331 Exam 2
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This 13 page Study Guide was uploaded by Kelsey Forbeck on Tuesday October 4, 2016. The Study Guide belongs to NURB 331 at University of Indianapolis taught by Professor Rairdon in Fall 2016. Since its upload, it has received 3 views. For similar materials see Lifespan 1 in NURSING at University of Indianapolis.
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Date Created: 10/04/16
OB EXAM II STUDY GUIDE Chapter 20-22: Anatomy and Physiology of Post-Partum, Nursing Care During Post-Partum, Transition to Parenthood (12 questions) After pains Caused by intermittent uterine contractions. They may cause severe pain 2-3 days after delivery. First time moms, uterine tone is good, the fundus remains firm, and the woman experiences only mild cramping. They are more severe in multiparas than primiparas, more severe with any over distention of the uterus. Breast feeding increases the severity of afterbirth pains because oxytocin stimulates uterine contractions. Post-partum recovery priorities FIRST HOUR: All vital signs will be assessed every 15 minutes except for temp SECOUND HOUR: vital signs every 30 minutes Vital signs per unit routine after that Temp should be assessed at the beginning of the recovery period and at the end of recovery period. Assess mom for predispose hemorrhage: precipitous birth, large baby, grand multiparty, induced labor. It is normal for post-partum moms to experience intense tremors that resemble shivering from chill and they are usually really hungry. C-section moms require special attention because of the anesthesia. They should be awake, alert, orient x3, normal respirations, oxygen sat above 95% Epidural moms should be able to raise legs, extend knees, flex knees, place feet flat, and raise butt off bed Post-partum fundal assessment Palpate the fundus when the bladder is empty. Place hand at the symphysis pubis so the uterus doesn’t fall out. The fundus should be firm. Check to see if the fundus is midline or displaced to one side. Fundus descends 1-2 cm every 24 hours. Two weeks after child birth uterus should lay in the true pelvis. Post-partum recovery Breasts Uterus Bladder Bowel Lochia: Rubra/ dark red for 3-4 days, Serosa/ pink brown for 22 to 27 days, Alba / creamy to yellow 2-6 weeks Episiotomy/Laceration Hemorrhoids Emotional Pain/Discomfort Bladder distention The fundus may be displaced to one side if the bladder is full. Have the mom try to empty her bladder. Moms who had anesthesia may have trouble emptying their bladder at first. The nurse may need to perform and in and out cath. Have them mom on a potty schedule where she tries to pee every two hours. Post-partum assignment priorities C-section moms Moms with risk factors of hemorrhage Complications with labor Multiparas Breast Engorgement Encourage a proper fitting bra Examine size, shape, abnormal, redness If breasts are engorged they will be firm, tender, hot Usually occurs 3-5 days, lasts 24 hours Difficult for the baby to latch Feed baby every two hours, massage, and pump Warm showers, cold compress after feeding, acetaminophen, cool cabbage Lactation suppression: wear supportive bra, shower with back toward water, do not stimulate nipples, meds are no longer used, ice packs on 15 minutes off 45 minutes Bottle and Breast Feeding Encourage breast feeding to help baby get antibodies Breast feeding positions: football or clutch (under the arm), across the lap (modified cradle), cradling, lying down. Tickle babies lower lip to get them to latched. Angle bottle to ensure that milk covers nipple. Don’t want baby sucking in air. Throw away used formula. Hispanic Culture Extended family plays an essential role Grandma is often primary helpers Ensure access to all family members They may want a liquid diet after birth, binder on abdomen, avoid cool air, sexual abstinence Normal fluid shifts in post-partum Urine output increases during the first 12-24 hours, kidneys must eliminate 200-300 ml of extracellular fluid with a normal pregnancy. Sweating is increased because the excess fluid and waste products via the skin. Blood volume increases elimination within the first two weeks after birth but should return to normal vales by 6 months. Blood volumes returns to normal by the end of the post partal period. Blood loss for vaginal deliveries is 200- 500ml and 700-1000ml for csection. Hgb and RBC should return to normal by 2-6 weeks. Elimination of the ureoplacental circulation reduces the size of maternal vascular bed by 10% to 15%. Hypovolemic doesn’t occur in pregnant women because they already have extra blood in their body. Coagulation factors remain elevated in post partum period. WBC’s may remain elevated, does not necessarily indicate infection. Mobilization of extracellular water stored during pregnancy increase blood volume Immediate peri care in recovery Clean blood off. Wipe from front to back. May use the spray bottle each time to restroom. Pat dry. Instruct mom to change pad each time to the restroom. REEDA, episiotomy, tearing, hemorrhoids Chapter 23-24: Normal Newborn Adaptation and Nursing Care of the Newborn (15 questions) Gestational assessment Done between 2 and 8 hours of age. If done earlier muscle movements may reflect fatigue. After 48 hours, plantar creases increase in number. Ballard Scale (-1 – 4) Healthy flexed, preterm floppy Wrist measure the angle preterm can measure angle, full term no angle Flex infants arms at elbows for 5 seconds then pull hands straight down to sides, quickly release hands and degree of flexion is estimated Popliteal angle: flex thing against abdomen and extend lower leg to point of resistance Scarf sign: move arm across chest Heel to ear Plantar creases: full term: deep, preterm: few Nipple: barely present in preterm Ear maturation: fold ear. Full term have instant recoil Female genitals: full term: covered Male genitals: full term: deep rugae Period of reactivity First 30-60 minutes. Heart rate and respirations increased. Blood pressure is the highest in this period. Newborn characteristics (Review Newborn sheet) APGAR score 1 minute – how well newborn tolerated at birth 5 minutes – how well they are tolerating their environment Heart rate (over 100) Resp rate (good cry) Muscle tone (well flexed) Reflex irritability (cry) Color (completely pinky) Anything above 7 is good, no difficulties adjusting 0-3 indicates severe distress Apgar does not predict future neuro outcome Priority at birth 1. Respiratory 2. Temperature Vitamin K Injection given to prevent hemorrhage which can occur due to low prothrombin, absence of gut bacterial flora, which influences production of Vit K in newborn 0.5 ml IM vastus lateralis 5/8 inch Jaundice Normal for first couple of days Check bilirubin levels Hypoglycemia Blood glucose lower than 35 or plasma concentration below 40 Occurs because at birth when cord is cut newborn abruptly loses its glucose supply Asymptomatic Glucose done soon after birth and repeat in 4 hrs More frequent testing is needed for SGA, LGA, or LBW infants or infants exposed to cold stress, perinatal asphyxia, or tocolysis to inhibit preterm labor, small baby doesn’t have brown fat, large baby could be a diabetic baby S/S: jitteriness, irregular resp pattern, cyanosis, apnea, lethargy, twitching, feeding difficulty, eye rolling, seizures, hunger CNA delegation Newborn bath Start with eyes first, hair, wash from head to toes, peri area front to back. Baby must be 98 before doing the newborn bath. Keep under warmer. Make sure they are completely dry. Bili lights therapy TCB is a noninvasive monitoring of bilirubin, has to be done in the dark Correlates with serum bilirubin levels Used to treat high serum bilirubin Unclothed infant is placed approximately 45-50 cm away from bank of lights Wear opaque mask, turn q2, done until levels decrease, do not occlude nares with mask, remove mask during feeds, keep infant on regular feeding schedule, monitor stools Bilirubin breakdown increases gastric motility, which results in frequent loose stools, monitor temp, watch hydration Bili blanket used for very jaundice kids. Chapter 28: Hemorrhagic Disorders of Pregnancy (11 questions) Ectopic pregnancy Fertilized ovum implanted outside the uterine cavity, mostly in the fallopian tube Leading cause of infertility Ruptured: lead to life threatening hemorrhage, Unruptured: take out the fallopian tube or ovary. Methotrexate- dissolves tubal pregnancy. High reoccurrence rate, contraception, cannot get pregnant for 6 months to one year S/S: abdominal pain, delayed menses, abnormal vaginal bleeding Risk factors: leisons, slapingitis, endometriosis, previous laparotomy GTD Molar pregnancy Gestational trophoblastic disease is a spectrum of pregnancy related trophoblastic disorders without a viable fetus Multiple sperm fertilizes one egg Increased HCG levels Malignant version: if mole is removed and go back hcg levels still high, chest xray to detect metasis, physical and pelvic exam. Chemotherapy will be started. Pregnancy delayed for 6months to 1 year because of tetragonic effects. Proliferative growth of placental trophoblast, chorionic villi hang like grape- like clusters. Can be cancerous Early stages normal pregnancy. Later stages: bright red or brown vaginal bleeding. Excessively enlarged uterus. Management: most will pass spontaneously, suction curettage is safe, oxytocin induction is not recommended Hydratidiform: more common in hyperemesis gravidarum, vaginal bleeding often prune color, may pass some, hcg elevated, anemia, excessive vomiting, gestational hypertension occurring during first half of pregnancy Cerclage Closing of incompetent cervix Incompetent cervix does not have contractions, just dilates Place in 11-15 weeks and remove at 37 weeks Risks: PROM, preterm labor, chorioamniotits (infection of amniotic) Give NDAIs and antibiotics to prevent inflammation and inhibits prostaglandins Bicornate uterus Uterus is split in two can lead to incompetent cervix Abruption risk factors Spontaneous – miscarriage Threatened – lab values low, bleeding Inevitable – ROM, bleeding Incomplete – loses part but some stays in mom, bleeding Complete – loses the whole baby Septic – caused by infection, nonsterile techniques Treatment of abortion D&C: dilated cervix and scrape uterine walls and remove uterine contents (tissue) D&S: same as D&C but suction used instead of curette D&E: can see baby 16-20 weeks use of prostaglandins RHOgam is given within 72 hours Pitocin given to prevent hemorrhage Excessive bleeding: methergine (prevents blood loss) and hemabate (makes blood thicker) Previa vs abruptio Abruptio: maternal and fetal tachycardia, falling BP, restlessness, placenta detaches from uterus. Concealed hemorrhage: increase fundal height, hard, board like abdomen, pain, late decels, vag bleeding mat be slight or absent. Risk factors: cocaine use, smoking, trauma, PROM, Hx of abruptio Associated with hypertension, diabetes, & kidney disease. Usually no warning signs. Hemorrhage may be internal or external. Pain may be present in varying degrees. Usually occurs in labor. FHT’s reflecting uteroplacental insufficiency. Placental attachments in normal locations. Uterus tender to woodlike. Previa: placenta attached at wrong site, before baby. Bleeding, no vaginal exam, cause trauma and bleeding, must be deliver c section, bedrest, lactated ringers, labs, 2 units for transfusions No underlying chronic disease. Warning signs of spotting hemorrhage always externally visible. No pain. Occurs rarely during labor, but is unrelated to labor. FHT’s & movement usually present & unaffected. Placenta in lower uterine segment. Soft uterus. Chapter 27: Hypertensive disorders of Pregnancy (8 questions) DTR’s (deep tendon reflexes) Want them to be 1 or 2 If 3 or 4 it could indicate preeclampsia Clonus Dorsiflex foot and let go: if foot jerks or taps indicates hyperactive reflexes Count the taps Reflexes may be diminished or absent with high doses of mag sulfate S/S HELLP SYNDROME Hemolysis of RBCs, elevated liver enzymes, low platelets May occur before s/s of preeclampsia develop 90% of women with HELLP syndrome present symptoms before 36 weeks gestation Dx by lab values CBC with elevated liver enzymes and low platelets Risk for: pulmonary edema, acute renal failure, DIC, placental abruption, liver failure, resp distress, sepsis, stoke *HIGH RISK FOR MATERNAL DEATH LOW PLATELET COUNT: thrombocytopenia less than 100,000. May need a platelet transfusion if under 20,000 Symptoms: N/V. malaise, flulike symptoms, epigastric pain (right: liver) Eclampsia Seizure activity or coma in woman dx with preeclampsia No history of previous seizure disorder s/s: head ache, blurred vision, severe epigastric pain, altered mental status immediate care: ensure airway, patient safety, post seizure (decision about method of birth) After seizure: mag sulfate, valium Mag Sulfate Drug of choice for prevention and management of seizures with preeclamptic and eclaamptic women Dosages is initial bolus 4-6 gm by IVPB, maintenance dose 2-3 gm/hr Complications: vasodilation, chest pain, palpitations, hypotension, cardiac arrest, respiratory depression, pulmonary edema, decreased deep tendon reflexes, headaches, electrolyte imbalances, drowsiness, lethargy, dry mouth, N/V, paralytic ileus, slows down contractions Mag toxicity: a sudden change in or loss of DTR, respirations of less than 12, urine output less than 30ml and hour. Above 8mg/dl. Antidote: calcium gluconate (IV push over 3 minutes) Pathophysiology of preeclampsia Hypertension that develops after 20 weeks and contains protein in urine, tissues not getting enough oxygen supply S/S develop only during pregnancy, goes away after delivering, High risk factors: primigravidity, multifetal pregnancy, obesity, preexisting medical condition, preeclampsia in prior pregnancy -physio: inadequate vascular remodeling – decreased placental perfusion and hypoxia – endothelial cell dysfunction – vasospasm, increased peripheral resistance, increased endothelial cell permeability – decreased tissue perfusion CNS: hyperflexia, seizures, head aches Kidney changes: hypovolemia and vasoconstriction Chapter 26: High risk fetal assessment (4 questions) Amniocentesis 14 to 16 weeks for genetic concerns, fetal maturity, hemolytic disease, meconium. DO not hold breath. Give RhoGAM post procedure. CVS Chromosomal analysis for defects Performed 8-12 weeks of gestation Removal of small tissue specimen from fetal portion of placenta Transcervically or transabdominally PUBS Take blood out of umbilical cord Biophysical profile Helps id a healthy fetus, score is out of 10. 10 is normal, 6 consider delivery, under 4 deliver if gestation is 26+ Breathing, body movements, tone, AFV, FHR AFV- at least 2 cm across is normal amount. Range is 5-20. Over 20: hydraminos. Under 5: oligohydramnios. Kick count Daily fetal movement count If the baby doesn’t move in 12 hours we could have a problem Consider variations, no absolute number have been established L/S ratio Lecithin and sphingomyelin are protein components of lung enzyme surfactant. nd th The alveoli begin to form about 22 to 24 weeks of pregnancy Ratio of 2 to 1 is traditionally accepted as lung maturity Infants of severe diabetics may have false mature readings Helps determine lung maturity AFP Alpha-fetoprotein is produced by fetal liver and is detectable in increasing amounts in the pregnant woman from 14 to 34 weeks A screening tool for neural tube defects Usually done 15-22 weeks Recommended for all pregnant women Abnormal findings genetic counseling, ultrasound, amniocentesis Quadruple Marker Test 16 to 18 weeks Consists of MSAFP, unconjugated estriol, HCG levels Third trimester high risk assessment Nonstress test: indicates if baby is prepared for delivery. Noninvasive. Pointed in semifowlers position with wedge under right hip. Started between 30-32 weeks and continued until birth. Patient records each fetal movement by pushing a button. Reactive shows 2 or more accelerations of 15 bpm or more within 20 minutes of beginning the test. Contraction stress test: ID fetus stable at rest but compromised after stress, more time consuming but an earlier warning, nipple or oxytocin stimulated
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