ATI N306F5

West Coast University, Orange County Study Guide NURSING 306 Chapter 7 DURHAM: High Risk Antepartum Nursing Care Week 5 Pre WORK • Due @ 2359 on Sunday, Week 5 • Upload your copy under Journal Week 5 for Week 5 Pre work • Complete ATI N306F5 Practice Assessment and attach the report with a minimum score of 76%, with your prework Chapter 7 DURHAM: High Risk Antepartum Nursing Care Handwrite or type Define and explain: Medical management Nursing Actions/Interventions Patient education • PROM p 140 o Prolong rupture of membrane o Greater than 24 hours o Risk Factors for preterm PROM ▪ Previous preterm PROM or preterm delivery ▪ Bleeding during pregnancy ▪ Hydramnios ▪ Multiple gestation (up to 15% in twins, up to 20% in triples) ▪ Sexually transmitted infections (STIs) ▪ Cigarette smoking o Risk for the Woman ▪ Maternal infections (ex: chorioamnionitis) ▪ Preterm labor and birth ▪ Increase rates of cesarean birth o Risk for the Fetus and Newborn ▪ Fetal or neonatal sepsis • The earlier the fetal gestation at ROM, the greater the risk for infection • The membranes serve as a protective barrier that separates the sterile fetus and fluid from the bacteria-laden vaginal canal ▪ Preterm delivery and complications of prematurity ▪ Hypoxia or asphyxia because of umbilical cord compression due to decreased fluid ▪ Fetal deformities if preterm PROM before 26 weeks’ gestation o Assessment Findings ▪ Confirmed premature gestational age by prenatal history and ultrasound ▪ Confirmed rupture of membranes with speculum exam and positive ferning test ▪ Oligohydramnios on ultrasound may be seen but is not diagnostic o Medical Management Week 5 Pre WORK ▪ Pt with PROM between 34-36 wks should be managed as if they were term with induction of labor and treatment for group B streptococcal prophylaxis recommended ▪ Pt with PROM before 32 weeks of gestation should be cared for expectantly until 33 completed weeks of gestational if no maternal or fetal contraindications exist. ▪ All women with preterm PROM and viable fetus, GBS-should receive intrapartum chemoprophylaxis to prevent vertical transmission of group B streptococci ▪ Corticosteriods should be administered to women with preterm PROM before 32 weeks of gestation tor reduce risk of RDS, perinatal mortality, and other morbidities ▪ Delivery is recommended when preterm PROM occurs at or beyond 34 weeks of gestation ▪ With preterm PROM at 32-33 completed weeks of gestation labor induction may be considered if fetal pulmonary maturity has been documented ▪ Digital cervical exam should be avoided in pt with PROM unless they are in active labor or imminent delivery ▪ Monitor for infection, labor, and fetal compromise ▪ Assess for fetal lung maturity with LS ratio/ phosphatidyl glycerol (PG) ▪ Administer prophylactic antibiotic therapy to reduce maternal and fetal infection ▪ Antibiotic prophylactic therapy o Nursing Actions ▪ Assess FHR and uterine contractions ▪ Assess for signs of infection • Tachycardia • Fever > 100.4 F or 38C • Uterine tenderness • Malodorous fluid or vaginal discharge ▪ Monitor for labor and for fetal compromise ▪ Provide antenatal testing including non stress test (NST) and (BPP) • PPROM p140 o Preterm premature rupture of membranes o Rupture of membrane with a premature gestation <37 weeks • Pregestational Diabetes p147 o Women with preexisting pregestational diabetes have a fivefold increase in the incidence of major fetal anomalies of the heart and central nervous system (CNS) o Risk for the woman ▪ Hypoglycemia or hyperglycemia ▪ DKA 1% especially in second trimester ▪ Hypertensive disorders and preeclampsia (10%-15% risk) Week 5 Pre WORK ▪ Metabolic disturbances related to hyperemesis, nausea, and vomiting of pregnancy ▪ Preterm labor (25%risk) ▪ Spontaneous abortion (30% risk) ▪ Polyhydramnios/ oligohydramnios ▪ CS delivery ▪ Exacerbation of chronic diabetes-related conditions such as: heart disease, retinopathy, nephropathy, and neuropathy ▪ Infection related to hyperglycemia 80% UTI, chorioamnionitis and postpartum endometritis ▪ Induction of labor o Risk for the Fetus and Newborn ▪ Congenital defects including cardiac, skeletal, neurological, genitourinary and gastrointestinal related to maternal hyperglycemia during organogenesis ▪ Growth disturbances, macrosomia related of feta hyperinsulinemia ▪ Hypoglycemia related to fetal hyperinsulinemia ▪ Hypocalcemia and hypomanesemia ▪ IUGR r/t maternal vasculopathy and decreased maternal perfusion ▪ Asphyxia r/t fetal hyperglycemia and hyperinsulinemia ▪ RDS r/t delayed fetal lung maturity ▪ Polycythemia (hct <65%) r/t increased fetal erythropoietin ▪ Hyperbilirubinemia r/t polycythemia and RBC breakdown ▪ Prematurity ▪ Cardiomyopathy r/t maternal hyperglycemia ▪ Birth injury r/t macrosomia ▪ Stillbirth in poorly controlled maternal diabetes esp >36wks o Assessment Findings ▪ Pregestational diabetes, history of type 1 or type 2 diabetes ▪ Abnormal blood glucose levels ▪ HbA1C test to determine the average blood glucose levels over the last 4-8 weeks ▪ Cardiac, renal, and ophthalmic function assessment and evaluation o Self management Week 5 Pre WORK ▪ Monitor blood glucose 4-8 times per day • AM fasting <90 • Premeal < 105 • 1hr post pradial <140 • mean blood glucose <100 ▪ Monitor urine ketone • Moderate- large inadequate food intake o Report to provider ▪ Record keeping of BG levels, food intake, insulin, and activity ▪ Exercise 3-4 times a week for 20 minutes ▪ S/S of hypoglycemia for the prevention and management o Medical Management ▪ Achieving euglycemic control for 1-2 mo is recommended ▪ Achieving HbA1C less than 7% ▪ Multidisciplinary management ▪ Screening at diagnosis pregnancy • Kidney • Heart • Thyroid function • Eye exam • Ultrasound • Insulin tx o Nursing action ▪ Physiological changes- gestational diabetes ▪ Dietary counseling ▪ Self monitoring glucose/ urine ketones ▪ Importance of record keeping dietary intake ▪ Bring records of prenatal appointment ▪ Review sign and symptoms and treatment of hyperglycemia/hypoglycemia ▪ S/S of DKA ▪ Provide information when to call provider ▪ Management of N/V ▪ Provide an expected plan of prenatal care, antenatal test, fetal surveillance ▪ Provide expected plan for labor and delivery ▪ Arrange to meet with diabetic nurse educator ▪ Emphasize that changes in the management plan due to physiological changes ▪ Arrange for antenatal testing ▪ Antenatal testing generally starts at 28 weeks’ gestation includes NST and BPP • Gestational Diabetes o Define as any degree of glucose intolerance with the onset or first recognition in pregnancy o Pregnancy is a condition characterized by progressive insulin resistance that begins mid-pregnancy and progress throughout the gestation o Two main contributors to insulin resistant ▪ Increased maternal adiposity ▪ Insulin desensitizing hormones produced by the placenta o Risk factors for GDM ▪ No known risk factors are identified in 50% of patients with GDM ▪ History of fetal macrosomia ▪ Strong family history of diabetes ▪ Obesity o Risk factor for the woman ▪ Hypoglycemia and DKA ▪ Preeclampsia ▪ CS birth ▪ Development of non-gestational diabetes o Risk factor for the Fetus and Newborn ▪ Macrosomia-places fetus at risk for birth injuries such as brachial plexus injury ▪ Hypoglycemia during the first few hours post birth ▪ Hyperbilirubinemia ▪ Shoulder dystocia ▪ RDS ▪ The magnitude of fetal-neonatal complications is proportional to the severity of maternal hyperglycemia ▪ Risk of GDM for newborns are similar to risks with pregestational diabetes, except they are not at risk for congenital anomalies o Assessment Finding ▪ Abnormal glucose screening results o Medical Management ▪ GDM consultation and referral ▪ Diet and exercise ▪ Insulin management ▪ Oral medication ▪ CS birth is recommended for estimated fetal weight >4,5OO g ▪ Women with GDM need to monitor type 2 diabetes after birth o Nursing action ▪ Management of GDM is glycemic control ▪ Test glucose 4 times per day (1 fasting, 3 postprandial checks/day) • 95mg/ dL before meals • 120-135 mg/ dL after meals ▪ Effects of elevated glucose on developing fetus ▪ Encourage active participation in management and decision making ▪ Teach the woman to monitor fasting ketonuria levels in the morning ▪ Teach self administration of insulin ▪ Teach for s/s & treatment for hypoglycemia, hyperglycemia, DKA ▪ Diet management 33-40% complex CHO, 35-40% fat, 20% protein ▪ Exercise 10-15 minutes after meal is beneficial and 3 X per week for 30 mins • Preeclampsia p 152 Week 5 Pre WORK o Hypersensitive, multisystem disorder of pregnancy o Mild to severe hypertension o Pregnant specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation o Risk Factors for preeclampsia/ Eclampsia ▪ Nulliparity ▪ Age younger than 19 or older than 35 years ▪ Obesity ▪ Multiple gestation ▪ Family history of preeclampsia ▪ Preexisting hypertension or renal diseas ▪ Previous preeclampsia or eclampsia ▪ Diabetes Mellitus o Risk for the woman ▪ Cerebral edema/ hemorrhage/stroke ▪ DIC ▪ Pulmonary edema ▪ CHF ▪ Hepatic failure ▪ Renal Failure ▪ Abruptio placenta o Risk for the Fetus and Newborn ▪ Prematurity delivery may be indicated preterm related to deterioration of maternal status ▪ Intrauterine growth restriction (IUGR) related to decrease uteroplacental perfusion ▪ Low birth weight ▪ Fetal intolerance to labor because of decrease placental perfusion ▪ Stillbirth o Assessment findings (accurate assessment) ▪ Elevated blood pressure- HTN >140mmHG, >90mmHg ▪ Proteinuria 1+ or greater ▪ Lab values (liver function, Kidney function, altered coagulopathy) o Medical management ▪ Magnesium Sulfate (IV)-CNS depressant tx for seizure ▪ Antihypertensive medications ▪ Management of preeclampsia- rest, frequent MD visit, Monitor BP ▪ Delivery for fetus and placenta- only CURE o Nursing action ▪ Early recognition and accurate assessment ▪ Accurate blood pressure measurement ▪ Administer hypertensive as per order BP > 160/110mmHg ▪ Administer Magnesium sulfate ▪ Assess for CNS changes including HA, Visual changes, DTR and clonus Week 5 Pre WORK ▪ Auscultate lung sounds ▪ Monitor respiratory rate ▪ Assess for S/S of respiratory edema ▪ Assess for epigastric pain ▪ Assess weight daily (edema/ fluid retention) ▪ Check urine for proteinuria (include 24 hr urine collection) and specific gravity ▪ Evaluate laboratory values • Serum creatinine (72mg/dL) • Hematocrit levels (>35) • Low platelet count (100,000 /mm3) • Elevated liver enzymes (AST>41 units/L, AST >30 units/L) ▪ Perform antenatal fetal testing and FHR monitoring (NST and BPP) ▪ Check intake of adequate calories and protein ▪ Maintain accurate I & O to evaluate kidney function (2000ml/24hr) restriction ▪ Provide a quiet environment to decrease CNS stimulation ▪ Maintain bed rest in the lateral recumbent position ▪ Provide education to family and the woman ▪ Report deterioration in maternal or fetus status to provider • Eclampsia Syndrome p 155 o Occurrence of seizure activity in the presence of preeclampsia o Can occur ante, intra, or postpartum o Eclampsia is triggered by ▪ Cerebral vasospasm ▪ Cerebral hemorrhage ▪ Cerebral ischemia ▪ Cerebral edema o Warning sign ▪ Severe persistent headaches ▪ Epigastric pain ▪ N/V ▪ Hyperreflexia with clonus ▪ Restlessness o Care during seizure ▪ Remain with the patient ▪ Call for help ▪ Assess airway and breathing • Lower the head of the bed and turn the head on one side • Anticipate the need for suction • Aspiration is leading cause of maternal mortality ▪ Prevent maternal injury • Padded tongue blade should be inserted to prevent tongue injury • Keep sides rail up ▪ Record the time, length and type of seizure activity ▪ Notify physician ▪ After the seizure is done • Rapidly assess maternal and fetus status • Assess airway, suction if needed • Administer supplemental oxygen 10L/min via mask Week 5 Pre WORK • Ensure IV access • Administer magnesium sulfate per order • Provide quiet environment • Preeclampsia superimposed on chronic hypertension p151 o Hypertensive women who develop new- onset proteinuria; proteinuria <20wks gestation; or sudden increase in proteinuria or BP or platelet count <100,000 in women with HTN and proteinuria in <20wks gestation • Gestational hypertension p 151 o Sytolic BP> 140/90BP for the first time after 20 weeks, without proteinuria. When the BP increases appreciably, it can be danger to mother and the fetus • Chronic hypertension p 151 o Hypertension BP> 140/90 before conception or before the 20 wks of gestation o Hypertension diagnose after 20 wks that persist after 12 weeks of postpartum may put the woman at high risk of developing preeclampsia • HELLP Syndrome p 156 o Hemolysis Elevated Liver ezymes and Low platelet o Variant changes in lab values that can occur as complication of severe preeclampsia ▪ Hemolysis is a result of RBC destruction as the cells travel through constricted vessels ▪ Elevated liver enzymes result from decreased blood flow and damage to the liver ▪ Low platelet result from platelets aggregating at the site of damaged vascular endothelium causing platelet consumption and thrombocytopenia ▪ Critical component • Platelets <100,000mm3 • Liver enzymes (AST > 70 units/L, ALT>50 units/L) • Bilurubin >1.2 mg/dL • LDH >600 units/L o Risk for the woman ▪ Abruptio placenta ▪ Renal Failure ▪ Liver hematoma and possible rupture ▪ Death o Risk for the fetus and newborn ▪ Preterm birth ▪ Death o Assessment findings ▪ The woman may present with a complaint of general malaise, nausea, and right upper gastric pain ▪ Unexplained bruising, mucosal bleeding, petechiae, and bleeding from injection and IV sites ▪ Lab test (changes in liver function and platelet) o Medical Management ▪ Cure is immediate delivery of fetus and placenta o Nursing Action ▪ Perform thorough assessment of the women related to diagnosis of preeclampsia ▪ Evaluate lab result ▪ Notify MD if HELLP syndrome is suspected ▪ Administer plt as per orders ▪ Assess and management the same with preeclampsia ▪ Provide information and treatment to woman and family ▪ Provide emotional support • Placenta Previa p157 o Occurs when the placenta attaches to the lower uterine segment of the uterus, near or over the internal cervical os instead of in the body or fundus of the uterus o TOTAL PLACENTA PREVIA- The placenta completely covers the internal cervical os o PARTIAL PLACENTA PREVIA- The placenta partially covers the internal cervical os o MARGINAL PLACENTA PREVIA- The edge of the placenta is at the margin of the internal cervical os o LOW LYING PLACENTA- The placenta is implanted in the lower uterine segment in close proximity to the internal cervical os o Risk factors for Placenta Previa ▪ Endometrial scarring • Previous placenta previa • Prior cesarean delivery • Abortion • Multiparity ▪ Impeded endometrial vascularization • Advance Maternal Age >35 years • Diabetes or hypertension • Cigarette smoking • Uterine anomalies/fibroids/ endometritis ▪ Increase Placental mass • Large placenta • Multiple gestation o Risk for the woman ▪ Hemorrhagic and hypovolemic shock related to excessive blood loss ▪ Large volume of maternal blood flow to uteroplacental unit at term, unresolved bleeding can result in maternal exsanguination in 10 minutes’ ▪ Anemia Week 5 Pre WORK ▪ Potential Rh sensitization as Rh-negative women antepartum bleeding episode o Risk for the fetus and Newborn ▪ Disruption of uteroplacental blood flow can result in progressive deterioration of fetal status and the degree of fetal compromise is related to the volume of maternal blood loss ▪ Blood loss, hypoxia, anoxia, and death related to maternal hemorrhage ▪ Fetal anemia may develop due to maternal blood loss ▪ Neonatal morbidity and mortality is related primarily to prematurity o Assessment findings ▪ The classic presentation of placenta previa is painless hemorrhage and fetal malposition ▪ Bleeding usually occurs near the end of the second trimester or in the third trimester of pregnancy and initial bleeding episodes may be slight ▪ The first episode of bleeding is rarely life threatening or a cause of hypovolemic shock ▪ Ultrasound confirms placental location at the cervix ▪ A vaginal exam is contraindicated o Emergency Medical Management ▪ CS delivery is necessary when either maternal or fetal status is comprised as a result of extensive hemorrhage ▪ CS birth is necessary with all women with placenta previa ▪ Vaginal delivery may be attempted with a low lying placenta if one can proceed with an emergency CS birth if needed ▪ Placenta previa may be associated with placenta accreta, placenta increate, placenta percreta ▪ Blood is transfused as needed o Medical Management After stabilization ▪ When the maternal and fetal status is stable and bleeding is minimal <250 ml, prolong pregnancy and delaying delivery may be possible- when fetus is premature to allow for fetal lungs to mature ▪ Maternal bed rest ▪ Antenatal surveillance o Nursing actions ▪ Assessment: eval of color, character, & amt of bleeding, USN, fetal well being, GA, fetal lung maturity, vital signs ▪ Assess abdominal pain, uterine tenderness, irritability, contractions ▪ IV access ▪ Bed rest with bathroom privileges ▪ Assess FHR and UCs ▪ Corticosteroids: accelerate fetal lung maturity ▪ Labs: CBC, platelets, clotting ▪ Anticipate C/S ▪ RhoGAM to Rh – mom Week 5 Pre WORK • Placental abruption p158 o Premature separation of a normally implanted placenta o Placental abruption is initiated by hemorrhage into the decidual basalis o Hematoma formed that lead to destruction of the placen o Classified as 1 (mild), 2 (moderate), or 3 (severe) o Signs and symptoms ▪ Severe sudden intense abdominal pain ▪ UCs ▪ Uterine tenderness ▪ Dark vaginal non clotting bleeding ▪ Concealed hemorrhage: blood trapped between placenta and decidua ▪ Signs of hypovolemia ▪ Abnormal FHR o Risk factors ▪ Previous abruption ▪ HTN ▪ Abdominal trauma ▪ Cocaine, meth, smoking ▪ PPROM ▪ Thrombophilia ▪ Uterine anomalies/fibroids o Risks for Woma ▪ Hemorrhagic shock ▪ DIC ▪ Hypoxic damage to kidneys and liver ▪ PP hemorrhage o Risks for the fetus and Newborn ▪ Preterm birth ▪ Hypoxia, anoxia, neurological injury, fetal death r/t hemorrhage ▪ IUGR ▪ Neonatal death o Assessment ▪ Hypovolemic shock; hypotension; oliguria; thread pulse; shallow irregular respirations; pallor; cold, clammy skin; anxiety ▪ Vaginal bleeding ▪ Severe abdominal pain ▪ UCs/uterine tenderness/hypertonus/increase uterine distention ▪ N/V ▪ Decreased renal output ▪ Fetal tachycardia, bradycardia, category II or III FHR patterns (loss or variability of FHR, late decels, decreasing baseline) o Emergency med management ▪ Monitor volume status ▪ Restore blood loss ▪ Monitor fetal status ▪ Monitor coagulation status Week 5 Pre WORK ▪ Correct coagulation defects ▪ Expediting delivery o Nursing actions ▪ Monitor vaginal bleeding ▪ Assess abdominal pain ▪ Palpate uterus for contractions/tenderness/hypertonus/increasing uterine distension ▪ Manage N/V ▪ Assess for decreased renal output ▪ Monitor for hypotension and tachycardia ▪ Maintain IV access ▪ Admin O2 8-10L/min mask ▪ Assess FHR ▪ Monitor labs: CBC and clotting ▪ If undelivered and mom is Rh -, give RhoGAM • Venous Thromboembolic Disease p 174 o DVT and PE o Pregnancy is a hypercoaguable state: increased fibrin, increased coagulation factors, and decreased fibrinolytic activity. o Venous stasis in lower extremities, increased blood volume, compression of inferior vena cava and pelvic veins with advancing gestation all combine to increase risk o Risk factors: ▪ bed rest ▪ obesity, ▪ severe varicose vein, ▪ dehydration ▪ trauma ▪ history of thrombosis, ▪ diabetes, heart disease, renal disease, serious infection o Assessment ▪ DVT signs: dependent edema, unilateral leg pain, erythema, low grade fever, positive Homan’s (pain with dorsiflexion) ▪ PE: SOB, tachypnea, tachycardia, dyspnea, pleural chest pain, fever, anxiety o Medical Management ▪ Doppler, magnetic resonance venography, pulsed Doppler study for DVT ▪ Chest xray, CT, electrocardiography for PE ▪ Anticoagulation therapy with heparin o Nursing action Week 5 Pre WORK ▪ Manage pain ▪ How to admin heparin SQ ▪ Report side effect: bleeding gums, nosebleeds, easy bruising, excessive trauma • Maternal obesity p 175 o Risk factor for the development of preeclampsia, gestational, thrombosis and type 2 diabetes o CO increase by 30-50ml/min for every 100g of fat o Increase of blood volume o Cardiac hypertrophy exaggerate the hypertrophy leads to myocardial dilation o Obstructive sleep apnea o Gastric reflux o Increase risk of thrombosis o Fatty apron (large panniculus) contribute to uterine compression and pressure to vena cava o BMI Category ▪ BMI > or equal to 30 kg/m2 o Medical Management ▪ Provide specific information on maternal risks of obesity in pregnancy ▪ Provide specific information on the increased risk for an infant with a neural tube defect and for a stillborn infant ▪ The risks require heightened and ongoing evaluation of the pregnant woman and fetus o Nursing action ▪ Reinforce information on maternal and fetal risks associated with obesity ▪ Provide s/s of preeclampsia, diabetes, sleep apnea, and vena cava syndrome ▪ Ensure woman understand plan of care/ evaluation of pregnancy ▪ Provide referral for dietitian- weight gain management ▪ Use caution when shifting the panniculus to assess FHR & providing hygiene as weight may alter maternal hemodynamic and increase risk of vena cava compression ▪ Encourage the woman to sleep in sitting position ▪ Making appropriate environment changes that accommodate larger pt • Incompetent Cervix p 142 o Mechanical defect in the cervix that results in painless cervical dilation in the second trimester that can progress to ballooning of the membranes into the vagina and delivery of a premature fetus o Risk to woman ▪ Repeated second trimester or early third trimester births ▪ Recurrent pregnancy losses ( eg. Spontaneous abortions) ▪ Preterm delivery ▪ Rupture of membranes/infection o Risk to the Fetus and Newborn ▪ Preterm birth and consequences of prematurity Week 5 Pre WORK o Assess findings ▪ Woman reports pelvic pressure and increased mucoid vaginal discharge ▪ Shortened cervical length or funneling of the cervix, although use of ultrasound to diagnose cervical incompetence is not currently recommended ▪ Obstetrical history of second trimester cervical dilation or fetal losses ▪ Live fetus and intact membranes o Medical Management ▪ Obtain transcervical ultrasound to evaluate cervix for cervical length and funneling ▪ Cervical cultures for chlamydia, gonorrhea, and other cervical infections ▪ Cervix Cerclage- purse string suture place cervically to reinforce cervical suture • Prophylactic cerclage • Rescue cerclage ▪ Antibiotics or tocolytics ▪ Remove sutures if membranes rupture, infections occurs or labor pain o Postoperative Nursing Actions ▪ Monitor for uterine activity with palpation ▪ Monitor for vaginal bleeding and leaking of fluid/rupture of membranes ▪ Monitor for infection ▪ Administer tocolytics to suppress uterine activity as per orders ▪ Discharge teaching may include teaching patient to monitor s/s of uterine activity, ROM, bleeding, infection and monitor activity and pelvic rest for a week) • Hyperemesis Gravidarum p 146 o Vomiting during pregnancy that is so severe it leads to dehydrations, electrolyte, and acid-base imbalance, starvation ketosis, and weight loss. o r/t rapidly rising of hCG, progesterone, and estrogen o Assessment Finding ▪ Frequent, prolonged, and severe vomiting ▪ Weight loss, acetonuria, ketosis ▪ Dehydration: dry mucous membranes, poor skin turgor, malaise, low BP o Medical Management ▪ First line pharmacotherapy: Vit B6 or Vit B6 + doxylamine ▪ IV hydration with dextrose and vitamins (thiamine) ▪ Antihistamine H1 receptor blockers, phenothiazines, benzamides ▪ Monitor kidney and liver function ▪ Correction of Ketosis and vitamin deficiency ( dextrose and vitamins) o Nursing Actions ▪ Reduce or eliminate factors that contribute to N/V: eliminate odors ▪ Ginger ▪ Antiemetics ▪ Emotional support, comfort measures ▪ IV hydration with vitamins and electrolytes Week 5 Pre WORK ▪ Check weight, I&O, specific gravity ▪ NPO until vomiting controlled then advance as tolerated ▪ Minimize fluid intake with meals Define the following: • Gestational trophoblastic Disease p163 o Hydatiform mole ▪ Benign proliferating growth of trophoblast in which chorionic villa develop into edematous, cystic, vascular transparent vesicles that hang in grapelike cluster without a viable fetus o Molar o Non molar ▪ gestational trophoblastic neoplasia or malignant gestational trophoblastic disease • HIV in pregnancy p 164 o Retrovirus that has an affinity for T lymphocytes, macrophages, and monocytes; through transplacental, intrapartal, and breast milk exposure o Assessment: fever, fatigue, vomiting, diarrhea, weight loss, generalized lymphadenopathy, oral gingivitis, vaginitis, and opportunistic infection • STI p 165 o Risk to woman ▪ Cause pelvic inflammatory disease ▪ PID can lead to infertility, chronic hepatitis, cervical cancer, other cancers Week 5 Pre WORK ▪ During pregnancy can lead to PTL, PROM, uterine infection o Risk to fetus ▪ STIs pass to the fetus by crossing placenta; some transmitted to baby during delivery as baby passes through birth canal ▪ Preterm birth, low birth weight, neonatal sepsis, neurological damage • T.O.R.C.H. Infections p168 o Maternal effects o Fetal effects o Prevention and management o Nursing actions TOXOPLASMOSIS o TOXOPLASMA GONDII o Single-celled protozoan parasite. o Transplacental transmission o Maternal Effects o Most infections are asymptomatic but may cause fatigue, muscle pains, pnuemonitis, myocarditis, and lymphadenopathy. o Fetal Effects o Severity varies with gesta- tional age and congenital infection. Can lead to spontaneous abortion, low birth weight, hepatosplenomegaly, icterous, anemia, chorioretinitis, and/or neurological disease. o Incidence of congenital infection is low. o Prevention and Management o Avoid eating raw meat and contact with cat feces. o Treatment with sulfadiazine or pyrimethamine after the first trimester o Nursing Actions o Teach women to avoid raw meat and cat feces. Week 5 Pre WORK o Almost 50% of adults have an antibody to this organism. o OTHER INFECTIONS /HEPATITIS B o Direct contact with blood or body fluid from infected person. o Maternal Effects o 30%–50% of infect- ed women are asymptomatic. o Symptoms include low-grade fever, nausea, anorexia, jaundice, hepatomegaly, preterm labor, and preterm delivery o Fetal Effects o Infants have a 90% chance of becoming chronically infected, HBV carrier, and a 25% risk of developing significant liver disease. o Prevention and Management o Infant receives HBIG and hepatitis vaccine at delivery. o Nursing Actions o Universal screening recommended in pregnancy. o HBV can be given in pregnancy. o RUBELLA (GERMAN MEASLES) o Nasopharyngeal secretions o Transplacental o Maternal Effects o Overall risk of congenital rubella syndrome is 20% for primary maternal infection in the first trimester with 50% if the woman is infect- ed in the first 4 weeks of gestation. Anomalies include deafness, eye defects, CNS anomalies, and severe cardiac malformations. o Fetal Effects o Overall risk of congenital rubella syndrome is 20% for primary maternal infection in the first trimester with 50% if the woman is infect- ed in the first 4 weeks of gestation. Anomalies include deafness, eye defects, CNS anomalies, and severe cardiac malformations Week 5 Pre WORK o Prevention and Management o Primary approach to rubella infection is immunization. o If the woman is pregnant and not immune, she should not receive the vaccine until the postpartum period o Nursing Actions o If the woman is not immune, she should not receive the vaccine until the postpartum period and be counseled to not become pregnant for 3 months. o CYTOMEGALOVIRUS o Virus of herpes group o Transmitted by droplet contact and transplacentally o Maternal Effects o Most infections are asymptomatic, but 15% of adults may have mononucleo- sis-like syndrome. o Fetal Effects o Infection to fetus is most likely with primary mater- nal infection and timing of infection with first- and second-trimester exposure. May result in low birth weight, IUGR, hearing impairment microcephaly, and CNS abnormalities. o Prevention and Management o No treatment is available. o Nursing Actions o HERPES SIMPLEX VIRUS (HIV) o Chronic lifelong viral infection o Contact at delivery and ascending infection o Maternal Effects Week 5 Pre WORK o Painful genital lesions. o Lesions may be on external or internal genitalia. o Fetal Effects o Transmission rate of 30%– 50% among women who acquire genital herpes near time of delivery and is low (<1%) among women with recurrent genital herpes. o Mortality of 50%–60% if neonatal exposure to active primary lesion is related to neurological complications of massive infection sepsis and neuro- logical complications. o Prevention and Management o No cure available. o Acyclovir to sup- press outbreak of lesions. o Nursing Actions o Most common viral STI. o Protect the neonate from exposure with cesarean delivery if active lesion. • Iron-deficiency Anemia p 172 o Result of iron deficiency related to a diet low in iron content and insufficient iron stores o Risk factors ▪ History of poor nutritional status or eating disorder ▪ Close spacing of pregnancies ▪ Multiple gestation ▪ Excessive bleeding ▪ Adolescence ▪ o Risk factors for fetus ▪ Preterm birth ▪ Intrauterine growth restriction o Assessment findings ▪ Pallor ▪ Fatigue, weakness, and malaise ▪ Reduced exercise tolerance and dyspnea Week 5 Pre WORK ▪ Anorexia and/or pica ▪ Edema ▪ Hemoglobin below 10–11 g/dL ▪ Hematocrit below 30% o Medical management ▪ Iron supplement o Nursing actions ▪ Refer the woman to a dietitian for nutritional counseling and reinforce dietary interventions. ▪ Advise that taking iron supplementation at bedtime and on an empty stomach may increase absorption and decrease gastrointestinal upset. ▪ Discuss strategies to deal with constipation PRN. ▪ Assess fatigue and develop interventions and a plan of care to deal with fatigue. • Substance abuse p175 o Types o Risks to pregnancy and fetus o Smoking ▪ Reduces uterine blood flow ▪ Risk of premature delivery, low birth weight infants, stillbirth o Alcohol ▪ Physical and mental birth defects, preterm births, miscarriages ▪ Growth deficiencies, facial abnormalities, CNS impairment, behavioral disorders, impaired intellectual development o Cocaine ▪ Hypertension, tachycardia, UCs, MI, dysrhythmias, subarachnoid hemorrhage, thrombocytopenia, seizures, sudden death ▪ Preterm labor, PROM, abruptio placentae, repcipitous delivery, increased risk for meconium staining, premature and low birth weight infants o Heroin ▪ Withdrawal symptoms, increased incidence of meconium aspiration at birth, sepsis, IUGR, neurodevelopmental behavioral problems o Marijuana ▪ Altered response to visual stimuli, increased tremilousness, high pitched cry which may indicate a problem with neurological development