Ob Chapter 15 (Cont'd)

Front 1

What patient teaching related to PROM is indicated?

Back 1

It is important to address side effects and alternative treatments. The couple needs to know that although the membranes have ruptured, amniotic fluid continues to be produced. Providing psychologic support for the couple is critical. The nurse may reduce anxiety by listening empathetically, relaying acurate information and providing explanations of procedures. Preparing the couple for a cesarean birth, a preterm newborn, and the possibility of fetal or newborn demise may be necessary.

Front 2

What is the nursing care for a patient in premature labor?

Back 2

Women who are at risk for preterm labor are taught to recognize the symptoms associated with PTL and to notify the physician or CNM if these signs are present as prompt diagnosis is necessary for successful intervening. Once diagnosis is made it is essetial that the patient is taught the signs of labor such as uterine contractions that occur every 10 minutes or less w/out pain, mild menstrual-like cramps, constant or intermittent feelings of pelvic pressure, ROM, constant or intermittent low, dull backache, a change in vaginal discharge, abdominal cramping with or without diarrhea.

Front 3

Discuss the use of Magnesium Sulfate in premature labor.

Back 3

Magnesium Sulfate acts as a CNS depressant by decreasing the quantity of acetylcholine realeased by the motor nerve impulses and therby blocking neuromuscular transmission. Secondarily, Magnesium Sulfate relaxes smooth muscle.

Front 4

How is Magnesium Sulfate given?

Back 4

Generally, it is given via IV to control dosage more accurately and prevent overdosage. On occasion a physician may order it IM.

Front 5

What contributing factors may predispose a patient to preeclampsia?

Back 5

The exact cause is unknown, preeclampsia is seen more often in teenagers and in women over 35, especially if they are primigravidas. Women with a history of preeclampsia are at increased risk, as are women with a large placental mass associated with multiple gestation, GTD, Rh incompatability and diabetes mellitus.

Front 6

What renal changes occur with preeclampsia?

Back 6

Normal renal perfusion is decreased. With a reduction of the glomerular filtration rate (GFR), serum levels of creatinine, BUN, and uric acid begin to rise from normal pregnant levels, while urine output decreases. Sodium is retained in increased amounts resulting in increased extracellular volume and edema. The decreased intracellular volume causes increased viscosity of the blood and a corresponding rise in hematocrit.

Front 7

What nursing care is important in the care of a patient with mild preeclampsia?

Back 7

The woman monitors her BP, weight and urine protein daily. Weight gains of 3 lbs. in 24 hours or 4 lbs. in a 3-day period are generally cause for concern. Remote NST's are performed on a daily to bi-weekly basis. In the hospital, the woman is placed on bedrest (left side), her diet should be well balanced, sodium intake should be moderate.

Front 8

What is done for the fetus while a mother is on bedrest for mild preeclampsia?

Back 8

There is a fetal movement record, nonstress test, ultrasonography q4 weeks for serial determination of growth, biophysical profile, serum creatinine determination, amniocentesis to determine lung capacity and doppler velocimetry beginning at 30 to 32 weeks to screen for fetal compromise.

Front 9

What nursing care is important in the care of a patient with severe preeclampsia?

Back 9

If the uterine environment is considered detrimental to fetal well-being, birth ay be the treatment of choice even if the fetus is immature. Other therapies include, bed rest, diet, anticonvulsants, fluid and electrolyte replacements, corticosteroids (beneficial for lung profile), and hypertensives.

Front 10

Describe the assessment of reflexes in the client with preeclampsia:

Back 10

The woman is assessed for evidence of hyperreflexia in the brachial, wrist, patellar, or achilles tendons. The platellar refles is the easiest to assess. Clonus should also be assessed by dorsiflexing the foot while the knee is held in a fixed position. Normally, no clonus is present, it is measure as beats and recorded as such.

Front 11

What are the ramifications of preeclampsia for the fetus?

Back 11

Infants of women with preeclampsia tend to be small for gestational age (SGA). The cause is related specifiacally to maternal vasospasm and hypovolemia, which result in fetal hypoxia and malnutrition. In addition, the neonate may be premature because of the necessity for early birth. At birth, the newborn may be oversedated due to medications, the newborn may also have hypermagnesia due to treatment of the woman with large doses of magnesium sulfate.

Front 12

What are the circumstances that predispose Rh isoimmunization?

Back 12

The Rh factor is present on the surface of erythrocytes of a majority of the population. When it is present, a person is designated as Rh positive. Those without the factor are Rh negative. If an Rh negative individual is exposed to Rh-positive blood, as antigen-antibody response occurs, and the person forms anti-Rh agglutinin and is said to be sensitive. Subsequent exposures to Rh-positive blood can then cause a serious reaction that results in agglutinin and hemolysis of RBC's.

Front 13

When does Rh alloimmunization (sensitization) occur?

Back 13

It most commonly occurs when an Rh-negative woman carries an Rh-positive fetus. It can also occur if an Rh-negative nonpregnany woman receives and Rh-positive blood transfusion.

Front 14

What other incompatabilities may cause problems for the fetus?

Back 14

Anemia resulting from Rh alloimmunization can cause marked fetal edema called hydrops fetalis. CHF may result, marked jaundice which can lead to neurologic damage is also possible. This severe hemolytic syndrome is known as erythroblastosis fetalis.

Front 15

What psychologic changes of pregnancy can complicate surgery in the pregnant patient?

Back 15

The incidence of spontatneous abortion is increased for women who have surgery in the first trimester. There is also increased incidence of fetal mortality and of low-birth-weight infants and lastly, when surgery is necessary, the incidence of preterm labor and intrauterine growth restriction increases.

Front 16

What post-op teaching follows a surgical intervention?

Back 16

The murse encourages the woman to turn, cough and deep breathe and to use any ventilation therapy such as incentive spirometer. The pregnant woman is at increased risk for thrombophlebitis, so the nurse applies antiembolism stockings, encourages leg exercises while the woman is confied to bed and introduces ambulation as soon as possible. Discharge teaching is especially important - activity level, discomfort, diet and medications should be understood as well as any warning signs that need to be reported to the physician.

Front 17

What traumas can cause special concerns in the pregnant patient?

Back 17

When major blunt trauma to the mother occurs in the second or third trimester the risk of fetal loss is 40-50%. Abruptio placentae is the leading cause of fetal death when the mothers injuries are not fatal. Motor vehicle accidents are the most common cause of trauma. Traumas that cause concern includes blunt trauma, penetrating abdominal injuries and the complications of maternal shock, premature labor and spontaneous abortion. In addition, uterine rupture is a rare but life-threatening complication of trauma.

Front 18

What affect can trauma have on pregnancy?

Back 18

Uterine rupture, separation of the placenta (abruptio placentae), premature labor.

Front 19

How do maternal structures protect pregnancy and the fetus?

Back 19

The bony pelvis, amniotic fluids and the uterine/abdominal muscles all aide in protection of the fetus.

Front 20

What nursing interventions may be necessary in a patient exeriencing a trauma?

Back 20

Focuses initially on life-saving measures for the woman including airway, controlling external bleeding, and IV fluids to alleviate shock. The woman must be kept on her left side to prevent further hypotension. Fetal heart rate is monitored. Exploratory surgery may be indicated, cesarean birth may also be done if she is near term and the uterus is damaged. If the fetus is still immature, the uterus can often be repaired and the pregnancy continues until term.

Front 21

What potential complications of pregnancy can be related to physical abuse?

Back 21

Physical abuse may result in loss of pregnancy, preterm labor, low-birth-weight infants and fetal death. Abused women have significantly higher rates of complications such as anemia, infection, low weight gain and first & second trimester bleeding.

Front 22

What are some physical and emotional signs of abuse?

Back 22

Asking every woman about abuse at various times during pregnancy is crucial. In addition, the woman may have nonspecific or vague complaints. The nurse should pay attention to old scars as well as any bruising or injury to the breasts, abdomen or genitalia. Other indicators include a decrease in eye contact, silence when the partner is in the room and a history of nervousness, insomnia, drug overdose or ETOH problems. Frequent visits to the ER and a hostory of accidents without understandable causes are possible indicators of abuse.

Front 23

How do nurse's intervene in cases of domestic abuse?

Back 23

The goals of treament are to identify the woman at risk, increase her decision-making abilities to decrease potential for further abuse, and provide a safe environment for the pregnant woman and her unborn child. She also needs to be aware of community resources available to her.

Front 24

What is toxoplasmosis?

Back 24

Toxoplasmosis is caused by the protozoan Toxoplasma gondii. It is innocuous in adults but, when contracted in pregnancy, it can profoundly affect the fetus.

Front 25

How is toxoplasmosis acquired?

Back 25

The pregnany woman may contract the organism by eating raw or undercooked meat, by drinking unpasturized goats milk or by contact with the feces of infected cats, either through the cat litter box or gardening in areas frequented by cats.

Front 26

What are the fetal effects of taxoplasmosis?

Back 26

The likelihood of fetal infection increases with each trimester of pregnancy, but the risk of serious impact on the fetus decreases. Thus, maternal infection contracted during the first trimester is associated with the lowest incidence of fetal infection but the highest risk of severe fetal disease or death. Most infants develop symptoms later. Severe neonatal disorders associated with congenital infection include convulsions, coma, microcephaly and hydrocephalus. The infant w/severe infection may die soon afer birth. Survivors are often blind, deaf and severely retarded.

Front 27

What are the maternal effects of rubella?

Back 27

A woman who develops rubella during pregnancy may be asymptomatic or may show signs of a mild infection including a maculopapular rash, lymphadenopathy, muscular achiness and joint pain.

Front 28

What are the fetal effects of rubella?

Back 28

The period of greatest risk for the teratogenic effects of rubella is during the first trimester. The most common signs of congenital infection include congenital cataracts, sensorineural deafness, and congenital heart defects, particularly patent ductus arteriosus. Other abnormalities such as mental retardation or cerebral palsy, may become evident in infancy.

Front 29

What is cytomegalovirus?

Back 29

CMV belongs to the herpes virus group and causes both congenital and acquired infections referred to as cytomegalic inclusion disease (CID). The significance of this virus in pregnancy is related to its ability to be transmitted by asymptomatic women across the placenta to the fetus or by the cervical route during birth.

Front 30

What are the fetal effects of cytomegalovirus?

Back 30

This infection can result in extensive intrauterine tissue damage that leads to fetal death; in survival with microcephaly, hydrocephaly, cerebral palsy or mental retardation; or in survival with no damage at all.

Front 31

What are the maternal effects of Herpes virus?

Back 31

This can cause painful lesions in the genital area. Lesions may also develop on the cervix.

Front 32

What are the fetal effects of Herpes virus?

Back 32

Primary infection poses the greatest risk to both the mother and her infant. Primary infection has been associated with spontaneous abortion, low birth weight, and preterm birth. Transmission almost always occurs after the membranes rupture. The infected infant is often asymptomatic at birth but develops symptims of fever, jaundice, seizures and poor feeding after an incubation period of 2-12 days. Half of infected infants develop characteristic lesions. Treatment includes Acyclovir.

Front 33

When and why is a cesarean section the mode of delivery in regards to Herpes?

Back 33

If the woman has any sogns of active genital lesions or prodromal symptoms of infection such as vulvar pain or burning, cesarean birth is indicated. The woman with active HSV and ROM should also gove birth by cesarean.

Front 34

What are the risks of pyelonephritis in pregnancy?

Back 34

Increased risk of premature birth and intrauterine growth restriction (IUGR).

Front 35

What are some of the other infections which can cause problems in pregnancy?

Back 35

UTI
Cystitis
Yeast Infection
Bacterial Vaginosis
Trichomonas
Chlamydia
Syphilis
Gonorrhea
Condyloma acuminata
These are on pages 363-364