NUR318 Exam III Study Guide Maternal Health Nursing|
Complete Questions with Correct Answers
-infants receiving phototherapy (for high bilirubin) need eye shields to protect eyes
During phototherapy the unclothed infant is placed under a bank of lights approximately 45 to 50 cm
from the light source. The distance may vary based on unit protocol and type of light used. A Plexiglas
panel or shield should always be placed between the lights and the infant when conventional lighting is
used. The most effective therapy is achieved with lights at 400 to 500 manometers, and a blue-green
light spectrum is the most efficient (Steffensrud, 2004). The lamp's energy output should be monitored
routinely with a photometer during treatment to ensure efficacy of therapy. Phototherapy is carried out
until the infant's serum bilirubin level decreases to within an acceptable range. The decision to
discontinue therapy is based on the observation of a definite downward trend in the bilirubin values.
Several precautions must be taken while the infant is undergoing phototherapy. The infant's eyes must
be protected by an opaque mask to prevent overexposure to the light. The eye shield should cover the
eyes completely but not occlude the nares. Before the mask is applied the infant's eyes should be closed
gently to prevent excoriation of the corneas. The mask should be removed periodically and during infant
feedings so that the eyes can be checked and cleansed with water and the parents can have visual
contact with the infant.
To promote optimal skin exposure during phototherapy a "string bikini" made from a disposable
facemask is often used instead of a diaper, which allows optimal skin exposure and provides protection
for the genitals and the bedding. Before use the metal strip must be removed from the mask to prevent
burning the infant. Lotions and ointments should not be used during phototherapy because they absorb
heat and can cause burns.
Phototherapy can cause changes in the infant's temperature, depending partially on the bed used:
bassinet, incubator, or radiant warmer. The infant's temperature should be closely monitored.
Phototherapy lights can increase the rate of insensible water loss, which contributes to fluid loss and
dehydration. Therefore the infant must be adequately hydrated. Hydration maintenance in the healthy
newborn is accomplished with human milk or infant formula; administering glucose water or plain water
has no advantage or benefit because these liquids do not promote excretion of bilirubin in the stools
and may actually perpetuate enterohepatic circulation, thus delaying bilirubin excretion.
It is important to closely monitor urinary output while the infant is receiving phototherapy. Urine output
may be decreased or unaltered; the urine may have a dark-gold or brown appearance.
The number and consistency of stools are monitored. Bilirubin breakdown increases gastric motility,
which results in loose stools that can cause skin excoriation and breakdown. The infant's buttocks must
be cleaned after each stool to help maintain skin integrity. A fine maculopapular rash may appear during
phototherapy, but this condition is transient. Because visualization of the infant's skin color is difficult
with blue light, appropriate cardiorespiratory monitoring should be implemented based on the infant's
overall condition.
,-pp hemorrhage- causes and treatments- drugs used such as methergine, hemabate, pitocon and
cytotec
Postpartum hemorrhage (PPH) continues to be a leading cause of maternal morbidity and mortality in
the United States and worldwide (American College of Obstetricians and Gynecologists [ACOG], 2006;
Johnson, Gregory, & Niebyl, 2007). It is a life-threatening event that can occur with little warning and is
often unrecognized until the mother has profound symptoms. PPH has been traditionally defined as the
loss of more than 500 ml of blood after vaginal birth and 1000 ml after cesarean birth. A 10% change in
hematocrit between admission for labor and postpartum or the need for erythrocyte transfusion also
has been used to define PPH (Francois & Foley, 2007). However, defining PPH is not a clear-cut issue.
The diagnosis is often based on subjective observations, with blood loss often being underestimated by
as much as 50% (Cunningham, Leveno, Bloom, Hauth, Gilstrap, & Wenstrom, 2005).
Traditionally, PPH has been classified as early or late with respect to the birth. Early, acute, or primary
PPH occurs within 24 hours of the birth. Late or secondary PPH occurs after 24 hours and up to 6 to 12
weeks postpartum (ACOG, 2006; Francois & Foley, 2007). Today's health care environment encourages
shortened stays after birth, thereby increasing the potential for acute episodes of PPH to occur outside
the traditional hospital or birth center setting.
Etiology and Risk Factors
Considering the problem of excessive bleeding with reference to the stages of labor is helpful. From
birth of the infant until separation of the placenta the character and quantity of blood passed may
suggest excessive bleeding. For example, dark blood is probably of venous origin, perhaps from varices
or superficial lacerations of the birth canal. Bright blood is arterial and may indicate deep lacerations of
the cervix. Spurts of blood with clots may indicate partial placental separation. Failure of blood to clot or
remain clotted indicates a pathologic condition or coagulopathy such as disseminated intravascular
coagulation (DIC) (Francois & Foley, 2007).
Excessive bleeding may occur during the period from the separation of the placenta to its expulsion or
removal. Commonly, such excessive bleeding is the result of incomplete placental separation, undue
manipulation of the fundus, or excessive traction on the cord. After the placenta has been expelled or
removed, persistent or excessive blood loss is usually the result of atony of the uterus or inversion of the
uterus into the vagina. Late PPH may be the result of subinvolution of the uterus, endometritis, or
retained placental fragments (Francois & Foley, 2007).
BOX 23-1 Risk Factors for Postpartum Hemorrhage
• Uterine atony
• Overdistended uterus
• Large fetus
• Multiple fetuses
• Hydramnios
• Distention with clots
• Anesthesia and analgesia
• Conduction anesthesia
• Previous history of uterine atony
,• High parity
• Prolonged labor, oxytocin-induced labor
• Trauma during labor and birth
• Forceps-assisted birth
• Vacuum-assisted birth
• Cesarean birth
• Unrepaired lacerations of the birth canal
• Retained placental fragments
• Ruptured uterus
• Inversion of the uterus
• Placenta accreta, increta, percreta
• Coagulation disorders
• Placental abruption
• Placenta previa
• Manual removal of a retained placenta
• Magnesium sulfate administration during labor or postpartum period
• Chorioamnionitis
• Uterine subinvolution
Drugs Used to Manage Postpartum Hemorrhage
DRUG: Oxytocin (Pitocin)
ACTION: Contraction of uterus; decreases bleeding
SIDE EFFECTS: Infrequent: water intoxication, nausea and vomiting
CONTRAINDICATIONS: None for PPH
DOSAGE AND ROUTE: 10 to 40 units/L diluted in lactated Ringer's solution or normal saline at 125 to 200
milliunits/min IV; or 10 to 20 units IM
NURSING CONSIDERATIONS: Continue to monitor vaginal bleeding and uterine tone
DRUG: Methylergonovine (Methergine)*
ACTION: Contraction of uterus
SIDE EFFECTS: Hypertension, nausea, vomiting, headache
CONTRAINDICATIONS: Hypertension, cardiac disease
DOSAGE AND ROUTE: 0.2 mg IM every 2-4 hr up to five doses; may also be given intrauterine or orally
NURSING CONSIDERATIONS: Check blood pressure before giving, and do not give if >140/90 mm Hg;
continue monitoring vaginal bleeding and uterine tone
DRUG: 15-Methylprostaglandin F2α (Prostin/15m; Carboprost, Hemabate)
ACTION: Contraction of uterus
SIDE EFFECTS: Headache, nausea and vomiting, fever, tachycardia, hypertension, diarrhea
CONTRAINDICATIONS: Avoid with asthma or hypertension
DOSAGE AND ROUTE: 0.25 mg IM or intrauterine every 15-90 min up to eight doses
NURSING CONSIDERATIONS: Continue to monitor vaginal bleeding and uterine tone
, DRUG: Dinoprostone (Prostin E2)
ACTION: Contraction of uterus
SIDE EFFECTS: Headache, nausea and vomiting, fever, chills, diarrhea
CONTRAINDICATIONS: Avoid with hypotension
DOSAGE AND ROUTE: 20 mg vaginal or rectal suppository every 2 hr
NURSING CONSIDERATIONS: Continue to monitor vaginal bleeding and uterine tone
DRUG: Misoprostol (Cytotec)
ACTION: Contraction of uterus
SIDE EFFECTS: Headache, nausea and vomiting, diarrhea
CONTRAINDICATIONS: History of allergy to prostaglandins
DOSAGE AND ROUTE: 800 to 1000 mcg rectally once
NURSING CONSIDERATIONS: Continue to monitor vaginal bleeding and uterine tone
-diabetes during pregnancy- risk for diabetes later on in life, insulin needs at the beginning of preg (low)
and later in preg (higher)
Metabolic changes associated with pregnancy
Normal pregnancy is characterized by complex alterations in maternal glucose metabolism, insulin
production, and metabolic homeostasis. During normal pregnancy, adjustments in maternal metabolism
allow for adequate nutrition for both the mother and the developing fetus. Glucose, the primary fuel
used by the fetus, is transported across the placenta through the process of carrier-mediated facilitated
diffusion, meaning that the glucose levels in the fetus are directly proportional to maternal levels.
Although glucose crosses the placenta, insulin does not. Around the tenth week of gestation the fetus
begins to secrete its own insulin at levels adequate to use the glucose obtained from the mother.
Therefore, as maternal glucose levels rise, fetal glucose levels are increased, resulting in increased fetal
insulin secretion.
TABLE 20-1 White's Classification of Diabetes in Pregnancy (Modified)
GESTATIONAL DIABETES
Class A1: Patient has two or more abnormal values on the OGTT with a normal fasting blood sugar.
Blood glucose levels are diet controlled.
Class A2: Patient was not known to have diabetes before pregnancy but requires medication for blood
glucose control.
PREGESTATIONAL DIABETES
Class B: Onset of disease occurs after age 20 and duration of illness <10 years.
Class C: Onset of disease occurs between 10 and 19 years of age or duration of illness for 10-19 years or
both.
Class D: Onset of disease occurs <10 years of age or duration of illness >20 years or both.
Class F: Patient has developed diabetic nephropathy.
Class R: Patient has developed retinitis proliferans.
Class T: Patient has had a renal transplant.
Complete Questions with Correct Answers
-infants receiving phototherapy (for high bilirubin) need eye shields to protect eyes
During phototherapy the unclothed infant is placed under a bank of lights approximately 45 to 50 cm
from the light source. The distance may vary based on unit protocol and type of light used. A Plexiglas
panel or shield should always be placed between the lights and the infant when conventional lighting is
used. The most effective therapy is achieved with lights at 400 to 500 manometers, and a blue-green
light spectrum is the most efficient (Steffensrud, 2004). The lamp's energy output should be monitored
routinely with a photometer during treatment to ensure efficacy of therapy. Phototherapy is carried out
until the infant's serum bilirubin level decreases to within an acceptable range. The decision to
discontinue therapy is based on the observation of a definite downward trend in the bilirubin values.
Several precautions must be taken while the infant is undergoing phototherapy. The infant's eyes must
be protected by an opaque mask to prevent overexposure to the light. The eye shield should cover the
eyes completely but not occlude the nares. Before the mask is applied the infant's eyes should be closed
gently to prevent excoriation of the corneas. The mask should be removed periodically and during infant
feedings so that the eyes can be checked and cleansed with water and the parents can have visual
contact with the infant.
To promote optimal skin exposure during phototherapy a "string bikini" made from a disposable
facemask is often used instead of a diaper, which allows optimal skin exposure and provides protection
for the genitals and the bedding. Before use the metal strip must be removed from the mask to prevent
burning the infant. Lotions and ointments should not be used during phototherapy because they absorb
heat and can cause burns.
Phototherapy can cause changes in the infant's temperature, depending partially on the bed used:
bassinet, incubator, or radiant warmer. The infant's temperature should be closely monitored.
Phototherapy lights can increase the rate of insensible water loss, which contributes to fluid loss and
dehydration. Therefore the infant must be adequately hydrated. Hydration maintenance in the healthy
newborn is accomplished with human milk or infant formula; administering glucose water or plain water
has no advantage or benefit because these liquids do not promote excretion of bilirubin in the stools
and may actually perpetuate enterohepatic circulation, thus delaying bilirubin excretion.
It is important to closely monitor urinary output while the infant is receiving phototherapy. Urine output
may be decreased or unaltered; the urine may have a dark-gold or brown appearance.
The number and consistency of stools are monitored. Bilirubin breakdown increases gastric motility,
which results in loose stools that can cause skin excoriation and breakdown. The infant's buttocks must
be cleaned after each stool to help maintain skin integrity. A fine maculopapular rash may appear during
phototherapy, but this condition is transient. Because visualization of the infant's skin color is difficult
with blue light, appropriate cardiorespiratory monitoring should be implemented based on the infant's
overall condition.
,-pp hemorrhage- causes and treatments- drugs used such as methergine, hemabate, pitocon and
cytotec
Postpartum hemorrhage (PPH) continues to be a leading cause of maternal morbidity and mortality in
the United States and worldwide (American College of Obstetricians and Gynecologists [ACOG], 2006;
Johnson, Gregory, & Niebyl, 2007). It is a life-threatening event that can occur with little warning and is
often unrecognized until the mother has profound symptoms. PPH has been traditionally defined as the
loss of more than 500 ml of blood after vaginal birth and 1000 ml after cesarean birth. A 10% change in
hematocrit between admission for labor and postpartum or the need for erythrocyte transfusion also
has been used to define PPH (Francois & Foley, 2007). However, defining PPH is not a clear-cut issue.
The diagnosis is often based on subjective observations, with blood loss often being underestimated by
as much as 50% (Cunningham, Leveno, Bloom, Hauth, Gilstrap, & Wenstrom, 2005).
Traditionally, PPH has been classified as early or late with respect to the birth. Early, acute, or primary
PPH occurs within 24 hours of the birth. Late or secondary PPH occurs after 24 hours and up to 6 to 12
weeks postpartum (ACOG, 2006; Francois & Foley, 2007). Today's health care environment encourages
shortened stays after birth, thereby increasing the potential for acute episodes of PPH to occur outside
the traditional hospital or birth center setting.
Etiology and Risk Factors
Considering the problem of excessive bleeding with reference to the stages of labor is helpful. From
birth of the infant until separation of the placenta the character and quantity of blood passed may
suggest excessive bleeding. For example, dark blood is probably of venous origin, perhaps from varices
or superficial lacerations of the birth canal. Bright blood is arterial and may indicate deep lacerations of
the cervix. Spurts of blood with clots may indicate partial placental separation. Failure of blood to clot or
remain clotted indicates a pathologic condition or coagulopathy such as disseminated intravascular
coagulation (DIC) (Francois & Foley, 2007).
Excessive bleeding may occur during the period from the separation of the placenta to its expulsion or
removal. Commonly, such excessive bleeding is the result of incomplete placental separation, undue
manipulation of the fundus, or excessive traction on the cord. After the placenta has been expelled or
removed, persistent or excessive blood loss is usually the result of atony of the uterus or inversion of the
uterus into the vagina. Late PPH may be the result of subinvolution of the uterus, endometritis, or
retained placental fragments (Francois & Foley, 2007).
BOX 23-1 Risk Factors for Postpartum Hemorrhage
• Uterine atony
• Overdistended uterus
• Large fetus
• Multiple fetuses
• Hydramnios
• Distention with clots
• Anesthesia and analgesia
• Conduction anesthesia
• Previous history of uterine atony
,• High parity
• Prolonged labor, oxytocin-induced labor
• Trauma during labor and birth
• Forceps-assisted birth
• Vacuum-assisted birth
• Cesarean birth
• Unrepaired lacerations of the birth canal
• Retained placental fragments
• Ruptured uterus
• Inversion of the uterus
• Placenta accreta, increta, percreta
• Coagulation disorders
• Placental abruption
• Placenta previa
• Manual removal of a retained placenta
• Magnesium sulfate administration during labor or postpartum period
• Chorioamnionitis
• Uterine subinvolution
Drugs Used to Manage Postpartum Hemorrhage
DRUG: Oxytocin (Pitocin)
ACTION: Contraction of uterus; decreases bleeding
SIDE EFFECTS: Infrequent: water intoxication, nausea and vomiting
CONTRAINDICATIONS: None for PPH
DOSAGE AND ROUTE: 10 to 40 units/L diluted in lactated Ringer's solution or normal saline at 125 to 200
milliunits/min IV; or 10 to 20 units IM
NURSING CONSIDERATIONS: Continue to monitor vaginal bleeding and uterine tone
DRUG: Methylergonovine (Methergine)*
ACTION: Contraction of uterus
SIDE EFFECTS: Hypertension, nausea, vomiting, headache
CONTRAINDICATIONS: Hypertension, cardiac disease
DOSAGE AND ROUTE: 0.2 mg IM every 2-4 hr up to five doses; may also be given intrauterine or orally
NURSING CONSIDERATIONS: Check blood pressure before giving, and do not give if >140/90 mm Hg;
continue monitoring vaginal bleeding and uterine tone
DRUG: 15-Methylprostaglandin F2α (Prostin/15m; Carboprost, Hemabate)
ACTION: Contraction of uterus
SIDE EFFECTS: Headache, nausea and vomiting, fever, tachycardia, hypertension, diarrhea
CONTRAINDICATIONS: Avoid with asthma or hypertension
DOSAGE AND ROUTE: 0.25 mg IM or intrauterine every 15-90 min up to eight doses
NURSING CONSIDERATIONS: Continue to monitor vaginal bleeding and uterine tone
, DRUG: Dinoprostone (Prostin E2)
ACTION: Contraction of uterus
SIDE EFFECTS: Headache, nausea and vomiting, fever, chills, diarrhea
CONTRAINDICATIONS: Avoid with hypotension
DOSAGE AND ROUTE: 20 mg vaginal or rectal suppository every 2 hr
NURSING CONSIDERATIONS: Continue to monitor vaginal bleeding and uterine tone
DRUG: Misoprostol (Cytotec)
ACTION: Contraction of uterus
SIDE EFFECTS: Headache, nausea and vomiting, diarrhea
CONTRAINDICATIONS: History of allergy to prostaglandins
DOSAGE AND ROUTE: 800 to 1000 mcg rectally once
NURSING CONSIDERATIONS: Continue to monitor vaginal bleeding and uterine tone
-diabetes during pregnancy- risk for diabetes later on in life, insulin needs at the beginning of preg (low)
and later in preg (higher)
Metabolic changes associated with pregnancy
Normal pregnancy is characterized by complex alterations in maternal glucose metabolism, insulin
production, and metabolic homeostasis. During normal pregnancy, adjustments in maternal metabolism
allow for adequate nutrition for both the mother and the developing fetus. Glucose, the primary fuel
used by the fetus, is transported across the placenta through the process of carrier-mediated facilitated
diffusion, meaning that the glucose levels in the fetus are directly proportional to maternal levels.
Although glucose crosses the placenta, insulin does not. Around the tenth week of gestation the fetus
begins to secrete its own insulin at levels adequate to use the glucose obtained from the mother.
Therefore, as maternal glucose levels rise, fetal glucose levels are increased, resulting in increased fetal
insulin secretion.
TABLE 20-1 White's Classification of Diabetes in Pregnancy (Modified)
GESTATIONAL DIABETES
Class A1: Patient has two or more abnormal values on the OGTT with a normal fasting blood sugar.
Blood glucose levels are diet controlled.
Class A2: Patient was not known to have diabetes before pregnancy but requires medication for blood
glucose control.
PREGESTATIONAL DIABETES
Class B: Onset of disease occurs after age 20 and duration of illness <10 years.
Class C: Onset of disease occurs between 10 and 19 years of age or duration of illness for 10-19 years or
both.
Class D: Onset of disease occurs <10 years of age or duration of illness >20 years or both.
Class F: Patient has developed diabetic nephropathy.
Class R: Patient has developed retinitis proliferans.
Class T: Patient has had a renal transplant.
