HIGH-RISK PREGNANCY

Prepared by:
ROSELYN S. PACARDO, MAN, MM, RN, RM
 BLEEDING IN PREGNANCY
First Trimester Bleeding

A. ABORTION – Any interruption of pregnancy

before 20 to 24 weeks of
gestation; at least 500 g
 TYPES OF ABORTION
TYPES SIGNS AND SYMPTOMS MANAGEMENT

1. Threatened  Slight, bright red •* Avoid strenuous

vaginal bleeding activity for 24 to
 Mild abdominal 48 hours; if
cramping bleeding will stop it
 No cervical usually stops within
dilatation on IE this time.
 No passage of fetal • No coitus for 2
tissue weeks after
bleeding stops.
•Advise patient to
save all pads, clots,
and expelled tissues
TYPES SIGNS AND SYMPTOMS MANAGEMENT

2. Inevitable Moderate vaginal • Vacuum

Abortion bleeding curettage
 Rupture of • Prostaglandin
membranes •analogs to
 Cervical dilatation empty uterus of
 Strong abdominal retained
cramping tissue
 Possible passage of
products of
conception
TYPES SIGNS AND SYMPTOMS MANAGEMENT

3.Incomplete • Client stabilization

 Intense abdominal
abortion (passage • Dilatation and
cramping
curettage
of some of the  Heavy vaginal
products of bleeding
conception)  Cervical dilatation

4.Complete  History of vaginal • No surgical or

abortion (passage bleeding and medical intervention
abdominal pain necessary
of all products of
 Passage of tissue • Follow-up
conception) with subsequent appointments to
decrease in pain and discuss family planning
significant decrease in
vaginal bleeding
TYPES SIGNS AND SYMPTOMS MANAGEMENT

5. Missed abortion • Evacuation of uterus

 Absent uterine
(nonviable embryo if inevitable abortion
contractions
does not occur;
retained in utero  Irregular spotting
suction curettage
for at least 6  Possible
during first semester;
weeks) progression to
dilatation and
inevitable abortion
curettage during
second trimester
• Induction of labor
with intravaginal PGE2
suppository to empty
uterus without surgical
intervention
TYPES SIGNS AND SYMPTOMS
6. Habitual
 History of three or
Abortion
more consecutive
spontaneous abortions
 Not carrying the pregnancy
to viability or term
MANAGEMENT
• Identification and
treatment of
underlying cause
• Cervical cerclage in
second trimester if
incompetent cervix is
the cause
B. ECTOPIC PREGNANCY - Any pregnancy
outside the uterus
Signs and Symptoms Management

 Severe, sharp, knife-like • Laparoscopy

stabbing pain • Salpingostomy – if fallopian tube
in either the right or left lower can still be replaced and
quadrant preserved, but the pregnancy has
 Rigid abdomen to be terminated
 (+) Cullen’s sign (bluish • Sal[ingectomy – removal of
umbilicus) fallopian tube plus blood
 Excruciating pain when cervix transfusion
is moved on IE • Combat shock:
 Signs of shock: falling BP, PR -Elevate foot of the bed
more than 100/min, rapid RR, - Cover with a thick blanket
lightheadedness
 SECOND TRIMESTER BLEEDING
- Abnormal proliferation
A. HYDATIDIFORM MOLE
and degeneration of the
trophoblastic villi
COMPLETE MOLE
PARTIAL MOLE
SIGNS AND SYMPTOMS
 Highly positive urine test for
Pregnancy (marked hCG level)
 Marked nausea and vomiting
 Rapid increase in fundic height
and weight
 PIH signs and symptoms appear
before the 24th week of gestation
 No fetal heart tones
 Vaginal bleeding seen as clear,
fluid-filled, grape-sized vesicles
 ultrasound “snowstorm
pattern”
* The client with H-mole is at risk of developing
choriocarcinoma.
MANAGEMENT
 D & C to evacuate the mole
 Prophylactic course of
methotrexate, the drug of choice
for choriocarcinoma
 Following evacuation, pelvic
exam and chest x-ray are done;
Serum test for hCG every 2
weeks till normal
 Serum hCG tested every 4
weeks for 6 to 12 months
 Advise not to get pregnant for
at least a year
B. PREMATURE CERVICAL DILATATION/INCOMPETENT CERVIX
-Cervix that dilates prematurely and cannot hold a fetus until term;
- Chief cause of habitual abortion
SIGNS AND SYMPTOMS MANAGEMENT
 Presence of show (pink- • McDonald/Shirodkar Procedure
stained vaginal discharge) Cerclage procedure wherein
 Painless dilatation pursed string sutures are placed
 Increased pelvic pressure around the cervix on the 14th to
followed by rupture of the 18th week of gestation; McDonald’s
membranes and discharge of Removed during a vaginal delivery;
amniotic fluid in caesarean section, Shirodkar
 Uterine contractions method is used
SHIRODKAR
METHOD
 Third Trimester Bleeding
A. Placenta Previa - Low implantation of the placenta

Low-lying placenta
Partial placenta previa Complete placenta
previa
Signs and Symptoms Management

 Painless, bright red • Ensure that the client

vaginal bleeding gets adequate rest
• Monitor V/S of the
mother and the FHR
• Prepare oxygen and
blood
• Never perform an IE
• If IE should be done,
prepare a double set-up
B. ABRUPTIO PLACENTA Premature separation of a
normally implanted placenta
Premature Separation of the
Placenta: Degrees of Separation

Grade Criteria
0 No symptoms of separation were apparent
from maternal or fetal signs; diagnosis is made
after the delivery of the placenta when there is
a recent adherent blood clot on the maternal
surface.
1 Minimal separation but enough to cause vaginal
bleeding & changes in maternal V/S; no fetal
distress or shock
2 Moderate separation; with fetal distress; uterus
is tense and painful

3 Extreme separation; without immediate

interventions, maternal shock and fetal death
will result
Signs and Symptoms
 Severe knife-like stabbing
pain high in the fundus
 Hard, board-like uterus; rigid
abdomen
 Signs of shock
• Concealed bleeding, if
extensive causes the uterus to
lose its ability to contract;
becomes ecchymotic and
copper-colored called
Couvelaire uterus, causing
severe bleeding
Management
• Fluid replacement
• Oxygen by mask to limit fetal
anoxia
• Monitor FHR
• Monitor maternal V/S every 5
to 15 minutes
• Lateral or side-lying position
• No IE or pelvic exam
• No enema
• For Grades 2 and 3
separation: Caesarean section
• Massive bleeding:
hysterectomy
POSTPARTUM HEMORRHAGE
 A. EARLY POSTPARTUM HEMORRHAGE – occurs during the
first 24 hours; greater than 500 mL blood loss in a 24 hour period
Types Signs and Symptoms Management

Uterine Atony Uterus not well- • Massage – first nursing

(most common contracted, action
cause) • Ice compress
relaxed or boggy • Oxytocin administration
• Empty the bladder
• Bimanual expression of
retained
placental fragments
• Hysterectomy – last resort
Lacerations Bleeding even if the Repair
uterus is well
contracted and there
is no retained
FUNDAL MASSAGE
 B. LATE POSTPARTUM HEMORRHAGE - Blood loss more than
500 mL ; occurs 24
hours after birth up
to 6 weeks
Types Signs & Symptoms Management

Retained Bleeding even if the Dilatation and

Placental uterus is well contracted Curettage
fragments and there are no
lacerations
Hematoma – Collection of blood in the • Ice compress
injury to blood subcutaneous tissue of • Analgesics
vessels the perineum • Site is incised and
bleeding vessel is
ligated
HEMATOMA
SITUATION H: Georgina attended a lecture about high
risk pregnancy. One of the most common danger signals
is hemorrhage.

36. In taking care of a client with placenta previa, the

nurse should do the following, EXCEPT:
A. Perform an internal examination.
B. Inform significant others to prepare blood for possible
transfusion
C. Monitor the vital signs
C. Prepare a double set-up delivery when labor is
imminent
SITUATION H: Georgina attended a lecture
about high risk pregnancy. One of the most
common danger signals is hemorrhage.
36. In taking care of a client with placenta previa,
the nurse should do the following, EXCEPT:
A. Perform an internal examination.
B. Inform significant others to prepare blood for
possible transfusion
C. Monitor the vital signs
D. Prepare a double set-up delivery when labor is
imminent

•Pillitteri p. 414
37. If a pregnant woman on her first
trimester of pregnancy has abdominal
cramping and bright red vaginal spotting
but the cervix is not dilated the woman
should suspect that she is most likely
experiencing a/an:

A. Missed abortion
B. Threatened abortion
C. Inevitable abortion
D. Complete abortion
37. If a pregnant woman on her first trimester of
pregnancy has abdominal cramping and bright
red vaginal spotting but the cervix is not dilated
the woman should suspect that she is most likely
experiencing :

A. Missed abortion – fetal death in utero

B. Threatened abortion
C. Inevitable abortion – cervix is dilated
D. Complete abortion – products of conception
are expelled

•Pillitteri p. 404
38. The nurse giving the lecture explains
further that a manifestation of a knife-like
stabbing pain in either the right or left
lower quadrant of the abdomen with a
bluish umbilicus is an indication of:

A. Gestational trophoblastic disease

B. Incompetent Cervical os
C. Ectopic pregnancy
D. Abruptio placenta
38. The nurse giving the lecture explains further that
a manifestation of a knife-like stabbing pain in
either the right or left lower quadrant of the
abdomen with a bluish umbilicus is an indication of:

A. Gestational trophoblastic disease – grape-like

B. Incompetent Cervical os – painless, pink-stained
bleeding
C. Ectopic pregnancy
D. Abruptio placenta – painful vaginal bleeding
with low back pain; uterus board-like

•Pillitteri p. 409
39. What would the first nursing action if
a client is having a uterine atony?

A. Massage the hypogastric area slightly

B. Apply cold compress
C. Administer the oxytocin as prescribed
D. Encourage the client to empty her
bladder
39. What would the first nursing action
if a client is having a uterine atony?
A. Massage the hypogastric area
slightly
B. Apply cold compress
C. Administer the oxytocin as
prescribed
D. Encourage the client to empty her
bladder

•Pillitteri pp. 657 - 658

40. Which of the following measurements,
best describes delayed postpartum
hemorrhage?
A. Blood loss in excess of 300 mL, occurring
24 hours to 6 weeks after delivery
B. Blood loss in excess of 500 mL, occurring
24 hours to 6 weeks after delivery
C. Blood loss in excess of 800 mL, occurring
24 hours to 6 weeks after delivery
D. Blood loss in excess of 1000 mL,
occurring 24 hours to 6 weeks after delivery
40. Which of the following measurements, best
describes delayed postpartum hemorrhage?

A. Blood loss in excess of 300 mL, occurring 24

hours to 6 weeks after delivery
B. Blood loss in excess of 500 mL, occurring
24 hours to 6 weeks after delivery
C. Blood loss in excess of 800 mL, occurring 24
hours to 6 weeks after delivery
D. Blood loss in excess of 1000 mL, occurring 24
hours to 6 weeks after delivery

•Ricci p. 614
 PREGNANCY-INDUCED
HYPERTENSION

-A vascular disease of unknown cause which occurs any

time after the 24th week of gestation up to two weeks
postpartum; vasospasm occurs both in small and large
arteries.
Triad of Symptoms:

a. Hypertension
b. Edema
c. Proteinuria
Diagnosis: Roll-over Test - Assesses the probability of
developing PIH when
performed between the 28th
and 32nd week of pregnancy
Procedure: Interpretation:
 Patient lies in the lateral  If diastolic pressure
recumbent position for 15 increases
minutes until BP is 20 mmHg or more, patient
stabilized. is prone to PIH.
 Patient then rolls over to
supine position.
 BP is taken at one minute
and 5 minutes after having
rolled over.
 1. PREECLAMPSIA
a. Mild Preeclampsia
 Sudden excessive weight
gain of 1 to 5 lbs per week
(earliest sign); 2 lb per wk in
2nd trimester and 1 lb/wk in
3rd trimester due to edema
which is found in the upper
half of the body (e.g. can’t
wear wedding ring)
 Systolic BP of 140, or an
increase of 30 mmHg or
more; Diastolic BP of 90
or a rise of 15 mmHg or more more than 1.2 mg/dL
taken 6 hours apart
 Proteinuria: 1+ or 2+ on a
reagent test strip in a
random sample; or 0.5
gm/liter or more
b. Severe Preeclampsia
 BP of 160/110 mmHg on at least
two occasions 6 hours apart at bed
rest
 Proteinuria: 5 gm/liter or more in 24
hours; 3+ or 4+ on a random urine
sample
 Oliguria of 500 mL or less in 24
hours (normal urine output per day =
1500 mL); elevated serum creatinine
 Cerebral or visual disturbances
 Pulmonary edema and cyanosis
 Epigastric pain – considered an
“aura” to the development of
convulsions
2. ECLAMPSIA – with seizure
(convulsions) accompanied by
signs and symptoms of
preeclampsia plus:
a. Increased BUN
b. Increased uric acid
c. Decreased carbon dioxide
combining power

* Seizure Precautions
 MANAGEMENT
MILD PIH
 Bed Rest
-Sodium is excreted faster when
the body is in a recumbent
position (promote lateral)
 Emotional Support
SEVERE PIH
 Hospitalized for Bed Rest
to be enforced
 Limit visitors
 Avoid loud noise
 Private room
 Darken the room
 Raise side rails
Avoid stress
 Let client verbalize feelings
 Monitor maternal well-being
 Monitor fetal well-being
 Diet: Moderate to high in
protein and moderate sodium
MEDICATION
Magnesium sulfate
• Muscle relaxant
• CNS depressant –
prevents seizures
• Vasodilator – decreases BP
• Cathartic causes a shift of
fluid for the extracellular
spaces into the intestines to
excrete the fluid
• Antidote for toxicity:
• 10 mL of 10% calcium
gluconate solution (1g) IV
• Drug of choice
• Loading dose IV 4 to 6 g;
• Maintenance dose 1 -2 g per hour
IV
• Infuse slowly over 15 – 30 minutes
• Always administer as a piggyback
infusion
• Maintain a serum level of 5 to 8
mg/mL
• Assess respiratory rate, urine
output, DTR, and clonus every hour
• Criteria for administration:
a. Urine output: over 30 mL per
hour
b. Respiratory rate: over 12 per
minute
c. DTR present
PATELLAR REFLEX Absence of DTR –
SCORING earliest sign of toxicity
0 No response; hypoactive;
abnormal
1+ Somewhat diminished
response but not
abnormal
2+ Average response
3+ Brisker than average but
not abnormal
4+ Hyperactive; very brisk;
abnormal
ANKLE CLONUS

2 Movements Mild
3–5 Moderate
movements
Over 6 Severe
movements
SITUATION I: Andrea, 30 year old G4P3 is
admitted to the high risk antepartal unit with a
diagnosis of
pregnancy-induced hypertension.

41. Which of the following is the main

difference between preeclampsia and
eclampsia?
A. Increased blood pressure
B. Proteinuria
C. Oliguria
D. Presence of convulsions
SITUATION I: Andrea, 30 year old G4P3 is
admitted to the high risk antepartal unit with a
diagnosis of pregnancy-induced hypertension.

41. Which of the following is the main

difference between preeclampsia and
eclampsia?
A. Increased blood pressure
B. Proteinuria
C. Oliguria
D. Presence of convulsions

•Pillitteri p. 428
42. What is the prodromal symptom of
the seizures associated with PIH?

A. (- ) deep tendon reflex

B. Sudden elevation of blood pressure
C. Oliguria
D. Epigastric pain
42. What is the prodromal symptom of the
seizures associated with PIH?
A. (- ) deep tendon reflex – sign of toxicity
B. Sudden elevation of blood pressure - PIH
C. Oliguria – sign of toxicity
D. Epigastric pain – due to abdominal edema
or ischemia to the pancreas and liver

•Pillitteri p. 428
43. Andrea receives magnesium sulfate for
severe preeclampsia. Which of the
following adverse effects is associated
with magnesium sulfate?

A. Anemia
B. Decreased urine output
C. Hyperreflexia
D. Increased respiratory rate
43. Andrea receives magnesium sulfate
for severe preeclampsia. Which of the
following adverse effects is associated
with magnesium sulfate?
A. Anemia
B. Decreased urine output – below 30
mL/hour
C. Hyperreflexia – absent DTRs
D. Increased respiratory rate - decreased

•Pilltteri p. 430 - 431

44. The latest assessment of Andrea reveals
that she has deep tendon reflexes of (+) 1, BP
of 150/100 mmHg, a pulse of 92 beats per
minute, and urine output of 20 mL per hour.
Which of the following actions would be
most appropriate?

A. Continue monitoring per standards of care.

B. Stop the magnesium sulfate infusion.
C. Increase the infusion rate by 5 gtts/minute
D. Decrease the infusion rate by 5 gtts/min
44. The latest assessment of Andrea reveals that
she has deep tendon reflexes of (+) 1, BP of
150/100 mmHg, a pulse of 92 beats per minute,
and urine output of 20 mL per hour. Which of the
following actions would be most appropriate?

A. Continue monitoring per standards of care.

B. Stop the magnesium sulfate infusion.
C. Increase the infusion rate by 5 gtts/minute
Decrease the infusion rate by 5 gtts/min
Pillitteri pp. 430 - 431
45. Which of the following drugs is the
antagonist for magnesium sulfate toxicity?

A. Calcium gluconate
B. Hydralazine hydrochloride
C. Naloxone
D. Rho (D) immune globulin – Rh in
45. Which of the following drugs is the
antagonist for magnesium sulfate toxicity?
A. Calcium gluconate
B. Hydralazine hydrochloride - (Apresoline)
for HPN
C. Naloxone hydrochloride hydrochloride
(Narcan) – for Demerol toxicity
D. Rho (D) immune globulin – (RhoGAM) for
Rh incompatibility; (Mother Rh (-); Fetus Rh
(+)

•Pillitteri p. 430; Leifer p.95

 DIABETES MELLITUS
-Chronic hereditary disease characterized by
hyperglycemia due to relative insufficiency or lack of
insulin from the pancreas which leads to abnormalities
in the metabolism of carbohydrates, proteins, and fats.

- Normal blood sugar: 80 to 120 mg/dL

Effects of Hyperglycemia Effects of Hypoglycemia
* Baby
 Hydramnios  Pallor
 Gestational hypertension  Tremors
 Ketoacidosis  Jitteriness
 Preterm labor secondary to  Lethargy
PROM  Poor feeding
 Cord prolapse
 Stillbirth
 Hypoglycemia
 UTI
 Moniliasis
 Difficult labor
 Macrosomia
 Others
 MANAGEMENT
Goals:To maintain glycemic control and minimize the risks of the
disease on the fetus.
1. Dietary Management
• Adhere to the same nutrient requirements and
recommendations for weight gain as the non-diabetic client.
• Avoid weight loss and dieting during pregnancy.
• Ensure food intake is adequate to prevent ketone formation
and promote weight gain.
• Eat three meals a day plus three snacks to promote glycemic
control. (1,800 – 2, 200 calorie diet)
• Include complex carbohydrates, fiber, and limited fat and sugar
in the diet.
• Continue dietary consultation throughout pregnancy.
2. Insulin Requirements
-Medication of choice
- Increased need during the 2nd and 3rd trimesters
- Regulated to keep +1 for sugar (minimal glycosuria is necessary
to prevent acidosis) but negative for acetone
- Long-acting insulin (Ultralente) will have to be changed to regular
insulin (Lente) during thelast few weeks of pregnancy.4.
3. Fetal and Maternal Surveillance

4. Mode of Delivery:
a.Vaginal birth preferred if at all possible.
b. Cesarean section – for macrosomic baby
SITUATION J: Bianca, 30 years old G2P0, on her 37
weeks of gestation is admitted to the labor room and is
having gestational diabetes mellitus.

46. The physician estimates that the fetus weighs at

least 10 pounds. Bianca asks the nurse, “What causes
the baby to be so large?” The nurse should explain that
fetal macrosomia is usually related to:

A. Genetic history of large infants

B. Fetal anomalies
C. Maternal hyperglycemia
D. Fetal hypoglycemia
SITUATION J: Bianca, 30 years old G2P0, on her
37 weeks of gestation is admitted to the labor room
and is having gestational diabetes mellitus.
46. The physician estimates that the fetus weighs at
least 10 pounds. Bianca asks the nurse, “What causes
the baby to be so large?”
The nurse should explain that fetal macrosomia is usually
related to:
A. Genetic history of large infants
B. Fetal anomalies
C. Maternal hyperglycemia leads to fetal hyperglycemia;
increased insulin to counteract hyperglycemia acts a
growth stimulant
D. Fetal hypoglycemia

•Ricci p. 546;Pillitteri p. 377

47. The goal of nursing care for Bianca is
to achieve and maintain normal maternal
glucose at which of the following levels in
a 24-hour period?

A. 30 to 50 mg/dL
B. 120 to 140 mg/dL
C. 60 to 80 mg/dL
D. 80 to 120 mg/dL
47. The goal of nursing care for Bianca is to
achieve and maintain normal maternal
glucose at which of the following levels in a
24-hour period?

A. 30 to 50 mg/dL
B.120 to 140 mg/dL
C. 60 to 80 mg/dL
C. 80 to 120 mg/dL

•Source: Pillitteri p. 377

48. The recommended calorie intake
for Bianca is:

A. 1000 – 1500 calories

B. 500 – 1000 calories
C. 1800 – 2200 calories
D. 2200 – 3000 calories
48. The recommended calorie
intake for Bianca is:

A. 1000 – 1500 calories

B. 500 – 1000 calories
C. 1800 – 2200 calories
D. 2200 – 3000 calories
•Pillitteri p. 380
49. The delivery of choice for
Bianca is:

A. Normal spontaneous vaginal

delivery
B. Caesarean section
C. Forceps delivery
D. Vacuum extraction
49. The delivery of choice for
Bianca is:

A. Normal spontaneous vaginal

delivery
B. Caesarean section
C. Forceps delivery
D. Vacuum extraction
•Pillitteri p. 383; p.605
50. All of the following are the
manifestations of hypoglycemia
in Bianca’s baby, EXCEPT:

A. Tremors
B. Shrill, high-pitched cry
C. Vigorous suck
D. Hypotonia
50.All of the following are the
manifestations of hypoglycemia
in Bianca’s baby, EXCEPT:

A. Tremors
B. Shrill, high-pitched cry
C. Vigorous suck
D. Hypotonia
•Ricci p. 678
 CARDIAC DISEASE
Classification
Class Description
1 Uncompromised: No limitation of physical
activity; ordinary physical activity causes no
discomfort; no symptoms of cardiac
insufficiency and no anignal pain
(asymptomatic)
II Slightly compromised: Slight limitation of
activity; ordinary activity causes excessive
fatigue, palpitation, and dyspnea or anginal
pain (symptomatic with increased physical
activity)
 III Markedly compromised: moderate to
marked limitation of physical activity; less
than ordinary activity, experience
excessive fatigue, palpitations, dyspnea, or
anginal pain (symptomatic)
1V Severely compromised: unable to carry
out any physical activity without
experiencing discomfort; experience
symptoms of cardiac insufficiency or
anginal pain

Prognosis:
a. Classes I and II – normal pregnancy and delivery
b. Classes III and IV – poor candidates
Signs and Symptoms
 Shortness of breath on exertion
 Cyanosis of lips and nail beds
 Swelling of face, hands, and feet
 Rapid respirations
 Abnormal heart beats, racing heart, or palpitations
(murmurs)
 Chest pain
 Syncope
 Increasing fatigue
 Moist, frequent cough
 Decreased cardiac output
 Ascites
 MANAGEMENT
a. Bed Rest • after the 30th week of gestation to ensure
that pregnancy is carried to term or at least 36
weeks of gestation; side-lying
• Prioritize household chores and childcare
b. Diet • Referral to nutritionist
• Limit sodium
• High fiber diet

c. Medications • Digoxin (Digitalis)

• Iron preparations – prevents anemia to
minimize increase cardiac output thereby
reducing cardiac workload

d. Diagnostic • ECG
tests • Non-stress test
e. Fetal surveillance •Assess fetal activity
• Frequent prenatal visits
•
f. Report to physician • Signs and symptoms of cardiac
decompensations
• Infection exposure
g. Support System • Encourage use of significant others

h. Preparation for • Classes III and IV should be on sitting

labor and birth position during delivery
• Epidural – anesthesia of choice; for
pushless and effortless delivery
• Method of delivery: forceps
SITUATION K: Loida, 30 years, 36 weeks of
gestation is admitted to the hospital with a
Class III heart disease.

51. All of the following are the cardiac

manifestations of Loida, EXCEPT:

A. Loud, harsh murmur associated with thrill.

B. Cardiomegaly
C. Increased cardiac output
D. Decreased cardiac output
SITUATION K: Loida, 30 years, 36 weeks of
gestation is admitted to the hospital with a
Class III heart disease.

51. All of the following are the cardiac

manifestations of Loida, EXCEPT:
A. Loud, harsh murmur associated with thrill.
B. Cardiomegaly
C. Increased cardiac output
D. Decreased cardiac output

•Pillitteri pp.354 – 356; Ricci p. 556

52. The primary goal of nursing care for
a client with cardiac problem is to:

A. Limit physical activity

B. Prevent anemia
C. Avoid excessive weight gain
C. Reduce the cardiac workload
52. The primary goal of nursing care
for a client with cardiac problem is to:

A. Limit physical activity

B. Prevent anemia
C. Avoid excessive weight gain
D. Reduce the cardiac workload
(umbrella)
•Pillitteri p. 356
53. Which of the following drugs
should not be given to Loida:

A. Iron preparations
B. Epinephrine
C. Digoxin
D. Diuril
53. Which of the following drugs
should not be given to Loida:

A.Iron preparations – prevent anemia

B. Epinephrine – causes
palpitations increasing workload
C.Digoxin – decrease contractility of
the heart
D. Diuril – diuretic to reduce edema
•Pillitteri p. 359
54. Class III classification of heart disease is
best described as:
A. Uncompromised: women have no
limitations of physical activity.
B. Slightly compromised: women have slight
limitation of physical activity.
C. Severely compromised: women are unable
to carry out any physical activity without
experiencing discomfort.
D. Markedly compromised: women have a
moderate to marked limitation of physical
activity.
54. Class III classification of heart disease is
best described as:
•A. Uncompromised: women have no
limitations of physical activity.
•Slightly compromised: women have slight
limitation of physical activity.
•Severely compromised: women are unable to
carry out any physical activity without
experiencing discomfort.
•Markedly compromised: women have a
moderate to marked limitation of physical
activity.
•Source Pillitteri p. 354
55. The preferred position that
Loida should assume during
delivery of the baby would be:

A. Dorsal recumbent position

B. Lithotomy position
C. Supine position
D. Semi-sitting position
55. The preferred position that Loida
should assume during delivery of the
baby would be:
A. Dorsal recumbent position
B. Lithotomy position
C. Supine position
D. Semi-sitting position – facilitate
easy respirations
•Pillitteri p. 359
 DYSTOCIA
- Abnormal or difficult labor and
delivery
1. Uterine Inertia - Sluggishness of contractions

Causes • Inappropriate use of analgesics

• Pelvic bone contraction
• Poor fetal position
• Overdistension
Types • relaxations are inadequate and mild, thus,
a. Primary ineffective; uterine muscles are in a state
of greater-than-normal tension, the latent
hypertonic
phase of the first stage of labor is
dysfunction prolonged.
Management: Sedation

b. Secondary uterine • contractions have been good but

dysfunction gradually become infrequent and of poor
Management: Oxytocin quality and cervical dilatation stops
adm. Or amniotomy
2. Precipitate Delivery - Completed in less than 3
hours after the onset of true
labor pains

Causes: • oxytocin administration

• amniotomy

Complications: • Extensive lacerations

• Abruptio placenta
• Hemorrhage
3. Prolonged Labor Primis: lasting more than
18 hours
Multis: lasting more than 12
hours
Complications: • Maternal exhaustion
• Uterine atony
• Caput succedaneum
4. Uterine Rupture - Uterus undergoes more
straining than it is capable of
sustaining
Causes: • Scar from previous classic CS
• Unwise use of oxytocics
• Overdistension
• Faulty presentation
• Prolonged labor
4. Uterine Rupture Occurs when the uterus undergoes more
straining than it is capable of sustaining

Causes • Scar from a previous classic CS

• Unwise use of oxytocins
• Overdistension
• Faulty presentation
• Prolonged labor

Signs and Symptoms • Sudden, severe pain

• Hemorrhage and signs of shock
• Change in abdominal contour

Management Hysterectomy
Physiologic Retraction Ring
Pathologic retraction ring or
Bandl’s ring
5. Uterine Inversion Fundus is forced through the cervix
and the uterus turns inside out
Causes • Insertion of the placenta at the fundus
• Strong fundal push when mother fails
to bear down properly during the
second stage of labor
• Attempts to deliver the placenta before
signs of placental separation appear
Signs and Symptoms Dramatic
• Woman in labor suddenly sits up and
grasps her chest due to dyspnea and
sharp chest pain
• Pallor then bluish-gray color associated
with pulmonary embolism
• Death may occur in a few minutes
Management • Emergency measures to maintain life: IV,
oxygen, CPR
6. Trial Labor Borderline pelvic measurements but
fetal position and presentation are good;
can be continued if there is progressive
fetal descent of the presenting part and
the cervix continues to dilate
Management • Monitor FHRs and uterine
contractions
• Empty the bladder
• Emotional support
7. Premature Labor and Uterine contractions occur before
Delivery the 38th week of gestation
Management • No bleeding, cervical dilatation;
FHR good – premature
contractions can be stopped by
drugs:
-Ethyl alcohol – blocks the release
of oxytocin
- Vasodilan IV – vasodilator
- Ritodrine – muscle relaxant given
orally
- Bricanyl - bronchodilator
• With premature uterine contractions
accompanied by fetal descent and cervical
dilatation, delivery is inevitable
-Pain medications kept to a minimum to prevent
respiratory depression
- Steroids (glucocorticoids) given for maturation of
the fetal lungs
- Caudal, spinal or infiltration anesthesia – does
not compromise with fetal respiration
- Forceps applied gently
- Cut cord immediately; do not wait for pulsation
to stop
INSTRUMENTAL DELIVERIES
1. Forceps Delivery metal instrument to extract
the baby; applied at +3 to +4
station and the sagittal suture is
in an anteroposterior position
in relation to the outlet

Purpose -Shorten the 2nd stage of labor

- Prevent excessive pounding on
fetal head
- Poor uterine contractions or rigid
perineum
Criteria • No CPD
• Fetal head deeply engaged
• Full cervical dilatation and
effacement
• Membranes ruptured
 • Vertical presentation has been
established
• Rectum and bladder are empty
• Anesthesia given for sufficient
perineal relaxation and to prevent
pain

Types • Low – fetal head is at station +2 or

lower but not yet crowning
• Mid – fetal head is engaged but at less
than +2 station
• Outlet forceps – fetal head is crowning
Complications • Forceps marks – 24 to 48h hours
• Bladder or rectal injury, facial paralysis,
ptosis, seizures, epilepsy, cerebral palsy -
Rare
FORCEPS MARK
2.Vacuum Extraction
3. Cesarean Section Delivery of the fetus through an
incision in the abdomen and uterus
Indications • CPD – most common cause
• PIH, placental accidents, fetal distress
Use of electronic fetal monitoring
• maternal age

Types a. Low segment – method of choice;

incision in the lower uterine segment
• Advantages:
-Minimal blood loss; Incision easy to
repair; low incidence of PP infection;
no possibility of uterine rupture
b. Classic – vertical incision
SITUATION L: A group of women on their third
trimester of pregnancy are given information
during a prenatal class about the manifestations
of abnormal or difficult labor and delivery as well
as the use of instrumental deliveries.

56. All of the following are the causes of dystocia

during labor and delivery, EXCEPT:
A. Maternal exhaustion
B. Analgesics
C. Pelvic bone contraction
D. Maternal Activity
SITUATION L: A group of women on their third
trimester of pregnancy are given information
during a prenatal
class about the manifestations of abnormal or
difficult labor and delivery as well as the use of
instrumental deliveries.
56. All of the following are the causes of dystocia
during labor and delivery, EXCEPT:
A. Maternal exhaustion
B. Analgesics
C. Pelvic bone contraction
D. Maternal Activity
•Pillitteri p. 590
57. Hypertonic contractions would lead to
which of the following complications:

A. Inverted uterus
B. Precipitate delivery
C. Prolonged Labor
D. Preterm delivery
57. Hypertonic contractions would
lead to which of the following
complications:

A. Inverted uterus
B. Precipitate delivery
C. Prolonged Labor
D. Preterm delivery
•Pillitteri p. 591- 592, 595; Ricci p. 587
58. These are the signs of complete uterine
rupture, EXCEPT:

A. Sudden, sharp abdominal pain

B. Continuation of uterine contraction
C. Cessation of uterine contraction
D. Change in the abdominal contour
58. These are the signs of complete uterine
rupture, EXCEPT:

A. Sudden, sharp abdominal pain

B. Continuation of uterine contraction
C. Cessation of uterine contraction
D. Change in the abdominal contour

•Pillitteri p. 596
59. Which of the following is the criterion
for induction of labor?

A. Twins
B. Cervix not dilated
C. Cephalopelvic Disproportion
D. Above 32 weeks of gestation
59. Which of the following is the
criterion for induction of labor?

A. Twins
B. Cervix not dilated
C. Cephalopelvic Disproportion
D. Above 32 weeks of gestation
•Pillitteri p. 606; Ricci p. 596
60. What type of cesarean section
would have minimal blood loss?

A. Classic CS
B. Low segment CS
C. Peritoneal CS
D. None of the above
60. What type of cesarean section
would have minimal blood loss?

A. Classic CS
B. Low segment CS
C. Peritoneal CS
D. None of the above
•Pillitteri pp. 573 - 574