Danger Signs

a. vaginal spotting/bleeding b. leaking of fluid from the vagina c. unusual abdominal cramps 1st trimester : 3rd trimester : d. persistent headache, blurring of vision

Danger Signs

e. marked swelling of hands & feet f. painful, burning urination discharge g. foul smelling vaginal discharge h. chills & fever i. persistent nausea & vomiting

Postpartum Blues
Onset
Symptoms Incidence Etiology Therapy

3-5 days after birth

sadness, fears 75% of all births probable hormonal changes, life changes support, empathy

Nursing Role

offer compassion & understanding

Postpartal Depression
Onset Symptoms Incidence Etiology Therapy Nursing Role 1 to 6 months after birth anxiety, feeling of loss, sadness 10% of all births history of poor parent relationship, hormonal response counseling refer for counseling

Onset: Symptoms: Incidence: Etiology:

within 1st month after birth delusions, hallucinations 2% of all births possible activation of previous mental illness, hormonal changes psychotherapy, drug therapy

Therapy:

Nursing role:

refer for counseling, safeguard mother from injury to self or newborn

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I. ABORTION
A. Spontaneous Abortion loss of a fetus before the age of viability ( 20 weeks or 500 gms) often associated with embryonic or trophoblastic disease

Classification 1. Threatened Abortion vaginal bleeding or spotting (with no or slight abdominal cramps) cervix is closed

Mgt: a. bedrest b. avoid coitus for 2 weeks following last evidence of bleeding

2. Inevitable / Imminent Abortion

abortive process is going on uterine contractions occur

Mgt: a. save tissue fragments for examination b. IV oxytocin is used to expel

3. Complete Abortion

minimal bleeding

4. Incomplete Abortion massive bleeding Mgt: Dilatation & Curettage (D&C)

5. Missed Abortion intermittent bleeding no increase in fundal height previously heard fetal heart sounds cannot be heard

Mgt: a. Evacuation b. Dilatation & Curettage

6. Habitual or Recurrent

3 spontaneous abortions
occurring successively Mgt: a.depends on what type of abortion

B. Induced Abortion
voluntary method of terminating pregnancy

Purposes: a. preserve health of the mother b. prevent the birth of an infant with severe gastric defects c. end pregnancy caused by rape or incest d. to terminate the pregnancy of woman who chooses not to have a child @ this time in her life MAJORITY OF REASONS

Types: 1. Therapeutic - termination of pregnancy done for the purpose of safeguarding the health of the mother

2. Elective - interruption of pregnancy @ the request of the woman but not for reasons of impaired maternal health or fetal distress

Methods: a. Vacuum aspiration or curettage done up to 13 weeks of gestation cramping is expected 20-30 mins after

RESULT

b. Dilatation & Evacuation - done from 13 weeks to 16 weeks of gestation - cervix is dilated with: Laminaria Prostaglandin Gel

c. Labor Induction - done on 16th week up to 24thweek gestation

A client 12 weeks pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms cervical dilation. The nurse would document these findings as which of the following?
A. Threatened abortion B. Imminent abortion C. Complete abortion D. Missed abortion
41

Sites:
cervix fallopian tube ovaries abdomen

Causes:
- narrowing of the tube - pelvic infection - endometriosis - Smoking

Manifestations:
1. 2. 3. 4. 5. 6. 7.

vaginal bleeding knife-like abdominal pain referred pain on the shoulder symptoms of shock pelvic pressure or fullness pelvic mass Cullens sign

Diagnosis: 1. Culdocentesis 2. UTZ 3. Hysterosalphingogram - performed 2-3 days after menstruation

Mgt: 1. monitor amount of bleeding 2. monitor V/S 3. assess/ observe for abdominal pain 4. blood transfusion 5. prepare for surgery

 Salpingostomy Salpingectomy Oophorectomy 6. psychological/ emotional care

Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?
A. Risk for infection B. Pain C. Knowledge Deficit D. Anticipatory Grieving
51

( H mole ) also called Gestational

Trophoblastic Neoplasm
characterized by proliferation of chorionic villi into mass of clear vesicles

Predisposing Factors: a. low socio economic status b. women below 18 or above 35 years old c. intake of Clomid d. women of Asian heritage

Types: 1. Complete / Classic

2.Incomplete / Partial

Manifestations: a. vaginal bleeding b. excessive nausea & vomiting c. rapid enlargement of uterus d. (+) pregnancy test e. abdominal cramps f. absent FHR g. elevated HCG titer: 1-2m IU

Diagnosis: 1. HCG titer 2. UTZ 3. X-Ray Mgt: a. D&C b. Chemotherapy: Methotrexate drug of choice c. Monitor HCG level d. Delay childbearing for 1 year e. Perineal pad count f. Chest X-ray

Causes: a. congenital anomaly b. trauma

Risks: a. Habitual abortion b. Preterm labor

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Manifestations:

- vaginal bleeding/show - painless dilatation - premature rupture of membranes

Mgt: a. bed rest in T-position b. medications: Tocolytics Ritodrine HCl (Yutopar) Terbutaline SO4 (Brethrine) MgSO4 c. surgery

Cervical Cerclage
a. Shirodkar - stitch through suture - suture is permanent
b. Mc Donalds - purse-string suture

Predisposing Factors:
1. multiparity 2. advanced maternal age 3. alteration in uterine structure

A nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment would the nurse expect to note? Uterine rigidity b. Uterine tenderness c. Severe abdominal pain d. Soft, relaxed, non-tender uterus
a.

Manifestations: - painless bleeding - heavy bright red bleeding - soft, non tender uterus

A multigravida at 38 weeks gestation is admitted with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided?
a. Maternal vital sign b. Fetal heart rate c. Contraction monitoring d. Cervical dilation
79

Nursing Intervention: 1. bed rest in L side lying position 2. Tocolysis 3. no IE/ enema 4. IVF as ordered 5. O2 by face mask 6. perineal pad count 7. assess for symptoms of shock 8. monitor FHB 9.psychological support

Predisposing Factors: 1. chronic hypertensive disease 2. multigravida 3. history of short cord 4. trauma 5. inhalation of cocaine

Types:

1. Covert or Central 2. Partial or Marginal 3. Complete or Total

Manifestations: - painful, dark brown bleeding - rigid, board like uterus - with abdominal tenderness

Complications: 1. Couvelaire Uterus 2. Shock 3. DIC

Interventions:
1. bedrest in side lying position 2. Tocolysis 3. no IE/enema 4. IVF 5. adm O2 as ordered 6. perineal pad count 7. assess s/s of shock 8. monitor fetal status 9. psychological support

PLACENTA PREVIA
Manifestations:

ABRUPTIO PLACENTA
Manifestations:

- painless - bright red bleeding - soft uterus - non tender uterus

- painful - dark brown bleeding - rigid, board like uterus - abdominal tenderness

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Contributing Factors: a. infection of the vagina b. incompetent cervix c. hydramnios d. amniotic sac with weak structure e. recent sexual intercourse

When PROM occurs, which of the following provides evidence of the nurses understanding of the clients immediate needs?
a. The chorion and amnion rupture 4 hours before the onset of labor. b. PROM removes the fetus most effective defense against infection c. Nursing care is based on fetal viability and gestational age. d. PROM is associated with malpresentation and possibly incompetent cervix
93

Complications: a. Infection - increase after 24 hours - risk for postpartum infection for mother - risk for neonatal sepsis b. RDS - occurs if preterm birth occurs c. Cord Prolapse

Dx: a. Nitrazine Test - to determine pH - alkaline > 6.5 change from blue green to dark blue

Mgt: a. Gestation Near Term - induction of labor - CS may be done b. Preterm gestation - cervix is usually not favorable for induction - CS may be done

Nsg. Intervention: a. check FHR b. check vaginally for prolapsed umbilical cord, or in case of advance labor for descent of presenting part c. check the color of amniotic fluid

Normal: clear Meconium Stained: Cephalic Breech

Which of the following best describes preterm labor?

a. Labor that begins after 20 weeks gestation and before 37 weeks gestation b. Labor that begins after 15 weeks gestation and before 37 weeks gestation c. Labor that begins after 24 weeks gestation and before 28 weeks gestation d. Labor that begins after 28 weeks gestation and before 40 weeks gestation
99

Contributing Factors: a. multiple gestation b. Polyhydramnios c. premature rupture of membranes d. incompetent cervix e. placenta previa / abruptio placenta f. previous preterm labor

Triad Signs and Symptoms:

1. Premature contractions every 10 mins 2. Effacement of 60 80 % 3. Dilation of 2-3 cm

Mgt: a. Prevention of Premature Delivery - bedrest - monitoring of contractions - IE - Tocolytic drugs

b. Patient Teaching - teach woman symptoms of preterm labor

uterine contractions in regular pattern more than 1 hour while @ rest intermittent or constant uterine cramps low, dull backache intestinal cramping rupture of membrane for

A nurse is monitoring a pretem labor client who is receiving IV magnesium sulfate. The nurse monitors for which adverse reactions of this medication? Select all that apply.
Flushing b. Hypertension c. Depressed respirations d. Extreme muscle weakness
a.

BURP

106

Types:

a. Monozygotic Twins

identical twins

108

Manifestations:
a.

uterine size is greater than expected

b. palpation of three or more large parts c. different FHT of different frequencies

Complications:
a. premature delivery b. Hemorrhage c. HPN d. Fetal malpresentation e. Uterine dysfunction due to overstretching f. Cord compression g. Twin-to-twin transfusion syndrome

Recipient Twin Donor twin

- larger - polycythemia - SGA - Anemia

Mgt: a. Prenatal Care b. Balanced diet c. Rest periods d. Anticipatory guidance & support

Rh (-) mom Rh (+) baby

1st Pregnancy Prevention: Rhogam within 72 hours after delivery 2nd Pregnancy:
ERYTHROBLASTOSIS FETALIS

Which of the following factors is the underlying cause of dystocia?

a. Nurtional b. Mechanical c. Environmental d. Medical
130

Powers
a. Hypertonic Labor Pattern
Occurrence: Latent Phase

Characteristics: contractions that are frequent, strong but uncoordinated contractions that are ineffective in accomplishing cervical effacement & dilatation

Treatment:
- rest & sedation - fetal monitoring

b. Hypotonic Contractions
Occurrence: Active Phase

Characteristics: uterine contractions that are inadequate

Causes:

early analgesia bladder or bladder distention multiple gestation large fetus hydramnios grandmultiparity

Treatment: oxytocin & amniotomy CS

Passageway
Mgt: b. evaluate pelvic diameters c. continue labor with careful monitoring d. perform assisted vaginal or caesarean delivery

Psyche fear, anxiety & tension increase stress & can decrease uterine contractility stress interferes clients ability to work with her contractions stress increases fatigue

Predisposing Factors: multiparity history of rapid labor premature or small fetus large bony pelvis Risks: perineal lacerations hemorrhage cerebral trauma

Mgt: fetal monitoring analgesia assess for birth injury assess for cervical vaginal & perineal lacerations

Causes:
1. breech presentation 2. transverse lie 3. unengaged presenting part 4. hydramnios 5. small fetus

S/S: 1. cord is protruding from vagina 2. cord can be palpated in the vagina or cervix 3. fetal distress

Which of the following is the nurses initial action when umbilical cord prolapse occurs?
a. Begin monitoring maternal vital signs and FHR b. Place the client in a knee-chest position in bed c. Notify the physician and prepare the client for delivery d. Apply a sterile warm saline dressing to the exposed cord
144

Mgt: 1. T position or knee chest 2. 02 prevent fetal hypoxia 3. push presenting part upward

4. apply moistened sterile towel 5. delivery ASAP

146

 FULL DILATED CERVIX

INCOMPLETE

DILATATION
MGT : - DELIVER THE INFANT QUICKLY (POSSIBLY WITH FORCEP) MGT : - CESAREAN BIRTH

147

Nursing Care: 1. monitor V/S closely 2. check dressing site 3. inspect perineal pad 4. check fundus for firmness 5. breathing exercises 6. out of bed 1st post op day 7. have the woman hold the baby ASAP

A home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? .
a. Proteinuria

b. Hypertension
c. Generalized edema d. All of the above

- a syndrome of HPN, edema & proteinuria appearing after the 20th week of pregnancy

Risk Factors: a. primi younger than 20 b. primi older than 40 c. low socio economic status d. hydramnios e. underlying diseases

Manifestations:

1. Mild Pre-Eclampsia - increase systole 30 mmHg - increase diastole 15 mm Hg - mild edema of hands & feet - weight gain of 1.5 lbs/week - proteinuria 1+ or 2+

2. Severe Pre-Eclampsia

- increase 160/110 mmHg - proteinuria 3+ - 4+ - oliguria (500 ml in 24 hours) - headache - blurring of vision - epigastric pain - hepatic dysfunction - generalized edema, pitting 3+ - 4+

3. Eclampsia
- presence of -

convulsions

Coma - hypertensive crisis or shock

Management: Mild/Severe Pre-Eclampsia

- Bed rest in side lying position - quiet & calm environment - monitor fetal/maternal well being

- good nutrition - administer meds Hydralazine (Apresoline) * antihypertensive

MgSO4 (drug of choice) - IV * prevents seizures * reduces edema

MgSO4 Toxicity

* absent patellar reflex * RR less than 12-14 cycles * Urine output less than 100 ml in 4 hours * Signs of fetal distress * Serum Mg level greater than 2.5 mEq/L ANTIDOTE:

2. Eclampsia
a. b. c. d. e.

adm O2 side lying external fetal monitor MgSO4 or diazepam termination of pregnancy

A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the clients plan of care?
a. Daily weights b. Seizure precautions c. Right lateral positioning d. Stress reduction

160

P I H baby.
161

Cause: glucose intolerance due to: inadequate response of insulin to CHO insulin resistance

Risk Factors: a. family history of diabetes b. obesity c. previous macrosomic baby d. previous infant with anomaly e. previous unexplained stillbirth

Effects on Pregnancy: a. increase incidence of UTI b. macrosomia c. hydramnios d. congenital anomalies e. stillbirth f. abortion

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168

Effects of DM on baby @ birth:

1. HYPOGLYCEMIA - characterized by tremors, lethargy - occurs 1 to 6 hours after birth

N: blood glucose: 45- 55 mg/dL

2. Respiratory Distress Syndrome (RDS) - also called Hyaline Membrane Disease If mother has DM delay production of phosphatidyl Glycerol decrease surfactant

RDS

Management: 1. Urine Testing check for presence of glucose

check for the presence of ketones

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3. Insulin Administration Early (1st trimester) a. increase production of insulin b. fetus consumes maternal glucose Late (2nd or 3rd trimester) a. increased insulin requirement b. placenta is well developed & produces:

placental insulinase HPL (Human Placental Lactogen)

Adm in Combination: Short acting insulin Regular Intermediate acting insulin NPH

Give insulin BID AM 30 mins before breakfast PM just before dinner

 Type II Diabetic

oral hypoglycemic agent (OHA) are not given 4. Dietary Mgt. well balanced diet refer to dietitian

5. Exercise 6. Fetal Surveillance a. Non Stress Test (NST) b. Amniocentesis c. Oxytocin Challenge Test(OCT) / Contractions Stress Test (CST)

The nurse is caring for a woman at 37 weekss gestation. The client was diagnosed with insulin-dependent diabetes mellitus (IDDM) at age 7. The client states, I am so thrilled that I will be breastfeeding my baby. Which of the following responses by the nurse is BEST?
a. You will probably need less insulin while you are

breastfeeding. b. You will need to initially increase your insulin after the baby is born. c. You will be able to take an oral hypoglycemic instead of insulin after the baby is born. d. You will probably require the same dose of insulin that you are now taking.

Classifications:
Class I Class II Asymptomatic with all activity Asymptomatic @ rest; symptomatic with heavy physical activity Asymptomatic @ rest, symptomatic with ordinary activity

Class III

Class IV

Symptomatic with all activity, symptomatic with rest

Effects on the Fetus: a. retarded growth b. fetal distress c. premature labor Mgt: Goal: to reduce workload of the heart

1. Promote rest 2. Promote a healthy diet

- increase iron to prevent anemia 3. Educate regarding meds a. Digitalis may be given to increase contractility of the heart b. Penicillin may be given to prevent endocarditis

4. Educate regarding avoidance of infection 5. Promote reduction of psychologic stress 6. Deliver

Class I & II : good prognosis for vaginal delivery Class III & IV : poor prognosis for vaginal delivery
no to lithotomy position and valsalva manuever high fowlers position

A nurse is conducting a clinic visit with prenatal client with heart disease. The nurse carefully assesses the clients vital signs, weight, and fluid and nutritional status to detect complications caused by: a. hypertrophy and increased contractility of the heart b. the increase in circulating blood volume c. fetal cardiomegaly d. Rh incompatibility

Causative Agent:

CANDIDA ALBICANS
S/Sx

cream cheese like vaginal discharge dyspareunia itchiness and reddening of the vulva

189

Management:

1% gentian violet nystatin suppository

Fetal Effect:

Thrush or Oral Candidiasis

194

Causative Agent: TRICHOMONAS VAGINALIS S/Sx FROTY-WHITE to greyish vaginal discharge pinpoint petechiae on the vagina

Management:

Metronidazole (Flagyl)
(given to a non pregnant women) Vaginal douching Dilute vinegar solution or betadine Clotrimazole (canesten)

Causative Agent: CLAMYDIA TRACHOMATIS S/Sx

heavy, gray white vaginal discharge dyspareunia dysuria friable cervix

Management:

erythromycin ampicillin
Fetal effects:

trachomonal inclusion conjunctivitis pneumonia

Causative Agent: Neisseria Gonorrhea S/Sx (F) - Asymptomatic (M) - Burning on urination - urinary frequency - purulent penile discharge

207

Management: - erythromycin - penicillin G Fetal effects: - Opthalmia Neonaturum may cause blindness Credes Prophylaxis given

Causative Agent: Treponema Pallidum S/Sx chancre - painless characteristic lesion that may appear on the mouth, genital area, rectal area

212

Management: erythromycin benzanthine penicillin

Fetal Effects: a. abortion b. still birth c. congenital syphilis

hutchinsons teeth (narrowed incisor teeth) saddle nose blisters and peeling skin fissures around hips and anus

Causative Agent: Toxoplasma Gondii MOT

eating undercooked meat contact with cat stool or litter (birds,cattle)

s/sx Almost no symptoms Cervical lymphadenopathy Malaise for few days

Fetal effects spontaneous abortion cns damage

Treatment: sulfadiazine

German Measles

Causative Agent:

viral
MOT droplet infection

s/sx Fever Rash lymphedema

Fetal effects - deafness - mental and motor retardation - cataracts - cardiac defects - facial clefts

A 1 day post partum clients rubella titer result is lower than 1:8 & a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.
a. Pregnancy needs to be avoided for 1 to 3 months. b. The vaccine is administered by the subcutaneous

route. c. A hypersensitivity reaction can occur if the client has an allergy to eggs. d. All of the above

Causative Agent: Cytomegalovirus (CMV)

MOT droplet infection

s/sx: asymptomtic Fetal effects brain damage eye damage chronic liver disease

Causative Agent: Herpes virus hominis type 2 (HVit.2) MOT sexually transmitted

s/sx

Painful pinpoint vesicles Fever Malaise Dyspareunia

239

Fetal effects - spontaneous abortion - vesicles covering the skin - dyspnea - fever - lethargy
Tx: Acyclovir (Zovirax)- unsafe for pregnant

A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. The nurse tells the client that : a. Total abstinence from sexual intercourse is necessary during the entire pregnancy b. A cesarean section will be necessary if vaginal lesions are present at the time of labor c. Sitz bath need to be taken every 4 hours while awake if vaginal lesions are present Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy

241

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