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Maternal and Child Health Nursing HESI Review Kauai Community College 2013 Prepared by: Jeffrey Viernes
Menstrual Cycle Indication of Ovulation Slight drop in temperature occur 1 day prior to ovulation, rise of 0.5 to 1 F occurs in ovulation Cervical mucus hyperplasia Goodles sign, Hegar sign and Chadwicks sign Spinnbarkeit Ferning test Fertilization Stages of Fetal Growth and Development Pre Embryonic Stage Zygote fertilized ovum (3 4 days travel, 4 days floating)> from fertilization Implantation 7 10 days after fertilization Embryonic Stage Zygote fertilization to 14 days Embryo 15th 2 mos/ 8 weeks Fetal Stage 2 mos to birth Signs of Pregnancy Fetal Changes 1st month: period of organogenesis, critical period 2nd month: placenta developed, all vital organs are developed 3rd month: sex is discernible, Doppler ultrasound (10-12 wks.) 4th month: FHT audible via Fetoscope @ 18 20 weeks 5th month: Quickening : 1st fetal movement Primi: 18 20, Nulli - 16 - 18 6th month: Skin is red and wrinkled, Vernix caseosa covers the skin 7th month: Surfactant development, Male: the testes begins to descent into the scrotal sac 8th month: Sub q fats deposits, steady weight gain, nails to fingers 9th month: L/S ration is 2:1

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Reva Rubin Psychological Adaptation to Pregnancy First Trimester Feeling of surprise Ambivalence Denial of pregnancy maladaptation Developmental Task: Accept biological facts of pregnancy Health Teaching: Body changes of pregnancy and Nutrition Second Trimester Mother identifies fetus as separate entity due to quickening Developmental Task: Accept growing fetus as a baby to nurture Health Teaching: Growth and development of fetus Third Trimester Mother has personally identifies with the appearance of the baby Developmental Task: Prepare child birth and parenting the child Health Teaching: responsible parenthood, prepare babys layette, Lamaze Class Address Mothers fear let she hear the FHT Antepartum Nursing Presumptive signs are subjective and recorded under the history of present illness Probable and positive signs of pregnancy are objective and recorded as physical assessment findings Prenatal Care Nageles Rule Weight Gain in Pregnancy Nutrition Inquire about dietary practices Gather 24-hour diet recall Suggest an addition of 300 healthy calories per day Encourage daily prenatal vitamin with 400 ug folic acid Suggest 68 glasses of water daily Encourage to follow food pyramid in daily choices Prenatal Visits and GTPAL

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Maternity Question The prenatal client states having three children at home. She reports that her son was born on his due date, but her daughters were both born a month early. She states that she lost a baby in her second month. What is the GTPAL of the client? Maternity Question A woman visits her obstetrician for a pregnancy test that is positive. In taking her history, she reports that she has been pregnant four times before. She has two children at home, one of which was born at 32 weeks gestation. She lost a set of twins at 14 weeks and another baby at 12 weeks. What is her para, gravida, and TPAL? a. G5, P4 (T1, P1, A2, L2) b. G5, P2 (T1, P1, A3, L2) c. G3, P2 (T1, P2, A2, L1) d. G3, P4 (T2, P3, A3, L2) Maternity Question The obstetrician asks the nurse to determine the due date for a pregnant client on her first prenatal visit. The client reports that her last menstrual period began on February 5, 2007 and ended on February 10, 2007. What is her due date? a. November 5, 2007 b. November 12, 2007 c. November 10, 2007 d. November 17, 2007

Determining the Gestation of the Fetus Warning Signs of Pregnancy Minor Complaints of Pregnancy Minor Complaints of Pregnancy Non-Stress Test Additional Tests Ordered During Pregnancy

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Maternity Question A fetus of a woman in labor is found to have a breech presentation, longitudinal lie, and a flexed attitude. In listening for fetal heart tones, the nurse would listen on the mothers abdomen a. below the umbilicus b. at the umbilicus c. above the umbilicus d. lateral to the umbilicus

A teenager purchases a home pregnancy test. She later asks the nurse how these tests work. The nurses response is that the pregnancy tests are based on which hormone? a. Oxytocin b. Estrogen c. Progesterone d. Human chorionic gonadotropin Maternity Question Monitoring the client during labor is the nurses responsibility. If the mother is not hooked up to a fetal monitor, the nurse would assess FHT at the following times: (Select all that apply.) a. on admission b. after each contraction c. immediately when the membranes rupture d. each time the mothers vital signs are taken e. as the mother enters each phase of labor Leopolds Maneuver Electronic Fetal Monitoring ACCELERATIONS Sudden increase of fetal heart rate over baseline Indication of fetal well-being Reassuring pattern Possible cause: Fetal movement/stimulation EARLY DECELERATION Decrease in FHR occurring with contractions

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Onset occurs before the contraction peak Commonly seen in active phase of first stage of labor Mirrors the contraction Continue to monitor FHR pattern for nonreassuring patterns Possible cause: Fetal head compression LATE DECELERATIONS Decrease in FHR occurring with contractions Onset with or after the peak of contraction Recovery to baseline rate occurs after contraction ends Repetitive pattern Nonreassuring requiring intervention Etiology: decreased uteroplacental blood flow/oxygen delivery VARIABLE DECELERATIONS Decrease in FHR occurring without regard to contractions Can range from mild to severe May be persistent or occasional Shaped like a V or W Onset variable Possible causes: Cord prolapse Umbilical cord compression Nursing Intervention for Nonreasuring FHR Patterns Turn patient to side-lying position O2 per mask at 810 L/min Discontinue IV Oxytocin Hydrate patient as indicated Notify primary health-care provider Document findings Monitoring Contraction Difference Between False and True Labor Signs and Impending Labor The 4 Ps of Intrapartum Passenger Passenger refers to the fetus. Fetal lieIt compares the long axis of the fetus (the spinal column) to the long axis (spinal cord) of the mother. Fetal presentationIt describes the part of the fetus that enters the maternal pelvis first. Fetal attitudeIt compares the relationship of fetal parts to each other.

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Fetal positionIt refers to the relationship between the presenting part of the fetus and the maternal pelvis. Passageway Made up of the birth canal and the maternal pelvis, the passageway can influence the delivery in either a positive or a negative manner. Gynecoidthe typical female pelvis provides the widest diameter in the true pelvis making delivery easier. Powers Power involves voluntary and involuntary powers that expel the fetus. Psyche The emotional state of the mother can affect the progress of labor. Intrapartum Nursing Latent phase onset of labor until the cervix is dilated to 3 cm. longest phase of the first stage of labor. Contractions palpate mild, every 510 minutes, lasting 3045 seconds The client is excited and talkative able to read and converse with others between contractions Active phase In this phase, there is 47-cm cervix dilation. Contractions palpate moderate to strong, every 25 minutes lasting 4060 seconds Patient may have greater difficulty coping with the pain of contractions Epidurals in labor Transition Contractions palpate strong, every 1.53 minutes lasting 4590 seconds Patient may feel a loss of control; provide encouragement to patient Cervical dilation (810 cm) Fetal descent (0/+1 station) Urge to push if presenting part is low Second Stage of Labor: Expulsion 10 cm dilated until the birth of the baby Power: Contractions palpate strong, every 23 minutes lasting 6090 seconds Patient may be eager or afraid to push Prepare for the birth of the baby Note precise time of birth Provide immediate care of the newborn

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Assign Apgar Score at 1 and 5 minutes Third Stage: Delivery of Placenta Strong uterine contractions cause the placenta to detach from the uterine wall Patient may be exhausted; encourage bonding with baby Signs of placental separation Sudden gush or trickle of blood from vagina Lengthening of visible umbilical cord at introitus Contraction of the uterus Fourth Stage of Labor First 12 hours after birth Remember the acronym BUBBLE HEB B breasts U uterus B bowel B bladder L lochia E episiotomy H Homans sign E Emotion B Bonding Maternity Question A pregnant woman at 14 weeks gestation calls the obstetricians office to report that she has noted some vaginal discharge. The discharge is clear and without odor. The office nurse would instruct the client to a. wear a peri-pad to absorb the liquid, which is normal b. douche with water to see if that improves the drainage c. do nothing, as vaginal discharge in pregnancy is normal d. report to the physicians office immediately for assessment

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Maternity Question A nurse is teaching a class of childbirth education to four women in late pregnancy. The women make the following statements. Which statement would most likely indicate that lightening has occurred? a. I can feel my baby move. b. Its hard to sleep at nightI have to lie on my side. c. I feel like my lungs are being crowded by the baby. d. d. I have to void frequently like I did in the first trimester.

A pregnant woman at term is being admitted to the labor room in early labor. During the admission process, the womans membranes suddenly rupture. Priority nursing activities at this time would include a. checking the fetal heart tones b. vaginal examination to determine dilation and effacement c. cleaning up the woman and making her comfortable d. completing the admission process so that all paperwork is completed before delivery

A woman is at the obstetricians office for her second prenatal visit. She has numerous complaints including all of the following. Which would require reporting to the physician? a. She has to void frequently. b. She is tired and wants to sleep all the time. c. She has a burning sensation when she urinates. d. Although she has not vomited, she feels nauseated most of the time.
Maternity Question A woman arrives at the labor unit in labor. She is talkative and smiling between contractions. Prior to completing the vaginal examination, the nurse would suspect the woman is in what phase/stage of labor? a. Latent phase b. Active phase c. Transition phase d. Second stage

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A teenager is admitted at term to the labor unit in early labor. She has not attended any childbirth education classes. Her mother is present as her support person. The best time to discuss breathing techniques with this teenager is a. during the latent phase of labor b. as she approaches transition stage c. after delivery in anticipation of future pregnancies d. as she approaches each labor stage that requires a different breathing technique Postpartum Assessment and Nursing Care Breast Care (lactating) Patient should wear a supportive bra Encourage frequent nursing (812 feedings in 24 hours) After feedings, leave colostrum/breast milk on nipples and expose the breasts to air Non-lactating Supportive bra, breast binder or sports bra No nipple stimulation Do not express breast milk Ice packs/analgesics for engorgement Postpartum Assessment and Nursing Care Uterine Involution Postpartum Blues temporary mood depression that is fairly common in the early postpartum period different from postpartum psychosis or postpartum depression, a serious emotional condition that occurs in some postpartum women All in One Newborn Assessment Newborn Assessment Vital Signs Axillary temperature 97.898.6 F 110160 beats per minute 3060 per minute Newborn Assessment Extremities/Activity Newborn posture flexed, Grasp reflex intact Pattern of Sleep 1316 hours per day, Lying the baby on the back

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Communication Crying is a means of communication Skin Acrocyanosis, Milia, Lanugo, Mongolian Spot, Erythema toxicum Head presence of soft spots Face Note for manifestation of Down Syndrome Chest Monitor for signs and symptoms of RDS Abdomen/Genitals Umbilical cord, first void and stool (24 hrs), urinary meatus, and bowel sounds Back Spine should be straight, monitor for the presence of tuft hair Cephalohematoma vs. Caput Succedaneum Complications of Pregnancy Ectopic Pregnancy sharp one-sided pain adnexal (area over ovary and tube) tenderness With tubal rupture, abdomen becomes hard and rigid and signs of circulatory collapse occur. Dx: Transvaginal ultrasound Rx: Methotrexate Nsg Intervention: Provide emotional support, Provide emergency resuscitation including IV fluids and oxygen Hyperemesis Gravidarum excessive vomiting during pregnancy. lead to electrolyte imbalances and dehydration Precipitating factors: It is associated with higher levels of HCG S&S: DHN, Elyte imbalance, alkalosis, vitamin deficiency Rx: Antiemetics and NPO are prescribed for 2448 hours, IV fluids, spicy and fatty foods are withheld, TPN Hydatiform Mole gestational trophoblastic disease or molar pregnancy grape-like clusters Choriocarcinoma Precipitating factors: woman over 35 years of age, low protein intake, Asian heritage

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S&S: HCG levels are higher than expected, Uterus grows more rapidly than expected, Dark brown spotting occurs Dx: Ultrasound diagnosis Rx: Suction curettage, HCG levels are monitored for 1 year after the termination of the pregnancy Client Teaching: Instruct the client to use a reliable birth control method for 1 year after the curettage Abortion termination of pregnancy before the fetus is viable, usually before 20 weeks gestation. Precipitating factors: fetal abnormalities due to a teratogenic agent or chromosomal abnormalities S&S: Vaginal spotting, Abdominal cramping Dx: viability of the fetus and the contents of the uterus with sonogram, HCG levels, and FHTs Rx: Threatenedavoid strenuous activities for 48 hours and intercourse for 2 weeks, All other forms of abortiondilation and curettage Incompetent Cervix premature dilation of the cervix. S&S: Painless second trimester cervical dilation, Little to no vaginal bleeding, Bulging membranes on vaginal examination Dx: Serial ultrasounds demonstrate progressive effacement and dilation Rx: Shirodkars operation, McDonalds procedure, CS delivery Preterm Labor occurs after the twentieth week and prior to the thirty-seventh week of gestation. S&S: Persistent backache, Feeling of pelvic pressure Dx: vaginal examination for cervical dilation and FHTs. + Nitrazine test Rx: betamethasone- given to mature fetal lungs, tocolytics (medications to halt preterm labor) Client teaching for self-care: bed rest; left-side lying is preferred, Void every 2 hours, Drink 812 glasses of water, Avoid heavy lifting, Prohibit sexual activity Pregnancy-Induced Hypertension (PIH) preeclampsia: the period before seizures occur eclampsia: generalized seizure.

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HELLP Syndrome (hemolysis, elevated liver enzymes, and low platelet count) Precipitating factors: primigravida, age under 20 or over 40, grand multipara, multiple gestation. S&S: Classic signs are hypertension, proteinuria, and edema, epigastric pain, visual or cerebral disturbances, hyperreflexia Rx: Bed rest, Diet high in protein, moderate sodium, Antihypertensives , Anticonvulsants Magnesium Sulfate Placenta Previa attachment of placenta in the lower uterine segment Precipitating factors: Previous history of placenta previa, multiparity, previous cesarean section(s), increasing maternal age, and cocaine use and smoking during pregnancy. S&S: Painless vaginal bleeding occurring in the third trimester; bleeding is bright red Dx: Ultrasound demonstrates location of placenta Rx: bed rest with bathroom privileges, no vaginal examinations, typed and cross-matched for transfusion, cesarean section if complete placenta previa Client teaching for self-care Assist the family in planning bed rest at home to minimize activity Teach the client and family about the signs and symptoms that must be reported immediately Abruptio Placenta premature separation of the normally implanted placenta. increased risk of developing disseminated intravascular coagulation (DIC) Precipitating factors: Hypertension and cocaine use, higher maternal age and parity, smoking, and abdominal trauma S&S: Dark bleeding or bleeding that may not be observed due to concealed bleed, Severe abdominal pain, Uterus is hard to touch Rx: immediate cesarean section, Intravenous fluids, client may require blood transfusions Rh Incompatibility Etiology: The Rh- woman usually does not have problems with Rh incompatibility in the first pregnancy with an Rh+ fetus, but becomes

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sensitized in the following delivery and will have problems in all subsequent pregnancies with an Rh+ fetus. S&S: fetal hydrops, hyperbilirubinemia, Fetal death Dx: Blood tests Rx: Administer Rh immune globulin as ordered prenatally and within 72 hours of birth Dystocia difficult delivery labor may be long and painful Etiology: difficult presentation, oversized fetus, small pelvis, lowlying placenta, cephalopelvic disproportionment (CPD) Precipitating factors: The client may be a very young primigravida or one with no prenatal care. S&S: Failure to progress despite adequate time Dx: Pelvimetry, ultrasound Rx: May require a cesarean section Prolapsed Cord a loop of the umbilical cord pre- cedes the presenting part into the birth canal and becomes compressed as the presenting part descends. Precipitating factors: Hydramnios, multiple gestation, noncephalic presentation, small fetus, CPD, and placenta previa S&S: fetal bradycardia, fetal monitoring demonstrates severe variable decelerations, umbilical cord is felt on vaginal examination Dx: Based on fetal assessment and vaginal examination Rx: Immediate cesarean delivery If prolapsed cord is suspected notify physician immediately place the woman in Trendelenburg position place a gloved hand in the vagina to elevate the presenting part off the cord administer oxygen per mask to mother if cord is protruding into room air, cover with a sterile saline moistened cloth to prevent drying prepare the client for an emergency cesarean section provide emotional support Amniotic Fluid Emboli causes a sudden onset of respiratory distress and circulatory collapse.

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Etiology: Amniotic fluid enters maternal circulation through a defect in the fetal membranes where it becomes an embolus when it reaches the lungs S&S: Sudden onset of chest pain, Cyanosis and dyspnea, Tachycardia, Hemorrhage, Shock, coma, and death Rx: Immediate intervention is required to restore circulation. Cardiopulmonary resuscitation is started immediately. Start intravenous fluids. Provide oxygen Postpartum Hemorrhage can occur in the first 24 hours after delivery or up to 6 weeks after birth There are numerous causes of hemorrhage including: uterine atony, retained placenta, hematomas of the pelvic region, lacerations, subinvolution, and uterine inversion Etiology: failure of the uterus to contract S&S: Excessive vaginal bleeding, decreasing blood pressure and increasing pulse, dropping hemoglobin and hematocrit Rx: Retained placenta: dilation and curettage. Oxytocins or Methylergonovine Maleate (Methergine) may be administered for subinvolution. Lacerations may require packing and/or suturing. Transfusions may be required if blood loss is extensive Nursing Process Elements Assess vaginal discharge for color and amount. frequency of pad Assess fundus, provide bimanual massage Assess perineum for hematoma formation Have client void frequently as a full bladder will hamper uterine contractions Maternity and Newborn Medications RhoGAM- 28 wks and within 72 hrs after birth, prevents issoimunization in Rh- clients Tocolytics- halts uterine contractions and prevent preterm birth Magnesium sulfate- CNS depressant, eclampsia Betamethasone- use for preterm baby Prostaglandins- causes dilation and effacement, cervical ripening Pitocin- augments the labor Methergine, Hemabate- postpartum hemorrhage Maternity and Newborn Medications Rubella Vaccine- SQ, rubella titer of 1:8, assess allergy to duck eggs, use of contraception

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Lung Surfactant- IT route, tx of RDS and premature infants Eye Prophylaxis- against ophthalmia neonatorum Vitamin K- hemorrhagic disease of the newborn Hepatitis B Vaccine- IM, vastus lateralis, 0.5 mL, against hepatitis B virus Maternity and Newborn Medications Opioids Analgesics Demerol/Dilaudid Not administered in early labor because it may slow the labor process Fentanyl Causes RDS, HPN, urinary retention, fetal distress Stadol/ Nubain Use with caution in opioid dependent client, it can lead to withdrawal sx in the client and the newborn Naloxone Antidotes for opioids

Which test is most diagnostic for syphilis? A. Culture B. VDRL C. RPR D. FTA-ABS
Which instruction should be given to the client being discharged after evacuation of a hydatidiform mole? A. Return to the clinic in six weeks for a urinalysis B. Avoid exercise for at least six weeks C. Do not become pregnant for at least twelve months D. Return to the clinic in six months for liver enzyme studies

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Maternal Question Which of the following obstetric clients should the nurse see first? a. The client who is 40 weeks gestation having contractions every 5 minutes lasting 50 seconds b. The client who is 32 weeks gestation with terbutaline (Brethine) intravenously c. The one-day postpartum client who has changed two peri-pads in the last six hours d. The diabetic obstetric client with a blood glucose level of 90 mg/dL The client being treated for preeclampsia has an infusion of magnesium sulfate. The magnesium level is checked and found to be 6.3 meq/L. Which action by the nurse is most appropriate? A. Stop the magnesium sulfate and administer calcium gluconate B. Continue the magnesium sulfate as ordered C. Contact the doctor immediately D. Prepare for an emergency delivery The pregnant client is admitted to the emergency room with a prolapsed umbilical cord. Which action is most appropriate? A. Cover the cord with dry, sterile gauze B. Place the client in high Fowlers position C. Push up on the presenting part with an examining finger D. Begin an IV of normal saline at keep-open rate

The pregnant client with AIDS is diagnosed with cytomegalovirus. The nurse is aware that the client probably contracted cytomegalovirus from: A. Blood or body fluid exposure to the virus B. Emptying her cats litter box C. Contaminated food or water D. Pigeon feces

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Which finding would require intervention in the client receiving oxytocin (Pitocin) for augmentation of labor? a. Contractions every 56 minutes lasting 60 seconds b. Variability of 68 beats per minute c. Drops in fetal heart tones after contractions lasting 90 seconds with hesitant return to baseline d. Drops in fetal heart tones prior to the contractions during pushing The client with premature labor is being treated with terbutaline (Brethine). Which assessment should be done prior to beginning Brethine? A. Creatinine B. Cortisol levels C. Blood glucose D. Liver profile

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