MATERNAL A 327 Maternal and child EXAM 3 study guide (Already Graded A)

Exam 3 Study guide 1 CH 24 1) Adolescent pregnancy: Factors that contribute to teenage pregnancy are peer pressure to begin sex, high rates of sexual activity, limited access to contraceptives de vices, lack of accurate information about how to use contraceptives, lack of use of contraceptives, fear of reporting sex to parents, feeling of invincibility, low self esteem and lack of appropriate role models. Many pregnant adolescents become pregnant within 2 years again. Check blood type and give rhoGam if needed. o Sex education is important, socioeconomic implications. And also maternal health issues such as preeclampsia, anemia, cephalopelvic disportion, preterm labor (due to UTI, STD, preeclampsia) and having low birth weight and depression. High incidence of STD (gonorrhea and chlamydia) o Educate them on proper nutritional choices and of their prefereences. o Increased use of drugs (smoking and drinking). Other may become homeless. Adolescents are at increased risk for 2 complications prematurity and low birth weight, these factors also contribute to low placental perfusion. Another factor is “phantom fathers” who are absent and non involved in raising the child, fathers tend to come from poverty, lack job skills and education. 2) Delayed pregnancy: Occurs in woman who want to give birth after the age of 35. They are at risk for many complications such as genetic disorders (down syndrome), PID, hypertension,, diabetes, uterine myomas, spontaneous bleeding, preterm, placenta previa, and may become infertile due to aging of ovaries. Other complication obestric complications include spontaneous abortion, vaginal bleeding, preeclampia, fetal demise, dystocia, c-sections. Prenatal care for the older mother is essential for her to have a healthy baby. o Advantages are they are more prepared, better decided and become good parents cause of high level of empathy and flexibility, and are more able to solve complex problems and keep relationships, and staying finicially stable. Older mothers tend to seek out information they need. o Disadvantages are they have less energy (esp after C-section), family support may be lacking because her parents may already be in 60-70’s, also they already may be ill. o It is important for delayed mother to get tested early in the pregnancy to detect early issues, and have time to deal with the decisions. 2) Substance abuse: When mothers use substance abuse such as drinking, smoking, snorting, or injecting it the fetus experience the same effect as the mother but more severely and for a longer time. The fetus cannot metabolize drugs efficiently therefore it has a huge impact. Fetal diagnostic test like ultrasound, nonstress test, BPP help identify problem, also weight gain. o S/S: Behaviors like seeking late prenatal care, failing to keep up with appointments and following recommended regimens. Poor grooming, inadequate weight gain or weight pattern. Signs of needle sticks are also assessed. Defensive or hostile behaviors due to the low self esteem, and improper hygiene. o Consideration: The nurse treating this patient needs to show patience, empathy, tolerance, and don’t judge. Allow her to verbalize feeling , identify strengths and resources for the woman. It is also important to be nonjudgmental and don’t put your feelings into the situation. Establishing a trusting relationship and providing ongoing care. Allow her to express guilt and reassure her that abstinence is possible. Use communication skills like paraphrasing, summarizing. o If the nurse suspects substance abuse report it to charge nurse. o Urine collection may be done to mother and fetus. 4) Perinatal loss (interventions): Early pregnancy loss include spontaneous abortion, ectopic pregnancy. Never say comments like “you shouldn’t have any problems getting pregnant again” or you still have one fallopian tube left”, this does not acknowledge to the mother that a child has been lost. o It is important to acknowledge the infant, present the infant to the parents, answer any questions they have, prepare a memory packet, respecting cultural practices, assisting with other needs, provide referrals and follow up. Exam 3 Study guide 3 5) Intimate partner violence: violence that starts or escalates throughout the pregnancy. Physical abuse may lead to spontaneous abortion, abruption placentae, premature labor, LBW and fetal death. o Associated with alcohol, smoking and other drugs. o Also an increase risk of STD and HIV, bruises and injuries to face abdomen and breast. Vaginal bleeding, n&v, UTI, low weight gain. The nurse role is to empower the woman and set her own beliefs aside. The 3 stages of violence are: o Tension building: man shows increasing hostile behavior (throws objects, pushing, sweating and threatning), the woman tried to stay out of the way. o Battered incident: man explosed in violence, may hit, burn, beat and rape the woman leaving physical injury. Woman feel powerlessness and endures the abuse, usually 2-24hrs o Honeymoon phase: batterer will do anything to make up with his partner. Promises to never do it again. May insist on having intercourse to confirm he is forgiven. Woman wants to believe that the abuse will never happen again. CH. 25 6) Abortions: the loss of pregnancy before the fetus is viable or capable of living outside of uterus. Not viable if less than 20 weeks. o Spontaneous Abortion o Termination of pregnancy without action taken by the woman or another person o Threatened Abortion i. Clinical Manifestations: 1. First sign is vaginal bleeding, may be brief or lasts for weeks, may be accompanied by uterine cramping, persistent backache, or feelings of pelvic pressure 2. Therapeutic Management a. Women must be advised to notify their physician or nurse-midwife if brownish or red vaginal bleeding is noted b. U/S examination helps to verify if the embryo or fetus is present and alive and the approximate gestational age c. Determining if the woman’s human chorionic beta gonadotropin (beta-hCG) levels are normal for the estimated gestational age provides additional info. about whether the pregnancy is likely to continue d. Woman may be advised to limit sexual activity until bleeding has ceased e. Drainage with a foul odor suggests infection o Inevitable Abortion ▪ Clinical Manifestations • Abortion is usually inevitable (cannot be stopped) when membranes rupture and the cervix dilates ▪ Therapeutic Management • Natural expulsion of uterine contents is common • Vacuum curettage is used to clear the uterus if the natural process is ineffective or incomplete o Incomplete Abortion ▪ Clinical Manifestations • Occurs when some but not all of the products of conception are expelled from the uterus • Active uterine bleeding and severe abdominal cramping. The cervix is open, fetal and placental tissue is passed • Products of conception may have been expelled from the uterus but remain in the vagina b/c of their small size • May lead to infection because of what is left inside. ▪ Therapeutic Management • Initial treatment should focus on stabilizing the woman’s cardiovascular state. • Blood specimen is drawn for blood type and screen or cross-match, and IV line inserted for fluid replacement • Women in stable conditions, usually require a D&C to remove the remaining tissue. This procedure may be followed by IV administration of Oxytocin (Pitocin) or IM administration of methylergonovine (Methergine) to contract the uterus and control bleeding o Complete Abortion ▪ Clinical Manifestations • Occurs when all products of conception are expelled from the uterus • Symptoms of pregnancy are no longer present and the pregnancy test becomes negative as hormone levels fall ▪ Therapeutic Management • Once it is confirmed, no additional intervention is required unless excessive bleeding or infection develops • Woman should be advised to rest and watch for further bleeding, pain, or fever o Missed Abortion ▪ Clinical Manifestations • Occurs when the fetus dies during the first half of pregnancy but is retained in the uterus • When the fetus dies the early symptoms of pregnancy (nausea, breast tenderness, urinary frequency) disappears ▪ Therapeutic Management • U/S examination confirms fetal death by identifying a gestational sac or fetus that is too small for the presumed gestational age. No fetal heart activity can be found. And pregnancy tests for hCG should show a decline in placental hormone production Exam 3 Study guide 5 • In most cases the women would expel the content of the uterus spontaneously. Therefore her uterus usually is emptied by the most appropriate method for the size when the diagnosis of missed abortion is made • Two complications: Infection and DIC. o Recurrent abortion: When 3 or more spontaneous abortions occur. 7) Ectopic pregnancy: Implementation of of a fertilized ovum in an area outside the uterine cavity, usually the fallopian tubes. It remained a significant cause of maternal death from hemorrhage and it reduces the womans chances of subsequent pregnancies because of damage or destruction of a fallopian tube. o Risk factors include history of STD, failed tubal ligation, intrauterine device, multiple abortions, older than 35, and assisted reproductive technology such as gamete infrafallopian transfer. o Manifestations: missed period, + pregnancy test, abdominal pain, vaginal spotting. Hypovolemic shock may occur (increase HR, RR and low UO) and lead to nerve damage radiating pain to shoulder. Chadwick may be seen on examination. o Diagnosis is done with transvaginal U/S, low beta hcG, gestational sac cannot be visualized, bluish swelling within the tube is most common. o Management: depends whether the tube is intact or ruptured. The goal is to preserve the tube and improve the chance of future fertility. If the tube is not ruptured methotrexate is used to inhibit cell division in the developing embry. Also a salpingostomy to salvage the tube. If it is ruptured then the goal is to control the bleeding and prevent shock. When the cardio status is stable, the salpingectomy is removed. Rhogam is given to RH-. • Methotrexate may be given to stop cell divion and save tube from rupturing. o Nursing considerations: monitoring the pelvic, shoulder or neck pain, dizziness or faintess, increased vaginal bleeding. Administer analgesic for pain. Abdominal pain may occur from methotrexate because expulsion of the products of conception. Avoid alcohol, vitamins that contain folic acid, having vaginal intercourse and having sex until hcG is non detectable. Monitor v/s (high HR, low bp may be hemorrhage). Have an 18ga IV to administer fluid in emergency. 8) Hydatidiform mole: A form of gestational trophoblastic disease that occurs when the trophoblasts develop abnormally. Proliferation and edema of the chorionic villi cluster and tissue rapidly grows large enough to fill the uterus to the size of an advanced pregnancy. The mole may be complete with no fetus or partial in which fetal tissue or membrane are present. It’s a baby with no DNA. Occurs in first trimester and in woman over 40. o Clinical manifestation are high levels or beta hcG than expected for gestation. U/S shows the vesicles and the absence of fetal sac or heart activity, uterus larger than expected, vaginal bleeding, hemorrhage, excessive n&v and early development of preeclampsia. o Diagnosed: by the abnormal high hcG. o Treatment: is evacuation of the trophoblastic tissue of the mole and continuous follow up of the woman to detect malignant changes of any remaining trophoblastic tissue. Before evacuation chest radiograph of MRI may be performed to detect metastatic disease. CBC lab assessment of coagulation status and blood type in case of transfusion. The mole is usually removed by vacuum aspiration followed by curettage. After, IV oxytocin is given to contract the uterus, avoid oxytocin before evacuation b/c uterine contractions can cause trophoblastic tissue to be pulled into large neous sinusoids, resulting in embolization of the tissue and respiratory distress. o Consideration: Pregnancy must be avoided during the first year of follow ups because the normal rise in beta hCG would obscure evidence of choriocarcinoma. Oral contraceptives are the preferred birth control. Important to rule out cancer during this time. Administer rhoGam 9) Hyperemesis gravidum: Excessive, uncontrollable vomiting that begins in the first week of pregnancy. Common in unmarried white woman, first pregnancies, multi fetal. May be due to elevated hormone (progesterone and estrogen). This places the fetus at risk for abnormal development or death from lack of nutrition, hypoxia and ketoacidosis o Assessment: H/H may be elevated from dehydration, elevated BUN/creatinine , dry mucous membrane and may lead metabolic alkalosis. o Treatment: The mom may take Phenergan, Benadryl, zantac, Zofran. Also LR and IV fluids with glucose, electrolytes and vitamin. o Intervention: administer antiemetic , monitor daily weight, encourage feedings, TPN if they cannot tolerate feeding. Monitor urine for ketones, 10) Hypertensive disorders Exam 3 Study guide 7 a. Gestational Hypertension (PIH): BP >140/90 that develops after 20 weeks of pregnancy but returns to normal within 6 weeks post partum. Proteinuria is not present. b. Preeclampsia: BP>140/90 that develops after 20 weeks of pregnancy and is accompanied by proteinuria > or = to 0.3g in 24 hr. urine collection. The goal is to deliver baby. May cause premature birth o Risk factors: African American, chronic HTN, renal disease, overweight, diabetes, twins, 1st pregnancy. o Management: Monitor bp, monitor FHR, rest, daily weight, U/A, diet. o Educate: report any continuous headaches, drowsiness, tingling, epigastric pain and decreased urine output. High protein diet, and do not restrict salt. EDUCATE THE PATIENT TO KEEP HAT IN THE TOILET (for urine analysis) and container has to be on ice. Also woman can get it from ex. o Treatment: Mg sulfate is used (muscle relaxer). If bp is over 160/110 then hydralazine is used. Other antihypertensives include nifedipine, labetalol. The normal levels for Mg is 4-8mg/dL. If higher STOP it. Assess for signs of toxicity. o Considerations: Assess RR, DTR, BP, educate the mom to report any visual disturbances, dizziness, blurred vision (retinal damage), other signs like epigastric pain can be liver distention. These are signs of imminent seizures. c. Eclampsia: Progression of preeclampsia to generalized seizures that cannot be attributed to other causes. Monitor for it 48 hrs after delivery d. Chronic Hypertension: BP >140/90 that was known to exist before pregnancy or develops before 20 weeks of gestation. Also diagnosed if the hypertension does not resolve during postpartum period e. Preeclampsia superimposed on chronic hypertension: Development of new onset proteinuria >0.3g in 24 hr urine collection in a woman who has chronic HTN. In women who had proteinuria before 20 weeks, preeclampsia should be suspected if woman has a sudden increase in proteinuria from her baseline levels, sudden increase in BP when it had been previously well controlled, development of thrombocytopenia (platelets <100,000) or abnormal elevations in liver enzymes (ALT or AST) 11) Signs of Mg toxicity: Normal levels are 4-8mg/dL. Signs of toxicity include absence of DTR, RR <12, O2 sat under 95% , Oliguria (under 30mL/hr), muscle weakness, sweating, hypotension. o After delivery assess for signs of preeclampsia for 48hrs. o Continue to administer Mg for 24hr (a boggy uterus is expected), and prolonged involution. • Keep calcium gluconate at bedsise. 12) HELLP syndrome (hemolysis, elevated liver enzymes, low platelets: May occur from preeclampsia and is life threatning condition. Can also occur in the postpartum period. o S/S: hyperbilirubinemia from the hemolysis and liver impairment, low platelets increasing the chances of bleeds (eyes, nose, IVs). Pain in RUQ , epigastric pain, N&V and severe edema. Liver rupture may occur and can lead to death in baby/mom. o Tx: may be given Mg sulfate and hydralazine to control BP. If the mother is at 34 weeks then induction of labor will be done. If younger than 34w then they will try to stabilize mom and give steroids (betamethasone) for lung maturity. If mom is far from term then C-section may be done. o Considerations: avoid palpating the abdomen because of liver distention and intraabdominal pressure that may radiate to shoulders. o The goal is to deliver the baby. 13) RH incompatibility : If mother is RH- and baby comes out RH+, then then mother will need to get rhoGam at 28 weeks, and then again 72hrs after birth. To prevent erythroblastosis fetalis in the baby and future pregnancies. 14) Diabetes: Gestational diabetes occurs when the pancreas is unable to meet the increased demand for insulin production during pregnancy. o Risk factors: overweight, obese, previous GDM, abnormal glucose tolerance, African/native Americans. o Effects of diabetes: maternal hydramnios  big uterus PPH (trouble with involution), preeclampsia, preterm labor (UTI’s), ketoacidosis, retinopathy, dystocia, stillbirth, macrosomia leading to shoulder dystocia, hypoglycemic baby, RDS and heart disease o Complications: Preterm delivery (delayed lung maturity), increased mortality and morbidity rate, Abortion, PROM, macrosomia leading to C-section or PPH, shoulder dystocia and laceration in the mothers cervix. Also hypocalcemia, hyperbilirubinemia, and RDS. o Diagnostic test: ▪ Glucose challenge test done at 24-24 weeks. No fasting needed. (woman drinks 50g of glucose), and if found to be over 140 then further testing is done OGTT. ▪ Oral glucose tolerance test: Woman is asked to fast, and drinks 100g of glucose and her levels are assessed every hour for 3 Fasting glucose- >95 1st hr- >180 2nd hr- >155 3rd hr - >140 o Insulin requirement: First trimester: insulin needs are low Exam 3 Study guide 9 Second trimester: increases Third: High After placent delivery: insulin requirements drop • The fetus produces his out insulin but gets glucose from the mother across the placenta. o S/S: Polyuria, polydipsia, polyphagia, UTI, yeast, glycosuria, ketones, abnormal glucose screening (24-28 weeks) o Consideration: if baby is hypoglycemic then encourage breast feeding/formula. For the mother encourage exercise. o Euglycemia: stable blood glucose • Hypoglycemia and withdraw syndrome symptoms are similar so look at the labs to differentiate. Hyperglycemia S/S • Recurrent infections are most common cause (UTI)  educate mother to report any infections. • Fatigue • Flushed, hot skin • Dry mouth; excessive thirst • Frequent urination • Rapid, deep respiration, odor or acetone breath • Drowsinss, headache • Depressed reflexes 15) Cardiac Disease: Inadequate adaptations of the heart during pregnancy may compromise the heart, such as the 30-50% increase of volume and cardiac output. Clients with class I and II have a good pregnancy outcome. • S/S: edema, dyspnea (increase fatigue, moist cough, basilar rales, cyanosis of nail beds), tachycardia with irregular pulse, murmurs and chest pain. • Interventions: monitor v/s, teach adequate nutrition (vitamins, minerals), avoid weight gain, emotional stress. Give prophylactic antiobiotics (if they had any invasive procedures it can lead to endocarditis, usually penicillin is used). Give digoxin, Lasix, heparin (safe during pregnancy)  warfarin is not. • Classification of cardiac disease I - Uncompromised II – Slightly compromised III – Markedly compromised IV – Severely compromised. • Anemia: a woman is considered anemic if her hmgb is under 10.5 or 11. o Iron defficieny, megaloblastic and thaleseemia. • IVH- Will cause frontal-occital head circumference to increase • Tetrallogy of fallot: causes R ventriculat hypertrophy • Meconium aspiration syndrome will cause pulm hypertension. • Cyanotic anomaly: will cause right to left defect (O2 will not help) • Right sided mix of blood will cause pulmonary congestion. 16) Infections during pregnancy: Mostly related to STD • Gonorrhea: occurs in 2-7% of moms. Does not cross the placenta but neonate may be exposed at birth, causing sepsis or blindness (this is why get erythromycin 4hrs after birth). Can also lead to infertility, PID and may spread to joints and blood. Treatment is penicillin, cipro, rocephin • Chlamydia: Causes a burning, dysuria. May go underdiagnosed in woman due to having internal organs. Seen mostly in teens. In the fetus it can lead to conjuctivits, pneumonia and bronchitis. But that is also why erythromycin Is given. Tx is Zithromax, levaquin, doxycycline for mother. • Herpes simplex: will need C-seciton if positive. Type 1 (up), type 2 (down in genitals). May be painful. Fetal may develop fever or hypothermia, jaundice, seizures. C-section will be needed if virus is present in mom. If it is not present then its OK to do vaginal delivery. • HIV: Constent needed for testing. Found in vaginal secretions. HIV particles die on surfaces in seconds. Transmissions include IV, blood and body secretions. Prophylactic antibiotics are given during pregnancy and labor. Important to protect fetus from mothers secretion Exam 3 Study guide 11 in birth. Wash infants eyes and all mothers secretions. Use standard precaution and avoid fetal scalp electrode. Mom treated with retrovir. o Educate the patient is important – do not breast feed. It may take up to 15 months for the infant to develop antibodies against virus and finally be diagnosed with HIV (testing done at 1, 6, 12, 18 months). o S/S in fetus: UTI, hepatomegaly , recurrent URI, yeast, diarrhea and weight loss in baby. o Administer zidovudine (ZDV) as ordered. • Trichomonas: strawberry like cervix. Grows in alkalizing enviorment  educate NOT to douche, avoid hot tubs and bubble baths while prego. o S/S: strawberry like, frothy, purulent, yellow/green, vaginal itchy o Tx: Flagyl • CMV: Respiratory or sexual transmission; neonate can contract during delivery through an infected birth canal. • Rubella: Uses droplet and isolation precautions. Mother should receive it after labor, but don’t try to conceive 28 days after. Can lead to microcephaly, congenital heart disease, intrauterine growth restrictions, fetal undergrowth and hearing loss. Infants born with rubella should be isolated. The virus can cross the placenta barrier and infect fetus. Woman who are immune to it do not become infected. • Toxoplasmosis: Protozoa that crosses the placenta. Contracted by raw or undercooked meat □ educate the mother to cook meat well. Can lead to spontaneous abortion, jaundice (liver and spleen damage), can lead to blindess. Diagnosis is done with igM. Associated with cat litter during pregnancy. • Syphillis: + RPR/VDRL test. May go unknown for weeks. Organism crosses the placenta around 16 week and infects fetus (affects liver, spleen, kidnets and bone marrow). Treated with penicillin early. • Thrush (candida): if they tell you they have white patches or the baby, tell them to come in to office and to not scrub. Treated with nystatin (mycostatin) • HPV: looks like cauliflower and is associated with cervical cancer. • Vaginalis bacterial vaginosis: Fishy odor, itchy burning. • PID: associated with gonorrhea/chlamydia. Womn under 25yo are at risk due to sexual activity. May cause intense pain and hemorrhaging. • UTI: prevelant in diabetics , and may cause premature labor. U/A is done. Group B Streptococcus (GBS) is a leading cause of life-threatening perinatal infections in the United States. The gram-positive bacterium colonizes the rectum, vagina, cervix, and urethra of pregnant as well as nonpregnant women. Approximately 15% to 40% of pregnant women are colonized by GBS in the vaginal or rectal area, but isolating the organism is often possible only intermittently. Often, these women are asymptomatic, although symptomatic maternal infections can occur. These infections include urinary tract infection, chorioamnionitis, and metritis. Most women respond quickly to antimicrobial therapy • Naturally occurring in normal flora. Can lead to chorioamniotits, PROM, UTI. Mother is tested for at week 34 and if positive treated with ampicillin. If the mom is treated she may have vaginal delivery. Health care providers have difficulty identifying pregnant women who are asymptomatic GBS carriers because the duration of carrier status is unpredictable. Revised guidelines to prevent perinatal GBS disease were released by CDC in 2010. Optimal identification of the GBS carrier status is obtained by vaginal and rectal culture between 35 and 37 weeks of gestation. Women who have had a previous infant with GBS or a GBS in their urine in any trimester will be considered GBS-positive at delivery. A woman who delivers at or before 37 weeks, has ruptured membranes for 18 hours or more, or has a temperature of 100.4°F (≥38°C) or higher is also considered positive for GBS and should receive antibiotic therapy. Cesarean birth before membrane rupture does not require GBS antibiotic therapy. Treated with penicillin or ampicillin. 17) Dysfunctional labor: o Infective contractions: May be due to maternal fatigue, fluid & electrolyte imbalance, hypoglycemia, excessive analgesia, , disproportion. • Hypotonic contractions: weak, less frequent contractions. Amniotomy may be done, Pitocin or c-section. Nursing care include encouraging position change, ambulation, emotional support. Associated with PROM and infection. • Hypertonic: irregular, short and poor with intensity, painful and cramplike. Light sedation may be done, hydration, or tocolyitcs may be given. Nursing care Exam 3 Study guide 13 includes promoting comfort, improving blood flow, promoting rest and relaxation and emotional support. The fetus is risk for hypoxia. The mother is at risk for pain and fatigue o Shoulder dystocia: Inability to deliver shoulders. may occur from a large baby (macrosomia- baby weighs more than 8lb .13oz), also diabetic mothers or small mothers. Is noticed when there is a “turtle sign”. Goal is to relieved umbilical pressure to provide oxygenation. The mother is at risk for lacerations and PPH. Baby is at risk for hypoxia, fracture clavicle and head and neck injury. It is important to document everything done and occurring. Nursing actions include • Mcroberts maneuver and Suprapubic pressure. o Precipitate labor is one in which occurs within 3 hours of its onset. (sudden labor). • Risk: Mother is at risk for lacerations in vagina, rectal or cervix, PPH. Fetus at risk for hypoxia, pneumothorax, intracranial hemorrhage. • Intervention: don sterile gloves, put sterile towel under mother. Don’t leave the client alone. Assess FHR, check umbilical cord around baby neck. Encourage pant/blow to decrease urge to push. 18) Premature rupture of membrane (PROM): Rupture of the amniotic sac before the onset of true labor. Usually begins spontaneuously withing 24 hrs of membrane rupture, and before week 37. The mother will be hospitalized until birth with prescribed antibiotics ▪ Risk factors: infection, sepsis, incompetent cervix and trauma. ▪ Assessment: gush of clear, or meconium stained fluid. The nitrazine strip will turn blue (indicating alkalotic). An engaged fetus is at risk for prolapse chord. ▪ Intervention: assess FHR (rule of prolapse chord), assess temperature q2hr to rule out infection. Avoid vaginal exams  infection (chorioamnionitis). Obtain cultures for GBS and administer antibiotics. ▪ Evaluation: ensure no prolapse chord or infection. • If before week 34 we may give tocolytics for irregular contractions and to hold baby in untill week 34, and give bethametasone for lung maturity. 19) Premature labor: occurs between 20-37 weeks. Occurs mostly in black mothers (adolescent and delayed) • Risk factors: UTI, reproductive organ disorders, dental disorders, GDM, connective tissue disorver, hypertension/preeclampsia, drug abuser, inadequate amniotic fluid or chromosomal abnormalities. Use of reproductive technology. Occurs in adolescent mothers and delayed mothers. • Education: tell mother that signs are low abdominal cramps with/without diarrhea, leaking amniotic fluid, vaginal discharge, contractions every 10mins or less with/without pain, vaginal spotting. ▪ Immediate actions: empty bladder, lay on side, drink 3-4 cups of water, rest , if it does not relief for an hour call MD. ▪ Medical actions: Monitor FHR, bedrest. Administer tocolytics to stop contractions (terbutaline, Mg sulfate, Procardia, Aldomet, yutopar) ▪ Give Mg sulfate: monitor for toxicity (DTR, RR, BP, FHR) low variability in fetal strip. Administer betamethasone for fetal lung maturity if before 37. ▪ We want to try and deliver baby by atleast 34th week (And administer betamethasone) 20) Prolonged labor: Pregnancy that goes passed 42th week. Main • Complication is placental insufficiency secondary to aging and infarction reduces transfer of oxygen and nutrients to the fetus and removal of waste, oligohyramnios, meconium in the amniotic fluid can cause RDS. The fetus may grow large and present dysfunctional labor issues (PPH) • Management: Evaluate the fetus and the mothers cervix conditions and try to deliver if favorable. • Considerations: Educate about induction, support her psychological/physical fatigue. 21) Intrapartum emergencies: • Placenta previa: When the placenta impants itself in the lower uterus, closer to the internal cervical os, prevent baby from coming out. o Marginal: more than 3cm from the internal os o Partial: Within 3cm of the internal os o Total: completely covers internal os  C-section o Risk factors: Older woman, multigestation, smokers/cocaine, African American/Asian. o S/S: PAINLESS uterine bleeding, no contractions o Intervention: NEVER perform vaginal exam (can cause more bleeding or infection). Maintain bedrest, monitor V/S to rule out infection/hemorrhage (1gram=1mL) of blood lost. Maintain 18ga needle incase of fluid replacement , provide emotional support. Provide proper nutrition to prevent anemia. • Placenta abruption: Separation of the placenta from the uterine wall before fetus is born. o Risk factors: cocaine users, maternal HTN, smokers, multigravida, abdominal trauma, PROM, short cord. o S/S: PAINFUL, hard board-like abdomen, vaginal bleeding, tachy, hypo, late decelerations in baby. o Intervention: if blood between mother and baby mix it can be crucial (administer rhoGam). Monitor BP, HR, RR, FHR. Have 18ga needle for fluids in, measure abdomen girth because It increases, monitor coagulation studies(DIC), and assess for bleeding in other sites. • DIC can occur  look out for bleeding and coagulation labs. • Disseminated intravascular coagulation (DIC): is a life threat defect in coagulation that may occur with several complications of pregnancy such as abruption placentae or hypertension. It is a malfunction of coagulation is the microcirculation. Exam 3 Study guide 15 o Assessment: The other result of DIC is tiny clots that form in the tiny blood vessels blocking blood flow to the organs and causing ischemia. Excessive bleeding from IV sites, incisions, gums, nose or other sites may occur. Goal is delivery the baby because delivery of the fetus and the placenta ends the production of thromboplastin. o Treatment: Blood replacement such as whole blood, RBC and cryoprecipitate are administered as needed to maintain circulating blood and to transport O2 to body cells. If coagulation studies are still abnormal an epidural block may be contraindicated because or possible bleeding into spinal canal. The goal is to deliver the baby and control bleeding. • Labs to diagnose: Levels of fibrinogen and platelets are decreased PT/PTT prolonged Fibrin degradation are increased. • Contraindicated with epidural • HELLP syndrome (hemolysis, elevated liver enzymes, low platelets: May occur from preeclampsia and is life threatning condition. Can also occur in the postpartum period. o S/S: hyperbilirubinemia from the hemolysis and liver impairment, low platelets increasing the chances of bleeds (eyes, nose, IVs). Pain in RUQ/epigastric pain (from liver distention), N&V and severe edema. Liver rupture may occur and can lead to death in baby/mom (elevated liver enzymes) o Tx: may be given Mg sulfate and hydralazine to control BP. If the mother is at 34 weeks then induction of labor will be done. If younger than 34w then they will try to stabilize mom and give steroids (betamethasone) for lung maturity. If mom is far from term then C-section may be done. o Considerations: avoid palpating the abdomen because of liver distention and intraabdominal pressure that may radiate to shoulders. o The goal is to deliver the baby. 22) Postpartum Hemorrhage (PPH): May occur from boggy uterus, uterine atony which (lack of muscle tone in uterus). The uterus should be at umbilicus 24hrs after delivery. With a dark red lochia that is scant to moderate. Saturation of 1 pad in 15min is excessive blood loss. Assessment of PPH includes tachy, hypo, excessive lochia, boggy uterus, low UO, pale/clammy • Early postpartum hemorrhage occurs within 24hrs. Caused by uterine atony and laceration. Absence of uterine contraction will cause blood loss. o Atony o Signs of uterine atony: fundus difficult to locate, soft/boggy, firm when massaged by loses tone after, fundus above expected level, excessive lochia that is bright red, excessive clots o Risk factors: large infant, twins, hydramnios, medications like Mg sulfate, anesthesia, and tocolytics. As well as low platelet count. o Lacerations o Occur with perineal, vaginal and cervical tears. o Risk factors include epidural, episiotomy, forceps, vacuum, macrosomia. o Hematoma (vulvar) o Collection of blood in vulvar or vagina caused by injury to blood vessels in the connective tissue under the overlying tissue. o Risk factors: spontaneous delivery, vacuum, forceps, prolong pressure on vag o S/S: signs of shock (tachy + hypo), severe pain that is unrelieved with pain medication. • If fundus and lochia are normal but the patient shows s/s of shock and pain  vulvar hematoma • Late PPH: Occurs after 24hrs of delivery. Lochia also failed to go from Rubra, serosa, alba. Causes of late PPH: o Subinvolution: delayed return of the uterus to its nonpregnant size. o Retained pieces of the placenta o Infection o Assessment: bleeding, large and numerous clots, bladder distention, turn the patient to assess sheets under her, weigh peripads, assess lochia, fundus, look for signs of shock. o Intervention: Massage the fundus, administer uterine stimulants (methergine, pit, hemabate). Monitor V/S, weigh peripads. Educate the woman to report any abnormals. • Medications to treat PPH: o Methergine: stimulates contractions of the uterus, contraindicated with mothers who have high BP. o Hemabate: Given IM when the mother cannot receive methergine due to high bp. However, hemabate is contraindicated with asthma o Pitocin: Given through rapid IV infusion, helps contract and stop bleeding. o Cytotec: given rectally/vaginal to control bleeding 23) Subinvolution: delayed return of the uterus to non pregnant state. It should be at umbilicus 24hr after delivery and a lower a fingerbreadth per day. By 14, it should be non Exam 3 Study guide 17 palpable. The most common causes are retained placenta fragments and pelvic infection. Also encourage voiding, a full bladder can cause it also. S/S of subinvolution include prolonged discharge from lochia, irregular and excessive bleeding, pelvic pain, and signs of shock. Educate the mother how to palpate fundus and to report any deviations from pattern or lochia, foul odor, fundal pain, backache or pelvic fullness. Other preventions • Prevent DVT/PE: Due to inactivity, bedrest, obesity, C-section, smokers, DM, dehydration, varicose veins. o DVT o S/S: leg swelling, warm, redness, tenderness, pain when walking, positive human sign. o Prevention: promote venous return, hydration, ambulation, coagg labs, and anticoagulant therapy. o PE o S/S: tachycardia, tachypnea, dyspnea, chest pain and hyptension. o Prevention: same as DVT, administer O2 is occurs. 24) Specific infections: Puerperal infections. Assess temperature after delivery and infection may be present if over 38C or 100.4F. • Reproductive tract infections: (GBS, E.coli, chlamydia, staph) may cause delayed involution. S/S are foul odor, tachy, elevated temp, rubra lochia remains, fundal height does no descend, pain . Assess Temp (over 100.4), labs (high WBC) , promote adequate nutrition, • Wound infection: Causes may be episiotomy, obesity, DM, immunosuppression and steroid. Assess by perform REEDA assessment. Administer antibiotics, recommend sitz bath. Promote good nutrition. • Breast (mastitis): Caused by staph/step, E.coli. Risk factors are fissured cracked nipples, may occur from engorgement, bad hygiene, tight cloth, or poor support of pendulous breast. o S/S: include warm, reddened, pain, flulike symptoms, headache, chills, hard tender breast. o A culture must be obtained, antibiotics prescribed. Supportive bra helps. Educate her on latching on. Start feeding unaffected breast first to stimulate milk-ejection reflex on the affected. o Consideration: provide warmth before feeding to unplug breast, empty breast completely after feedings to prevent stasis or feed every 2 hours. Massage the affected side, encourage fluids. • UTI: (cystitis, pylenonephritis) Assess frequency, pain, hematuria, temp, and get culture 25) Late preterm infants: Infants born between 34-36th week. They are not fully matured and may present complications. Are at risk of RDS, hypoglycemia, hyperbilirubinemia, kernictus, seizures, feeding difficulties, sepsis and thermoregulation. o Considerations: they tend to be stable since they are late preterm, but require more frequent monitoring. • Thermoregulation: assess q1-4hrs until stable. They are risk for developing cold stress that is not noticed until signs appear. Kangaroo care, radiant warmer, incubator may help. • Feedings: they have a weaker suck, difficult latching on, sleep through feedings and have weaker tone . The nurse must assess feeding to ensure the baby is feeding correctly. Urine and stool are monitored as indications of adequate nutrition, as well as daily weight. If not then TPN may be needed. Everything needs to be documents. And monitor blood glucose because preemies are at risk for hypoglycemia. • Discharge: infants should have fed successfully for 24hrs before discharge. Parents need to understand teaching off keeping baby warm, and identify common complications such as jaundice, dehydration, and hyperbilirubin. 26) Preterm infants: Born between 32-36th week. (late preterm fall under this category) • Assessment: appear frail and weak (hypotonic), their head is large in comparison to the rest of the body. May lack subcutaneous fat or white fat. Vernix and lanugo may be present. No ear recoil, undescended testicles in males. They become easily exhausted from noise and routine activities. Grunting may be heard RDS o Respiration: a concern because the amount of surfactant in the lungs is inadequate, which can lead to collapsed lung. Also they have no developed a cough reflux so the airway is narrow and also cause aspiration. Apnea for more than 20sec is abnormal. Observe for retraction breathing due to weak chest wall. Position changes help drain air passages and prevent stasis of secretions (prone and side lying are not recommended). Also suction the secretions because they may not be able to cough. Suction only for 5-10 seconds, starting Exam 3 Study guide 19 with the mouth to nose. Improper suctioning can cause trauma to the babys mucous membrane and lead to more respiratory issues. o Hydration: adequate hydration is important to keep secretions thin so they can be removed by drain or suction. If the baby is dehydrated secritions become thick and viscous  can lead to obstruction. o Thermoregulation: infants maintain heat by flexion of limbs and cannot shiver (so they use brownfat) , but since they are premature they don’t have enough and lose ability to produce heat. The hypothalamus is also immature to produce heat, all these factors contribute to heat loss. o S/S: irritability, weak cry or suck, decrease muscle tone, pale, hypoglycemia, resp difficulty and poor weight gain. o Complications: RDS, hypoglycemia, metabolic acidosis. o Nursing intervention: maintaining a neural and thermal enviorment, preventing conduction (prevent cold surfaces), convection (away from ac), evaporation (dry him well) and radiation (away from windows). You may also place the infant in a warmer. Wrap the baby in a blacket, also a sterile polyethylene bag to prevent evaporation from the baby skin. When the baby is in the incubator the nurse should ensure doors are closed to prevent cold from coming in. encourage kangaroo care. Look out for over heating the baby as well. o Fluid & electrolyte: fluids are lost easily because lack of keratin that has developed (kertin maintains water in the skin, develops 32-33 week). Other water loss Is through respiratory and GI tract. Assess UO (1mL/kg/hr), weight, hydration status (sunken fontanels), skin turgor, and electrolyte levels. Fluids may be given IV to maintain hydration 0.1mL/hr o Skin problems: the infant skin is very thin and fragile, avoid invasive procedure, adhesives, alcohol, tape, disinfectants, cleaners , soap. Adjust the humidity in the incubator to reduce drying affects of heat. And change position frequent o Infections: preterm infants are at 3-10x more risk of infection than full-term, this may be due to the longer hospital stay. Also he did not receive enough immunoglobbins while in uteral (IgG), other factors include IV sites, PICC or central lines. Nuring intervention include handwashing, assess all dressing changes using sterile technique, and assessing v/s and temperature. o Pain: Infants in the NICU undergo many painful procedures such as intubation, heel stick, chest tube, venipuncture, suctioning. S/S include high pitched cry, cry face, eyes squeezed shut, grimacing, increase HR, RR, BP, decreased O2, tense muscle. Intervention include waking the the infant for procedures slowly, handling them with care (positioning then right, asking another nurse to help), maybe give them a pacifier, talking, holding, stroking them lightly and promoting comfort measures for the baby. Last resort is using medications such as acetaminophen, or opioids like morphine and fentanyl. 27) Environmental caused stress: Noise, sounds, movement, arousal can all effect the infant. Educate visitors to keep their noise down. Sleep interruptions also effect neuronal maturation. Overstimulation can alter oxygenation and behavior. o Interventions to reduce stress include scheduling care, reducing stimuli, promoting rest, promoting motor development, individualizing care and meeting infant needs. o Oxygenation changes: blood pressure, pulse, respiratory instability, cyanosis, pallor or mottling. Flaring nares, decreased oxygenation , sneezing, coughing and hiccups. o Behavioral changes: Stiff, extended arms and legs, fisting of the hands or splaying of the fingers, arching, alert, turning away from eye contact, gagging, yawning and fatigue. 28) Nutrition: Adequate nutrition is important in a preterm infant, because they lack calcium, iron and nutrients that full-term have in reserve. Low blood glucose develops easily. The average preterm infant should gain 15-20g/kg/day. Preterm GI does not absorb nutrients the same way full term do because they lack bile and pancreatic lipase to absorb fats. They overall need more nutrients per kg. assess how well they are tolerating the feedings by checking for abdominal distention, emesis, stools, IO and daily weigt. Gavage may also be done decompress stomach, or to feed. o Readiness for nipple: rooting, sucking on gavage tube or finger, RR over 60/min, gag reflex. Also the use of “preemie” nipple helsp o Signs of nonreadiness for nipple: RR under 60, no rooting, no gag reflec, excessive gastric residual. o Adverse signs of nipple feeding: Tachy, brady, increase RR, nasal flaring, markedly, decreased O2 sat, apnea, coughing, gagging, falling asleep during feeding, feeding time longer than 20-30min 29) Kangaroo care benefits: Infant must be stable, wearing diaper and hat only. It is encouraged as soon as possible. Parents should carry the baby upright for an hour if possible. It provides an opportunity for the parents to participate in the infants care and increase attachment. Its associated with increasing growth and decreasing hospital stay. Infants show improved O2, sleep patterns, less crying, less pain. As a nurse encourage it and provide comfort and privacy for the mother. Exam 3 Study guide 21 30) Common complications of preterm infant: o RDS: Is caused by insufficient production of surfactant, which helps the lungs expand. It mainly occurs with infants born under 28 weeks. o S/s: tachypnea, tachycardia, nasal flaring, xiphoid and intercoastal retractions grunting and cyanosis. May lead to resp acidosis. o Management: surfactant is instilled in the infants trachea during stabilization immediately after birth or when RDS is apparent. Other treatments are CPAP o BPD (bronchopulmonary dysplasia): results from high levels of oxygen , oxygen free radicals and high positive pressure ventilation that injures brochial epithelium and interfere with alveoli development. S/S include tachypnea, tachycardia, wheezing, acidosis, bronchospasms, edema. Treatment may be bronchodilators, diuretics. Steroids are not given because they interrupt growth in the infant. o Periventricular- intraventricular hemorrhage: rupture in the brain. S/s are lethargy, poor muscle tone, apnea and seizures. Treated with shunts to drain. Considerations is ventilator care. o Tetinopath of prematurity (ROP) may result in visual impairment or blindness in preterm infants. ROP is caused by injury to immature blood vessels in the eye. o Necrotizing enterocolitis (NEC) is a serious inflammatory condition of the intestinal tract that may lead to cellular death of areas of intestinal mucosa. Although the exact causes are unknown, immaturity of the intestines is a major factor in preterm infants. 31) Post-term infant: When the infant is born after 42 weeks of gestation. Most infants will be normal at birth. These babies have no vernix, lanugo or peeling skin, contain more hair, wrinkles and long nails. However, the placenta may decline in function and oligohyramnios may occur with cord compressions. This condition can lead to hypoxia and malnourisment, called postmaturity syndrome. Assess for hypoglycemia and temperature. May be born large- for-gestational age (4000g) 32) Respiratory complication: o (RDS) is a condition caused by insufficient production of surfactant in the lungs. It occurs most often in preterm infants under 28 weeks of gestation and increases as the gestational age decreases. o Management: Surfactant is instilled into the infant's trachea shortly after birth or as soon as signs of RDS become apparent. Doses are repeated, if necessary. Infants treated with surfactant have higher survival rates, although the incidence of other complications of prematurity such as bronchopulmonary dysplasia (BPD) is unchanged o Meconium Aspiration Syndrome :Meconium staining of amniotic fluid occurs in 10% to 15% of births. (MAS) is a condition in which there is obstruction, chemical pneumonitis, and air trapping caused by meconium in the lungs. It develops in 5% of those infants. The condition occurs most often in infants who are postterm, small for gestational age, and are compromised before birth by placental insufficiency with decreased amniotic fluid and cord compression. o S/S: Fetal distress, APGAR of 6 (at 1 and 5min), immediate resp distress at delivery (cyanosis, tachypnea, retractions), barrel chest or overdistended, diminished breath sounds, yellow staining of nails, skin and cord. o Causes: MAS develops when meconium in the amniotic fluid enters the lungs during fetal life or at birth. It may be drawn into the lungs if gasping movements occur in utero as a result of asphyxia and acidosis, or the meconium in the upper airways may be pulled deep into the respiratory passages when the infant takes the first breaths after birth. o Management: Infusing LR/NS into the uterus to try and dilute the meconium in the sac. Suctioning the infant's secretions as soon as the head is born has not been found to reduce the incidence of MAS. At birth, the vigorous infant (who has a heart rate more than 100 beats per minute, spontaneous respirations, and good muscle tone) does not need special suctioning and receives routine care. In infants with depressed respirations and muscle tone or a heart rate below 100 bpm, an endotracheal tube is used to remove as much meconium as possible. Suction the babys mouth and nose while his head is out of the vagina (before he takes his first breath), the baby may be put in a warmer after, administer O2 o Persistent Pulmonary Hypertension of the newborn: when the vascular resistance of the lungs does not decrease after birth and normal changes to neonatal circulation are impaired. o Transient Tachypnea of the Newborn (Retained lung fluid): develop rapid respirations soon after birth. Usually resolves within 12 to 72 hours. Risk factos are c-section, macrosomia,DM, excessive mother sedation. o Asphyxia : lack of oxygen and increase of carbon dioxide in the blood. (leading to Respiratory Acidosis). Causes include HTN, infection, drug use, placenta previa, abruption, premature. 33) Hyperbilirubinemia: Occurs from the breakdown of RBS due to an immature liver. Exam 3 Study guide 23 o Physiological jaundince: the normal jaundice that is seen in newborns , begins 24hrs after life. Encourage the mother to breast feed, so the baby eliminates it. o Pathological (non-physiological) jaundice: usually related to hemolytic disease. Occurs early (within the first 24hrs). this can be do to RH incompatibility (erythroblastosis fetalis). Or also in ABO incompatibility (when mother is type O, but baby is A,B, or AB) o Assessment: positive coombs test (detects antibodies). Also golden amniotic fluid suggest hemolytic disease. Assess for jaundice in the infant after delivery. TSB >13-15 indicates hyperbilirubinemia. Baby may have enlarged spleen, liver dark urine and anemia. o Intervention: Frequent feedings to promote elimination. Phototherapy (cover the infants eyes) Turn the baby frequent, assess his temperature q2hr, hydrate baby and assess for green stools meaning bilirubin excretion. • When phototherapy does not work then exchange transfusion is done, by exchanging infant circulation with donors new blood (only use RH- blood). Keep calcium gluconate because it causes hypocalcemia and assess v/s q15min. 34) Infections: Newborns can acquire infections before (rubella, CMV, syphilis, HIV, Toxoplasmosis) during (GBS, herpes, hepatitis) and after birth (HAIs). Newborn especially preterm have fewer antibodies and are unable to localize infection as well as older children. The blood brain barrier is less effective in stoping organisms from crossing and can CNS. • Causes: GBS, staph, strep, , pseudomonas, candida etc. usually from PROM, prolonged labor, or chorioamniotitis. Early onset infections occur during first 24 hrs. late occur within the first week. • Dx testing: CBC ( neutrophils). The presence of igM levels in the cord blood indicated infection was acquired in utero because igM does not cross placenta. CRP (detects inflammation), may be elevated 4-6 hours after and is abnormal after 24hrs. culture of nose, umbilical cord, stomach may be obstained to show colonization. X-ray is also used to determine between RDS and sepsis. • Treatment: Broad spectrum antibiotics after culture is read. (ampicillin, aminoglycosides, cephalosporins, vanco) • Considerations: monitor infant O2 status, give O2 if needed, check UO, fluid and electrolytes, BG, temperature, and v/s. Signs of Sepsis in the Newborn • General Signs • Temperature instability (usually low), Nurse's or parents' feeling that the infant is not doing well, Rash • Respiratory Signs • Tachypnea, Respiratory distress (nasal flaring, retractions, grunting), Apnea • Cardiovascular Signs • Color changes (cyanosis, pallor, mottling), Tachycardia, Hypotension, Decreased peripheral perfusion , Edema • Gastrointestinal Signs • Decreased oral intake, Vomiting, Excessive gastric residuals, Diarrhea, Abdominal distention, Hypoglycemia or hyperglycemia • Neurologic Signs • Decreased or increased muscle tone, Lethargy, Jitteriness, Irritability, Full fontanel, High-pitched cry • Signs That May Indicate Advanced Infection • Jaundice, Evidence of hemorrhage (petechiae, purpura, pulmonary bleeding), Anemia, Enlarged liver and spleen, Respiratory failure, Shock, Seizures 35) Infant of diabetic mom: Face challenges and have more complications such as macrosomia, hypoglycemia, UTI, GI abnormalities, NTD, cardiac and respiratory problems. Cardiomegaly is the most common problem and leads to heart failure. Issues with the mother such as high BP, compromises fetal O2. Polycythemia may occur due to hypoxia from RDS. Due to the macrosomia liver, adrenals, heart and spleen become enlarged also. • Management: controlling and maintain the mothers condition during the pregnancy. With the baby, monitor BG q4hr. BG under 40-45 is hypoglycemia. Feedings should be started early to prevent hypoglycemia. Look out for s/s of low BG, which can lead to hypocalcemia. Infants with polycythemia will need hydration to prevent stasis of blood. During this time provide emotional support to the parents. 36) Polycythemia: Occurs with infants with hmbg over 22. This increases the viscosity of the blood, leading to organ and tissue ischemia. Hypertension, renal vein thrombosis, CHF, and hyperbilirubinemia. Polycythemia occurs when there is poor oxygenation, the baby tries to produce more RBC for O2. Seen with mothers who smoke or had HTN. • Manifestations: cardiomegaly, lethargy, poor suck, vomiting, cyanosis, RDS, hypoglycemia/calcemia, and thrombocytopenia. With hyperbilirubinemia. • Consideration: hydration, and can be treated with transfussions. • Prenatal drug exposure: When there is substance abuse in mom, it crosses the placenta and the baby gets the effects. Neonatal abstinence syndrome (NAS) Is neonatal abstinence syndrome, in which drug exposed babys demonstrate signs of withdrawal. These include diarrhea, crying, fever, irritability, trembling, sleep problems, rapid breathing, sweating, increased muscle tone. • When drug exposure is suspected, a urine specimen is collected for analysis. Drugs or their metabolites are present in the newborn's urine for various lengths of time after the mother has used them. Some drugs last several days because the infant's immature liver and kidneys delay excreting them, whereas others disappear very soon. Therefore, it is important to obtain the first urine output from the infant, if possible. Meconium analysis is sensitive for drug exposure from the 24th week of gestation. A hair sample or a segment of umbilical cord is tested in some facilities. 37) PKU: Autosomal recessive disorder in which causes toxicity of CNS due to high levels of amino acid phenylalanine. It is caused by a deficiency of the liver enzyme phenylalanine Exam 3 Study guide 25 hydrolase which breaks down and digest the amino’s. • Manifestations: vomiting, seizures, musty urine odor. Older children get eczema, hypertonia, hyperactive behavior, hypopigmentation of hair • Management: low PKU diet (no meats, protein, milk). The infant will receive a special formula (low in protein and PKU). • Considerations: Ensure all babies are screened for PKU. At 24 hrs and then after to identify proteins that they have ate. 38) Common congenital anomalies: Is the leading cause of death in the first year of life Ancephaly: Cleft palate • Assessment: severe clefts, palpate the hard and soft palate of all neonates • Management: lip surgery, palate surgery, speech therapy in long term. • Considerations: try to find out what is best way to feed (breast, bottles, assistive devices). Feed slowly, feed in upright position to prevent feeding into nose, provide emotional support, prevent infection, and follow up. Esophageal atresia and transesophageal fistula: when the esophageos divides into two unconnects segments and can be to trachea. • Assessment: occurs with polyhydramnios, suspect it when infant has excessive drooling and suction needed. • Management: Dx with Xray, gastrostomy tube is place, ligation of fistula, long term follow up • Considerations: observe for respiratory difficulty, prevent aspiration, maintain suction equipment. Omphalocele and gatroschisis: the intestine protrudes the base of umbilical cord. Gastroschisis is a defect on side of abdomen in which instestine protrude. Not covered by peritoneum or skin and float freely in amniotic sac. • Assessment: elevated AFP and u/s shows. • Management: gastric tube is placed. Surgery Is performed as soon a the infant is stable. A pouch may be used to replace intestine to prevent pressure on other organs. • Considerations: place torso in sterile plastic bag or cover intestines. Look for RDS from increased abdominal pressure. Also position to avoid pressure on intestine. Diaphragmatic hernia: When the diaphragm is moved into the chest cavity. Can prevent lung expansion and lungs can fail to develop. • Assessment: RDS, diminished breath sounds, barrel chest, bowel sounds heard in chest. Scaphoid abdomen. • Management: ETT is placed for mechanical ventilation and gastric tube to decompress stomach. Replace the intestines. • Considerations: position infant on the affect side to allow the unaffected lung to expand. Elevate head to decrease pressure on lungs. Monitor respiratory status. Spina bifida: Failure of vertebrae to close Meningocele: protrustion of meninges and spinal bifida through the spina bifida covered by skin of a thin membrane. Myelomenigocele: protrustion of membrane covered sac through the spina bifida. Contains meninges, nerves, cord and fluid. Infant may have hydrocephalus. • Assessment: elevelated AFP, examine movement below defect to determine the degree of paralysis. • Management: surgery, shunt to divery CSF, antibiotics. • Considerations: observe for infections, increase folic acid, handle infant carefully, position on belly or the side. Check head circumference, fontanels and signs of ICP. Congenital hydrocephalus: Problem with absorption or obstruction of CSF in verntricles of brain, causing compression of brain and head enlargement. • Assessment: fontanels bulging, large head, poor feeding • Management: surgery, ventricular shunt to drain. • Consideration: measure head circumference daily, prevent pressure, prevent infection 39) Congenital cardiac defects: Possible factors: genetics, teratogens, maternal diabetes, and rubella. 1. Acyanotic Defects: an obstruction of blood flow from the left side of the heart or a defect that causes increased flow of blood to the lungs. Both increase the work of the heart. 2. Cyanotic Defects: blood flow to the lungs decreases or venous blood and oxygenated blood are mixed in the general systemic circulation, decreasing the oxygen carried to the tissues and resulting in cyanosis. Right to left shunt 3. Left to right shunting defects: blood flows from the higher pressure of the left side of the heart to the right side or from the aorta to the pulmonary artery. This increases the blood flow to the lungs and is called a left-to-right shunt. 4. Defects with obstruction of blood outflow: a decrease in the blood flow through a vessel or valve occurs because of stenosis (narrowing). This adds work to the heart, causes hypertrophy of the heart or major blood vessels, and may lead to heart failure. 5. Defects with decreased pulmonary blood flow: an impairment in the blood flow from the right side of the heart to the lungs. System hypoxia causes cyanosis. 6. Cyanotic defects w/ increased pulmonary blood flow: there is increased blood flow to the lungs and a mixture of venous and oxygenated blood in the systemic circulation. Manifestation Exam 3 Study guide 27 The most common indications of cardiac problems are cyanosis, heart murmurs, tachycardia, and Tachypnea. Cyanosis • A major sign of cardiac anomaly when is not a result of respiratory disease. • Of cyanosis is caused by mixing of oxygenated and unoxygenated blood, giving oxygen will not improve the infant’s color • Cyanosis increases with crying, feeding, or other activity. • Pallor, mottling, or a gray color may be present in infants who do not have cyanosis Heart Murmurs • May sound like clicks machinery, rumbling, swishing, or other muffled noises. • Although many infants may have temporary murmurs, all abnormal sound must be referred to HCP Tachycardia and Tachypnea • May occur anytime the heart and lungs have to work harder to provide sufficient oxygen to the body. • They are present in both respiratory and cardiac conditions • They increase CHF’ Therapeutic Management • Echocardiograms • Cardiac catheterizations • Oxygen and drugs such as digitalis, diuretics, potassium supplements, and sedatives may be prescribed Nursing considerations • Assess for changes in conditions and reduce infant’s need for oxygen • Infants with rapid respirations are at risk for aspiration and may need feeding and gavage • Frequent rest periods are provided by clustering small amounts of nursing care • Maintaining a neutral thermal environment is important to avoid increasing oxygen needs. 40) Sterilization: Is a method of contraception. It should be considred a permanent end to fertility. Couples need to ensure they understand all aspects of the procedure. The greatest risk for later regret are woman under the age of 30 because they may want children again. Complications of sterilization are the same from any surgery, such as hemorrhage, infection Exam 3 Study guide 29 and anesthesia complications. 41) Oral contraceptives: Drugs that inhibit ovulation. If a woman is breast feeding she should not take oral contraceptives with estrogen. She has to take non-estrogen contraceptives. Postpartum woman should avoid COC for 3 weeks after giving birth and lacatating woman should avoid COC for 4 weeks, and should take progestin only OC because they do not affect milk quantity/quality. • Risk when take OC: Thrombophlebitis, CVA, breast cancer, HTN, DVT/PE. May not be taken in woman with liver damage, smoke, have vaginal bleeding or having major surgery. • Side effects: bleeding, nausea, headache, breast tenderness, cloasma. 42) Intrauterine device: IUDs can be inserted at any time the woman is not pregnant and does not currently have an STD or pelvic infection. Althought many woman have safety concerns about IUDs, they are considered very safe and provide long term, continuous contraception without the need to take pill, injections or other task before intercourse. It work by progestin thickening the cervical mucous and prevent transport of sperm into fallopian tubes. • Side effect: menorrhagia (increased menstrual bleeding) and dysmenorrhead. Irregular bleeding, spotting. NSAID like ibuprofen may be used to reduce bleeding and cramping , as well as iron to treat anemia. 43) Barrier methods: Involve chemical barriers (spermicides) or devices that prevent sperm from entering the cervix . It works by killing the sperm while avoiding hormones and providing protection from std. • If a patient is promiscuous recommend using condoms or they have an STD. • If the patient is monogamous you can tell them to use a IUD. (Depending on religion and belief educate them that it is like have an abortion ) 44) Natural family planning methods: The use of physiological cues to predict ovulation so that woman can determine when conditions are favorable for fertilization and to become pregnant. Some methods include calendar , standard day , basal temperature, cervical mucus, two day and symtothermal method. 45) Abstinence: Avoidance of having sex and activity that may allow sperm to enter the vagina. Nurses must show support toward woman choosing abstinence. It has no cost, no use of hormones and no side effects or medical risk. It include no oral, anal or exposure to any STD. 46) Extent of infertility: Infertility is defined as the inability to conceive after 1 year of unprotected, regular sexual intercourse. Coupled with primary infertility may never conceive and couples with secondary may have but are unable too again. 47) Factors contributing to infertility: • Factors in the man include not have enough sperm with normal structure and function, such as in the seme, seminal fluid, erection or ejaculation. Azoospermia (sperm absent in semen), oligospermia (decreased sperm in the semen) are factors. Factors that affect function of sperm include, ren