N482 Exam 2 Questions and Complete Solutions Graded A+

N482 Exam 2 Questions and Complete Solutions Graded A+ what is preconception health? - Answer: -the health of an individual before and between pregnancies -good preconception health= a lifespan of good overall health -managing health risks, chronic conditions, genetic/hereditary factors -knowing and making healthy choices; practicing healthy habits -having a trusted and supportive healthcare professional -preconception care that addresses both physical health and mental wellness is for everyone of reproductive age (15-44) every time they are seen -one half of all infant deaths and health problems with babies are directly related to the health of the mother before pregnancy (mostly modifiable) reproductive life planning - Answer: -encourage men and women to have a reproductive life plan -increase public awareness about preconception health -provide risk assessment and counseling during primary care visits -increase the number of own who receive interventions after risk screening -use the time between pregnancies to provide intensive interventions to women have have had a pregnancy that resulted in infant death, low birth weight, or premature birth -offer one pregnancy visit -increase health insurance coverage among low income women -integrate preconception health objectives into public health programs -augment research -maximize public health surveillance why are unintended pregnancies a concern? - Answer: -miscarriage -premature birth -low birth weight -birth defects -late entry into prenatal care -societal costs key health behaviors for men that improve preconception health - Answer: -maintaining a healthy weight -no smoking -good sleeping habits -exercising/being active -decrease stress -schedule an annual wellness check well-man visits - Answer: -ensures pregnancies are planned and wanted -improves the male genetic and biologic contributions to the pregnancy -improves reproductive health and outcomes for female partners -improves capacity for and understanding of parenthood -enhances overall health through access to primary care tying all concepts of preconception care together - Answer: -early experiences: mother's health before conception, exposure in utero -events during critical periods of development: early childhood, adolescence -presence of risks and cumulative experiences: impact of multiple stresses; exposure to tobacco use, substance use, housing and food insecurity, lack of education and access to health and contraception services, domestic violence, immigration status and racial discrimination -protective factors: economic security, access to health care, access to eduction, nurturing family, positive relationships, safe neighborhoods very preterm - Answer: <32 weeks moderate preterm - Answer: 32-34 weeks late preterm - Answer: 34 to 36 weeks 6 days early term - Answer: 37 to 38 weeks 6 days full term - Answer: 39 to 40 weeks 6 days late term - Answer: 41 to 41 weeks 6 days post term - Answer: 42+ weeks menstrual cycle - Answer: -28 day cycle -mid cycle= ovulation (egg expelled from follicle) zygote - Answer: early fertilizer human egg implantation - Answer: day 7 to 8 post fertilization placental development - Answer: -made from trophoblast cells of the chorionic villi -maternal-placental-embryonic circulation is in place by day 17 -embryonic blood circulating by end of 3rd week -structurally complete by 12w grows until 20w stages of development - Answer: -ovum: conception to day 14; not susceptible to teratogens -embryo: day 15 to 8 weeks; most critical time for development; all organ systems and external features present by the end -fetus: 9 weeks to birth pregnancy dating - Answer: -pregnancy is dating from first day of LMP -10 lunar months (28 day cycles) -40 weeks -280 days -266 days post conception pregnancy vs fetal development dating - Answer: -pregnancy from first day of LMP -fetal development from conception developmental goal for early pregnancy - Answer: -acceptance of pregnancy -life changes -family formation -easiest for 55% of people experiencing planned pregnancies -other 45% of people may have difficulties accepting pregnancy relationship adaptations in pregnancy - Answer: -partners: pregnant people need love and acceptance of pregnancy -existing children (siblings): need preparation for new family member -grandparents: pregnant people need support and acceptance fraternal twins - Answer: two eggs, two sperm, two placenta, two sets of membranes, two babies identical twins - Answer: one egg, one sperm first missed menses - Answer: -4 weeks since LMP -2 weeks post fertilization -unplanned pregnancy=45%, planned = 55% pregnancy tests - Answer: -detect beta-hCG in urine or blood -home tests able to detect as early as first missed menses -recommendation is to wait a week to prevent false-negative readings -blood tests --> generally only used for complicated situations signs of pregnancy - Answer: presumptive, probable, positive presumptive sings of pregnancy - Answer: -physiologic changes that a woman experiences -subjective sensations or assessments noted by women -suggestive but not diagnostic of pregnancy -amenorrhea, breast changes, vaginal changes, skin changes, N/V, urinary frequency, fatigue, fetal movement probable sings of pregnancy - Answer: -maternal physiological and anatomical changes that can be observed or palpated by a health care provider on exam -objective findings on clinical exam -suggestive but not diagnostic of pregnancy -enlargement of abdomen, vaginal changes, cervical changes, uterine changes, palpation and ballottement of the fetus, basal body temp elevation, endocrine pregnancy tests positive signs of pregnancy - Answer: -findings directly attributable to the fetus that can be detected by the healthcare provider -considered "absolute" proof of pregnancy -diagnostic of pregnancy -detection of the embryo or fetus by ultrasound or x-ray, identification of fetal heart activity, detection of fetal movement by examiner Certified Nurse Midwives - Answer: -well known for attending births -identify reproductive care -primary care -annual exams, writing prescriptions, basic nutrition counseling, parenting education, patient education, and reproductive health visits -licensed, independent health care providers with prescriptive authority in all 50 states midwife attended births - Answer: -in 2019 there were 372,991 births (10% increase) -CM attended 92% of all midwife attended births and 10.3% of all US births major goals of prenatal care - Answer: -physically and emotionally healthy outcome for family -define health status of pregnant person and fetus -determine gestational age of fetus and monitor fetal development -identify the client at risk for complications and provide support to minimize risk whenever possible -provide appropriate education and counseling prenatal care choices - Answer: -approximately 74% of clients begin care in first trimester -types of OB providers: midwife (CNM, CM, CPM, lay midwife), physician (OB/GYN-MD, DO, family physician), other (PA, NP) -model of care- getting to know provider, philosophy of care? -care/birth setting (often dictated by provider choice) model of care- traditional prenatal care - Answer: -clients see providers at regular intervals throughout the pregnancy -first visit is often the longest and includes support form nursing and other disciplines as well -interval of visits change based on gestational age -may see many providers in a given practice over time model of care- group prenatal care - Answer: -centering is an example -care provided in a group space -3 components healthcare assessment, education, and peer support -patient participation in physical assessment -education runs throughout 10 sessions -care is focused on health outcomes and personal empowerment -group can provide a setting that is supportive of culture and language -groups minimize repetition and permit sufficient time for more in-depth discussion -total provider/patient time throughout pregnancy is approximately 20 hours -within 2 hour period 8-10 women can receive total care outcomes associated with group PN care - Answer: -less likely to have preterm birth -increased rates of breast feeding initiation -better psychosocial outcomes --> more prenatal care knowledge, more prepared for labor, higher satisfaction with PNC barriers to prenatal care - Answer: -not all pregnant people have choices in care (provider, setting) -substantial structural barriers to care exist for many, especially for Black, Latinx, and Native or Indigenous clients -rural counties without any prenatal care providers/birth locations (maternity care deserts) maternity care deserts - Answer: -a county is classified as a maternity care desert if there are not hospitals providing obstetric care, no birth centers, not OB/BYN/ certified nurse midwives -in maternity care deserts alone, approximately 2.2 million people of childbearing age and almost 150,000 babies are affected -there is a 2% increase in countries that are maternity care deserts since our 2020 report. thats 1,119 counties and an additional 15,933 people with no maternity care trimesters - Answer: first trimester (1-13 weeks) second trimester (14-26 weeks) third trimester (27 to birth) types of antepartum testing across three trimesters - Answer: -cfDNA, Quad screen -chorionic villus sampling (CVS) -amniocentesis -ultrasound (vaginal, abdominal) -nonstress test (NST) -kick counts -biophysical profile carrier screening for genetic conditions - Answer: -test is done on parents -preconception or 1st trimester -recommendations made by a genetic counselor --> includes careful family history and discussion of risks and benefits -checks blood or saliva to see whether parent(s) carry certain genetic conditions -if both partners are carriers, greater chance of baby having condition fetal testing (1st and 2nd trimester)- screening vs. diagnostic testing - Answer: -screening tests: provide information to see if fetus is more likely to have a health condition (generally less invasive and less risk than a diagnostic test); screening test positive --> offered a diagnostic test -diagnostic tests: provide a diagnosis of a health condition (these generally carry risk more than screening tests) -all decisions require careful assessment of pros and cons of testing, including risks maternal blood screening tests in first trimester - Answer: -cell free DNA testing (cf DNA) -screening test for chromosomal conditions -approximately 9-10 weeks LMP -consider risks/benefits (costs, false positives, plans for how to proceed) maternal blood screening tests in second trimester - Answer: -Quad test (measures four items) -screening test for chromosomal conditions and NTDs -approximately 16-18 weeks -consider risks/benefits (costs, false positives, plans for how to proceed) fetal testing diagnostic tests in first trimester - Answer: Chorionic Villus Sampling -procedure to test fetal cells between 10-13 weeks -prenatal genetic studies including chromosomal conditions (does not test for NTDs) -two types: trans abdominal and transcervical -risks include miscarriage and infection fetal testing diagnostic tests in second trimester - Answer: Amniocentesis -most common indication = prenatal genetic studies; approximately 15-17 weeks -prenatal genetic studies including chromosomal conditions, NTDs -transabdominal procedure -risks include miscarriage and infection major uses of ultrasonography in first trimester - Answer: *not always indicated* -confirm pregnancy -confirm viability -determine gestational age -rule out ectopic pregnancy -detect multiple gestation -determine causes of vaginal bleeding -use for visualization during chorionic villus sampling -detect maternal uterine conditions (bicornuate uterus, ovarian cysts, fibroids) major uses of ultrasonography in second trimester - Answer: -establish or confirm dates -confirm viability -anatomy scan and detect fetal conditions -detect polyhydramnios, oligohydramnios -detect IUGR -assess cervical length and placental location -use for visualization during amniocentesis *may be transvaginal or trans abdominal depending on the indication* major uses of ultrasonography in third trimester - Answer: *most often in 3rd trimester ultrasound is transabdominal* -confirm gestational age -confirm viability -detect macrosomia -detect fetal conditions -detect IUGR -use for visualization during amniocentesis (e.g. for lung maturity) external version -determine fetal position -detect placenta previa or placental abruption -BPP (BioPhysical profile) -doppler flow studies -detect placental maturity initial prenatal visit - Answer: -history --> thorough -physical --> full exam -education --> comprehensive -going to be a much longer visit than subsequent visits -in many settings nurses provide a significant amount of education prenatal care interview - Answer: -how are you? what's on your mind? -questions or concerns today? -current s/s pregnancy -medications/supplements -allergies (reaction) -menstrual history -GYN and OB history -medical history -surgical history -social history -mental health history -nutritional history -substance use (alcohol, tobacco, other) -intimate partner violence -review of systems menstrual history - Answer: -LMP --> was it normal for you? -age at menarche -cycle length past OB history - Answer: -month/year gave birth -gestational age at time of birth -length of labor and outcome; type of birth -birth weight -complications -infant feeding method gravidity and parity - Answer: -gravidity: total number of times a person has been pregnant, regardless of outocme -parity: number of pregnancies in which fetus reached 20 weeks TPAL (term [37+ weeks], preterm [20-26 weeks], abortions, living children) example- Jo is currently 16 weeks pregnant. Jo has history of one abortion, one miscarriage, and they have two children born at 39 weeks who are now 3 and 6 years old. What are Jo's G's and P's? - Answer: G5 P 2022 (full term, preterm, abortion/miscarriage, living) prenatal cervical changes - Answer: -goodell's sign: softening of cervical tip -chadwick's sign: bluish color of cervix (and vagina) -Hegar's sign: softening of lower uterine segment; pressure on bladder -operculum: mucus plug *see table 14.1* prenatal vaginal changes - Answer: -Chadwick's sign: bluish color of vagina -Leukorrhea: white or grey discharge -darkening of perineum -vulvar varicosities (sometimes) prenatal abdominal assessment - Answer: -fundal assessment height: may begin to assess for uterine softening and enlargement as early as 6 weeks LMP (only with bimanual exam); measure fundal height from symphysis pubis to top of fundus (#cm roughly equals #weeks) -FHT: quadrant with clearest sounds; should heart FHTs with handheld doppler or fetoscope by 12 weeks -Leopold's Maneuver: fetal position (3rd trimester) prenatal laboratory tests - Answer: -HGB/HCT -blood type and Rh -rubella titer -uterine dipstick/culture -gonorrhea -chlamydia -syphilis (RPR) -Hep B -HIV -Pap -varicella titer -genetic screening or diagnostic tests per client wishes *table 14.2* health promotion and education- prenatal care - Answer: -content and flow of prenatal care -nutrition and prenatal supplements -exercise -alcohol and other substance use -safety -teratogens- exposure -common discomfort -danger or warning signs -fetal development traditional prenatal visit schedule - Answer: -every 4 weeks until 28 weeks -every 2 weeks from 28-36 weeks -every 36-40/41 weeks -twice a week weight gain in pregnancy for underweight BMI - Answer: -total first trimester 2.2-6.6 lbs -second and third trimester 1.-1.3 lbs per week weight gain in pregnancy for normal (healthy) BMI - Answer: -total first trimester 2.2-6.6 lbs -second and third trimester 0.8-1.1 lbs per week weight gain in pregnancy for overweight BMI - Answer: -total first trimester 2.2-6.6 lbs -second and third trimester 0.5-0.7 lbs per week weight gain in pregnancy for obese BMI - Answer: -total first trimester 0.5-4.4 lbs -second and third trimester 0.4-0.6 lbs per week nutrition in pregnancy - Answer: *table 15.3* -may be helpful to start with food intake recall or questionnaire (box 15.4) to tailor teaching to individual -calcium is important --> review foods rich in calcium, non-dairy sources of calcium -fats (even saturated) no longer considered bad, fetus needs fat to develop healthy neurological system -vegan diets may need supplements--> B vitamins, need to ensure adequate iron, protein, vitamin D, calcium, omega 3 iron deficiency amenia - Answer: -common in pregnancy -review foods that are iron rich -discuss best practice for taking supplements (vitamin c/orange juice, not with milk; take at different time than prenatal vitamin) exercise in pregnancy - Answer: a client can generally continue doing whatever they have been doing with following exceptions: -contact sports -skydiving -fall risk (downhill skiing) -hot yoga, hot pilates -scuba diving -activities performed >6000 ft (unless you already live there) *may need some adjustments to level of activity in 3rd trimester as the pregnancy grows and center of gravity changes* alcohol and pregnancy - Answer: -no known "safe" amounts -known teratogen -instruct clients to avoid alcohol during pregnancy -fetal alcohol spectrum disorders (FASD) issues following alcohol use in pregnancy - Answer: -physical issues: low birth weight and growth, problems with heart, kidneys, and other organs, damage to parts of the brain -behavioral and intellectual disabilities: learning disabilities and low IQ, hyperactivity, difficulty with attention, poor ability to communicate in social situations, poor reasoning and judgement skills -lifelong issues with: school and social skills, living independently, mental health, substance use, keeping a job, trouble with the law safety in pregnancy - Answer: -changing center of gravity (watch for falls) -posture (may develop lordosis) -body mechanics -lifting -seat belt use teratogens/toxins in everyday environment - Answer: -other screening questions during visit -toxoplasmosis -lead -asbestos -avoid: seafood more likely to be high in mercury, raw or undercooked meats and seafood, hot dogs, lunch meats common discomforts in first trimester - Answer: -"morning" sickness (N/V of pregnancy) -breast tenderness -constipation -vaginal discharge -fatigue -food cravings and aversions -frequent urination -heartburn -mood swings *table 14.3* danger signs in first trimester - Answer: *review table 14.4* -severe abdominal pain -vaginal bleeding -severe dizziness -severe N/V -fever history in second trimester - Answer: interview -problems/concerns/questions; what's on your mind today? -how are you feeling? -fetal movement physical focused exam in second trimester - Answer: -vitals (BP, HR, RR, Temp) -weight -urine (glucose, protein, leukocytes) -fundal height -Leopold's -FHT (fetal heart tracings) -fetal movement assessment of fetal growth- fundal height - Answer: -12 weeks: fundus just above pubic bone -36-38 weeks: fundus usually right up under sternum -40 weeks: fundus drops below 38 week level as presenting part drops down into pelvis breast changes in second trimester - Answer: -increase in size and sensitivity -nipples and areala darken and enlarge -prominent montgomery tubercles -colostrum production begins at 4-5 months second trimester (14-26 weeks) - Answer: -with quickening (first sensation of fetal movement) increase realization of pregnancy -becomes "real" -developmental task is to begin establishing relationship with fetus cardiovascular system pregnancy - Answer: -blood volume increases 40-45% (1500 mL) -increase in CO= amount of blood the heart pumps through the circulatory system in 1 minute -HR may increase 10-15 bpm at 14-20 weeks -BP decreases 1st and 2nd trimester (relaxation of vessels); returns to normal at term hematology in pregnancy (what is true anemia? do WBC increase?) - Answer: -physiologic anemia of pregnancy= normal change -plasma volume increases mL (45%) and leads to hemodilution -true anemia if Hgb <11; Hit <33 (depending on source/provider) -increased clotting tendency (related to increased estrogen levels) -WBCs increase during 2nd and 3rd trimester changes in integumentary system (generally begin in 2nd trimester) - Answer: -hyperpigmentation stimulated by melanotropin (anterior pituitary) -darkening of areola and perineum -chloasma -"mask of pregnancy" -linea nigra -striae gravidarum: 50-80% of pregnant people; 2nd half of pregnancy; familial -angiomas: vascular spiders -acne or clearing of complexion gallbladder changes in pregnancy - Answer: -distended secondary to decreased muscle tone, increased emptying time, and thickened bile -predisposes to gallstones renal changes in pregnancy - Answer: -increased urination and nocturia during 1st and 3rd trimesters -1st related to progesterone and hCG -3rd related to growing baby neurological system changes in pregnancy - Answer: -compression of pelvic nerves cause sensory changes in legs -carpal tunnel syndrome vaccines in pregnancy - Answer: -pregnant people more likely to become seriously ill from flu (and now COVID) -Tdap--> babies most likely to contract whooping cough (pertussis) and flu from members of their family -recommendation is immunization for both parents during every pregnancy -the following vaccines are recommended during pregnancy --> flu, Tdap, COVID -live vaccines (including flu nasal spray) are not recommended nor is MMR, varicella, or HPV common discomforts in second trimester - Answer: -backache -breast enlargement -congestion and nosebleeds -heartburn -constipation -hemorrhoids -skin changes (hyperpigmentation and linea nigra) -spider and varicose veins -round ligament pain *table 14.3* danger signs in second trimester - Answer: *table 14.4* -severe abdominal pain or cramping -vaginal bleeding -severe dizziness -rapid weight gain/severe edema -fever history in third trimester - Answer: interview -fetal movement -problems/concerns/questions --> what's on your mind? -how are you feeling? physical focused exam in third trimester - Answer: -vitals (BP, HR, RR, temp) -weight -urine (glucose, protein, leukocytes) -fundal height -Leopold's -FHT -fetal movement third trimester lab/tests - Answer: @35-37 weeks -GBS culture -gonorrhea culture -chlamydia culture -RPR (plasma) -repeat H/H if anemia suspected Group B strep - Answer: -leading cause of early onset sepsis and meningitis in USA -primary risk factor of early onset GBS disease is maternal colonization -10-30% of pregnant people are colonized -intrapartum antibiotic prophylaxis is highly effective at preventing early onset GBS -screen --> vaginal rectal swab at 35-37 weeks non-stress test (NST) - Answer: -reactive= reassuring -non-reactive= non-reassuring and more testing will be indicating -the NST is reactive (reassuring) from 32 weeks-term if there are two or more FHR accelerations reaching a peak of at least 15 bpm above baseline rate and lasting at least 15 seconds from onset to return to baseline (15 x 15) in a 20 minute period -before 32 weeks of gestation, a reactive NST may be defined as two accelerations that rise at least 10 bpm above baseline and have a duration of at least 10 seconds (10x10) fetal kick counts - Answer: -another measure of fetal wellbeing may be recommended for clients near term -perception of at least 10 fetal movements over up to two hours when the pregnant person is at rest and focused on counting ("count to 10" method) -perception of at least 10 GMs over a typical 12 hours -perception of at least 4 GMs in one hour when the pregnant person is at rest and focused on counting biophysical profile (BPP) - Answer: -noninvasive "physical exam" of the fetus. indications may include conditions related to increased risk in pregnancy -done in second or third trimester and thought to be a reliable predictor of fetal well being -a BPP of 8/10 with normal amniotic fluid volume (AFV) is considered normal and an indicator of fetal wellbeing biophysical profile (BPP)- scoring criteria - Answer: -nonstress test: 2 points if reactive, defined as at least 2 episodes of FHR accelerations of at least 15 bpm and at least 15 second duration from onset to return associated with fetal movement within a 30 minute observation period -fetal breathing movements: 2 points if one or more episodes of rhythmic breathing movements of >30 seconds within a 30 minute observation period -fetal tone: 2 points if one or more episodes of extension of a fetal extremity or fetal spine with return to flexion -amniotic fluid volume: 2 points if a single deepest vertical pocket >2 cm is present. the horizontal dimension should be at least 1 cm -fetal movement: 2 points if three or more discrete body or limb movements within 30 minutes of observation. an episode of active continuous movement is counted as one movement common discomforts in third trimester - Answer: -backache -Braxton Hicks -breast enlargement -fatigue -frequent urination -heartburn and constipation -hemorrhoids -shortness of breath -spider and varicose veins -swelling in lower extremities -round ligament pain -carpal tunnel -sleep disturbance *table 14.3* Braxton Hicks Contraction - Answer: *Physioloigic, non-labor uterine contractions* -painless -irregular -usually fundal -facilitate circulation and oxygenation -do not increase in frequency or intensity -can increase with dehydration danger signs in third trimester - Answer: *table 14.4* -severe abdominal pain or cramps -severe N/V -vaginal bleeding -severe dizziness -pain or burning during urination -fever -rapid weight gain -significant or sudden swelling, especially facial -severe headache -visual changes -epigastric pain -decrease fetal movement -S/S labor <37 weeks -leaking fluid third trimester (27 weeks - birth) - Answer: preparation for childbirth and parenting -classes--> childbirth education/lactation -plans and intentions for birth -education about infant feeding and discussing plans -education and discussion of circumcision -prepare space for baby education and planning in third trimester (weeks 33-36) - Answer: -Braxton hicks vs. labor -discussing preparation for childbirth -making plans for support after birth -answering questions about infant feeding and care -discussing circumcision -securing a pediatric provider -setting up support network for after birth education and planning in third trimester (weeks 37-birth) - Answer: -weekly visits to discuss changes/concerns -preparing home for baby -contraception plans -plans for labor (when to call, where to go, etc.) -providing support and last-minute information how does trauma lead to poor health? - Answer: -neuroendorine inflammatory and epigenetic mechanisms affecting mood, memory, learning -psychological and social facors (anxiety, stigma) -adaptive but unhealthy "coping" (tobacco, alcohol, drugs, reckless behavior, overeating) ways healthcare can replicate trauma - Answer: -power dynamics of relationship -personal questions that may be embarrassing or distressing -loss of privacy -physical touch in intimate areas -feelings of pain -removal of clothing -vulnerable physical position -feeling a lack of control over the situation -gender of healthcare provider 4 Rs of trauma informed approach - Answer: -realizes the widespread impact of trauma and understands potential paths for recovery -recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system -responds by fulling integrating knowledge about trauma into policies, procedures, and practices -seeks to actively avoid re-traumatization universal precautions in trauma informed care - Answer: -educate yourself and patient --> continue learning about trauma and TIC -awareness (of power and control issues) --> opportunity to rebuild control and empowerment -safety (ask permission, show respect) --> collaborative patient centered approach -strength based --> building on strengths and developing resilience with clients trauma informed care rebuilds resilience - Answer: -strengths based -physical and emotional safety -opportunity to rebuild control and empowerment -trauma understanding -cultural humility -safety and stability -compassion and dependability -collaboration and empowerment -resilience and recovery TIC exam - Answer: -ask about trauma exposure before examining -ask permission before examining -no fast moves, stand to the side rather than behind, at eye level -avoid "for me" when giving directions during exam vicarious trauma - Answer: -trauma exposure via work -resulting in changes in world view -can lead to changes in your life that affect your family, work, patients/clients -produces a spectrum of possible responses -negative: secondary traumatic stress, compassion fatigue, burnout -vicarious resilience: "transforming" and feeling empowered by witnessing resiliency from trauma survivors types of IPV - Answer: -physical abuse: hitting, slapping, shoving, grabbing, pinching, hair pulling, etc. also denying a partner medical care or forcing alcohol and/or drug use -sexual abuse: coercing or attempting to force any sexual contact or behavior without consent -emotional abuse: undermining an individual's sense of self-worth and/or self esteem, constant criticism, diminishing one's abilities, name calling, or damaging one's relationship with their children -economic abuse: making or attempting to make an individual financially dependent by maintaining total control over financial resources or forbidding someone from attending school or employment; making partner work while controlling paycheck -psychological abuse: causing fear by intimidation, using threats, destruction property, abusing pets, and forcing isolation from family, friends, or school and/or work impacts of IPV on health - Answer: -physical health: fatal and nonfatal injuries, chronic health conditions, conditions caused by behavioral changes -mental/behavioral health: anxiety, depression, PTSD, self-medicating behaviors -sexual and reproductive health: HIV and other STIs. unwanted pregnancy, low birth weight/preterm labor -direct effects: injury or direct health effects -access to care: abuser restricting access, survivor choosing not to access due to past trauma -health behaviors affected by abuse/violence: substance use, self-injurious behaviors other impacts of IPV - Answer: -work/school: concentration/productivity, missed class/work, abuser interference -children:e. children witnessing events, awareness of tensions, disruptions to development and schedules cycle of abuse - Answer: 1) tensions building: tensions increase, breakdown of communication, victim becomes fearful and feels need to placate the abuser 2) incident: verbal, emotional, and physical abuse; anger. blaming, arguing, threats, intimidation 3) reconciliation: abuser apologizes, gives excuses, blames the victim, denies the abuse occurred, or says it wasn't as bad as victim claimed 4)calm: incident is "forgotten"; no abuse is taking place, the "honeymoon phase" CUES intervention for IPV - Answer: 1) Confidentiality 2) Universal Education 3) Support --> listen and validate *never screen in presence of partner or other family members* response components of IPV screening - Answer: -listen and validate -assess for safety -resources -document safely resources for IPV - Answer: -hotline number for local domestic violence and sexual assault agencies -suicide hotline number -brochures from local DV/SA agencies -materials hosted in bathrooms and waiting rooms -social work resources -any UNC hospital/clinic -Beacon Sharepoint mandatory reporting in NC - Answer: four categories: 1) any suspicion that a juveniles is being abused or neglected by caretaker or if juvenile has no caretaker (CPS) 2) gun inflicted wounds, poisonings, knife wounds (if criminal act is suspected( or any other "grave wound" that may have been caused by criminal act of violence (Law Enforcement and CPS if juvenile patient) 3) any suspicion that a disabled adult is being abused , neglected, or exploited (Adult Protective Services) 4) any acts of violence, sexual offenses, or misdemeanor child abuse committed on juveniles (law enforcement) what we dont report - Answer: -IPV -sexual assault (of an adult) -sexual harassment -human trafficking (adult patients/clients) -other violence incidents against component adults diabetes mellitus- pregestational and gestational - Answer: -most common endocrine disorder associated with pregnancy -high risk pregnancy -inter-professional care management classification of diabetes - Answer: -T1DM -T2DM -Gestational Diabetes Mellitus (GDM) is any degree of glucose intolerance with onset or recognition during pregnancy normal maternal metabolic changes during pregnancy - Answer: -1st trimester; increased endogenous insulin --> lower BG levels (decreased insulin requirements) -2nd and 3rd trimester: insulin resistance (increasing insulin requirements, peaks at 36 weeks) -postpartum: return to normal BG within 7-10 days normal fetal metabolic changes during pregnancy - Answer: -glucose (but not insulin) crosses placenta -fetal pancreas produces insulin at 10 weeks preconception counseling and care with diabetes - Answer: -reduces perinatal mortality , congenital anomalies -helps protect mother's health -plan optimal time for pregnancy -establish glycemic control -diagnose vascular complications -may include contraception use maternal complications associated with pre gestational diabetes - Answer: -preeclampsia -miscarriage -preterm birth -infections -polyhydramnios -C/S or operative vaginal birth -shoulder dystocia -postpartum hemorrhage -postpartum depression effects of pre gestational diabetes on fetus - Answer: -congenital anomalies (CNS, cardiac, skeletal) -stillbirth (IUFD) -macrosomia or small at birth -birth injury -respiratory distress syndrome -hypoglycemia -hyperbilirubinemia pre gestational diabetes- changes for pregnancy - Answer: -blood glucose goals: fasting (60-99), 1 hour post prandial (100-129), 2 hours post prandial (120 or less) -insulin needs drop first trimester, then rise beginning week 14-16 -sleep, diet, insulin, BG testing, exercise on consistent daily schedule pre gestational diabetes- intrapartal care - Answer: -BG every hour: goal is 90-110 ml/dL -IV: continuous insulin infusion, saline or LR until BG <70, then switch to dextrose -fetal monitoring -alert for shoulder dystocia -peds/NICU present for birth. newborn close monitoring -skin to skin and breastfeed early pre gestational diabetes-post partum - Answer: -IV insulin until eating regular diet -insulin needs will be close to pre-pregnancy levels, lower if breastfeeding (recommended) -monitor for pre-eclampsia, hemorrhage, infection gestational diabetes - Answer: -diagnosis typically occurs during 2nd half of pregnancy -pancreas, stressed by adaptation of pregnancy, falls behind on insulin production -increasing prevalence due to risking mean maternal age and weight maternal risks/complications of gestational diabetes - Answer: -operative birth -increased risk of future T2DM -increased risk of future cardiovascular problems -increased risk of PPD fetal risks/complications of gestational diabetes - Answer: -macrosomia -birth trauma -hypoglycemia GDM screening - Answer: -initial prenatal visit -screening by history, risk factors, blood glucose -universal screening at 24-48 weeks GDM screening and diagnosis - OGTT - Answer: -screening: positive 1 hour OGTT > 130 mg/dL -diagnostic: 3 hours OGTT (done if 1 hour OGTT >130) fasting >95 1 hour >180 2 hour >155 3 hour >140 -positive for GDM if 2 results are at or above levels -oral glucose tolerance test 50 g of sugar risk factors for GDM - Answer: -age >25 years -obesity -family history of T2DM -polycystic ovarian syndrome (PCOS) -previous pregnancy history: macrosomia (>4500g), polyhydramnios, unexplained stillbirth, miscarriage, infant with congenital anomalies GDM management - Answer: -diet and exercise -BG monitoring; urine testing -possible pharmacologic therapy: oral (glyburide, metformin); about 25% need insulin -fetal surveillance: U/S, monitor growth, non stress test (NST), start at 32 weeks if on insulin GDM - intrapartal and PP - Answer: -BG goal 80-110 -avoid dextrose IV -may need rapid acting insulin IV -postpartum: encourage breastfeeding, follow up glucose levels, assess for PPD summary of diabetes - Answer: -normal pregnancy insulin requirements go down in 1st trimester and increase in 2nd and 3rd -pregestational DM can cause fetal anomalies, IUGR or macrosomia. requires tight control with insulin. IV insulin in labor -gestational DM occurs after 20 weeks, may not need insulin. screen at 24 weeks. macrosomia common -intrapartally. no IV dextrose unless BG <70. risk for pre-eclampsia, infection, birth injury -newborns at risk!! keep them warm hyperemesis gravidarum - Answer: -severe nausea and vomiting of pregnancy -weight loss, dehydration, electrolyte imbalance, nutritional deficiencies, ketonuria -usually occurs in first 20 weeks risk factors for hyperemesis gravidarum - Answer: -nulliparity -overweight -history of migraines -Hx psychiatric problems -thyroid disorder -diabetes -self or family history of hyperemesis -fetus with chromosomal abnormality (e.g. trisomy 21) -multifetal gestation -gestational trophoblastic disease -female fetus maternal complications of hyperemesis gravidarum - Answer: -metabolic acidosis -jaundice -esophageal rupture -vitamin K deficiencies; Wernicke's encephalopathy fetal complications with hyperemesis gravidarum - Answer: -Intrauterine Growth restriction (IUGR) -Low birth weight -preterm nursing assessment for hyperemesis gravidarum - Answer: -history: N/V, other GI symptoms, precipitating factors, nonpharmacologic and pharmacologic interventions, pre pregnancy weight (gain or loss), self or family hx of hyperemesis -assessment: vitals, weight, dehydration -Labs: electrolytes, CBC, liver enzymes, bilirubin, thyroid, urine for ketones, specific gravity -psychosocial assessment management of hyperemesis gravidarum - Answer: -NPO initially until vomiting stops -slowly introduce liquids and bland foods -IV fluids -medications: B6+ sleep aid, antinausea, corticosteroids (if not responding to other meds, risk of facial clefting in first trimester) -severe cases --> enteral or parenteral nutrition non-pharmacologic management of hyperemesis gravidarum - Answer: -hypnosis -supportive psychotherapy -acupressure --> stimulate median nerve nursing care of hyperemesis gravidarum - Answer: -I + O, amount and character of emesis -good oral hygiene -quiet environment -avoid strong odors -psychological support for patient and family education for hyperemesis gravidarum - Answer: -small frequent meals q 2-3 hours -low fat, high protein -no greasy foods -herbal tea --> ginger, chamomile, raspberry leaf -ginger ale (warm with sugar) -salty and sweet approach preterm labor - Answer: contractions causing cervical change between 20 and 35 6/7 weeks gestation preterm birth - Answer: -birth between 20 and 36 6/7 weeks -longer hospital stays and higher costs -premies often face serious and long term health problems -ethical decisions regarding treatment -higher rates in black women risk factors for preterm labor - Answer: -history of prior preterm births--> most significant -PPROM -infection (Group B strep, STIs, bacterial vaginosis, UTI) -age <17 or >34 -short cervix or cervical "insufficiency" -uterine variations or complications (e.g. fibroids) -multiple miscarriages -multiple gestation -smoking, cocaine, and other substance abuse -socioeconomic factors, work/stress, access to care -underweight/low BMI RN role in preterm labor - Answer: -identify clients at risk for PT birth -help clients modify risk factors (smoking, STIs, etc) -educate patients to identify symptoms of PTL PTL assessment - Answer: -screen for risk factors -patient eduction --> teach s/s to report 6 contractions/hour or more menstrual like cramps discharge pushing down pressure low, dull backache PTL diagnosis - Answer: -nursing contribution: history taking, observation -cervical changes: early effacement, dilation, consistency -diagnostic tests: fetal fibronectin (FFN), cervical length fetal fibronectin (FFN) - Answer: *biochemical marker for risk assessment* -test checks for FFN (glycoprotein "glue") in vaginal secretions -presence is normal after 35 weeks -presence is abnormal between 22-35 weeks preterm labor- benefits of negative FFN - Answer: has positive predictive value that patients will not give birth in the next two weeks postitive FFN - Answer: *requires further evaluation* -low predictive value --> does not reliably predict going into labor but requires action -do ultrasound for cervix length -consider steroids for fetal lung development -consider meds to stop contractions -plan for potential need for intensive care spirometry (ICN) cervical length determination by ultrasound - Answer: -cervix less than 3 cm increases likelihood of preterm birth -the shorter the cervix, the higher the risk of PTB preterm premature rupture of membranes (PPROM) - Answer: -rupture of membranes before 37 weeks -diagnosis: nitrazine paper (alkalinity), ferrying (fern pattern microscope; more specific) -serious complication is chorioamnionitis (bacterial infection) -intervention: assess for infection, PTL, and fetal well being, administer meds if ordered; active v/s expectant management causes of PPROM - Answer: -infection in uterus -STIs/UTIs -smoking -cervical ionization or LEEP procedure -short cervix -over distended uterus -low BMI/nutrition deficiencies/low socioeconomic status interventions for preterm labor - Answer: -prevention is #1: 17 P (alpha hydroxyprogesterone); early recognition and diagnosis; lifestyle modifications -treatment: cerclage for cervical problems -tocolytic therapy --> stops uterine contractions: terbutaline/berthine, nifedipine/procardia, magnesium sulfate, indomethacin/indocin -steroids for fetal lung maturity: betamethasone 12 mg (IM) x 2 doses 24 hours apart nursing support when PTL/PTB occurs - Answer: -emotional support and sensitivity -education advocacy -breast pumping -promote bonding -refer for additional resources early pregnancy bleeding - Answer: before 20 weeks gestation spontaneous abortion - Answer: -a pregnancy that ends due to "natural causes" before 20 weeks gestation -also referred to as miscarriage -when after 12 weeks GA considered late miscarriage -25% of all losses result from chromosomal abnormalities -other causes: endocrine imbalance (diabetes), immunologic (antiphospholipid antibodies), and systemic disorders (lupus) and genetic factors risk factors for second trimester loss - Answer: *a late miscarriage occurs at 12-20 weeks of gestation* risk factors for second trimester loss: -poor outcomes in previous pregnancy -extremes of maternal age -severe dietary deficiencies -regular or heavy alcohol use -morbid obesity -excessive caffeine intake classifications of spontaneous abortion - Answer: -threatened: spotting and mild cramping, the cervix is closed -inevitable: moderate to heavy bleeding and mild to severe cramping; the cervix dilates -incomplete: retained placenta; results in heavy bleeding and severe cramping -complete: after all fetal tissue is expelled; the cervix is closed; results in slight bleeding and mild cramping -missed: the fetus dies in utero but is not expelled -recurrent: loss of three or more pregnancies <20 weeks -septic (uncommon): slight to heavy vaginal bleeding that is usually malodorous, fever and abdominal tenderness assessment for spontaneous abortion - Answer: -pregnancy history, last menstrual period -vital signs -type and location of pain -quantity and nature of bleeding -emotional status -Labs: beta hCG and CBC *management depends on the classification of the miscarriage and the s/s* care management for spontaneous aortion - Answer: -threatened abortion --> bed rest (50% remain pregnant) -most miscarriages will end with passing POC -some will have dilation and curettage (D + C) -recurrent --> if due to weakness of cervical tissues can be corrected surgically by cerclage placement -administer RhoGam if RH -provide and refer for support as needed review of spontaneous abortion - Answer: -spontaneous abortion = loss of pregnancy <20 weeks due to natural causes -early = <12 weeks, 25% of losses result from chromosomal abnormalities -late = 12-20 weeks -diagnosed by history, S+S, labs, cervical exam, and transvaginal ultrasound -care management depends on the classification of the AB and S&S ectopic pregnancy - Answer: fertilized ovum is implanted outside the uterine cavity etiology of ectopic pregnancy - Answer: -the uterine tubes have fimbriated (fringed) ends that pull the ovum into the tube at ovulation -the ovum is usually fertilized in the mid/outer section of the tube then travels to the uterus to implant -with an ectopic pregnancy the ovum does not travel to the uterus often due to a blockage in the tube -risk factors: tubal surgery, infection and or damage, STDs, IUD, assisted reproductive technologies unruptured ectopic pregnancy - Answer: -occurs around 6-8 weeks after LMP -abdominal pain which begins as dull lower quadrant pain (on one side) then changes to sharp pain as tube stretches -believes experiencing a delayed period (1-2 weeks) or lighter than usual -abnormal vaginal bleeding (mild/moderate, dark red or brown) ruptured ectopic pregnancy - Answer: -occurs between 6-12 weeks gestation -pain increases and may be generalized, one sided or in deep lower quadrant -referred shoulder pain as blood enters the peritoneal cavity -signs of shock (low BP, increased HR, confusion, decreased LOC, clammy skin) diagnostic tests for ectopic pregnancy - Answer: -transvaginal ultrasound -hCG -progesterone level -CBC care management for unruptured ectopic pregnancy - Answer: -<4cm in size and no cardiac activity --> IM methotrexate -antimetabolite, antineoplastic agent -stops growth of actively dividing cells (embryonic, fetal and early placental cells) -helps to maintain tubal patency and fertility care management for ruptured ectopic pregnancy - Answer: -surgical repair of uterine tube -administer RhoGAM for Rh- clients -increased risk for infertility and recurrent ectopic pregnancy -refer for support late pregnancy bleeding - Answer: after 20 weeks gestation placenta previa - Answer: the placenta impacts in lower uterine segment near or over the cervical os risk factors for placenta previa - Answer: -previous cesarean section or placenta previa -multiple gestation (larger placental area) -closely spaced pregnancies -maternal age >35 -multiparity -smoking classification of placenta previa - Answer: classified according to the degree that the internal cervical os is covered (visualized by ultrasound) -complete: internal os entirely covered with placenta -marginal (partial): the edge of the placenta is 2.5 cm or closer to the internal cervical os -low lying: placental implanted in lower uterine segment, but does not reach the os *clients will not be able to have a vaginal delivery if there is complete or partial placenta previa* clinical manifestations of placenta previa - Answer: -painless, bright red vaginal bleeding -bleeding due to stretching and thinning of lower uterine segment which disrupts placental blood vessels -bleeding is intermittent and varies in quantity -maternal vital signs may be WNL even with heavy blood loss complications of placenta previa - Answer: -maternal: hemorrhage, surgical complications from a c/s, anemia, infections, thrombophlebitis -fetal: preterm birth, IUGR, malpresentation and stillbirth care management for placenta previa - active bleeding - Answer: -admit to L+D for continuous fetal monitoring and uterine monitoring -insert a large bore IV --> anticipate need for blood products -no vaginal examinations are performed as a pelvic exam can precipitate a hemorrhage (Put a sign above the bed) -labs: CBC, coagulation profile, type and screen -steroids to promote fetal lung maturity if <34 weeks ->36 weeks gestation, or if bleeding is excessive or persistent immediate cesarean is indicated (placenta <2 cm of the cervix) -provide emotional support care management for placenta previa - stable with no active bleeding - Answer: *may be hospitalized at a tertiary care perinatal center* expected management: -observation and bed rest with BRP -assess bleeding by a pad count -fetal surveillance testing: NST, ultrasound -serial labs --> CBC and coagulation values -monitor for signs of preterm labor home care management for placenta previa - Answer: *criteria vary and are determined on a case by case basis* -stable condition with no bleeding for 48 hours -must have resources to be able to return to the hospital immediately if active bleeding resumes -limited activity (bedrest with BRP, pelvic rest) -close supervision by family/friends -the patient is taught how to assess fetal movement counts, uterine contractions and amount of bleeding (pad count) -diversional activities, refer to online support group -frequent fetal surveillance testing (NST, ultrasound) blood tests (HCT) and prenatal visits 1-2 times a week review of placenta previa - Answer: -placenta implanted over or near cervix, classified according to degree of cervical coverage -S/S = bright red painless bleeding -diagnosed by ultrasound only -care management depends on whether the bleeding is active and maternal/fetal status -home care is an option when stable placental abruption - Answer: -detachment of a normally implanted placenta from the uterus (part or all) after 20 weeks gestation and before the birth of the fetus -accounts for significant maternal/fetal morbidity and mortality placental abruption risk factors - Answer: -hypertension -cocaine usage -blunt abdominal trauma or motor vehicle accident -other: cigarette smoking, history of abruption in a previous pregnancy classification of placental abruption - Answer: *classified according to type and severity* -grade 1: mild separation (10-20%) -grade 2: moderate separation (20-50%) -grade 3: severe separation (>50%), fetal death -the separation may be partial or complete or only the margin of the placenta may be involved -vaginal bleeding can be apparent or concealed--> bleeding is apparent if a placental edge has lifted, bleeding can be concealed if the placental edges remain intact clinical manifestations of placental abruption - Answer: -vaginal bleeding -abdominal pain -uterine tenderness and contractions -mild to severe uterine hypertonicity (board like) -increasing fundal height D/T concealed bleeding -non reassuring FHR complications of placental abruption - Answer: hemorrhage, hypovolemia (shock, oliguria, anuria), coagulopathy, preterm birth, IUGR, newborn neurological deficits placental abruption care management - Answer: -labs: abnormal clotting profile, decrease in hemoglobin and hematocrit -ultrasound not always diagnostic -management depends on severity of blood loss, fetal maturity, and maternal/fetal status -birth will be expedited if the fetus is term, bleeding is moderate or severe or if the patient or fetus is in jeopardy -if <34 weeks and in stable condition, expectant management can be implemented. the care is the same as for placenta previa -home care is not an option placental abruption review - Answer: -abruptio placentae= detachment of part or all of placenta before delivery -risk factors: HTN, cocaine, MVA/blunt trauma -separation may be partial or complete, and bleeding is not always evident -S/S= closely spaced contractions, non reassuring FHR, abnormal labs -care management depends on severity of blood loss, and maternal/fetal status -home care is not an option risks of hypertensive disorders of pregnancy - Answer: one of the leading causes of maternal morbidity and mortality -maternal risks: placental abruption, renal, cardiac, or hepatic failure, coagulopathy, seizures, and stroke -fetal risks: IURG (intrauterine growth retardation), preterm birth, fetal demise pathophysiology of hypertensive disorders of pregnancy - Answer: -normal adaptations of pregnancy: increased plasma volume (40-50%), vasodilation, decreased peripheral resistance, elevated CO, decreased BP (peaks 28-32 weeks) -with hypertension: generalized vasospasm, poor tissue perfusion to all organ systems, increased peripheral resistance and BP, increased cell permeability and capillary leakage classifications of hypertensive states of pregnancy - Answer: -gestational hypertension -preeclampsia eclampsia --> without severe features, with severe features, eclampsia -chronic hypertension with or without superimposed preeclampsia gestational hypertension - Answer: -development of mild hypertension without proteinuria after 20 weeks gestation -diagnostic criteria: BP>140/90, two occasions at least 4 hours apart, after 20 weeks gestation in a woman with previously normal BPs preeclampsia without severe features - Answer: -development of mild hypertension with proteinuria after 20 weeks gestation -diagnostic criteria: BP>140/90 (two at least 4 hours apart), urine dipstick >1 OR protein/creatinine ratio >0.3 mg/dL OR 24 hour urine >300 mg protein preeclampsia with severe features - Answer: *presence (addition) of at least one severe feature* -BP >160/110 -thrombocytopenia (platelet count <100,000) -renal insufficiency (elevated serum creatinine) -impaired liver function (elevated liver enzymes) -pulmonary edema -cerebral or visual symptoms eclampsia - Answer: -the onset of seizure activity or coma in a woman with preeclampsia who has no history of preexisting pathophysiology that can result in seizure activity -50% occur in antepartum period HELP syndrome for preeclampsia - Answer: *laboratory variant of preeclampsia with severe features with hepatic dysfunction* H-hemolysis of RBCs EL-elevated liver enzymes LP-low platelet count -usually develops in 3rd trimester or within 48 hours after birth -women present with flu like symptoms (malaise, epigastric or RUQ pain, HA, N/V) -small number present with bruising or hematuria (from thrombocytopenia) -potential complications: acute renal failure, pulmonary edema, liver hemorrhage or failure, DIC< placental abruption, ARDS, stroke, IUDR -rate of preterm birth 70% chronic hypertension - Answer: -chronic hypertension: prior to pregnancy OR prior to 20 weeks gestation OR persists longer than 6 weeks postpartum -with superimposed preeclampsia: women with chronic hypertension that develop proteinuria, new onset severe features, significant increase in BP review of hypertension in pregnancy - Answer: -gestational HTN: occurs after 20 weeks gestation -preeclapsia: HTN and proteinuria after 20 weeks gestation, classified with or without severe features, progressive diorder -ecclampsia --> onset of seizures or coma -HELP syndrome--> variant of preeclampsia with hepatic dysfunction, based on abnormal lab results -chronic HTN and or proteinuria- occurs before pregnancy or before 20 weeks gestation or persists beyond 6 weeks postpartum risk factors for preeclampsia - Answer: -primiparity -previous preeclamptic pregnancy -chronic HTN or chronic renal disease or both -history of thrombophilia -multifetal pregnancy -family history of preeclampsia -Type I or II diabetes mellitus -obesity -systemic lupus erythematosus -maternal age (<19 or >40 years) -paternal history (partner previously fathered a preeclamptic pregnancy in other women) -maternal infection/inflammation in current pregnancy routine pregnancy care to aid in preeclampsia - Answer: -early prenatal care -identify women at risk -early detection -education -routine assessment --> weight, BP, edema, urine dipstick nursing assessments for clients with elevated blood pressure - Answer: -monitor BP: two blood pressures 4 hours apart needed for diagnosis of preeclampsia; if in severe range have patient rest and retake BP in 15 minutes, treat severe BP immediately -lab work: CBC with platelet count, liver enzymes, creatinine -24 hour urine protein assessments -fetal evaluation: non stress test, biophysical profile, ultrasound -assess for S/S of severe features: severe headaches, visual changes, mental confusion, RUQ or epigastric pain, nausea or vomiting, shortness of breath, decreased output -assess DTRs, breath sounds, edema -provide emotional support preeclampsia prevention - Answer: -low dose aspirin (81 mg) taken nightly starting at 12 weeks gestation recommended for those with high risk of developing preeclampsia -risk factors include: history of preeclampsia, multifetal gestation, renal disease, autoimmune disease, Type I or II diabetes, chronic hypertension -aspirin is also recommended for those with 2 or more moderate risk factors (AMA, BMI >30, family history, etc) nursing care for gestational hypertension or preeclampsia without severe features - Answer: for diagnoses prior to 37 weeks: -inpatient or outpatient management -evaluate twice weekly (client's BP/S&S; fetal NST) -if <37 weeks, steroids for fetal lung maturity -induction of labor at 37 weeks -home care (if BP <150/100, no symptoms, labs within NWL) -self assessment: BP, urine dipstick, fetal movement counts, S/S severe features (headache, dizziness, blurred vision) -modified bedrest review of preeclampsia - Answer: -risk factors: occurs most often with first pregnancies, new partner or age extremes -etiology unknown but placental abnormalities are thought to be the root cause, thus the disease begins to resolve after birth -prenatal care: identify women at risk and early detection -preeclampsia without severe features --> initially hospitalized for a thorough evaluation, home on modified bed rest with close maternal/fetal surveillance -labor will be induced at 37 weeks interventions for preeclampsia with severe features - Answer: -admit to L+D for a thorough evaluation -labs (platelet count, liver enzymes, kidney function tests) -maternal assessments (vital signs, DTRs, subjective symptoms- headache, vision changes, epigastric pain) -bedrest, IV, Foley catheter, hourly I+O -initiate seizure precautions --> dim lights, reduce noise, limit visitors, check oxygen, suction, oral airway at bedside, side rails up preeclampsia with severe features- 34 weeks or more - Answer: immediate induction of labor or cesarean birth -risks of continuing pregnancy outweighs premature birth -give corticosteroids for fetal lung maturation if not received before (dependent on severity of symptoms) preeclampsia with severe features- less than 34 weeks - Answer: monitor closely and induce or perform cesarean as indicated -give corticosteroid for fetal lung maturation and wait 48 hours if possible -notify pediatric team to attend birth antihypertensive medication - Answer: -treatment of BP for systolic >160 and/or diastolic >110 -IV labetalol: onset 2-5, peak 5 minutes -IV hydralazine: onset 5-20 minutes, peak 15-30 minutes -PO labetalol: onset 20 min-2 hours; peak 1-4 hours -PO Nifedipine: onset 5-20 minutes, peak 30-60 minutes magnesium sulfate - Answer: -CNS depressant, anticonvulsant, and smooth muscle relaxant -loading dose: 4-6 grams in 100 mL IV -maintenance dose: 40 g in 1000 mL of NS at 2 g/hour -excreted by kidneys, toxicity will develop quickly with renal compromise -side effects: feeling warm, flushed, diaphoresis, burning at IV site -S/S toxicity: lethargy, respiratory depression, severe muscle weakness, absent DTRs, blurred vision, slurred speech, cardiac arrest -labs to check magnesium levels --> therapeutic level 4-8 mEq/L -antidote: calcium gluconate IV push slowly, typically by an MD eclampsia nursing priorities - Answer: -stay at the bedside --> call for help, note time of onset and duration of seizure, stabilize mother first -set priorities (ABC) : Airway (suction mouth, insert oral airway), Breathing (turn her on her side [recovery position], oxygen), Circulation (assess VS, then pad the side rails) -magnesium sulfate is drug of choice for treatment -then assess fetal status, uterine activity and cervical status --> during seizure the bag of waters may have ruptured eclampsia postpartum care - Answer: -seizures can still occur after birth -magnesium sulfate will be continued for 12-24 hours after birth -increased risk of PP hemorrhage (on magnesium sulfate) -methergine is contraindicated due to side effects of HTN -patient assessment: vital signs, I+O, DTRs, subjective S/S and normal PP assessments (uterine tone and lochia) -BP monitored for 72 hours -repeat BP assessment 7-10 days postpartum -repeat earlier in patients with symptoms -persistent hypertension --> treat with antihypertensives -long term: increased risk of chronic hypertension and cardiovascular disease later in life pre-eclampsia review - Answer: -preeclampsia with severe features --> admit to L+D for continuous maternal/fetal monitoring and seizure precautions -plan to deliver if 34 weeks gestation -magnesium sulfate is a CNS depressant and smooth muscle relaxant -eclampsia --> set priorities (ABCs) -first stabilize the patient then assess fetal and labor status -seizures can still occur after birth what parents experience with perinatal loss - Answer: -shock/disbelief -anticipatory grief -fear and anxiety -making impossible decisions -second guessing their decisions informing patients about perinatal loss - Answer: -give information both verbally and in writing -use layman's terms, speak their language -give every possible treatment option -repeat key points -give you contact information -follow up supporting patients with perinatal loss - Answer: -empathy and compassion -refer to the fetus as a baby/child -call the baby by. name -do not assume anything -do not share your beliefs or opinions -give them time and space -offer counseling or social worker -offer local resources nursing interventions with loss - Answer: -making memories: normalize the experience, reduce future regrets, give family time they need, discuss photographs, creating memorial items and healing experiences, remember all trauma is individual and relative -parenting the baby: naming the baby, having skin to skin, rocking/holding/kissing the baby, bathing the baby, putting a diaper and clothes on the baby, singing and reading to the baby, taking photographs, ask parents if they would like to request religious experience or ceremony what not to do with perinatal loss - Answer: -do not offer cliches or platitudes -do not impose faith or beliefs -do not judge or offer advice -do not compare losses what is helpful to say with perinatal loss - Answer: -we are here to support and guide you through this -I am so sorry for your loss -I care about you -You didnt do anything wrong -this isn't your fault -ask about the baby's name -tell them their baby is beautiful -if possible provide quiet and separate place for their family and loved ones -check on the spouse and partner typical trauma symptoms - Answer: -depressed mood, irritability, and anger -feelings of insecurity, guilt and low self worth -anxiety -flashbacks to loss -inability to remember moments around the loss experience -inability to concentrate, recurring thoughts, being in mental fog -sleep too much or too little expressions of secondary trauma - Answer: