Transcript HESI/ATI Review - wcunurs206and216

HESI/ATI Review
Catherine Ramos Marin, MSN/Ed, WHCNP, RN
August 12, 2011
Physiological Changes in
Pregnancy



Integumentary- as result of increased
estrogen and progesterone- linea nigra,
cholasma, and palmar erythema
Neurological- Carpal Tunnel Syndrome,
decreased attention span
Heart- increased blood flow- 30-50%,
“physiological anemia 11-12 Hgb
Physiological Changes in
Pregnancy (Continued)



Supine Hypotension Syndrome- don’t
have patient lie on her back (complaints
of dizziness, diaphoresis and pallor)
Respiratory Syndrome- increased
oxygen requirements,
Eyes, Ears, Nose and Throat- c/o blurry
vision, increased mucus membranes,
throat congestion
Physiological Changes in
Pregnancy


GI- gingivitis, ptyalism (increased
saliva), heartburn
Urinary System- Increased urgency,
frequency and nocturia (1st trimester),
urine urgency and nocturia decreases
(2nd trimester), increased urgency and
frequency (3rd trimester) because fetus
starts engaging in the pelvis
Physiological Changes in
Pregnancy

Thyroid- increased size, HPL (humal
placental lactogen- insulin antagonistincreases the number of circulating fatty
acides to meet maternal metabolic
needs and decreases maternal glucose
utilization which increases glucose
availability to the fetus- Macrosomia
babies- decreased HPL and large
babies ten to be Hypoglycemic
Physiological Changes in
Pregnancy

Musculoskeletal System- diastasis recti,
relaxin- produced by placenta and
causes laxity of ligaments
Prenatal Labs

Blood Group with Rh factor, RPR,
Hepatitis B, CBC, HIV, Sickle Cell
screen for women at risk
Signs of Pregnancy



Presumptive changes- breast changes,
n/v, amenorrhea, frequent urination,
fatigue, uterine enlargement,
quickening, linea nigra, melasma, striae
gravidarum
Probable- elevated HCG
Definite- fetal heart tones
Gravida-parity
•Gravida- number of times a woman has been pregnant
•Para- number of times infants delivered after twenty weeks
gestation born dead of alive
•Remember, multiple births counts as one delivery
•TPAL is a detailed description of Para
Danger Signs of Pregnancy
Vaginal bleeding
 Persistent vomiting
 Chills and fever
 Ruptured membranes

Danger Signs of Pregnancy
(Continued)







Severe, persistent headache
Visual disturbances
Edema of face or hands
Abdominal pain
Epigastric pain
Painful urination persistent vomiting
Change in or absence of fetal movement (e.g., no
movement for 6-8 hours)
Identifying the High-Risk
Pregnancy

High-risk pregnancy

A concurrent disorder, pregnancyrelated complication, or external
factor jeopardizes the health of the
mother, fetus or both
Preterm Labor
Terbutaline, Procardia, Nifedipine, MgSo4
For Terbutaline make sure you consider maternal pulse
Shoulder Dystocia



Dispositions leading to shoulder
dystocia?
Result- brachial plexus injury
McRoberts Maneuver
Positions other than cephalic
(pages 604-605, Pilletteri)



Transverse, Breech
Usually at 34 weeks the presentation is
established
Leopold’s Maneuver



Grasp the uterine fundus between the
thumb and middle finger of one hand
Soft feeling (buttocks)
Round, firm and easily moved (head)
Other presentations of fetus

If it is Breech





Complete, frank and footling
Higher risk because of anoxia from
prolapsed cord, traumatic injury to the
aftercoming head
Fracture of the spine or arm
Dysfunctional labor
Early rupture of membranes
Multiple Gestations


Susceptible to complications such as
PIH, hydramnios, placenta previa,
preterm labor, and anemia
Increased Incidence of Postpartum
Bleeding
Placenta
80% of low-lying placentas are
resolved or go down in proper
position by 28 weeks
Abruptio Placentae







“Premature separation of the normally implanted placenta from
the uterine wall
Can occur from 20 weeks of pregnancy or in the 1st or 2nd stage
of labor
Factors: multiple gestations, hydramnios (excess fluid) cocaine
use, decreased blood flow to the placenta
Trauma to the abdomen
Low serum folic acid level
Vascular or renal disease
Gestational hypertension
Abruptio Placentae




Signs- abdominal pain, contractions,
back pain
Vaginal bleeding and uterine
tenderness may be absent
“Boardlike” abdomen, uterine irritability,
tetanic contractions
Result- hypotension, shock, fetal
bradycardia and fetal death
Placenta Previa




“Placenta implants in varying degrees in
the lower uterine segment, below the
presenting part of the baby”
A total or complete previa covers the
entire internal cervical os:
Partia previa-covers part of the internal
os
Painless bleeding
Placenta Previa



Can be diagnosed as early as first 20
weeks of gestation. However, this
usually resolves 90% of the time
Need to be on pelvic rest (nothing in the
vagina such as intercourse, tampon,
douching)
Avoid masturbation- don’t want uterine
contractions
Maternal and Fetal Responses to Labor

Danger signs of labor - fetal
Heart rate
 Meconium staining
 Hyperactivity


Fetal acidosis
Maternal and Fetal
Responses

Danger signs of labor - maternal
Blood pressure
 Abnormal pulse
 Inadequate or prolonged contractions
 Pathologic retraction ring
 Abnormal lower abdominal contour
 Apprehension

Premature Rupture of
Membranes



Loss of amniotic fluid before 37 weeks
of pregnancy
Usually associated with
chorioamnionitis (infection in the fluid).
Increased risk of cord prolapse
Complications of Premature
Rupture of Membranes

Respiratory Distress Syndrome

Infants try to compensate by releasing
surfactant (to aid in the maturation of the
lungs)
NST AND CST





Non-stress test- evaluates HR in response to fetal
movement
Reactive= 2-4 FHR accelerations in 10 minutes
without side effects
Contraction stress test-evaluates FHR in response to
uterine contractions
Negative-no late FHR decels produced by UCS
Side effects of CST include overstiumulation of the
uterus secondary to use of oxytocin
True vs. False Labor: Client
Preparation

False Labor (Contractions)




Benign and irregular contractions
Felt first abdominally and remain confined
to the abdomen and groin
Often disappear with ambulation and
sleep.
Contractions do not increase in duration,
frequency or intensity
False Labor (Cervix)




No significant change in dilation or
effacement
Often remains in posterior position
No significant bloody show
Fetus- presenting part is not engage in
pelvis
True Labor (Contractions)




Contractions begin irregularly but become
regular and predictable
Felt first in lower back and sweep around to
the abdomen in a wave
Contractions continue no matter what the
women’s level of activity
Contractions increase in duration, frequency,
and intensity
True Labor (Cervix)




Progressive change in dilation and
effacement
Moves to anterior portion
Bloody show
Fetus is in the presenting part engages
in pelvis
Labor Induction

Definition- the deliberate initiation of
uterine contractions to stimulate labor
before spontaneous onset to bring
about the birth either by chemical or
mechanical means
Methods include





Prostaglandins (Cervidil, prostin gel,
Prepidil, Cytotec) applied cervically)
Pitocin administration
Amniotomy or stripping of membranes
Nipple stimulation to trigger the release
of endogenous oxytocin
Sexual intercourse
Indications for induction of
labor







Postterm pregnancy (beyond 42 weeks)
Premature or prolonged rupture of membranes
Dystocia (prolonged, difficult labor)
Maternal complications (Rh isoimmunization,
Diabetes, Pulmonary disease, Pregnancy-induced
hypertension)
Fetal demise
Chorioamnionitis
Suspected fetal problems- Intrauterine Growth
restriction and hydrops (fetal hemolytic disorder as
result of Rh isoimmunization when maternal immune
system attacks fetal red blood cells
Cervical Ripening and
Assessment



Baseline data on fetal and maternal
well-being (at least half an hour of
monitoring)
Fetal monitoring and uterine contraction
monitoring is imperative
Notify MD is hyperstimulation or fetal
heart rate distress is noted
Oxytocin Induction





Confirmation that the head is presented in a
cephalic position and at 0 station (ideally)
IUPC- Intrauterine Pressure Catheter
monitors precisely frequency, duration, and
intensity of contractions
V/S done at least every 30 minutes and when
dose is titrated
FHTs and UCS monitored every 15 minutes
I/Os
Oxytocin Induction
(Continued)




Bishop Score- rating that determines if the
cervix is adequate for induction
Titration of Oxytocin till UCs every 2-3
minutes, lasting 60-90 seconds, intensity 4090mm HG (IUPC)
Cervical dilation should be 1cm/hr (ideally)
Reassuring FHTs between 110-160
beats/min
When to discontinue Oxytocin




Frequency of UCs less than 2 minutes apart
Contractions longer than 90 seconds
Contractions intensity greater than 90mm Hg
on IUPC
Uterine resting tone greater than 20 mm Hg
between contractions (no rest between UCs)
Nonreassuring fetal heart rate



FHTs baseline less than 110 and
greater than 160 beats/minute
Loss of variability
Late or prolonged decelerations
Intervention for oxytocin
hyperstimulation







Turn off oxytocin
Side-lying position, preferably left to increase
uteroplacental perfusion
Increase IVFs
O2 via mask 8-10 L/min
Tocolytics (Brethine subcutaneously or IV)
Monitor FHTS and V/S
Document responses to all above interventions
Need for Fetal Heart Rate
Monitoring (Intermittent)



Home births and birthing centers
Allows for greater maternal freedom of
movement
Non Stress Tests
Continuous Fetal Monitoring






Multiple gestations
Placenta Previa
Oxytocin infusion
Fetal bradycardia
Maternal Complications (Gestational
Diabetes
Intrauterine Growth Retardation
Continuous Fetal Monitoring







Post dates
Meconium-stained amniotic fluid
Abruption placenta- suspected or actual
Abnormal non-stress test
Abnormal uterine contractions
Fetal distress
Provider preference and facility protocol
Fetal Heart Tones

Between 110-160-

Early Decels- head comprehension
Variable Decels- Cord compression
Late Decels- Placental
uterounsuffciency


Ruptured Membranes




Nitrazine paper turns black or dark blue
Vaginal fluid “ferns” under microscope
Note color, amount of amniotic fluid
If laboring mom ambulates, fetus MUST
be at station zero or below (ENGAGED)
or there is an increased risk chance of
prolapsed cord
Rupture of Membranes




Spontaneous rupture of membranes can initiate labor
or can occur anytime during labor, most commonly
during the transition phase
Labor usually occur within 24 hours of rupture of
membranes
Prolonged rupture of membranes greater than 24
hour before delivery of fetus may lead to an infection
Immediately following the rupture of membranes,
assess fetal heart rate for abrupt decelerations
indicative of fetal distress to rule out umbilical cord
prolapse
Assessment of amniotic fluid





Color- pale to straw yellow
Odor- should not be foul
Clarity- watery and clear
Volume between 500 to 1200 ml
Nitrazine paper tests pH of fluid wnd will turn
deep blue determining alkalinity- if negative it
remains yellow or it may be urine instead of
amniotic fluid
Amniotomy




“AROM”- Artificial Rupture of
Membranes
Nurse should record baseline of FHT
prior and after procedure
Assess color, amount, consistency and
odor
Document time of amniotomy and
findings
Regional Anesthesia

Injection of local anesthesia to
block specific nerve pathways

Epidural anesthesia
Nursing care
 Administration


Spinal anesthesia
Problems with the
Passenger
Prolapse of umbilical cord
 Multiple gestation

Prolapsed Cord




It is safer for patient to remain in bed after
rupture of membranes (especially in they
rupture in Stage 1 of labor)
Place patient in Tredelenberg or knee-chest
position
Also vaginally push the head back away from
the cord.
If during the V.E. you feel the cord you may
not be able to let go and your hand may
remain in place till C-section is performed.
Stages of labor




Stage 1- LAT
Stage 2- pushing at 10 cm to delivery of
infant
Stage 3- Delivery of infant to Delivery of
placenta
Stage 4- Delivery of Placenta to 2-4
hours of recovery
Assessment for WellBeing

Apgar scoring
Heart rate
 Respiratory effort
 Muscle tone
 Reflex irritability
 Color

Appearance of a
Newborn

Head






Fontanelles
Sutures
Molding
Caput succedaneum
Cephalhematoma
Craniotabes
Appearance of a Newborn

Skin
Vernix caseosa
 Lanugo
 Desquamation
 Milia
 Erythema toxicum
 Forceps marks

Appearance of a Newborn
Eyes
 Ears
 Nose
 Mouth
 Neck
 Chest

Appearance of a Newborn
Abdomen
 Anogenital area



Male genitalia
Female genitalia
Back
 Extremities

FAS Newborn
Note The Facial Features
Assessment for WellBeing
Keeping the newborn warm
 Promoting adequate breathing pattern
 Record of first cry
 Inspection and care of umbilical cord
 Eye care
 Infection precautions
 Heelstick- lateral portion of foot

Heel stick
Altered Gestational
Age or Birthweight

Large for gestational age
Causes
 Assessment
 Appearance
 Cardiovascular dysfunction
 Hypoglycemia

Altered Gestational
Age or Birthweight

Small for gestational age
Causes
 Assessment

Prenatal
 Appearance
 Laboratory findings

Hypoglycemia



Due to decreased glycogen storage in
liver.
Hypoglycemia usually happens to
infants of Gestational Diabetes Mothers
S/S includes jitteriness, tremors,
lethargy, hypotonia, apnea weak or
high-pitched cry, eye-rolling and
seizures
Post Term Infant


Definition- born after 42 weeks
gestation
Causes

Dysmaturity- uteroplacental insufficiency
which may result in fetal hypoxia, fetal
distress. This conditions can result in
polycythemia (increase in the number of
RBCs) and meconium aspiration and
neonatal respiratory problems
Post Term Infant

In a fetus continues to grow- this can
result in cephalopelvic disproportion and
high insulin reserves and insufficient
glucose reserves at birth.


Birth Trauma- perinatal asphyxia, clavicle
fracture, seizures, hypoglycemia and
temperature instability- cold stress
LGA or SGA
Post Term Infant

Persistent Pulmonary Hypertension
(persistent fetal circulation)


As a result from meconium aspiration
Interference in the transition from fetal to
neonatal circulation and the ductus
arteriosus(connecting main artery and the
aorta) and foramen ovale (shunt between
the right and left atria)
Nursing Assessments
1. Signs and Symptoms






Wasted appearance (thin and loose
skin)
Peeling, cracked, dry skin
Long thin body
Meconium staining (fingernails)
Long hair and nails
Increased alert (similar to a 2 week old)
Signs and Symptoms of
Postterm infant




Difficulty establishing respirations
(secondary to meconium aspiration)
Signs and symptoms of cold stress
Increased development of neurological
skills
Macrosomia
Nursing assessment of
postterm infant





Observe for birth injury or trauma
Respiratory status
Reflexes
Monitoring vital signs and temperature
Monitoring intravenous fluids
Nursing Diagnoses



Ineffective airway clearance related to
meconium aspiration
Risk for aspiration related to the
presence of meconium
Ineffective thermoregulation related to
decreased subcutaneous fat
Nursing interventions for the
postterm infant



Assisting with surfactant lavages during
delivery to prevent meconium aspiration
Suctioning meconium from the
neonate’s mouth and nares before the
first breath
Mechanical ventilation PRN
Nursing Interventions for the
Postterm infant (continued)



Administering oxygen as prescribed
Administering intravenous fluids
Preparing or assisting with exchange
transfusion if hematocrit is high
Nursing Interventions for the
Postterm infant (continued)

Exchange Transfusion

First, aspirate stomach first in order to
avoid potential aspiration. Then, the
umbilical vein is catheterized as the site for
transfusion. The procedure involves
alternatively withdrawing 2-10ml of the
infant’s blood and then replacing it with
equal amounts of donor blood. Blood is
exchanged slowly to prevent hypovolemia
and hypervolemia. Takes 1-3 hours.
Nursing Interventions for the
Postterm infant (continued)



Provide thermoregulation in an
incubator in order to avoid cold stress
Provide early feedings to avoid
hypoglycemia
Identify and treating birth injuries
Newborn Assessment:
Respiratory Distress

5 symptoms of respiratory distress





Tachypnea
Cyanosis
Flaring nares
Expiratory grunt
Retractions
Neonates at risk for Respiratory
Distress Syndrome
Preterm infants
 Infants of diabetic mothers
 Infants born by cesarean birth
 Decreased blood perfusion of the lungs
(one cause is meconium aspiration)
Remember, surfactant usually don’t form
until 34th week gestation

Betamethasone
Infants cannot receive surfactant after 34 weeks
Measure L/S ratio and PG hormone presence
using amniocentesis
Sample Question

Which of the following signs pertaining
to respirations indicate that a newborn
is having no difficult adapting to
extrauterine life?




Expiratory grunting
Respirations of 46/min
Inspiratory nasal flaring
Apnea for 10 second periods
Sample Question



Obligator nose breathing
Respirations of 26/min
Crackles and wheezing
Answer to Sample Question



Respirations of 46/min
Apnea for 10 sec periods
Obligatory nose breathing
Risk Factors contributing to
RDS






Decreased gestational age
Perinatal asphyxia
Maternal diabetes
Premature rupture of membranes
Maternal use of barbiturates or
narcotics close to birth
Maternal hypotension
Risk Factors contributing to
RDS (continued)



Cesarean birth without labor
Hydrops fetalis (massive edema of the
fetus caused by hyperbilirubinemia)
Maternal bleeding during the third
trimester
Assessment of infants with
Respiratory Distress Syndrome




Low Body Temperature
Nasal Flaring Sternal and subcostal
retractions
Tachypnea (more than 60 respirations
per minute)
Cyanotic mucous membranes
Newborn Care: Positions for
Sleep



Baby is to be positioned on the back
Sudden Infant Death Syndromesudden, unexplained death of an infant
younger than 1 year of age.
Positioning on the back decreases the
incidence of SIDS
Sleep Wake Cycle




Supine position decreases risk for SIDS
Sleep 16 our of 24 hours and 2-3 hours
at a time
Don’t add cereal to diet till 4-6 months
of age
Infants should never sleep in parents’
bed
Hyperbilirubinemia: Phototherapy
Nursing Care

Hyperbilirubin- results from destruction
of red blood cells either a normal
physiologic process or abnormal
destruction or RBCs
Physiologic Jaundice


Benign condition
Usually occurs after 24 hours of age
Pathologic Jaundice




Before 24 hours or persistent after day 7
Bilirubin increases more than 0.5 mg/dl/hr,
peaks at greater than 13 mg/dl or associated
with anemia and hepatosplenomegaly
Rh incompatibility/isoimmunization, infection,
RBC disorder
Kernicterus (bilirubin encephalopathy) can
result from untreated hypergbilirubinemia with
bilirubin levels at or higher than 25 mg/dl.
Factors that affect development of
hyperbilirubinemia






Increased RBC production or
breakdown
Rh or ABO incompatibility
Decreased liver function
Maternal enzymes in breast mil.
Ineffective breastfeeding
Certain medications (aspirin,
tranquilizers, and sulfonamides).
Factors that affect development of
hyperbilirubinemia(Continued)



Hypogycemia
Hypothermia
Anoxia
Lab Testing





Elevated serum bilirubin (direct and indirect)
Blood group incapability between the mother
and newborh
Hemoglobin and hematocrit
Direct Coomb’s test- reveals presence of
antibody-coated (sensitized) Rh-positive
RBCs in the newborn
Electrolyte levels for dehydration from
phototherapy (treatment of
hyperbilirubinemia)
Nursing Assessments of
Hyperbilirubinemia



Yellowish tint to skin, sclera and mucus
membranes
Press infant’s skin lightly and release
and notice yellowish tint
Note time of jaundice (integral in
differentiating between physiologic and
pathologic jaundice)
Circumcision Care



Circumcision- surgical removal of foreskin of penis
Newborns with hypospadias and epispadias shouldn’t
have circunmcisions
Circumcision should not be done immediately
because the Vitamin K the infant receives hasn’t
kicked in and thermoregulation is not stabilized (cold
stress can occur)
Circumcision Care




Surgical methods include Yellen, Mogen,
Gomco clamps and Plastibell
Anesthesia is now mandatory for all
circumcisions (ring block, dorsal penile nerve
block and topical anesthetic)
Circumcision site is covered with sterile
petroleum
With plastibell the foreskin drops off after 5 to
8 days
Circumcision Care





Postprocedure- bleeding assess every 15 minutes for
the first hour then every hour for 24 hours.
First voiding
Check for bleeding
Apply diapers loosely to prevent irritation
Teach parents to keep area clean and check diaper
every 4 hours
Circumcision Care



Notify provider if there is any redness, discharge,
swelling, strong odor, tenderness, decrease in
urination, or excessive crying from infant
A film of yellowish mucus may form over the glans by
day 2 and it is normal- don’t have to wash off
Avoid premoistened towlettes to clean penis because
they contain alcahol
Circumcision Care
(Continued)



Circumcision will heal in a couple of weeks
Monitor for hemorrhage,
coldstress/hypoglycemia, complications
(infection, urethral fistula, delayed healing
and scarring, fibrous bands
Provide discharge instructions to parents
about signs and symptoms to observe for and
how to report them to provider
Postpartal Hemorrhage

Uterine atony

Therapeutic management
Bimanual massage
 Prostaglandin administration
 Blood replacement
 Hysterectomy

Postpartal Hemorrhage

Lacerations
Cervical lacerations
 Vaginal lacerations
 Perineal lacerations

Postpartal Hemorrhage





Retained placental fragments
Disseminated intravascular coagulation
Subinvolution
Perineal hematomas
Fundus at umblicus at day of delivery
(deviation may mean that bladder is full
Nursing Care: First 24 Hours
Postpartum
Assess peripheral circulation
 Prevent/alleviate breast
engorgement
 Breast hygiene
 Promote uterine involution

Nursing Care: First 24 Hours
Postpartum






Perineal care
Perineal self-care
Rest
Adequate fluid intake
Prevent constipation
Prevent development of
hemorrhoids
Breastfeeding Problems

Mastitis (Signs and Symptoms)





Milk stasis from a blocked duct
Nipple Trauma and cracked or fissured nipples
Poor breastfeeding technique with improper
latching of the infant onto the breast- sore and
cracked nipples
Decrease in Breastfeeding frequency due to
supplementation with bottle feeding
Poor Hygiene
Nursing Interventions for
Mastitis







Breast Hygiene (handwashing, frequent
changes of breast pads, air-dry nipples)
Client education
Icepacks or warm packs for discomfort
Continue breastfeeding every 2-4 hours
(especially on affected side)
Encourage rest, analgesics and a fluid intake
of at least 3000 ml per day
Well-fitting bra
Report redness and fever
Episiotomy Care




Anesthetic spray, cortisone-based cream, sitz
bath, witch hazel pads (decreases
inflammation and relieve tension in the area)
Perineal exercises (Kegel exercises)- start
and stop voiding in midstream
Ice packs for first 24 hours- reduceds perineal
edema and hematoma formation
After 24 hours dry heat (hot packs or moist
heat with sitz bath & heating lamps)
Episiotomy Care (Continued)


Nursing Diagnosis: Risk for infection
related to lochia and episiotomy
Good perineal care (handwashing,
changing pads, washing front to back)
Psychological
Changes

Development of parental love
and positive family relationships
Rooming-in
 Sibling visitation

Emotional and Psychological
Complications
Child born with illness or is
physically challenged
 Child who has died
 Postpartal depression
 Postpartal psychosis

Postpartal
Hemorrhage

Lacerations
Cervical lacerations
 Vaginal lacerations
 Perineal lacerations

Reproductive System Disorders
Reproductive tract displacement
 Separation of symphysis pubis

Postpartal
Hemorrhage
Retained placental fragments
 Disseminated intravascular
coagulation
 Subinvolution
 Perineal hematomas

Pulmonary Embolus

Obstruction of the pulmonary
artery with a blood clot
Usually a complication of
thrombophlebitis
 Therapeutic management

Mastitis

Infection of the breast
Prevention
 Assessment
 Therapeutic management
