interventions during the
    postpartum period include
  • Assessing the perineum for swelling and
    discoloration, as well as for the healing of the
    episiotomy (if performed).
  • Assessing mother-infant bonding and the clients
    emotional status

98
Check Your Knowledge
99
Antenatal period
  • 22 year old has missed two regular periods. Her
    doctor confirms an early intrauterine pregnancy.
    To determine her ED
  • c, which of the following assessments is most
    important?
  • Dates of first menstrual period.
  • Date of last intercourse.
  • Dates of last normal menstrual period.
  • Age at menarche.

100
Antenatal Period
  • A 24 year pregnant woman is in her seventh month,
    she complains of backache. The nurse teaches her
    to
  • 1. Sleep in a soft mattress
  • 2. Walk barefoot at least once daily
  • 3. Perform Kegel exercises once daily
  • 4. Wear low heeled shoes

101
Antenatal Period
  • A woman is admitted for severe preclampsia.
    What type of room should the nurse select for
    her?
  • 1. Room next to the elevator
  • 2. Room farthest from the nursing station
  • 3. The quietest room on the floor
  • 4. The labor suite

102
Antenatal Period
  • The action of hormones during pregnancy affect
    the body by
  • 1. Raising resistance to insulin
  • 2. Blocking the release of insulin from the
    pancreas
  • 3. Preventing the liver from metabolizing
    glycogen
  • 4. Enhancing the conversion of food to glucose

103
Antenatal Period
  • During an initial prenatal visit, a woman states
    that her last menstrual period began on 11/21,
    she also reports some vaginal bleeding about
    12/19. The nurse would calculate that this
    clients expected date of confinement is
  • 1. July 21
  • 2. August 28
  • 3. September 26
  • 4. October 1

104
Antenatal Period
  • The pregnant couple asks the nurse what is the
    purpose of prepared childbirth classes. The
    nurses best response would be
  • 1. The main goal of most types of childbirth
    classes is to provide information that will help
    decrease fear and anxiety
  • 2. The desired goal is childbirth without the
    use of analgesics
  • 3. These classes help to reduce the pain of
    childbirth by exercise and relaxation methods
  • 4. The primary aim is to keep you and your baby
    health during pregnancy and after

105
Antenatal Period
  • At 38 weeks, a woman is having an amniocentesis
    to evaluate fetal maturity. The L/s ratio is 21.
    The nurse knows that this finding indicates
  • 1. Fetal lung maturity.
  • 2. That labor can be induced.
  • 3. The fetus is not viable.
  • 4. A nonstress test is indicated

106
Antenatal Period
  • A woman at 36 weeks gestation is having a CST
    with an oxytocin IV infusion pump. After two
    contractions, the uterus stays contracted. The
    best initial action of the nurse is to
  • 1. Help the client turn on her left side
  • 2. Turn off the infusion pump
  • 3. Wait 3 minutes for the uterus to relax
  • Administer prn terbutaline sulfate

107
Antenatal Period
  • A pregnant client is having severe abdominal
    pain. With assessment, the nurse finds a hard,
    board-like abdomen, hypotension and tachycardia.
    The nurse call for help and evaluates fetal heart
    ton1es suspecting
  • 1. An ongoing spontaneous abortion.
  • 2. Placenta abruption
  • 3. Placenta previa
  • 4. A gallbladder attack

108
Antenatal Period
  • A pregnant woman at 35 weeks has phoned with the
    concern of leaking vaginal fluid. The client
    will need to
  • 1. Report to the hospital when the uterine
    contractions are five minutes apart
  • 2. Report to the hospital immediately
  • 3. Be placed on home bed rest
  • 4. Keep her prenatal appointment tomorrow

109
Antenatal Period
  • After being hospitalized for PIH, the client asks
    the nurse why the baby is in danger from her a
    high blood pressure. The nurse responds based on
    which of the following
  • 1. The fetuss blood pressure will also be
    elevated
  • 2. The placental perfusion is at risk
  • 3. The clients headache will prevent her from
    taking adequate nutrition
  • 4. The clients hypertension early in pregnancy
    has already damaged the fetus

110
Antenatal Period
  • A pregnant client undergoing electronic fetal
    monitoring evidence a fetal heart rate of 190.
    The nurse interprets this as
  • 1. Fetal tachycardia
  • 2. Normal
  • 3. Maternal tachycardia
  • 4. Normal variability

111
Antenatal Period
  • When a client who is pre-eclamptic complains of
    epigastric pain and nausea. Which of the
    following disorders should the nurse consider as
    the priority explanation for causing these
    clinical manifestations?
  • 1. Ischemic changes in the liver
  • 2. Appendicitis
  • 3. Gastritis
  • 4. Peptic ulcer

112
Cont.
  • After reviewing the lab reports in a client which
    is pregnant, the nurse should report which of the
    following?
  • 1. Hemoglobin of 14g/dl
  • 2. Serum glucose of 88mg/dl
  • 3. Hematocrit of 45
  • 4. Platelet count of 50,000

113
Cont.
  • A woman 40 weeks gestation is admitted to L/D
    with possible placenta previa. On the admission
    assessment, the nurse would expect to find
  • 1. Signs of a Couvelaire uterus
  • 2. Severe lower abdominal pain
  • 3. Painless vaginal bleeding
  • 4. A board-like abdomen

114
Postpartum Period
  • Which of the following clinical manifestations
    would the nurse assess as indicative of PIH in a
    client two days after vaginal delivery?
  • 1. Epigastric pain
  • 2. Ringing in the ears
  • 3. Chest pain
  • 4. H/A
  • 5. Visual changes
  • 6. Edema

115
Cont.
  • On the second day postpartum, the nurse asks the
    new mother to describe her vaginal bleeding. The
    nurse should expect her to say that it is
  • 1. Red and moderate
  • 2. Red and clots
  • 3. Scant and brown
  • 4. Thin and white

116
Cont.
  • A woman delivered her baby 12 hours ago. During
    the postpartum assessment, the uterus is found to
    be boggy with a heavy lochia flow. The initial
    action of the nurse is to
  • 1. Notify the MD or nurse Midwife
  • 2. Administer prn oxytocin
  • 3. Encourage the woman to increase ambulation
  • 4. Massage the uterus until firm

117
Cont.
  • A breastfeeding mother is visited by a home
    health nurse 2 weeks after delivery. The woman
    is febrile with flu like symptoms on assessment
    the nurse notes a warm, reddened, painful area of
    the right breast. The best initial action of the
    nurse is to
  • 1. Contact the MD for an order for antibiotics
  • 2. Advise the mother to stop breastfeeding and
    pump
  • 3. Assess the mothers feeding technique and
    knowledge of breast care
  • 4. Obtain a sample of breast milk for culture

118
Newborn
  • Which nursing action should be included in the
    care of the infant with a caput succedaneum?
  • 1. Aspiration the the trapped blood under the
    periosteum
  • 2. Explanation of the parents about the
    cause/prognosis
  • 3. Gentle rubbing in a circular notion to
    decrease size
  • 4. Application of cold to reduce size

119
Newborn
  • A baby girl was born at 915 AM and at 920 Am
    her heart rates was 132, crying vigorously,
    moving all extremities, and only her hands and
    feet were still slightly blue. The nurse should
    enter her Apgar score as
  • 1. 7
  • 2. 8
  • 3. 9
  • 4. 10

120
Newborn
  • Which of the following findings in a newborn baby
    girl is normal?
  • 1. Passage of meconium within the first 24 hours
  • 2. Respiration rate of 70/min at rest
  • 3. Yellow skin tones at 12 hours of age
  • 4. Bleeding form umbilicus

121
Newborn
  • A new mother asks how much weight her newborn
    will lose. The nurse replies
  • 1. None
  • 2. 5
  • 3. 5-8
  • 4. 10-15

122
Newborn
  • Which of the following muscles would the nurse
    choose as the preferred site for a newborn
    vitamin K injection?
  • 1. Gluteus medius
  • 2. Med-deltoid
  • 3. Vastus lateralis
  • 4. Rectus femoris

123
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