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Fina L Exam Review OB - Lecture notes Topic 15
Nursing Care of the Childbearing Family (NSG-432)
Grand Canyon University
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FinaL Exam Review Exam 1: Topic 1: Introduction to Childbearing Family Chapters 1, 2, 8 Describe the scope and standards of nursing. Maternity nursing: care during antepartum, labor, birth, recovery, and NICU Provides education Provides care throughout all stages of pregnancy, childbirth, recovery, and parenting Standards: Prevention of error Sentinel event : bad outcome Failure to rescue : not looking at trends Ethical issues Legal issues Family nursing: Family theories: Bonding Family assessment Cultural factors Beliefs spirituality Home care in the community Discuss contemporary issues and trends in nursing Problems with health care High cost Even with insurance Limited access Health care reform Health literacy Infant mortality Health disparities Structure of the healthcare delivery system Maternal mortality : a lot of them are preventable if access was improved United States: Cardiovascular disease (hypertension) disease (diabetes) Infection Obesity Recent trends: Preconception and prenatal care Childbirth education Decrease in VBAC Increase in Nurse midwife doulas Trends in fertility and birth rate Age of childbearing women is increasing Less teen births Family focused Allow alternatives in care and Integrative Health Care complementary and alternative therapies Aromatherapy, breathing, massage therapy Ethical concerns have increased In Vitro increase Genetically testing on embryos Medical termination Early discharge within 24 hours Community based care Birthing centers Examine health considerations and nursing care related to the client with female reproductive health needs. Concerns after birth: BUBBLEHE: Breasts Uterus Bladder Bowels Lochia rubra : vaginal bleeding Episiotomy sign Checking for pain dorsiflexing the foot Because patient is susceptible for blood clots Emotional status GTPAL: Gravidity : what number pregnancy is it? Term birth : weeks Preterm: weeks Abortions : pregnancy ends prior to 20 weeks Can be termination, miscarriage, ectopic, molar Living : living children Terminology: Vaginal exam Antepartum before birth Intrapartum during birth couplet care after birth ROM rupture of membrane SROM spontaneous rupture of membrane AROM artificial rupture of membrane Assessment of amniotic Risk Group B streptococci status Caring: Hydration IV Catheterization Bowel elimination Ambulation Positioning Supportive care Differentiate the five major factors that affect the laboring process. (FIVE ch. 13) Passenger Fetus and placenta The movement of the passenger, or fetus, through the birth canal is determined several factors: Size Weight of the ba Size of the fetal head Composed to two parietal bones, two temporal bones, the frontal bone, occipital bone Where to bones meet fontanel Allows for a simpler passage through the birth canal Fetal presentation vertex presentation The part of the fetus that enters the pelvic inlet first and leads through the birth canal Fetal lie Lie: the relation of the spine of the fetus to the spine of the mother Fetal attitude Attitude: the relation of the fetal body parts to one another Easiest: chin to the chest delivery Fetal position Position is the relationship of reference point on the presenting part to the four quadrants of the pelvis Station: the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines and is a measure of the degree of descent of the presenting part of the fetus through the birth canal Above negative number At or below positive number Engagement: the term used to indicate that the largest transverse diameter of the presenting part has passed through the maternal pelvic brim or inlet into the true pelvis and usually corresponds to station. Three factors: Is the back on the right or left side? Head first: O Are they anterior or posterior or transverse? Most important to know how to rotate the child Passageway Birth canal Pelvis Soft tissues Powers Types of powers: Primary force: involuntary contraction Secondary force: voluntary pushing Contractions PRIMARY GOAL OF CONTRACTIONS: Effacement and dilation of the cervix and descent of the fetus Effacement: shortening and thinning of the cervix during the first stage of labor Dilation: enlargement or widening of the cervical opening and the cervical canal that occurs once labor has begun Involuntary contractions originate at certain pacemaker points in the thickened muscle layers of the upper uterine segment Contractions move downward over the uterus in waves How to measure contractions: Frequency Duration Intensity Position of the mother Frequent changes in position relieve fatigue, increase comfort, and improve circulation Important to find the most comfortable positions All fours position: best position for rotating Psychological response (chapter 16) Support Past experience Pain tolerance and coping abilities Everyone copes differently Culture Emotional readiness Childbirth education Be aware of history of sexual abuse Aspects of labor: Induction Only done if it is medically necessary Medication may be used to thin the cervix Cytotec Hydrotherapy Music Visualization Imagery Attention focusing Touch and massage Acupressure Hypnosis Heat cold Aromatherapy Biofeedback Vocalization : moaning , chanting Kissing partner Discuss the classification, mechanism of action, indications for use, major adverse effects, therapeutic effects, and nursing considerations of selected medications used for the laboring client. Used in addition to non pharmacological methods as the labor increases Sedatives relieve anxiety and induce sleep Vistaril Phenergan Ambien Barbiturates Seconal Try to stay away from them: Easily crosses the placenta Respiratory and vasomotor depression Affects both newborn and mom Antiemetics Phenergan Zofran Drug of choice Used during pregnancy Reglan Bicitra Analgesics: Alleviation of the sensation of pain without loss of consciousness Delayed until labor is well established IV faster with more control Given during a contraction Narcotics Analgesics: Alleviation of the sensation of pain without loss of consciousness Delayed until labor is well established IV faster with more control Given during a contraction Demerol side effects, respiratory depression that cannot be reversed. Nubain Stadol Fentanyl Effect of fetus: Respiratory depression Decreased alertness Delayed sucking Administration: May be given every hours Administer slowly Timing Too early: slow down labor process Too late: fetal neurobehavioral changes or respiratory depression Can cause excessive CNS depression Narcan can promptly reverse the CNS depressant effects, especially respiratory depression Opioids: Morphine Heroine Codeine CAUTION: Decrease in maternal heart rate and RR Cross placenta Absent of minimal variability Nitrous oxide: Laughing gas Client holds mask Increased interest in US Feeling of euphoria and decreased anxiety May cause nausea and dizziness General Anesthesia: Necessary for emergency Keep anesthesia time to a minimum to decrease side effects for mother and fetus Regional blocks Pudendal nerve block Spinal block Injection through the third, fourth, or fifth lumbar interspace Used for Provides anesthesia from nipple to feet Epidural block Injection of a local anesthetic into the epidural space Complications: Hypotension leading to fetal bradycardia: Maternal hypotension: Signs and symptoms: decrease of BP from baseline Fetal bradycardia Absent or minimal FHR variability Interventions: Lateral position Increased IV rate O2 at min mask Notify anesthesiologist and health care provider More progression in effacement of the cervix and little increase in descent Active phase More rapid dilation of the cervix and increased rate of descent Transition phase Pushing couple pushes 2 hours Lasts from the time the cervix is fully dilated to the birth of the fetus Two phases: Latent (passive fetal descent) Fetus continues to descend passively through the birth canal Active phase Strong urge to bear down begins as presenting part of the fetus descends and presses on the stretch receptors Can be longer with epidural When, push effectively Once kid it out 2nd phase is over Placenta minutes Lasts from the birth of the fetus until the placenta is delivered Recovery room Skin to skin for an hour Delivery of the placenta and at least 2 hours after They need to return to homeostasis Perineal trauma: Lacerations: perineal lacerations usually occur when head is being delivered 1st 4th degree (extent of tear) Skin 1st degree Rectal wall 4th degree Episiotomy: incision made in the perineum to enlarge vaginal opening Status of Membranes: Bag of Water (BOW) Assessment C. O. A. T. Color of fluid Clear or meconium stained Odor Amount of amniotic fluid Time of rupture Always assess fetal heart tones Cord prolapse Confirmation Tests: Fern Test: vaginal fluid swabbed and placed on microscope slide. Fern pattern confirms amniotic fluid True vs False Labor: True Labor False Labor Contractions regular Cervical change Fetus engages BOW may break may break prior to labor Change of position matter Contraction irregular Braxton Hicks Cervix unchanged Fetus not engaged No ROM or bloody show Lie down or move any may make it stop Identify typical signs of normal and abnormal fetal heart rate patterns and appropriate nursing interventions. Examine the pathophysiology, signs and symptoms, common diagnostic studies, and normal and abnormal findings related to child birth. Rates: Baseline FHR: for 10 min. Tachycardia: 160 for min. Bradycardia: for 10 min. Periodic changes: Accelerations: Visual abrupt increase Transient increases above the FHR baseline Positive reassuring Indicators: Fetal movement Contractions Decelerations: Visual abrupt decrease Types: Early Cause: Fetal head compression Normal finding Variable Cause: Cord compression Nursing: Change position Late Cause: Uteroplacental insufficiency Nursing: Indicate presence of fetal hypoxia stemming from insufficient placental perfusion during ctxs Note how the deceleration in heart rate comes after the contraction Can lead to metabolic acidemia Prolonged Decrease in FHR of at least 15 below the baseline and lasting more than 2 minutes but less than 10 minutes Cause: Disruption in fetal oxygen HOW TO REMEMBER: veal chop Internal About: Membranes must be ruptured and cervix dilated at least 2 cm More accurate Internal fetal scalp electrode (FSE) Measures fetal heart rate Intrauterine catheter (IUPC) Measures strength of uterine contractions internally Baseline variability Significance: Indicator of well oxygenated fetus Indicates fetal oxygen reserve Reflects neurological modulation of the sympathetic and parasympathetic nervous system Affected b drugs given to mother or ba sleep cycle Terminology: Absent 0 BPM Abnormal Needs immediate attention Minimal: less than or equal to 5 BPM Can result from fetal hypoxemia CNA depressant medications Preexisting neurologic injury Congenital anomalies Moderate: BPM Marked: 25 BPM Fetal Heart Rate Patterns Category I Baseline rate Variability moderate Early decelerations either present or absent Accelerations either present or absent Late or variable decelerations are absent Category II Rate: Bradycardia or Tachycardia No acceleration in response to fetal stimulation Variability: Minimal or marked variability Absent variability without recurrent decelerations Variable decelerations with minimal to moderate variability Prolonged deceleration minutes) Category Rate: Bradycardia Absent Variability with: Recurrent late decelerations Recurrent variable decelerations Sinusoidal pattern Not included in definition of FHR variability Severe fetal anemia Uncommon pattern How often to monitor: Low risk pregnancy: Latent labor: Q 30 60 minutes Active labor: Q 30 minutes Transition labor: Q 15 minutes High risk pregnancy Latent labor: Q 30 minutes Active labor: Q 15 minutes Transition stage: Q 5 minutes Jeopardy Fetal Monitoring These decelerations are greater than 2 minutes in length but return to baseline within 10 minutes Prolonged decelerations When it goes down, deliver or C section Normally happen and resolve themselves What deceleration is caused uteroplacental insufficiency? Late decelerations These decelerations vary in timing, length and depth. Easy to recognize due to rapid fall and rapid rise of the fetal heart rate. Variable decelerations What are the 2 signs of fetal well being on electronic fetal monitoring? heart rate with accelerations, moderate variability These decelerations indicate fetal head compression and do not require intervention? Early decelerations Alphabet Soup Define POISON Position Oxygen IV Sterile vaginal exam Oxytocin OFF Notify health care provider Define VEAL CHOP Variable cord compression Early head compression Passageway Psychological Exam 2: Topic 3: Postpartum and Puerperal Care Examine the pathophysiology, signs and symptoms, common diagnostic studies, and normal and abnormal findings related to the postpartum client and family. Involution Return of the uterus to a state after birth Begins immediately after the placenta is delivered with contractions of the uterine muscle In 24 hours, uterus size of 20 weeks gestation (umbilical level) Decreased estrogen and progesterone levels causes autolysis Autolysis: self destruction of excess hypertrophied tissue Subinvolution Failure of the uterus to return to the state Most common causes are: Retained placental parts Infection Postpartum hemostasis Promoted and achieved compression of the intramyometrial blood vessels as the uterus contracts Oxytocin released from the posterior pituitary gland and strengthens and coordinates uterine contraction Ba to breast after birth stimulates oxytocin to release Pitocin given IV or IM to stimulate uterine contractions After pains For first time moms: uterine tone is good with mild contractions Subsequent pregnancies: vigorous contractions cause uncomfortable camping called after pains More cramping when uterus has been over distended Breast feeding and IV or IM oxytocin stimulated ctxs Placental site: Unique healing process prevents scar formation Enables usual cycle changes and placentation in future pregnancies Upward growth of the endometrium prevents this scar formation Lochia Lochia rubra: bright red lasting days Lochia serosa: pinkish color Containing old blood and serum tissue debris Occurring after rubra lasting days Lochia alba: yellow to white containing leukocytes, mucus, serum, and bacteria Lochia may persist weeks after birth Examine components of a systematic postpartum assessment. Fundal check Vital signs: Temperature during the first 24 hours can increase to 38 C or 100 F as a result of dehydrating effects of labor After 24 hours, afebrile BP may have orthostatic hypotension for 48 hours Respirations Pulse Placental site Lochia Note amount Should not exceed more than 1 pad per hour BUBBLEHE Breast Uterus Bowel Bladder Lochia Episiotomy Homens sign Emotions Cervix: The cervix is soft immediately after birth Within days postpartum, it shortens, firms and regains its form 2 fingers may still be inserted into cervix for days External os never regains its appearance Vagina and Perineum: Estrogen deprivation that occurs after birth is responsible for causing the thinness of the vaginal mucosa and absence of rugae Returns to weeks post delivery lubricate during intercourse is recommended for estrogen deficiency responsible for decreased lubrication Lacerations: First degree Involves perineal skin and vaginal mucous membrane Second degree Involves skin and mucous membrane plus fascia of perineal body Third degree Involves skin, mucous membrane, and muscle of perineal body, extends into rectal sphincter Fourth degree: Extends into the rectal mucosa to expose the lumen of the rectum Perineum Initially the introitus is erythematous edematous, particularly with episiotomy and lacerations Hematomas Hemorrhoids (anal varicosities) Hygiene Nursing interventions Endocrine System Placental hormones: Expulsion of the placenta results in dramatic decreases of the hormones produced Cardiovascular system Average blood loss for vaginal delivery is cc is cc Vital signs: few alterations are seen, a small transient BP change may occur (orthostatic hypotension is common) Blood Components Hemoglobin and hematocrit: total blood volume decreases after birth resulting in transient anemia Normal in 8 weeks WBC leukocytosis normal Coagulation factors: increased risk for thromboembolism (fibrinogen) Varicosities Neurologic System Headache requires careful assessment Musculoskeletal system Joint stabilized within weeks Integumentary system Chloasma disappears (brown patches on face) Hyperpigmentation of the linea nigra and areola may not Stretch marks may fade but probably disappear Vascular abnormalities usually regress Hair loss (due to decrease in hormones and prenatal vitamins) Profuse diaphoresis that occurs is the most notable change Immune system No significant change Determine need for rubella varicella or prevention of RH isoimmunization Sexuality Discuss before discharge, possibility of pregnancy Contraception Practice contraception every time Diaphragm refitted at 6 week visit IUD not placed until 6 week visit Combined oral contraceptives decrease milk production May use temporary contraception Condoms until 6 week visit clients may be given OC prior to discharge Physiologic change Safe to resume intercourse when lochia turns alba After delay intercourse for 6 weeks Reduction in rapidity and intensity of the sexual response for 3 months of the year Continued low estrogen levels result in vaginal dryness, may need jelly If lactating, orgasm may stimulate the reflex Psychological change Menstrual cycle and ovulation resumption Discuss the classification, mechanism of action, indications for use, major adverse effects, therapeutic effects, and nursing considerations of selected medications used for the postpartum client. Postpartum depression Antidepressants agents Mood stabilizers Antipsychotics Analyze the psychosocial needs of the woman in the postpartum period. Postpartum Psychological Adaptations Time of vulnerability to psychiatric disorders Disrupts family life disorders likely to recur at this time Failure to address may result in tragic consequences Postpartum coping Assess level of anxiety Assess sources of concern Identify unmet needs and expectation Assess support system of family Assess past coping mechanism Assess emotional reaction of birth Postpartum emotional reactions Ba blues Occurs of time in first several weeks Sadness Tearfulness Crying spells Irritability, anxious Mood swings sleep caused sleep deprivation Appetite disturbance Postpartum depression Occurs of the time Increased incidence with: Personal or family history of mood disorder Negative life event such as loss of loved one, poor martial support, divorce, financial difficulties, or thyroid disorder More serious than Intense sadness Persist past the first few weeks of life Incidence of PPD among teenage mothers is higher than older mothers Signs and symptoms: Depressed mood Functional impairment Lack of affectionate bonding Changes of sleep pattern or eating pattern Excessive fatigue Psychomotor agitation Feelings of worthlessness Suicidal ideation Loss of interest in pleasurable activities Medical management
Fina L Exam Review OB - Lecture notes Topic 15
Course: Nursing Care of the Childbearing Family (NSG-432)
University: Grand Canyon University
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