Care of Mother and Child At-Risk or with

Problems (Acute and Chronic)- Lecture

STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR
Session # 7

LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT Materials:

CLIENT (PRE-GESTATIONAL CONDITIONS- ANEMIAS OF
Book, pen, SAS and notebook
PREGNANCY) AND (GESTATIONAL CONDITIONS-
HYPEREMESIS GRAVIDARUM AND ECTOPIC
References:
PREGNANCY)
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
LEARNING OUTCOMES: th
Maternal and Child Health Nursing, 8 Edition.
At the end of the lesson, the student nurse can: USA: Lippincott Williams and Wilkins

1. Define Anemia, Hyperemesis Gravidarum and Ectopic
Pregnancy) its relation to pregnancy, including pre-existing
factors that contribute to its development.
2. Integrate knowledge of Anemia, Hyperemesis Gravidarum
and Ectopic Pregnancy in relation to pregnancy and nursing
process to achieve quality maternal and child health nursing
care.
Perry, Shannon, Hockenberry, Marilyn J.,
Lowdermilk Deitra Leonard and Wilson, David
th
(2015) Maternal and Child Nursing Care,6
Edition. USA: Elsevier
Hockenberry, Marilyn and Wilson, David (2013)
Wong’s Essential of Pediatric Nursing,9th
Edition. USA: Elsevier

LESSON PREVIEW/REVIEW (5 minutes)

MAIN LESSON (50 minutes)

(Chapter 20: Nursing Care of a Family Experiencing Complication From a Pre-existing or Newly Acquired Illness:
Hematologic Disorder page 498)

ANEMIA- is a condition of too few RBCs, or a lowered ability of the RBCs

Most Common Types during Pregnancy: Risk Factors
Iron deficiency Anemia Poor nutrition
Vitamin B12 Anemia Excess alcohol consumption
Anemia dt Blood Loss Illnesses that reduce absorption of nutrients
Folate Deficiency Use of anticonvulsant drugs (Tegretol, lithium,
carbamazepine, etc.)
Previous use of oral contraceptives
G6PD Deficiency
Complications of Anemia
Premature labor
Intrauterine growth retardation (IUGR)
Dangerous anemia from normal blood loss during labor, requiring transfusions
Increased susceptibility to maternal infection after childbirth
IRON DEFICIENCY ANEMIA
nd rd
Most common type, develops in the 2 & 3 trimester when the Fe requirements increase to compensate for the
expanding blood volume
Predisposing factors:
Poor diet & poor nutrition
Heavy menses
Successive pregnancies w/in 2 yrs or <6 mos interval
Unwise reducing programs
Low socioeconomic status

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Signs & Symptoms of IDA Diagnosis
Easy fatigability Lab findings:
Sensitivity to cold -low hemoglobin <10 g/100ml
Dizziness -low hematocrit <37% in the 1st trimester, <35%
Brittle, flattened nails in the 2nd trimester and <33% in the 3rd trimester
VS: rise in systolic pressure, tachycardia, tachypnea -Serum ferritin < 100 mg/dl
-Serum Fe level < 30 ug/dl
-Hypochromic, microcytic RBCs
Effects of Anemia on Pregnancy
Decreased resistance to infection
Associated with prematurity & LBW infants
Predisposes to heavy bleeding during labor & delivery
Associated with PICA
Megaloblastic Anemia
Types:
Folic Acid Deficiency/(Pernicious anemia)
Vit B12 Deficiency/Addison Pernicious Anemia)

Folic acid vs. Folate

Folate is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs, citrus
fruit, avocados, and beef liver.
Folic acid is a synthesized version of vitamin B9 that is added to processed foods and the common version used in
supplements.

Folic Acid Deficiency Anemia-is necessary for normal formation of RBC and in the prevention of NTDs
Deficiency leads to formation of large & immature RBCs with shorter lifespan
develops if diet is mostly meat with little Green leafy vegetables

Effects on Pregnancy: Signs and Symptoms of Folic Acid Deficiency

-abortion Nausea
-abruptio placenta Vomiting
-Neural Tube Defect Anorexia
Most often seen in:
Multiple pregnancies because of the increased fetal demand
Women with secondary hemolytic illness
Women who are taking Hydantoin
Poor gastric absorption due to gastric bypass for morbid
obesity

Gestational Conditions
Hyperemesis gravidarum (sometimes called pernicious or persistent vomiting) is nausea and vomiting of pregnancy
prolonged past week 16 of pregnancy or that is so severe that dehydration, ketonuria, and significant weight loss occur
within the first 12 weeks of pregnancy (O’Donnell et al., 2016). Chapter 13: The Nursing Role in Promoting Nutritional
Health During Pregnancy,p.299)

HYPEREMESIS GRAVIDARUM

Description & Etiology

-PERNICIOUS or PERSISTENT VOMITING OF PREGNANCY

-extreme nausea and vomitng that is prolonged past week 12 of pregnancy or is so severe (DHN, ketonuria, weight
st
loss)within the 1 12 weeks AOG

-associated with H. pylori

Assessment Management

-Nausea and Vomiting is so severe that nutrition cannot 1. 24-hour Hospitalization. (I & O, blood chemistries &
be maintained and weight loss is severe rehydration)

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-Elevated hct due to hemoconcentration
-Reduced Na, K Cl and hypokalemic alkalosis may occur
-Polyneuritis dt deficiency in Vitamin B
-Urine may be (+) for ketones due to breakdown of
protein & fat for cell growth
-Intrauterine Growth Restricition or preterm birth
2. NPO; IVF ( 3L Ringer’s lactated solution+ vitamin B) to
control vomiting
st
3. If no vomiting after the 1 24h, sips of clear fluid
gradually advanced to a soft, then normal, diet.
4. If vomiting returns, TPN or enteral nutrition may be
prescribed

In history taking ask frequency/quantity of vomiting, how

much she eats in a typical day.

Ectopic Pregnancy
An ectopic pregnancy is one in which implantation occurred outside the uterine cavity. The most common site (in
approximately 95% of such pregnancies) is in the fallopian tube. Of these fallopian tube sites, approximately 80% occur in
the ampullar portion, 12% occur in the isthmus, and 8% are interstitial or fimbrial (Jurkovic, 2012). (Chapter 21: Nursing
Care of a Family Experiencing a Sudden Pregnancy Complication, p.533)

Ectopic Pregnancy Etiology

-It is the implantation of a fertilized ovum outside of the Salpingitis, tumors, adhesions, or scarring, IUD use,
uterus narrowed oviducts

-Sites: ovary, cervix, peritoneal cavity, fallopian tube (most

common)

Assessment Complication

1. Missed period, usual signs of pregnancy (Nausea and 1. Hemorrhage,

Vomiting, positive pregnancy test, etc)
2. Shock,
2. Spotting, bleeding (dark red or brownish), possible signs
of hypovolemic shock 3. Peritonitis

3. If at the fallopian tube, by 6 to 12 weeks AOG, slowly

increasing or sudden sharp, stabbing pain in LLQ or RLQ
(due to rupture of fallopian tube), followed by bleeding,
abdominal rigidity

4. referred shoulder pain (KEHR’S SIGN) due to blood in

the peritoneum irritating the phrenic nerve

5. CULLEN’S SIGN- ecchymotic blueness around the

umbilicus indicating blood pooling in the peritoneum

6. Dizziness, syncope

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7. UTZ confirms extrauterine pregnancy & rupture

Management

Before rupture, oral administration of METHOTREXATE (folic acid antagonist which destroys fast-growing cells)
followed by LEUCOVORIN; treated until hCG is (-); hysterosalpingogram to assess patency of the tube

After rupture, BT if needed, laparoscopy to ligate bleeding vessels & remove or repair damaged tubes

Assess for bleeding & pain

Monitor VS, start IV with 18-gauge needle

Provide O2 therapy

Administer RhOGAM if Rh (-)

Provide emotional support

CHECK FOR UNDERSTANDING (30 minutes)

You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.

Multiple Choice

1. A mother asks the nurse if her child’s iron deficiency anemia is related to the child’s frequent infections. The
nurse responds based on the understanding of which of the following?
A. Little is known about iron-deficiency anemia and its relationship to infection in children.
B. Children with iron deficiency anemia are more susceptible to infection than are other children.
C. Children with iron-deficiency anemia are less susceptible to infection than are other children.
D. Children with iron-deficient anemia are equally as susceptible to infection as are other children.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Camille is 12-week pregnant and she was suspected to have Iron-Deficiency Anemia. Which statements by
the pregnant woman would lead the nurse to suspect that the she has iron-deficiency anemia? Select all that
apply.
A. “I drinks over 3 cups of milk per day.”
B. “I can’t keep enough apple juice in the house; I drink over 10 ounces per day.”
C. “I do not want to eat more than 2 different kinds of vegetables.”
D. “I do not like meat, but I can eat small amounts of it.”
E. “I sleep 12 hours every night and take a 2-hour nap.”
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. You are encouraging Camille to eat foods that are rich in iron. Which of the following foods would you
encourage the pregnant mother like Camille with iron deficiency anemia?
A. Rice cereal, whole milk, and yellow vegetables
B. Potato, peas, and chicken
C. Macaroni, cheese, and ham
D. Pudding, green vegetables, and rice
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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4. Camille is admitted with iron- deficiency anemia and has been receiving iron supplementation. The patient
voices concern about how their stool is dark black. As the nurse you would?
A. Notify the doctor
B. Hold the next dose of iron
C. Reassure the patient this is a normal side effect of iron supplementation
D. None of the options are correct
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. A 21-year old client. 6 weeks' pregnant is diagnosed with hyperemesis gravidarum. This excessive vomiting
during pregnancy will often result in which of the following conditions?
A. Bowel perforation
B. Electrolyte Imbalance
C. Miscarriage
D. Pregnancy Induced Hypertension

ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. A 25 y.o. has arrives to the ER with c/o cramping abdominal pain and mild vaginal bleeding. Pelvic exam
shows a left adnexal mass that's tender when palpated. Culdocentesis shows blood in the culdesac. This
client probably has which of the following conditions?
A. Abruptio placentae
B. Ectopic pregnancy
C. Hydatidiform mole
D. Pelvic Inflammatory Disease
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Jhoanne Rose is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled.
Preoperatively, which of the following goals is MOST important for the nurse to include on the client’s plan of
care?
A. Fluid replacement
B. Pain relief
C. Emotional support
D. Respiratory therapy
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Claudia a 16 weeks pregnant and is diagnosed with Hyperemesis Gravidarum. The client with hyperemesis
gravidarum is at risk for developing:
A. Respiratory alkalosis without dehydration
B. Metabolic acidosis with dehydration
C. Respiratory acidosis without dehydration
D. Metabolic alkalosis with dehydration
E. A client is being admitted to the antepartum
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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9. Which of the following statements best describes hyperemesis gravidarum?
A. Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical
problems.
B. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of
other medical problems.
C. Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing
maternal nutrients
D. Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. The main reason for an expected increased need for iron in pregnancy is:
A. The mother may have physiologic anemia due to the increased need for red blood cell mass as well as the fetal
requires about 350-400 mg of iron to grow
B. The mother may suffer anemia because of poor appetite
C. The fetus has an increased need for RBC which the mother must supply
D. The mother may have a problem of digestion because of pica
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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3. ANSWER: ________
RATIO:_______________________________________________________________________________________
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4. ANSWER: ________
RATIO:_______________________________________________________________________________________
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5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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6. ANSWER: ________
RATIO:_______________________________________________________________________________________
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7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________
RATIO:_______________________________________________________________________________________
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LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.
PERIOD 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
PERIOD 2
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
PERIOD 3
41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

AL STRATEGY: Minute Paper

1. You will be ask to use index cards or half-sheets of paper to provide written feedback to the following questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?
2. Your instructor will collect or pass your responses before you leave.
3. Respond to students’ feedback during the next class meeting or as soon as possible

(For next session, review Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication-
Bleeding During Pregnancy page 526 and page. 537.)

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