NURSING 120 EXAM 2 STUDY GUIDE

NURSING 120 EXAM 2 STUDY GUIDE Placenta previa • Placenta abnormally implants in the lower segment of the uterus • Painless, bright red bleeding in the 2nd and 3rd trimester • Delivery by cesarean only • No vaginal exams • Betamethasone given for fetal lung maturity Placenta abruptio • Separation of the placenta from the uterine wall (partial or complete detachment) • Significant maternal and fetal morbidity / mortality • Leading cause of maternal death • Increased risk with cocaine use • Uterine pain with or without dark-red (old) vaginal bleeding • Abdomen may be board-like, with intense pain • Keilhauer Betke test to detect fetal blood cells in maternal circulation Ectopic pregnancies • A pregnancy in which the fertilized egg implants outside the uterus • Unilateral pain in the lower abdominal quadrants • Can lead to massive hemorrhage, infertility and death • Caused from Inflammatory Disease (PID); result of scarring from gonorrhea, chlamydia, or NOTHING • Signs: painful abdomen, vaginal bleeding, and amenorrhea • It is a medical emergency for mother = a pregnancy loss Accelerations and decelerations in FHR • Variable decelerations o Caused by cord compression o Unpredictable U, V, W shape o Usually occur abruptly • Early decelerations o Caused by head compression o Begin with the contraction o FHR return to baseline after contraction o Resulting in vagal stimulation and slowing of HR • Accelerations o Always good • Late decelerations o Caused by placental insufficiency o After the peak of contraction o FHR does not return to baseline until well after the end of contraction o Imply some degree of fetal hypoxia Drugs in labor • Induce labor – hyperstimulation: don’t want the contractions to be too close • Oxytocin/ Pitocin o Stimulates contractions of the uterus and breast milk production o Uses: start labor, augment labor, tx postpartum hemorrhage • Misoprostol / Cytotec o Synthetic prostaglandin o Uses: initiate labor and tx postpartum hemorrhage • Prostaglandin E2 o Synthetic prostaglandin o Uses: induction of labor and ripening of the cervix Measuring contractions • Frequency – from the start of one contraction to the start of the next contraction • Duration – from the beginning of one contraction to the end of the same contraction • Intensity – manual palpation or internal intrauterine pressure catheter Tachysystole - hyperstimulation • May occur with or without FHR changes o 4 or more contractions in 10 minutes over 30 min period or o Contractions lasting more than 2 mins in duration or o Contractions of normal duration occurring 60 secs of each other • Nursing interventions 1. Turn off oxytocin infusion immediately (prevent fetal anoxia and uterine rupture) 2. Turn mother on to left side (to improve fetal placental blood flow) 3. Increase primary IV to 200 ml/hr unless contraindicated (to provide adequate intra-vascular volume, support maternal BP, and IV route for emergency medications) Fetal station • The measurement of fetal descent • Zero is at level with ischial spine • Plus is below the IS, minus is above the IS Engagement • occurs when the greatest transverse diameter of the head in vertex (biparietal diameter) passes through the pelvic inlet (usually 0 station) • Measure effacement o Cervical canal 2 cm in length would be described as 0% effaced o Cervical canal 1 cm in length would be described as 50% effaced o Cervical canal 0 cm in length would be described as 100% effaced • Measure dilation o External cervical os closed: 0 cm dilated o External cervical os half open: 5 cm dilated o External cervical os fully open: 10 cm dilated – cervix is no longer palpable in vag. Exam Meconium stained amniotic fluid • Risk of meconium aspiration – gestational age 38 wks Maternal assessment • Cardiovascular system adaption o C/O returns to pre-pregnant levels by 3 mos o Tachycardia warrants further investigation • Endocrine system adaption o Decreased estrogen associated with breast engorgement and diuresis of excess extracellular fluid o Decreased estrogen diminishes vaginal lubrication o Decreased progesterone results in increased muscle tone throughout the body o Decreased placental enzyme insulinase results in reversal of diabetogenic effects of pregnancy, which lowers glucose levels • Lochia o Lochia rubra – bright red, lasts 3-5 days o Lochia serosa – pinkish/brown, lasts 3-10 days o Lochia alba – creamy white or light brown, occurs from 10-14 days but can last 3-6 wks o Should not have a foul odor • Phases of maternal attainment o Dependent – taking in phase, first 24-48 hrs o Dependent/independent – taking hold phase, begins day 2-3 o Interdependent – letting go phase, resumption of role • Postpartum hemorrhage o Risk factors – uterine atony, complication during pregnancy (previa or abruption), precipitous delivery, lacerations and hematomas o Medications – Pitocin (oxytocin) – promotes uterine contractions, Methergine – controls postpartum hemorrhage, monitor BP (can cause HTN) o Misoprostol -controls postpartum hemorrhage • Postpartum period o Oxytocin, released from the posterior pituitary gland, coordinates and strengthen uterine contractions o Afterpains – uterine cramping after birth and during breastfeeding o After delivery of placenta, estrogen, progesterone, and placental enzyme insulinase decrease resulting in decrease resulting in decreased BG, estrogen, and progesterone levels • Placenta accreta o 3 grades ▪ Placenta accrete: the chorionic villi are in contact with the myometrium • Currently the most common indication of peripartum hysterectomy ▪ Placenta increta: the chorionic villi invade the myometrium ▪ Placenta precreta: the chorionic villi penetrate the uterine serosa Circumcision after care Immediately after – the tip of the penis is covered with petroleum jelly – coated gauze to keep the wound from sticking to the diaper • Assess for bleeding q 30 mins for at least 2 hrs • Document the first voiding to evaluate for urinary obstruction or edema • Keep area clean • Change diaper q 4 hrs • Heals completely in 2-3 wks • Check daily for any foul-smelling drainage, bleeding, or unusual swelling • If Plastibell used – it will fall off within a week First period of reactivity • Begins at birth and may last from 30 mins up to 2 hrs • The newborn is alert and moving and may appear hungry • It allows parents to interact and enjoy close contact with newborn • Sucking and rooting behaviors provides a good opportunity for initiating breast-feeding • Many newborns latch on the nipple and suck well at this first experience Neonatal abstinence syndrome (withdrawal) • Neonatal withdrawal after intrauterine exposure to certain drugs (illicit or rx) • Occurs with the abrupt cessation of the drug exposure • Once the cord is cut, newborns will experience withdrawals • Keep for newborn for up to a wk for observations • Assessment o CNS hypersensitivity, respiratory distress, temperature instability, hypoglycemia, seizures, abnormal cry patterns, feeding difficulties, GI disturbances o Score newborn withdrawal signs every 4 hrs o Morphine therapy for newborn if high scores (8 or above) of withdrawals o Monitor weight gain, fluid intake, feeding tolerance o Neurobehavioral assessment – reflexes, response to light, overall condition (crying/calm) • Breast feeding can help the baby withdrawal easier Heat loss Newborns have several characteristics that predispose them to heat loss • Thin skin with BVs close to the surface • Lack of shivering Limited stores of metabolic substrates (glucose, glycogen, fat) • Large body surface area relative to BW • Lack of SQ fat • Inability to communicate Conduction – heat loss through direct contact with a cold surface (scales, unwarmed mattress) Convection – heat loss from cooler air when exposed Evaporation – heat loss through wet skin Radiation – heat loss from heat moving towards a cooler surface (a cold window, wall, or incubator wall) Thermoregulation • Newborns utilities brown fat stores to keep themselves warm • Brown fat is highly dense and vascular adipose tissue that is unique to neonates • Only limited available Newborn transitioning and assessment • Cardiovascular system adaptions o At birth, the circulatory system must switch from fetal to newborn circulation and from placental to pulmonary gas exchange o HR 110-160 o BV depends on the amount of blood transferred from the placenta at birth o Delaying cord clamping – reduced risk of intraventricular hemorrhage (big risk in babies, babies’ brains are fragile) o Hemoglobin declines as result of decrease in neonatal RC mass (anemia) o Leukocytes is present as a result of birth trauma • Respiratory adaptions o Normal lung function depends on the presence of surfactant o Surfactant lung stability for gas exchange o Fetuses begin to produce surfactant between 24-28 wks ▪ By 35 wks, most babies have enough naturally produced surfactant to keep the alveoli from collapsing o Lung maturity assessment – L/S ratio 2:1 o RR 30-60 breaths per min – short periods of apnea 15 secs o Transient tachypnea 60 breaths per min – need intervention – can fail to breath • Jaundice pathophysiology o Normal newborn has high levels of Hgb levels at birth o Bilirubin is a byproduct of Hgb destruction o Immature liver cannot conjugate and excrete bilirubin in the intestines (lack of enzymes) o Reabsorption and inadequate feeing increase the bilirubin levels o Breastfed newborns may be at increased risk for early onset exaggerated physiologic jaundice d/t relative caloric deprivation in the first dew days of life o Supplemental water or dextrose water should be avoided o Hyperbilirubinemia – frequency of feeding needs to be increased to more than 10/day o Appearance of jaundice within 24hrs after brith o Phototherapy – helps eliminate bilirubin in the blood; light absorbs into the skin and blood, changes bilirubin to products that can be eliminated • Gastrointestinal system adaptions o Mucosal barrier protection o Bowel elimination – meconium (greenish black and tarry) o Admin vit K for prophylaxis for hemorrhagic disease • Renal system adaptions o Most void immediately after birth o Newborn body mass in 75% water o Void frequently and urine has low specific gravity • Immune system adaptions o Natural immunity – if we get sick and build up immunity o Acquired immunity – what is passed down from the mother • Integumentary system adaptions o Protect barrier between the body and the environment o Limits loss of water, prevents absorption of harmful agents, help thermoregulation and fat storage, protects against trauma Postpartum assessment • Posture o Flexed position with arms and legs in moderate flexion o Resistant to extension of extremities • Vernix caseosa o Protects the baby’s skin in womb o More is baby is preterm and less is baby is to term • Mongolian spots o Refers to a macular blue-gray pigmentation usually on the sacral area of healthy infants o Disappears within 4 years o DOCUMENT!!! To prevent abuse allegations • Port wine stain (nevus flammeus) o Caused by vascular anomaly o Persists throughout life o Grows in proportion to general growth • Caput succedaneum o Refers to swelling of an infant’s scalp, appears as a lump or bump on the head shortly after delivery o Harmless and is caused by pressure put on the infant’s head during delivery • Cephalohematoma o Collection of blood under the periosteum of a skull bone o Impossible to cross suture lines • Ortolani and Barlow maneuvers for hip dysplasia o Congenital his displacement Respiratory complications • Bradypnea – RR 25 per min • Tachypnea – RR 60 per min • Distress – nasal flaring, retractions, grunting, labored breathing • Bulb syringe – always kept by baby o Nose breathers for first 4 mos o Suction mouth before nose, to prevent aspiration in case baby gasps through nose after being suctioned Newborn complications • Cold stress – can lead to hypoxia, acidosis, hypoglycemia • Respiratory distress syndrome – usually develops within first 24 hrs of birth in premature infants born 6 or more wks early • Hypoglycemia – persistant hypoglycemia is an abnormal endocrine condition and possible neurological sequelae Bereavement and working with parents • Role of staff o Provide relationship-based and family cantered care o Offer empathetic support and anticipatory guidance o Provide info, offer choices, follow up • After a perinatal loss o Parents are sometimes in or care afterwards for up to 4-5 days o Offer sympathy and choices ▪ Choices: a name for the baby, a blessing or baptism, create mementos and keepsakes, genetic testing / studies or autopsy, disposition / funeral options o Giving parents an opportunity to participate in rituals and create mementos of their child is one way they can regain some control o Give parents as much time as they need to bond with their baby and allow parents to visit with their baby as often as they need, if in morgue we can place the baby in a warming blanket o Ask for the baby’s name and use it when talking about the baby Health literacy • Literacy – person’s ability to read, write, speak and compute and solve problems o Importance: to function in society, achieve goals, develop knowledge and potential • Health literacy – the degree to which individuals have the capacity to: obtain, process and understand basic health information and services needed to make appropriate health decisions • Affects people’s ability to navigate the healthcare system, share health hx with providers, and engage in self-care and chronic disease management • Health literacy leads to longer life, reduced chronic disease, decreases health disparities, and decreased healthcare cost • Outcomes – use of preventive services, knowledge about medical conditions and tx, decreases rates of hospitalization, increase health status of pt (decrease anxiety, prepares pt for d/c, decrease re- admissions), decrease healthcare costs, decreased stigma and shame • Improvement begins with assessment (know where the pt stands) • Is the information appropriate? Is the information easy? • Teach back – “ask me 3” have pt ask himelf these 3 questions: o What is my main problem? o What do I need to do? o Why is this important for me? • Easy to understand o Organize information so important points come first o Move complex information into small pieces o Use simple language o Use active voice Levels of preventative care • Primary prevention (PREVENTION) – health promotion and prevention of illness • Secondary prevention (SCREENING) – health maintenance and early detection • Tertiary (TREATMENT) – minimizing deterioration and improving quality of life Health promotion • Components o Self-responsibility – personal accountability for one’s actions or behavior o Nutritional awareness – understanding the importance of a healthy diet; as well as the relationship between diet and disease o Stress reduction and management – behaviors, techniques used to strengthen person’s resources against stress o Physical fitness – condition of being physically health from proper exercise • Promotion throughout lifespan o Starts before birth and extends through old age o Health screenings counseling o Immunizations o Preventive medications • Specific age groups o Adolescents – focus on creating healthy habits early to prevent negative results of risky behaviors o Young/middle-aged adults – focus on healthy behaviors, pregnancy and the family, cancer screening, chronic illness, activities offered at the workplace o Older adults – Very health conscious, benefit from activities that help them maintain their independence and achieve optimal health • The role of the nurse o Promote activates that foster well-being, self-actualization, personal fulfillment ▪ Every interaction is an opportunity to promote health attitudes and behaviors Ethics • The study or examination of morality through a variety of different approaches • How you respond to an ethical situation is a reflection of the core values, beliefs, and character that make you the person who you are and, ultimately, the professional who you will become • Bioethics – ethical question surrounding biological sciences and technology • Clinical ethics – decisions made at the bedside • Research ethics – conduct of research using humans and animals • Dilemmas – involves a problem for which in order to do something right, you have to do something wrong • Ethical dilemma – two or more clear moral principles apply but support mutually inconsistent courses of action • Ethical distress – occurs when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action • Autonomy – make own decisions • Non-maleficence – do no harm • Beneficence - doing good • Justice – process that distributes benefits, risks, and cost fairly • Fidelity – keeping promises and commitments • Veracity – truth telling, privacy, confidentiality • Paternalism – promoting another’s good but occurring without consent • Altruism – concern for welfare and well-being of others • Human dignity – respect for inherent worth and uniqueness of individuals and populations • Integrity – acting according to code of ethics and standards of practice • Social justice – upholding moral, legal, and humanistic rights • Ethics of duty – right thing to do – deontology: focus on the act not the consequence • Ethics of consequence – the greatest good for the greatest number – utilitarianism ANA code of ethics • The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems Perfusion Congenital Heart Defects The flow of blood through the arteries and capillaries delivering nutrients and oxygen to cells and removing cellular waste Depending on volume, vascular resistance and cardiac output Decreased Perfusion Decreased blood flow impacts oxygen delivery decreased oxygen in the cells decreased ATP in the cells increased anaerobic metabolism from ATP dysfunction acidosis in the cells = CELL DEATH Adaptions 1. Umbilical vein 2. Ductus venosus 3. Foramen ovale 4. Ductus arteriosus 5. Umbilical artery Circulatory changes from gestation to birth The FHR is present ~17 days after conception Week 2-8 during gestation – 4 chambers of the heart and arteries are formed During the fetal development, oxygenation of the fetus occurs in the placenta The foramen ovale allows the blood to flow from the right atrium to the left atrium The ductus arteriosus allows blood flow between the pulmonary artery and aorta Once lungs inflate after birth  Pulmonary vascular resistance  Pulmonary artery pressure  Right atrium pressure