Care of Mother and Child At-Risk or with

STUDENT ACTIVITY SHEET Problems (Acute and Chronic)- Lecture

BS NURSING / SECOND YEAR

LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT Session # 5

CLIENT (PRE-GESTATIONAL CONDITIONS- ANEMIAS OF
PREGNANCY) AND (GESTATIONAL CONDITIONS- Materials:
HYPEREMESIS GRAVIDARUM AND ECTOPIC PREGNANCY) Book, pen, SAS and notebook
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:
Reference:
1. Define Anemia, Hyperemesis Gravidarum and Ectopic
Pregnancy) its relation to pregnancy, including pre-existing Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
factors that contribute to its development. Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
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.

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)
ANEMIAS OF PREGNANCY
(Chapter 20: Nursing Care of a Family Experiencing Complication From a Preexisting or Newly Acquired Illness:
Hematologic Disorder page 498)

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

• Many women lack the sufficient amount of iron needed for the second and third trimesters. When the body
needs more iron than it has available, a woman can become anemic.

• Mild anemia is normal during pregnancy due to an increase in blood volume.

• More severe anemia can put the baby at higher risk for anemia later in infancy.

Most Common Types during Pregnancy: Risk Factors

• Iron deficiency Anemia • Poor nutrition
• Vitamin B12 Anemia • Excess alcohol consumption
• Anemia due to 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

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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
• Most common type, develops in the 2nd & 3rd 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

Signs & Symptoms of IDA Diagnosis

• Easy fatigability
• Sensitivity to cold
• Dizziness
• Brittle, flattened nails
• Changes in Vital Signs: rise in systolic
pressure, tachycardia, tachypnea
Management of Iron Deficiency Anemia The
World Health Organization and most experts
recommend prevention of iron deficiency anemia
with prophylactic iron supplementation in
pregnancy.
• Pregnancy requires an additional 700–1200
mg of iron. Of this, 200–300 mg is transferred
to the fetus.
Lab findings:
-low hemoglobin <10 g/100ml
-low hematocrit <37% in the 1st trimester, <35% in the
2nd trimester and <33% in the 3rd trimester
-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

• Most of the iron requirements of pregnancy are

in the second half of pregnancy, and they are
approximately 5–6 mg/day.

• An average balanced diet will supply only 1–2

mg/day.

• Daily supplementation with 300 mg ferrous

sulfate (which contains 60 mg elemental iron)
will satisfy the pregnancy requirement.

MEGALOBLASTIC ANEMIA
Types:
1. Folic Acid Deficiency/(Pernicious anemia
2. 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.

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Folic acid is a synthesized version of vitamin B9 that is added to processed foods and the common version used
in supplements.

1. Folic Acid Deficiency Anemia-is necessary for normal formation of RBC and in the prevention of Neural
Tube
Defects
– 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 MANAGEMENT
Most often seen in: • Treatment of patients with pernicious anemia is
• Multiple pregnancies because of the increased undertaken with parenteral therapy because oral
fetal demand absorption of vitamin B12 is deficient.
• Women with secondary hemolytic illness
• Women who are taking Hydantoin • Daily injections of 200 μg are given for the first week
• Poor gastric absorption due to gastric bypass followed by weekly injections for 3 weeks and then
for morbid obesity once a month thereafter.

• Therapy must continue for life to prevent recurrence

of anemia.

• Response to therapy is usually manifested by a

brisk production of reticulocytes within the first few
days of therapy.
2. Vit B12 Deficiency/Addison Pernicious Anemia
Vitamin B12 deficiency is extremely uncommon during pregnancy.

Vitamin B12 deficiency (pernicious anemia) is primarily caused by deficiency in oral absorption.

Present in:
• The most common type is that caused by autoimmune atrophic gastritis, which occurs most frequently in
patients of Scandinavian and Northern European ancestry as well as those of Hispanic origins.

• Women between 30 and 40 years of age

Rare causes of vitamin B12 deficiency:

• Infection by the fish tapeworm (Diphyllobothrium latum)

• Chronic conditions such as Crohn’s disease.

Diagnosis
• Patients demonstrating a macrocytic anemia with an abnormally low serum vitamin B12 level.

Management of Vitamin B12 Deficiency is same as Iron Deficiency Anemia

GESTATIONAL CONDITIONS
Please refer to Chapter 13: The Nursing Role in Promoting Nutritional Health During Pregnancy p.299

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HYPEREMESIS GRAVIDARUM
-PERNICIOUS or PERSISTENT VOMITING OF PREGNANCY
-extreme nausea and vomiting that is prolonged past week 12 of pregnancy or is so severe (DHN, ketonuria,
weight loss) within the 1st 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)

-Elevated Hematocrit due to hemoconcentration
-Reduced Na, K Cl and hypokalemic alkalosis may occur
-Polyneuritis due to deficiency in Vitamin B
2. NPO; IVF ( 3L Ringer’s lactated solution+ vitamin
B) to control vomiting
3. If no vomiting after the 1st 24h, sips of clear fluid
gradually advanced to a soft, then normal, diet.

-Urine may be (+) for ketones due to breakdown of 4. If vomiting returns, TPN or enteral nutrition may
protein & fat for cell growth be prescribed

-Intrauterine Growth Restriction or preterm birth 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)

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Assessment Complication
1. Missed period, usual signs of pregnancy
(Nausea and Vomiting, positive pregnancy test, etc) 1. Hemorrhage,
2. Shock,
2. Spotting, bleeding (dark red or brownish), 3. Peritonitis
possible signs of hypovolemic shock

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

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. Berta a pregnant patient was diagnosed with Iron Deficiency Anemia. She asked you what are the other
types of Anemia that can be seen in pregnancy. Which of the following are Anemias of Pregnancy, EXCEPT:
A. Vitamin B12 Anemia
B. Anemia due to Blood Loss
C. Folate Deficiency
D. Thalassemia
ANSWER: ________
RATIO: All are Anemias of Pregnancy, except D. Thalassemia.

2. Cilla a student-nurse who takes care of Berta asked you what are the factors that puts the patient at
risk of developing anemia in pregnancy. All but one are risk factors of Anemia, EXCEPT: A. Poor nutrition
B. Excess alcohol consumption

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C. Illnesses that reduce absorption of nutrients
D. Use of anticonvulsant drugs
E. Elevated hematocrit due to hemoconcentration
ANSWER: ________
RATIO: All but one is risk factors of Anemia, except Elevated hematocrit due to hemoconcentration

3. Cilla a student nurse asked you what is the difference between Folic Acid and Folate. Which of the following
are the correct definition of Folic acid and Folate?
A. Folic Acid is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs,
citrus fruit, avocados, and beef liver while Folate is a synthesized version of vitamin B9 that is added to processed
foods and the common version used in supplements.
B. Folate is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs,
citrus fruit, avocados, and beef liver while Folic acid is a synthesized version of vitamin B9 that is added to processed
foods and the common version used in supplements.
C. Folate is the common form of vitamin B9 present in many synthesized version of vitamin B9 that is added to
processed foods and the common version used in supplements while Folic acid is the common form of vitamin B9
present in many whole foods, including leafy greens, beans, eggs, citrus fruit, avocados, and beef liver.
D. Folate and Folic Acid is both present in many whole foods, including leafy greens, beans, eggs, citrus fruit,
avocados, and beef liver
ANSWER: ________
RATIO: Folic Acid is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs,
citrus fruit, avocados, and beef liver while Folate is a synthesized version of vitamin B9 that is added to processed
foods and the common version used in supplements.

4. 4 patients came to the Out Patient Department with Iron Deficiency Anemia EXCEPT:
A. Multiple pregnancies because of the increased fetal demand
B. A woman with secondary hemolytic illness
C. Poor gastric absorption due to gastric bypass for morbid obesity
D. A woman at 36 years of age ANSWER: ________
RATIO: 4 patients came to the Out Patient Department with Iron Deficiency Anemia except D. a woman at 36 years of
age.

5. Erina will be having a case presentation regarding the complications of Anemia in pregnancy. The following
are part of Complications of Anemia in Pregnancy, EXCEPT:
A. Premature labor
B. Intrauterine growth retardation (IUGR)
C. Dangerous anemia from normal blood loss during labor, requiring transfusions D. Poor diet & poor nutrition
ANSWER: ________
RATIO: All are part of Complications of Anemia in Pregnancy, except D. Poor diet & poor nutrition.

6. Belle is diagnosed with Hyperemesis Gravidarum, Which of the following is true regarding Hyperemesis
Gravidarum?
A. Extreme nausea and vomiting that is prolonged past week 12 of pregnancy or is so severe
B. Nausea and Vomiting is so severe that nutrition cannot be maintained and weight loss is severe
C. Urine may be (+) for ketones due to breakdown of protein & fat for cell growth
D. Intrauterine Growth Restriction or preterm birth

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E. All of the choices are true
ANSWER: ________
RATIO: All of the following are true.

7. Belle was confined to the hospital due to Hyperemesis Gravidarum, The following are part of management
for Hyperemesis Gravidarum, EXCEPT: A. 24-hour Hospitalization
B. If no vomiting after the first 24 hours, sips of clear fluid gradually advanced to a soft, then normal, diet.
C. If vomiting returns, TPN or enteral nutrition may be prescribed
D. Provide oxygen therapy
ANSWER: ________
RATIO: The following are part of management for hyperemesis Gravidarum, except Provide oxygen therapy.

8. Karlie is diagnosed with Ectopic Pregnancy. Your instructor ask you which of the following is the common
site of Ectopic Pregnancy?
A. ovary
B. cervix
C. peritoneal cavity
D. fallopian tube
ANSWER: ________
RATIO: All of the following are common site of Ectopic Pregnancy.

9. Karlie is experiencing sharp shoulder pain. Which of the following conditions is

experiencing? A. Cullen’s Sign
B. Charcot’s Sign
C. Kehr’s Sign
D. Leopold’s Sign
ANSWER: ________
RATIO: Referred shoulder pain (KEHR'S SIGN) due to blood in the peritoneum irritating the phrenic nerve.

10. As you do physical examination on Karlie, you saw that her abdomen has an ecchymotic blueness around
the umbilicus. You know that its:
A. Cullen’s Sign
B. Charcot’s Sign
C. Kehr’s Sign
D. Leopold’s Sign
ANSWER: ________
RATIO: CULLEN'S SIGN-ecchymotic blueness around the umbilicus indicating blood pooling in the peritoneum.

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: ________

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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

PERIOD 2

17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

PERIOD 3

32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

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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