NUR 254 STUDY GUIDE
(1, 2, 3, & 4)
Maternal and Pediatrics
Galen College of Nursing.
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This study guide contains:
➢ study guide notes anything in yellow on exam
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,Table of Contents
NUR 254 Exam 1 Study Guide............................................................................. 2
NUR 254 Exam 2 Study Guide........................................................................... 14
NUR 254 Exam 3 Study Guide........................................................................... 24
NUR 254 Exam 4 Study Guide........................................................................... 40
NUR 254 Exam 1 Study Guide
Childbearing Exam #1
Galen College
Nur-254
Childbearing / maternity
Unit 1: Antepartum
What in yellow was on this exam
Nursing Management
o Page 178 Signs/symptoms related to pregnancy
▪ Categorizing signs/symptoms of pregnancy
• Presumptive: subjective (Patient says they experience), least reliable – not definitive
signs of pregnancy, COULD be caused by something other than pregnancy,
QUICKENING
o Breast changes, amenorrhea, nausea and vomiting, urinary frequency,
fatigue, quickening
• Probable: objective, (practitioner can see) “more than likely” pregnant
o Positive pregnancy (false), (cervical
Goodell’s softening),
sign
test,
Chadwick’s sign (increased cervical vascularization), Hegar’s sign (softening of
lower
uterine segment), enlarging uterus, ballottement (pushing of the uterus – do you feel a fetus move and come back?)
• Positive: visualization, hearing fetus HR, feel the fetus, VISUAL ULTRA SOUND;
practitioner feels
kicking
▪ What is considered normal or expected?
• Effects on body systems
o Breasts: increase in size, fullness, heaviness, tingling, darkening of the areola,
lactation
can occur as early as 18 weeks
o GI: delayed GI motility, constipation, heartburn, nausea and vomiting,
hemorrhoids, increased vascularity of gums, increased saliva
o GU: increased urination; NORMAL
o Cardio: pulse increase, increased blood volume, increased cardiac output
o Respiratory: increased O2 consumption, nasal and sinus congestion,
increased vascularity
o Musculoskeletal: center of gravity shifts, unsteady gait
o Sensory: sciatica, restless legs, muscle cramps, syncope, tension headache
o Integumentary: melasma mask (hyperpigmentation), striae gravidarum (stretch
marks), vascular malformation (spider veins)
• Vital signs
o HR: slight increase
o BP: should not change dramatically from baseline
o RR: SOB is common, difficulty breathing is NOT
o O2: remains stable
, o Temp: can slightly increase
▫ Page 187 Calculating GTPAL
• Number of pregnancies, regardless of the outcome – including current
• Delivery at 37-42 weeks
• Delivery between 20 weeks and 36 weeks 6 days
• Before 20 weeks, including miscarriage
• Number of children that are still living
▪ REMEMBER! With multiples, they count as one pregnancy!
▫ Page 178 Calculating Naegele’s Rule/EDD (expected date of delivery) – two ways to calculate
▪ First day of last menstrual period
• Add 7 days + 9
months OR
•
▪ EXAMPLE:
• LMP: 1/12/22
• + 7 days = 1/19/22
• + 9 months = 10/19/22
▫ Analyzing labs
▪ Blood work
o
▪ Live vaccines are contraindicated (page 193)
o No booster while pregnant, can offer postpartum
o Toxoplasma- Don’t not clean cat litter, eat raw meat or touch dirt
• CBC
, o H&H will increase ( normal Hemoglobin for PG 11)
o Monitor for anemia
• Coombs screening: Rh factor and antibodies
o Rh negative mom, Rh positive baby
o ( rh+ fetal blood crosses into maternal blood stimulating maternal antibodies)
▪ Rhogam UP to 72hr after birth or any instance when blood may become
mixed
• Blood type
• STI screening: HIV, syphilis, chlamydia, gonorrhea
▫ Therapeutic communication
▪ Speaking with patients about common symptoms of pregnancy
• Current exercise can continue, unless uncomfortable
• HYDRATE
• Careful in HOT weather
• Sleep 8 hours every day if possible
• Change bra, shoes and other clothing to ensure comfort
• Sleep on side after 1st
trimester Providing culturally competent care- always ask about preferences of food/ pain ect; check chart for previous
don’t offend,
o Priority Actions
▪ What to do first?
▫ Page 198 Relieving discomforts of PG signs/symptoms
▪ Breast changes= wear supportive maternity bra
▪ Urgency frequency- empty bladder, kegel exercises, limit fluid before bed, avoid coffee
▪ N/V= avoid empty overload stomach; dry carb and hot tea, Avoid fried, spicy food;
▪ Bleeding gums= go to dentist; eat fresh fruit & veggies and soft toothbrush
▪ Constipation= Drink 2L of water; no stool softner, no laxative, only w/ Dr order
▪ Not preventable=mask of pg, spider nevi, pruritis, palpitations, food craving, carpal tunnel
• Education
o Page 208 Dietary management
▪ Weight gain of 25-35lbs is normal
• First trimester: no increase in calories
• 2nd and 3rd: 300 calorie increase
▪ Iron-deficiency anemia
• Organ meats, green veggies, nuts, beans; PeanutButter; cereal,whole wheat, spinach, eggs
omelet
• Take supplements on an empty stomach – mild nausea is common
• Vitamin C will increase absorption= orange , broccoli
• Stools can turn dark green to black and cause constipation
• No calcium blocks absorption of Iron; can take 2hrs before and 2 hours after > no
milk, yogurt, butter
▪ Folic acid
• Low levels linked to fetal neural tube defects
• Leafy greens
Signs of possible complications of PG
▫ Page ▪ 1st trimester
200 • Severe vomiting= hyperemesis gravida
• Chills, fever; burning upon urination; diarrhea= infection
• Abd cramps; vag bleeding= miscarriage, ectopic pg
▪ 2nd & 3rd Trimester
▪ Persistent severe vomiting= hyperemesis gravida, HTN, Preclampsia
▪ Sudden discharge fluid from vag before 37w= Preterm Pre labor rupture of
membranes
▪ Vag bleed, severe abd pain=miscarriage, placenta previa, abruptio
placental
▪ Chills, fever, burning on urination, diarrhea= infection
▪ Severe backache or flank pain= kidney infection or stones, preterm labor
▪ Change in fetal movements = absence after quickening, any usual pattern or
amt=fetal jeopardy, intrauterine fetal death
▪ Absence of FHR=intrauterine fetal death
▪ Uterine contractions, pelvic pressure; cramping before 37w= preterm labor
▪Epigastric / abd pain = htn , preeclampsia, placenta abruption
▪Glycosuria, + glucose tolerance reaction= gestational DM
o Knowing if teaching is effective/ineffective
▪ Red flag /warning pregnancy symptoms
• Fluid from vagina that is not leukorrhea (thin, white, scant vaginal discharge)
• Abdominal or pelvic pain
• Epigastric pain or severe heartburn
• Sudden or severe edema in face and hands
, • Severe or continuous headache
• Dizziness, blurred vision, seeing spots
• Persistent vomiting
• Dysuria, oliguria
• No fetal movement for over 12 hours
• Leg edema with pain or redness
• Chest pain or dyspnea (not just shortness of breath)
▫ Page 183 Preparing siblings for new baby
o Take child on Prenatal visit. Let them listen to FHR
o Involve child in preparations; help decorate
o If child in crib move to bed 2 months before baby due
o Read books, videos, dvd and hospital tour
o Answer questions about birth. Babies are like
o Take to homes of friends who have babies (realistic expectations)
o With baby doll show sibling how to hold
• Fundal height- measuring from pubic symphysis to highest part of uterus)
o 12 weeks
o 16-36 fundal hieght = weeks of pg
o 20 weeks @ umbilicus
o 36 weeks
o 36-38 weeks lightening
o 40 weeks
Unit 2: High-Risk Childbearing
• Nursing management
o Priority actions
▪ Recognizing signs/symptoms that should be reported
• Page 294 Miscarriage/ spontaneous abortion: spontaneous loss of pregnancy before
20th week
o Risk factors: maternal age, previous miscarriages, uterine or cervical problems,
smoking, alcohol, drugs
o TYPES:
▪ Threatened abortion: showing signs but cervix hasn’t opened, light bleeding and
cramping- treatment complete bedrest ..only one baby can be safed
▪ Inevitable: vaginal bleeding, strong lower stomach cramps, dilated cervix,
fetus is expelled with bleeding
▪ Complete: all pregnancy tissues leaves uterus
▪ Incomplete: some pregnancy tissue remains (D&C might be indicated)
▪ Missed: placental and embryonic tissues remain in uterus but the embryo has
died or never formed – brownish vaginal discharge
• Page 299 Ectopic pregnancy: pregnancy develops/implants anywhere outside of the uterus
o s/s: light vaginal bleeding with abdominal or pelvic pain referred to shoulder
o if blood from fallopian: shoulder pain, urge to have a BM; pink tinge
o if ruptured: stabbing pain in lower quadrant, can radiate to leg or chest, – followed by
lightheadedness, fainting or shock
o GOPHER- gush of blood; one sided pain, pain stops, hemorrhage, Emergency
for Rupture
o Treatment – methotrexate if only stretched; if bleeding sur remove part of fallopian
tube
• Page 297 Incompetent cervix: painless dilation of the cervix without labor or contractions of the
uterus
o Risk factors: congenital conditions, exposure to DES (synthetic estrogen), cervical
trauma, excessive cervical dilation = repeated D&C
o Starts between weeks 14 and 20: pelvic pressure, backache, mild abdominal cramps,
light bleeding or spotting
o Treatment- abd Cerclage (tie cervix) tocolytics, bedrest for a few days after procedure,
progesterone, anti inflammatory drugs, antibiotics, hydration
o I need Cerclage because my cervix is weak
▪ Recognizing signs/symptoms that require follow-up
• Pregnancy complications
o Hyperemesis gravidarum: severe nausea, vomiting, weight loss and dehydration
▪ Tx: IV hydration, control vomiting, stabilize mom
▪ Monitor for metabolic alkalosis
• Physician orders that contradict patient conditions
o NO vaginal exam if a mom is bleeding
o Don’t give Pitocin to Patient w/ Abruption placenta they need c-section
▪ Who to see first?
▪ Patient priorities based on signs/symptoms
• Immediate stabilization
• End goal is to have mom and baby safe, that being said…
, o Stabilize mom first! ABCs
o Now, is baby still alive?
o Medication management for high-risk conditions
▪ Page 280 Preeclampsia: hypertension AND proteinuria after 20 weeks> seizure related
• Risk factors: family history, multiple pregnancy, African-American, obesity, younger than 19yo,
older than 40yo, pre-existing medical or genetic conditions
• Decreased placental perfusion, generalized vasospasm, vasoconstriction, capillary leaking,
reduced organ perfusion, can affect liver and brain function
o Page 282 HELLP syndrome: lab diagnosis for a variant of preeclampsia that involves
hepatic dysfunction – starts because of hypertension
▪ H: hemolysis: breakdown of RBCs
▪ EL: elevated liver enzymes – AST, LST, LFTs
▪ LP: low platelets (normal 400,00-150,000)
▪ Increased risk for: pulmonary edema, renal failure, liver hemorrhage or failure,
DIC, placental abruption, acute respiratory distress syndrome, sepsis, stroke,
fetal and maternal death
• Mild Preeclampsia : BP 140/90 or greater, urine dipstick > 1+
• Moderate Preclampsia: BP 160/110, urine dipstick > 3+, persistent or severe headache,
blurred vision, photophobia, epigastric pain, intrauterine growth restriction of fetus
• S/S: independent edema (edema in lower extremities is normal, NOT in upper extremities or
face), deep tendon reflexes = hyperreflexia, clonus = jerky spasms, rhythmic and
involuntary (over 3)
Severe preeclampsia: BP126/110 • prevent seizures, control blood pressure
o Assess respirations, level of consciousness, intake/output
o Pregnancy-safe medications: methyldopa or hydralazine
o (can also stop them)
Magnesium sulfate: manage and prevent seizures
▪ Keep calcium gluconate bedside
▪ Monitor Mg levels
▪ Page 289 Eclampsia: onset of seizure activity or coma in a woman with preeclampsia and no prior
history
▪ Page 242 Diabetes: can be pregestational or gestational (management is pretty much the same)
• Monitor comorbidities, preterm labor, macrosomia (big baby), C -section, polyhydramnios,
hyper/hypoglycemia, increased risk for postpartum hemorrhage, sudden or unexplained stillborn,
congenital malformations
• Insulin needs: change throughout pregnancy
o 1st trimester: reduced
o
o
o Birth: decrease
o Breastfeeding: decrease
• At 24-28 weeks: glucose tolerance test
o Negative = less than 130-140
o Positive = more than 140 (requires further testing)
o Recognizing signs/symptoms
▪ Placenta abnormalities
•
low lying placenta classified by where Page 303 Placenta
egg implants and howprevia:
much of the cervix is covered (total, partial, marginal)
o placenta covers some or all of the cervix
o Dx – with/ ultrasound
o
o
▪ usually occurs towards ends of 2nd trimester or later
o Tx: bed rest, monitoring, possible C-section depending on degree of cervical coverage
• Page 306 Abruptio placenta: partial or complete separation of the placenta from the uterine lining
o MEDICAL EMERGENCY : C-section is necessary
o
pain,amopnitic fluid port wine color
o causes/risk factors: hypertension, abdominal trauma, cigarette smoking, alcohol or
cocaine use, blood clotting disorders, diabetes, previous history
▪ DIC (disseminated intravascular coagulation): “excessive clotting and bleeding at the same time”
• can be triggered by abruptio placentae, serious infection or trauma, escape of amniotic fluid into
bloodstream
, • Tx: replace blood and clotting factors, treat the cause, support vital functions
▪ UTI (urinary tract infection)
• If untreated, infection can move and induce preterm labor
• Treatment- antibiotics
▪ Active labor/preterm labor
• Definitive diagnosis: 20-36 weeks gestation, uterine activity = true uterine contractions,
progressive cervical change (effacement and/or dilation)
,
Cholestistatis, stress, obesity, Periodontal disease
• or less for 1hr or more (6 or more in an hour), lower abdominal menstrual -like cramps, dull and
s/s: contractions every 10 minutes
intermittent lower back pain, suprapubic pain or pressure, pelvic
pressure or heaviness, membranes, signs of UTI, change in character or amount
, rupture of cervical discharge
of amniotic
super pubic pain and pressure
• Tx: bedrest, decreased activity and lifting, hydrate, tocolytic medications (relax smooth muscle)
• We want to prolong pregnancy as long as possible (2-7 days)
o Once “water” breaks, increased risk of infection
• Education
o Managing pregnancy symptoms
▪ Recognizing signs/symptoms that should be reported
o Knowing if teaching is effective/ineffective
▪ Complications of pregnancy
Glucose Tolerance test – done at 24-28 weeks =don’t eat before, tell drink glucose, need bloodwork after 1hr for 1st and 3 hours
for 2nd
Unit 3: Intrapartum (cervix dilation definite sign)
• Nursing management
o Factors affecting labor – the five P’s
▪ Passenger (fetus)
▪ Passageway (birth canal)
▪ Powers (contractions)
▪ Position of mother
▪ Psychological response
Factor affect times- augmentation( Pitocin), maternal / infant size, maternal age, gravida status, elective induction, persistent
posterior, victim of SA, maternal movement, maternal hydration
o Fetal assessment
▪ Page 319 Fetal position (passenger)
• Presentation (enter into birth canal)
o Vertex: head down
o Transverse: shoulder- cannot be delivered vaginally
o Breech: butt or feet first
• Lie: alignment to mother’s spine
o Longitudinal or vertical
o Horizontal (transvers)
• Attitude: flexion (hands tight, head rest on chest)
o Relaxed (not normal)
• Position: relation of fetal head to maternal pelvis (BEST start is LOA)
o Divide pelvis to R and L
o Leopold's manuever ( 4 steps)
▪ Find the back vs front of baby
o Head up or head down, what is the presenting part?
▪ O = occiput= head
▪ S = sacrum = butt or feet
o Is baby looking up or down? Where is back of head of baby?
▪ where the presenting part of baby is in the birth canal (cm)
▪ Fetal heart patterns
o Powers (changing of
▪ Primary powers
• Effacement: thinning cervix(%)
• Dilation: opening (cm) 10cm completely dialated
• Ferguson reflex: baby is placing pressure on pelvic floor, mom feels she “HAS” to push”
o If not ready not dialted completely mom change positions
▪ Secondary powers
, • Mom pushing- Bear-down
▪ External powers
• Gravity- (walk to help dilate)
• Medications-(pitocin help) (Tocolytic- slow down contractions) (prostaglandin cervidol gel to ripen
cervix)
o Positioning
▪ Encourage mom to find whatever position is the most comfortable for her
• Lithotomy ( stirr up), squatting
▪ Frequent changes in position: relieve fatigue, increase comfort and improve circulation
o Recognizing signs/symptoms
▪ Labor: process of moving fetus, placenta, and membranes out of uterus through the birth canal
• Changes can start to occur days to weeks before true labor onset
o Lightening: fetus drops into pelvis
o Bloody show/mucus plug: pink or blood-streaked mucus
▪ Page 327 Stages of labor
• Stage 1: onset of true contractions to full dilation (10cm) of cervix
o True contractions and cervical changes
1. Early phase: up to 5cm of dilation
▪ Usually the slower phase, may go quicker after 1st pregnancy
2. Active phase: 6-10 cm
Transitional phase= 8+ cm
o Epidural
▪ Offer between 4cm - 7cm
▪ Can give up to 7cm (then it cannot be given)
• Mom won’t be able to feel ANYTHING (meaning she won’t be able to
push properly)
• Baby will be “drugged” at birth
• Epidural contraindicated= maternal hemorrhage, maternal
hypotension, heparin within 12hrs, blood disorder, infection at site, ICP,
allergy to anesthesia, refusal, some cardiac conditions
• Stage 2: full dilation to birth
o Time for delivery!
o Push with contractions; rest when contraction over
o Latent = passive movement
o Active = actively pushing
• Stage 3: birth of fetus to delivery of placenta
o You MUST assess placenta
▪ All of it HAS to come out (bleeding, infection)
▪ Placenta accreda: placenta is implanted too deeply into uterus
• Must be manually or surgically removed
• Stage 4: 2 hours post-delivery of placenta to transfer to postpartum
o Immediate recovery
o Usually 2 hours – monitor bleeding and any abnormalities
o Page 328 7 cardinal movements of the mechanism of labor
• Engagement: head passes pelvic inlet
• Descent: refers to the progress of the presenting part through the pelvis
• Flexion: occurs when head meets resistance – normally, head will flex so the chin is brought
closer to fetal chest
• Internal rotation: head must rotate in order to exit, begins at ischial spine
• Extension: when head reaches perineum for birth
• External rotation (restitution): after head is born, it rotates back to previous position – realigns
with baby’s back and shoulders
• Expulsion: baby has emerged completely
▪ Analyzing contraction characteristics
• Intensity = peak, strength of contraction
• Duration = how long do they last (beginning to end of a single contraction)
• Frequency = how far apart they are occurring (beginning of one contraction to the beginning of
the next)
• Relaxation = uterus NEEDS time to
relax Questioning orders based on client condition
o Page 396 Priority
▪ Actions based on fetal heart patterns
• Page 362 Variability: changes from baseline
o Absent = not good sign
o Minimal = 5-10bpm difference
▪ Can occur if baby is asleep or if narcotics have been administered
o Moderate = 10-25bpm difference
▪ Normal
o Marked = over 25bpm difference
▪ Generally indicates distress
, • Page 365 Acceleration = any increase in HR
o 15x15 rule: peak is at least 15bpm above baseline and lasts 15seconds or more
o Returns to baseline within 2 min of start of acceleration
o Can occur with spontaneous fetal movement, vaginal exam, contractions, fundal
pressure, abdominal palpation
o No intervention required
• Page 365 Deceleration = any decrease in HR for fetus
o Early Deceleration= contraction (fundus) starts, FHR decreases (good)
▪ Should mirror contractions
▪ Normal = no intervention required; monitor
o Late Deceleration= begins AFTER the contraction occurs........................KNOW WHAT IT LOOKS
LIKE
▪ NOT good! = uteroplacental insufficiency
▪ MUST take action
o = “random” drops in HR, usually caused by cord
compression ..............KNOW WHAT IT LOOKS LIKE
▪ If mild and intermittent, no action necessary
▪ Position change may help
▪ BIG drop = distress
▪ Absent variablilty – NOT good/ min vriability (narcotic meds 5-10 beats per min)
▪ Moderate varibaility – GOOD 10-25
▪ Marked – sea-saw – c section 25 or higher from baseline
▪ Managing patients during labor
• Page 360 External monitoring
o Tocotranducer: monitors contractions – placed on fundus
o Ultrasound tranducer: monitors fetal heart rate – placed below umbilicus on baby’s
back where HR can be best heard
o Page 384 Leopold Maneuver -
• Intrauterine pressure catheter
o Membranes must have ruptured
o Monitors a more precise pressure of contraction
• Internal fetal monitoring
o Inserts into top of baby’s head
o More precise fetal heart rate
▪ Who to assess first?
o Interventions
▪ Managing ruptured membranes
• PRIORITY = assess FHR
• Assess amniotic fluid
o Amount
o Color = should be clear
▪ Brown ormeconium
green –
▪ Blood / port wine
placental red–
abruption?
▪ Cloudy- i nfection
▪ Amber – Bilirubin
o Odor = Should not have significant odor
▪ Page 449 Managing prolapsed cord
• EMERGENCY!
• Cord cannot come before baby
• Priority is to get pressure OFF the cord to restore blood flow
• Emergency C-section
• Wrap cord in normal saline
o Providing culturally competent care
Page 447 Understanding
o
• Education
o Maternal behaviors during stages/phases of labor
▪ Signs Preceding Labor= lightening, return of urinary frequency, backache, stronger braxton hicks
contractions, weight loss 1-3.5lbs, surge of energy, increased vag discharge (bloody show), cervix ripe,
possible ROM
▪
o Knowing if teaching is effective/non-effective
▪ Recognizing labor stages/phases
▪ Relieving labor discomforts
(1, 2, 3, & 4)
Maternal and Pediatrics
Galen College of Nursing.
study guide notes anything in yellow on exam
This study guide contains:
➢ study guide notes anything in yellow on exam
➢ study guide 1, 2, 3, & 4
➢ 100% Guarantee Pass.
,Table of Contents
NUR 254 Exam 1 Study Guide............................................................................. 2
NUR 254 Exam 2 Study Guide........................................................................... 14
NUR 254 Exam 3 Study Guide........................................................................... 24
NUR 254 Exam 4 Study Guide........................................................................... 40
NUR 254 Exam 1 Study Guide
Childbearing Exam #1
Galen College
Nur-254
Childbearing / maternity
Unit 1: Antepartum
What in yellow was on this exam
Nursing Management
o Page 178 Signs/symptoms related to pregnancy
▪ Categorizing signs/symptoms of pregnancy
• Presumptive: subjective (Patient says they experience), least reliable – not definitive
signs of pregnancy, COULD be caused by something other than pregnancy,
QUICKENING
o Breast changes, amenorrhea, nausea and vomiting, urinary frequency,
fatigue, quickening
• Probable: objective, (practitioner can see) “more than likely” pregnant
o Positive pregnancy (false), (cervical
Goodell’s softening),
sign
test,
Chadwick’s sign (increased cervical vascularization), Hegar’s sign (softening of
lower
uterine segment), enlarging uterus, ballottement (pushing of the uterus – do you feel a fetus move and come back?)
• Positive: visualization, hearing fetus HR, feel the fetus, VISUAL ULTRA SOUND;
practitioner feels
kicking
▪ What is considered normal or expected?
• Effects on body systems
o Breasts: increase in size, fullness, heaviness, tingling, darkening of the areola,
lactation
can occur as early as 18 weeks
o GI: delayed GI motility, constipation, heartburn, nausea and vomiting,
hemorrhoids, increased vascularity of gums, increased saliva
o GU: increased urination; NORMAL
o Cardio: pulse increase, increased blood volume, increased cardiac output
o Respiratory: increased O2 consumption, nasal and sinus congestion,
increased vascularity
o Musculoskeletal: center of gravity shifts, unsteady gait
o Sensory: sciatica, restless legs, muscle cramps, syncope, tension headache
o Integumentary: melasma mask (hyperpigmentation), striae gravidarum (stretch
marks), vascular malformation (spider veins)
• Vital signs
o HR: slight increase
o BP: should not change dramatically from baseline
o RR: SOB is common, difficulty breathing is NOT
o O2: remains stable
, o Temp: can slightly increase
▫ Page 187 Calculating GTPAL
• Number of pregnancies, regardless of the outcome – including current
• Delivery at 37-42 weeks
• Delivery between 20 weeks and 36 weeks 6 days
• Before 20 weeks, including miscarriage
• Number of children that are still living
▪ REMEMBER! With multiples, they count as one pregnancy!
▫ Page 178 Calculating Naegele’s Rule/EDD (expected date of delivery) – two ways to calculate
▪ First day of last menstrual period
• Add 7 days + 9
months OR
•
▪ EXAMPLE:
• LMP: 1/12/22
• + 7 days = 1/19/22
• + 9 months = 10/19/22
▫ Analyzing labs
▪ Blood work
o
▪ Live vaccines are contraindicated (page 193)
o No booster while pregnant, can offer postpartum
o Toxoplasma- Don’t not clean cat litter, eat raw meat or touch dirt
• CBC
, o H&H will increase ( normal Hemoglobin for PG 11)
o Monitor for anemia
• Coombs screening: Rh factor and antibodies
o Rh negative mom, Rh positive baby
o ( rh+ fetal blood crosses into maternal blood stimulating maternal antibodies)
▪ Rhogam UP to 72hr after birth or any instance when blood may become
mixed
• Blood type
• STI screening: HIV, syphilis, chlamydia, gonorrhea
▫ Therapeutic communication
▪ Speaking with patients about common symptoms of pregnancy
• Current exercise can continue, unless uncomfortable
• HYDRATE
• Careful in HOT weather
• Sleep 8 hours every day if possible
• Change bra, shoes and other clothing to ensure comfort
• Sleep on side after 1st
trimester Providing culturally competent care- always ask about preferences of food/ pain ect; check chart for previous
don’t offend,
o Priority Actions
▪ What to do first?
▫ Page 198 Relieving discomforts of PG signs/symptoms
▪ Breast changes= wear supportive maternity bra
▪ Urgency frequency- empty bladder, kegel exercises, limit fluid before bed, avoid coffee
▪ N/V= avoid empty overload stomach; dry carb and hot tea, Avoid fried, spicy food;
▪ Bleeding gums= go to dentist; eat fresh fruit & veggies and soft toothbrush
▪ Constipation= Drink 2L of water; no stool softner, no laxative, only w/ Dr order
▪ Not preventable=mask of pg, spider nevi, pruritis, palpitations, food craving, carpal tunnel
• Education
o Page 208 Dietary management
▪ Weight gain of 25-35lbs is normal
• First trimester: no increase in calories
• 2nd and 3rd: 300 calorie increase
▪ Iron-deficiency anemia
• Organ meats, green veggies, nuts, beans; PeanutButter; cereal,whole wheat, spinach, eggs
omelet
• Take supplements on an empty stomach – mild nausea is common
• Vitamin C will increase absorption= orange , broccoli
• Stools can turn dark green to black and cause constipation
• No calcium blocks absorption of Iron; can take 2hrs before and 2 hours after > no
milk, yogurt, butter
▪ Folic acid
• Low levels linked to fetal neural tube defects
• Leafy greens
Signs of possible complications of PG
▫ Page ▪ 1st trimester
200 • Severe vomiting= hyperemesis gravida
• Chills, fever; burning upon urination; diarrhea= infection
• Abd cramps; vag bleeding= miscarriage, ectopic pg
▪ 2nd & 3rd Trimester
▪ Persistent severe vomiting= hyperemesis gravida, HTN, Preclampsia
▪ Sudden discharge fluid from vag before 37w= Preterm Pre labor rupture of
membranes
▪ Vag bleed, severe abd pain=miscarriage, placenta previa, abruptio
placental
▪ Chills, fever, burning on urination, diarrhea= infection
▪ Severe backache or flank pain= kidney infection or stones, preterm labor
▪ Change in fetal movements = absence after quickening, any usual pattern or
amt=fetal jeopardy, intrauterine fetal death
▪ Absence of FHR=intrauterine fetal death
▪ Uterine contractions, pelvic pressure; cramping before 37w= preterm labor
▪Epigastric / abd pain = htn , preeclampsia, placenta abruption
▪Glycosuria, + glucose tolerance reaction= gestational DM
o Knowing if teaching is effective/ineffective
▪ Red flag /warning pregnancy symptoms
• Fluid from vagina that is not leukorrhea (thin, white, scant vaginal discharge)
• Abdominal or pelvic pain
• Epigastric pain or severe heartburn
• Sudden or severe edema in face and hands
, • Severe or continuous headache
• Dizziness, blurred vision, seeing spots
• Persistent vomiting
• Dysuria, oliguria
• No fetal movement for over 12 hours
• Leg edema with pain or redness
• Chest pain or dyspnea (not just shortness of breath)
▫ Page 183 Preparing siblings for new baby
o Take child on Prenatal visit. Let them listen to FHR
o Involve child in preparations; help decorate
o If child in crib move to bed 2 months before baby due
o Read books, videos, dvd and hospital tour
o Answer questions about birth. Babies are like
o Take to homes of friends who have babies (realistic expectations)
o With baby doll show sibling how to hold
• Fundal height- measuring from pubic symphysis to highest part of uterus)
o 12 weeks
o 16-36 fundal hieght = weeks of pg
o 20 weeks @ umbilicus
o 36 weeks
o 36-38 weeks lightening
o 40 weeks
Unit 2: High-Risk Childbearing
• Nursing management
o Priority actions
▪ Recognizing signs/symptoms that should be reported
• Page 294 Miscarriage/ spontaneous abortion: spontaneous loss of pregnancy before
20th week
o Risk factors: maternal age, previous miscarriages, uterine or cervical problems,
smoking, alcohol, drugs
o TYPES:
▪ Threatened abortion: showing signs but cervix hasn’t opened, light bleeding and
cramping- treatment complete bedrest ..only one baby can be safed
▪ Inevitable: vaginal bleeding, strong lower stomach cramps, dilated cervix,
fetus is expelled with bleeding
▪ Complete: all pregnancy tissues leaves uterus
▪ Incomplete: some pregnancy tissue remains (D&C might be indicated)
▪ Missed: placental and embryonic tissues remain in uterus but the embryo has
died or never formed – brownish vaginal discharge
• Page 299 Ectopic pregnancy: pregnancy develops/implants anywhere outside of the uterus
o s/s: light vaginal bleeding with abdominal or pelvic pain referred to shoulder
o if blood from fallopian: shoulder pain, urge to have a BM; pink tinge
o if ruptured: stabbing pain in lower quadrant, can radiate to leg or chest, – followed by
lightheadedness, fainting or shock
o GOPHER- gush of blood; one sided pain, pain stops, hemorrhage, Emergency
for Rupture
o Treatment – methotrexate if only stretched; if bleeding sur remove part of fallopian
tube
• Page 297 Incompetent cervix: painless dilation of the cervix without labor or contractions of the
uterus
o Risk factors: congenital conditions, exposure to DES (synthetic estrogen), cervical
trauma, excessive cervical dilation = repeated D&C
o Starts between weeks 14 and 20: pelvic pressure, backache, mild abdominal cramps,
light bleeding or spotting
o Treatment- abd Cerclage (tie cervix) tocolytics, bedrest for a few days after procedure,
progesterone, anti inflammatory drugs, antibiotics, hydration
o I need Cerclage because my cervix is weak
▪ Recognizing signs/symptoms that require follow-up
• Pregnancy complications
o Hyperemesis gravidarum: severe nausea, vomiting, weight loss and dehydration
▪ Tx: IV hydration, control vomiting, stabilize mom
▪ Monitor for metabolic alkalosis
• Physician orders that contradict patient conditions
o NO vaginal exam if a mom is bleeding
o Don’t give Pitocin to Patient w/ Abruption placenta they need c-section
▪ Who to see first?
▪ Patient priorities based on signs/symptoms
• Immediate stabilization
• End goal is to have mom and baby safe, that being said…
, o Stabilize mom first! ABCs
o Now, is baby still alive?
o Medication management for high-risk conditions
▪ Page 280 Preeclampsia: hypertension AND proteinuria after 20 weeks> seizure related
• Risk factors: family history, multiple pregnancy, African-American, obesity, younger than 19yo,
older than 40yo, pre-existing medical or genetic conditions
• Decreased placental perfusion, generalized vasospasm, vasoconstriction, capillary leaking,
reduced organ perfusion, can affect liver and brain function
o Page 282 HELLP syndrome: lab diagnosis for a variant of preeclampsia that involves
hepatic dysfunction – starts because of hypertension
▪ H: hemolysis: breakdown of RBCs
▪ EL: elevated liver enzymes – AST, LST, LFTs
▪ LP: low platelets (normal 400,00-150,000)
▪ Increased risk for: pulmonary edema, renal failure, liver hemorrhage or failure,
DIC, placental abruption, acute respiratory distress syndrome, sepsis, stroke,
fetal and maternal death
• Mild Preeclampsia : BP 140/90 or greater, urine dipstick > 1+
• Moderate Preclampsia: BP 160/110, urine dipstick > 3+, persistent or severe headache,
blurred vision, photophobia, epigastric pain, intrauterine growth restriction of fetus
• S/S: independent edema (edema in lower extremities is normal, NOT in upper extremities or
face), deep tendon reflexes = hyperreflexia, clonus = jerky spasms, rhythmic and
involuntary (over 3)
Severe preeclampsia: BP126/110 • prevent seizures, control blood pressure
o Assess respirations, level of consciousness, intake/output
o Pregnancy-safe medications: methyldopa or hydralazine
o (can also stop them)
Magnesium sulfate: manage and prevent seizures
▪ Keep calcium gluconate bedside
▪ Monitor Mg levels
▪ Page 289 Eclampsia: onset of seizure activity or coma in a woman with preeclampsia and no prior
history
▪ Page 242 Diabetes: can be pregestational or gestational (management is pretty much the same)
• Monitor comorbidities, preterm labor, macrosomia (big baby), C -section, polyhydramnios,
hyper/hypoglycemia, increased risk for postpartum hemorrhage, sudden or unexplained stillborn,
congenital malformations
• Insulin needs: change throughout pregnancy
o 1st trimester: reduced
o
o
o Birth: decrease
o Breastfeeding: decrease
• At 24-28 weeks: glucose tolerance test
o Negative = less than 130-140
o Positive = more than 140 (requires further testing)
o Recognizing signs/symptoms
▪ Placenta abnormalities
•
low lying placenta classified by where Page 303 Placenta
egg implants and howprevia:
much of the cervix is covered (total, partial, marginal)
o placenta covers some or all of the cervix
o Dx – with/ ultrasound
o
o
▪ usually occurs towards ends of 2nd trimester or later
o Tx: bed rest, monitoring, possible C-section depending on degree of cervical coverage
• Page 306 Abruptio placenta: partial or complete separation of the placenta from the uterine lining
o MEDICAL EMERGENCY : C-section is necessary
o
pain,amopnitic fluid port wine color
o causes/risk factors: hypertension, abdominal trauma, cigarette smoking, alcohol or
cocaine use, blood clotting disorders, diabetes, previous history
▪ DIC (disseminated intravascular coagulation): “excessive clotting and bleeding at the same time”
• can be triggered by abruptio placentae, serious infection or trauma, escape of amniotic fluid into
bloodstream
, • Tx: replace blood and clotting factors, treat the cause, support vital functions
▪ UTI (urinary tract infection)
• If untreated, infection can move and induce preterm labor
• Treatment- antibiotics
▪ Active labor/preterm labor
• Definitive diagnosis: 20-36 weeks gestation, uterine activity = true uterine contractions,
progressive cervical change (effacement and/or dilation)
,
Cholestistatis, stress, obesity, Periodontal disease
• or less for 1hr or more (6 or more in an hour), lower abdominal menstrual -like cramps, dull and
s/s: contractions every 10 minutes
intermittent lower back pain, suprapubic pain or pressure, pelvic
pressure or heaviness, membranes, signs of UTI, change in character or amount
, rupture of cervical discharge
of amniotic
super pubic pain and pressure
• Tx: bedrest, decreased activity and lifting, hydrate, tocolytic medications (relax smooth muscle)
• We want to prolong pregnancy as long as possible (2-7 days)
o Once “water” breaks, increased risk of infection
• Education
o Managing pregnancy symptoms
▪ Recognizing signs/symptoms that should be reported
o Knowing if teaching is effective/ineffective
▪ Complications of pregnancy
Glucose Tolerance test – done at 24-28 weeks =don’t eat before, tell drink glucose, need bloodwork after 1hr for 1st and 3 hours
for 2nd
Unit 3: Intrapartum (cervix dilation definite sign)
• Nursing management
o Factors affecting labor – the five P’s
▪ Passenger (fetus)
▪ Passageway (birth canal)
▪ Powers (contractions)
▪ Position of mother
▪ Psychological response
Factor affect times- augmentation( Pitocin), maternal / infant size, maternal age, gravida status, elective induction, persistent
posterior, victim of SA, maternal movement, maternal hydration
o Fetal assessment
▪ Page 319 Fetal position (passenger)
• Presentation (enter into birth canal)
o Vertex: head down
o Transverse: shoulder- cannot be delivered vaginally
o Breech: butt or feet first
• Lie: alignment to mother’s spine
o Longitudinal or vertical
o Horizontal (transvers)
• Attitude: flexion (hands tight, head rest on chest)
o Relaxed (not normal)
• Position: relation of fetal head to maternal pelvis (BEST start is LOA)
o Divide pelvis to R and L
o Leopold's manuever ( 4 steps)
▪ Find the back vs front of baby
o Head up or head down, what is the presenting part?
▪ O = occiput= head
▪ S = sacrum = butt or feet
o Is baby looking up or down? Where is back of head of baby?
▪ where the presenting part of baby is in the birth canal (cm)
▪ Fetal heart patterns
o Powers (changing of
▪ Primary powers
• Effacement: thinning cervix(%)
• Dilation: opening (cm) 10cm completely dialated
• Ferguson reflex: baby is placing pressure on pelvic floor, mom feels she “HAS” to push”
o If not ready not dialted completely mom change positions
▪ Secondary powers
, • Mom pushing- Bear-down
▪ External powers
• Gravity- (walk to help dilate)
• Medications-(pitocin help) (Tocolytic- slow down contractions) (prostaglandin cervidol gel to ripen
cervix)
o Positioning
▪ Encourage mom to find whatever position is the most comfortable for her
• Lithotomy ( stirr up), squatting
▪ Frequent changes in position: relieve fatigue, increase comfort and improve circulation
o Recognizing signs/symptoms
▪ Labor: process of moving fetus, placenta, and membranes out of uterus through the birth canal
• Changes can start to occur days to weeks before true labor onset
o Lightening: fetus drops into pelvis
o Bloody show/mucus plug: pink or blood-streaked mucus
▪ Page 327 Stages of labor
• Stage 1: onset of true contractions to full dilation (10cm) of cervix
o True contractions and cervical changes
1. Early phase: up to 5cm of dilation
▪ Usually the slower phase, may go quicker after 1st pregnancy
2. Active phase: 6-10 cm
Transitional phase= 8+ cm
o Epidural
▪ Offer between 4cm - 7cm
▪ Can give up to 7cm (then it cannot be given)
• Mom won’t be able to feel ANYTHING (meaning she won’t be able to
push properly)
• Baby will be “drugged” at birth
• Epidural contraindicated= maternal hemorrhage, maternal
hypotension, heparin within 12hrs, blood disorder, infection at site, ICP,
allergy to anesthesia, refusal, some cardiac conditions
• Stage 2: full dilation to birth
o Time for delivery!
o Push with contractions; rest when contraction over
o Latent = passive movement
o Active = actively pushing
• Stage 3: birth of fetus to delivery of placenta
o You MUST assess placenta
▪ All of it HAS to come out (bleeding, infection)
▪ Placenta accreda: placenta is implanted too deeply into uterus
• Must be manually or surgically removed
• Stage 4: 2 hours post-delivery of placenta to transfer to postpartum
o Immediate recovery
o Usually 2 hours – monitor bleeding and any abnormalities
o Page 328 7 cardinal movements of the mechanism of labor
• Engagement: head passes pelvic inlet
• Descent: refers to the progress of the presenting part through the pelvis
• Flexion: occurs when head meets resistance – normally, head will flex so the chin is brought
closer to fetal chest
• Internal rotation: head must rotate in order to exit, begins at ischial spine
• Extension: when head reaches perineum for birth
• External rotation (restitution): after head is born, it rotates back to previous position – realigns
with baby’s back and shoulders
• Expulsion: baby has emerged completely
▪ Analyzing contraction characteristics
• Intensity = peak, strength of contraction
• Duration = how long do they last (beginning to end of a single contraction)
• Frequency = how far apart they are occurring (beginning of one contraction to the beginning of
the next)
• Relaxation = uterus NEEDS time to
relax Questioning orders based on client condition
o Page 396 Priority
▪ Actions based on fetal heart patterns
• Page 362 Variability: changes from baseline
o Absent = not good sign
o Minimal = 5-10bpm difference
▪ Can occur if baby is asleep or if narcotics have been administered
o Moderate = 10-25bpm difference
▪ Normal
o Marked = over 25bpm difference
▪ Generally indicates distress
, • Page 365 Acceleration = any increase in HR
o 15x15 rule: peak is at least 15bpm above baseline and lasts 15seconds or more
o Returns to baseline within 2 min of start of acceleration
o Can occur with spontaneous fetal movement, vaginal exam, contractions, fundal
pressure, abdominal palpation
o No intervention required
• Page 365 Deceleration = any decrease in HR for fetus
o Early Deceleration= contraction (fundus) starts, FHR decreases (good)
▪ Should mirror contractions
▪ Normal = no intervention required; monitor
o Late Deceleration= begins AFTER the contraction occurs........................KNOW WHAT IT LOOKS
LIKE
▪ NOT good! = uteroplacental insufficiency
▪ MUST take action
o = “random” drops in HR, usually caused by cord
compression ..............KNOW WHAT IT LOOKS LIKE
▪ If mild and intermittent, no action necessary
▪ Position change may help
▪ BIG drop = distress
▪ Absent variablilty – NOT good/ min vriability (narcotic meds 5-10 beats per min)
▪ Moderate varibaility – GOOD 10-25
▪ Marked – sea-saw – c section 25 or higher from baseline
▪ Managing patients during labor
• Page 360 External monitoring
o Tocotranducer: monitors contractions – placed on fundus
o Ultrasound tranducer: monitors fetal heart rate – placed below umbilicus on baby’s
back where HR can be best heard
o Page 384 Leopold Maneuver -
• Intrauterine pressure catheter
o Membranes must have ruptured
o Monitors a more precise pressure of contraction
• Internal fetal monitoring
o Inserts into top of baby’s head
o More precise fetal heart rate
▪ Who to assess first?
o Interventions
▪ Managing ruptured membranes
• PRIORITY = assess FHR
• Assess amniotic fluid
o Amount
o Color = should be clear
▪ Brown ormeconium
green –
▪ Blood / port wine
placental red–
abruption?
▪ Cloudy- i nfection
▪ Amber – Bilirubin
o Odor = Should not have significant odor
▪ Page 449 Managing prolapsed cord
• EMERGENCY!
• Cord cannot come before baby
• Priority is to get pressure OFF the cord to restore blood flow
• Emergency C-section
• Wrap cord in normal saline
o Providing culturally competent care
Page 447 Understanding
o
• Education
o Maternal behaviors during stages/phases of labor
▪ Signs Preceding Labor= lightening, return of urinary frequency, backache, stronger braxton hicks
contractions, weight loss 1-3.5lbs, surge of energy, increased vag discharge (bloody show), cervix ripe,
possible ROM
▪
o Knowing if teaching is effective/non-effective
▪ Recognizing labor stages/phases
▪ Relieving labor discomforts
