Exam 5 Study Guide

Chapters 10, 11, 12, 19, & 20

39 Multiple Choice
11 Multiselect

1. Adaptation to pregnancy- (Normal body changes what to expect and when)

o 1st Trimester
o 2nd Trimester
o 3rd Trimester

2. Common discomforts & interventions (How will the changes above cause discomfort for the
pregnant mother and what can she be taught to elevate these problems.)

o 1st Trimester
o 2nd Trimester
o 3rd Trimester

3. Fetal development (Chart in PowerPoint)

o Embryo
 Week 4-5
 Week 6
 Week 8
o Fetus
 Week 12
 Week 16
 Week 20
 Week 24
 Week 28
 Week 36
 Week 40

4. Signs of pregnancy

o Presumptive (subjective)
o Probable (objective)
o Positive (diagnostic)
5, HIPPA

6. Informed consent

7. Genetic disorders (Understand how Autosomal, Dominant, Recessive, and X linked affect the
children of both carriers and parents who have the disease.) Use your Punnett squares.

o Autosomal Dominant- inherited d/o that occurs when a single gene in the
heterozygous state is capable of producing the phenotype. The abnormal or
mutated gene overshadows the normal gene, and the person will
demonstrate s/s of the d/o. The affected person generally has one affected
parent. Females and males are equally affected by autosomal dominant d/o
and affected males CAN pass the d/o on to his son. Example: Huntington’s
Disease
o Autosomal Recessive-inherited d/o occurs when two copies of the mutant or
abnormal gene in the homozygous state are necessary to produce the
phenotype. Both parents of the affected person must be heterozygous
carriers of the gene (clinically normal, but carriers of the gene.) Two
abnormal genes are needed to express the phenotype. Carrier state- if only
one gene is abnormal the trait will not be expressed (appears normal
phenotype). Females and males are equally affected by autosomal dominant
d/o and an affected male CAN pass the d/o on to his son. Example: Cystic
Fibrosis
o X linked – inherited d/o are those associated with altered genes present on
the X chromosome. They differ from autosomal d/o.
o X-linked recessive If a male inherits an X-linked altered gene, he will
express the condition. This is because the male has only one X chromosome,
therefore all the genes on the X-chromosome will be expressed. Certain
diseases result from mutations in the DNA (mitochondrial DNA) are almost
exclusively from the mother. The female needs both X-chromosomes to be
affected to carry the disease.
o X-linked dominant- RARE Abnormal gene on the X-chromosome results
in expression of the d/o. If the FATHER has the d/o, 100% of the
daughters and NONE of the sons. If the MOTHER had the d/o 50% of
the daughters and 50% of the sons. FATHERS CANNOT PASS ON AN
X-LINKED D/O TO HIS SON B/C THEY ONLY GET Y-Chromosomes
FROM THEIR DAD!!

8. Preconception- genetic evaluation and counseling should be done if there are

reasons for concern like a family history on either side of abnormalities.
Some risk factors are:

Maternal age >35 yrs.

Paternal age >50 yrs.

History of genetic abnormalities/conditions

Positive screening

Environmental teratogen exposure

o Office visits- Education

 The best time to have the testing complete is before starting a family.
 What are some considerations before the testing is done?
 Testing can provide answers, but it can create many tough questions
for the parents. A lot on a moral and ethical level.
 This is a subject that should be discussed before testing is ordered in
a open and nonjudgemental way.

Nursing Responsibilities and Roles

 Make sure you get a thorough history of both members of the couple and their
family members.
 Make sure you’re giving the couple the support they’re going to need.
 Helping them to be able to vocalize their concerns.
 Educate them.

9. Prenatal Visits (Initial and Sequential)

 Establishment of trusting relationship

 Focus on education for overall wellness
 Detection and prevention of potential problems
 Comprehensive health history, physical examination, and laboratory
tests
The assessment process begins at this initial prenatal visit and continues throughout the
pregnancy. The initial visit is an ideal time to screen for factors that might place the woman and
her fetus at risk for problems such as preterm delivery.

Reasons for making an initial visit:

o Suspicion of pregnancy
o s/s of pregnancy
o date of LMP
o Urine test for HCG ( +pregnancy test)

Physical Examination

o VS
o Head to toe assessment
o Head and neck
o Chest
o Abd-
 Fundal ht if appropriate
 FHR
o Extremities
o Pelvic exam
 Internal and external genitalia are inspected.
 A Pap smear and STI specimens are collected if deemed necessary.
 Pelvic size, shape, and measurements are noted.
o Lab tests
o Urinalysis, urine drug screen
o Complete blood count
o Blood typing
o Rh factor
o Rubella titer
o Hepatitis B surface antigen
o HIV, VDRL, and RPR testing
o Cervical smears
o Ultrasound for anatomy and EDD if LMP is questionable.

The urine is analyzed for albumin, glucose, ketones, and bacteria casts. Blood studies usually
include a complete blood count (CBC) (hemoglobin, hematocrit, red and white blood cell counts,
and platelets), blood typing and Rh factor, glucose screening for high-risk women, a rubella titer,
hepatitis B surface antibody antigen, HIV, venereal disease research laboratory (VDRL) or rapid
plasma reagin (RPR) tests, and cervical smears to detect STI.

o Schedule appts Q4 weeks until 28 weeks

o Schedule appts Q2 weeks until 36 weeks
o Schedule appts Q week until delivery
At each subsequent prenatal visit, the following assessments are completed: Weight
and blood pressure, which are compared with baseline values Urine testing for
protein, glucose, ketones, and nitrites Fundal height measurement to assess
fetal growth Assessment for quickening/fetal movement to determine fetal well-
being Assessment of fetal heart rate (should be 110 to 160 bpmFundal height
(see Figure 12-5) Fundal height is the distance (in centimeters) measured with a
tape measure from the top of the pubic bone to the top of the uterus (fundus)
with the client lying on her back with her knees slightly flexed (Fig. 12.5).
Measurement in this way is termed the McDonald method. Fundal height
typically increases as the pregnancy progresses; it reflects fetal growth and
provides a gross estimate of the duration of the pregnancy. In most
pregnancies the fetal heart rate cannot be found until around 12 weeks due to
the uterus has not grown above the top of the pelvic bone. When the
pregnancy is at 20 weeks- half way, the fundus of the uterus should be at the
navel, which is 20cm. Cm should equal week gestation. By 36 weeks, the
fundus is just below the xiphoid process and measures approximately 36 cm.
Fetal heart rate assessment is to determine the rate and rhythm. The normal fetal heart
rate range is 110 to 160 bpm.

Quickening/fetal movement (see Box 12-3)- A woman should feel the

quickening/fluttering of the baby moving around 20 weeks. Fetal movement is a
easy tool for screening of fetal wellbeing that the mother can do at home.

Fundal height (see Figure 12-5) Fundal height is the distance (in centimeters) measured
with a tape measure from the top of the pubic bone to the top of the uterus
(fundus) with the client lying on her back with her knees slightly flexed (Fig.
12.5). Measurement in this way is termed the McDonald method. Fundal height
typically increases as the pregnancy progresses; it reflects fetal growth and
provides a gross estimate of the duration of the pregnancy. In most
pregnancies the fetal heart rate cannot be found until around 12 weeks due to
the uterus has not grown above the top of the pelvic bone. When the
pregnancy is at 20 weeks- half way, the fundus of the uterus should be at the
navel, which is 20cm. Cm should equal week gestation.
By 36 weeks, the fundus is just below the xiphoid process and measures approximately
36 cm.
Fetal heart rate assessment is to determine the rate and rhythm. The normal fetal heart
rate range is 110 to 160 bpm.

Quickening/fetal movement (see Box 12-3)- A woman should feel the

quickening/fluttering of the baby moving around 20 weeks. Fetal movement is a
easy tool for screening of fetal wellbeing that the mother can do at home.

15-21 weeks Marker screening test are ordered early in first semester. This test
identifies fetal outcome risks.
 24 and 28 weeks - a blood glucose level is obtained using an oral 50-g glucose
load followed by a 1-hour plasma glucose determination. If the result is more
than to 140 mg/dL, further testing, such as a 3-hour 100-g glucose tolerance
test, is warranted to determine whether gestational diabetes is present (ADA,
2020). Although you may see a 75 or 100 gram glucose test. Encourage
prenatal vitamins, good nutrition, and daily reasonable exercise. Test for
antibody screen for Rh negative patients.
28 weeks-Rhogam is given if indicated to Rh negative mother carrying a Rh-
positive fetus. RhoGAM is used to prevent development of antibodies to Rh-
positive red cells whenever fetal cells are known or suspected of entering the
maternal circulation such as after a spontaneous abortion or amniocentesis. It
is also recommended following birth if the infant is Rh-positive.
Between 29 and 36 weeks’ gestation, all the assessments of previous visits are
completed with attention being paid to periorbital, hand and shin edema. S/S
of HTN-Pre-eclampsia
Between 37 and 40 weeks’ gestation, the same assessments are done as for the
previous weeks. In addition, screening for group B streptococcus, gonorrhea,
and chlamydia is done.
40-42- vaginal exam may be performed to determine readiness for delivery
During each visit, review the common discomforts of pregnancy, evaluate any client
complaints, and answer questions. Prepare the patient for what to expect during the
next stage of pregnancy and during next prenatal visit.

o Management- Know the testing and why it is important.

US- A transducer that emits high-frequency sound waves is placed on the

mother’s abdomen and moved to visualize the fetus
NST non-invasive test to measure placental function. Basically, an NST
correlates if fetal movement produces increase in fetal heart rate.
• Obtain a baseline fetal monitor strip over 15 to 30 minutes.
• During the test, observe for signs of fetal activity with a
concurrent acceleration of the fetal heart rate. Interpret the NST
as reactive or nonreactive.
• A reactive NST includes at least two fetal heart rate
accelerations from the baseline of at least 15 bpm for at least 15
seconds within the 20-minute
• Currently, an NST is recommended twice weekly (after 28
weeks’ gestation) for clients with diabetes and other high-risk
conditions, such as intrauterine growth restriction (IUGR),
preeclampsia, post-term pregnancy, renal disease, and
multifetal pregnancies
The BPP is a scored test with five components, each worth two points if present.
A total score of 10 is possible if the NST is used. Thirty minutes are allotted
for testing, though less than 10 minutes are usually needed.
 • Body movements: three or more discrete limb or trunk
movements= 2points
• Fetal tone: one or more instances of full extension and flexion of
a limb or trunk= 2points
• Fetal breathing: one or more fetal breathing movements of more
than 30 seconds= 2 points
• Amniotic fluid volume: one or more pockets of fluid measuring 2
cm= 2 points

NST: normal NST = 2 points; abnormal NST = 0 points

o Education

Nutrition/weight-

o Naegele’s Rule- Weight Gain

o 1st trimester= 3-5 lbs
o 2nd trimester= 1 lb/ week
o 3rd trimester= 1 lb/ week

Prenatal nutritional needs:

 Calories +300/day over the 1800-2200 calories already for nonpregnant
women.
 80 mg protein/day
 Iron (30mg), folic acid* supplement (600mcg)
 Drink 2 quarts (64 oz) of water/day
 Avoid cheeses (listeria)
 Fish- swordfish/shark
 Limit tuna, salmon, shrimp 2X/week.
 Increase protein intake to 80g/day
 Increase folic acid from 400 to 800mcg/day
 To help alleviate nausea and vomiting, advise the woman to eat small, frequent
meals that are bland and low in fat (five or six times a day) to prevent her
stomach from becoming completely empty. Other helpful suggestions include
eating dry crackers, Cheerios, or cheese or drinking lemonade before getting out
of bed in the morning and increasing her intake of foods high in vitamin B6, such
as meat, poultry, bananas, fish, green leafy vegetables, peanuts, raisins, walnuts,
and whole grains, or making sure she is receiving enough vitamin B6 by taking
her prescribed prenatal vitamins.
Review the client’s usual dietary intake and suggest that she limit or avoid gas-producing or fatty
foods and large meals. Instruct the woman to pay attention to the timing of the discomfort.
Usually, it is heartburn when the pain occurs 30 to 45 minutes after a meal. Encourage the client
to maintain proper posture and remain in the sitting position for 1 to 3 hours after eating to
prevent reflux of gastric acids into the esophagus by gravity. Urge the client to consume small,
frequent meals and eat slowly, chewing her food thoroughly to prevent excessive swallowing of
air, which can lead to increased gastric pressure. Instruct the client to avoid foods that act as
triggers such as caffeinated drinks; greasy, gas-forming foods; citrus; spiced foods; chocolate;
coffee; alcohol; and spearmint or peppermint.
Vaccines- Vaccines are among the greatest public health achievements of the 21st
century, credited with significant reduction of morbidity and mortality from many
diseases caused by bacteria and viruses (Sverrisdottir et al., 2019). Ideally, clients
should receive all childhood immunizations before conception to protect the fetus from
any risk of congenital anomalies. If the client comes for a preconception visit, discuss
immunizations such as measles, mumps, and rubella (MMR), hepatitis B, and
diphtheria/tetanus (every 10 years); administer them at this time if needed.
Vaccines That Should Be Considered Unless Contraindicated
• Hepatitis B
• Influenza (inactivated) injection
• Tetanus/diphtheria (Tdap)
• Rabies
Vaccines Contraindicated during Pregnancy
• Influenza (live, attenuated vaccine) nasal spray
• Measles
• Mumps
• Rubella
• Varicella
• BCG (tuberculosis)
• Typhoid
Medication use is common during pregnancy, with prevalence estimates generally exceeding
65% and increasing over the years. Pregnant women use a wide variety of both prescription and
OTC medications for both pregnancy-related conditions and conditions unrelated to pregnancy
conditions. Little is known about the effects of taking most medications during pregnancy. Less
than 10% of medications approved by the FDA since 1980 have enough information to determine
their risk for birth defects (CDC, 2019h). Based on this lack of evidence, it is best for pregnant
women to not take any medications during their pregnancy. At the very least, encourage them to
discuss with the health care provider their current medications and any herbal remedies
Testing- US- A transducer that emits high-frequency sound waves is placed on
the mother’s abdomen and moved to visualize the fetus
NST non-invasive test to measure placental function. Basically, an NST
correlates if fetal movement produces increase in fetal heart rate.
• Obtain a baseline fetal monitor strip over 15 to 30 minutes.
• During the test, observe for signs of fetal activity with a
concurrent acceleration of the fetal heart rate. Interpret the NST
as reactive or nonreactive.
 • A reactive NST includes at least two fetal heart rate
accelerations from the baseline of at least 15 bpm for at least 15
seconds within the 20-minute
• Currently, an NST is recommended twice weekly (after 28
weeks’ gestation) for clients with diabetes and other high-risk
conditions, such as intrauterine growth restriction (IUGR),
preeclampsia, post-term pregnancy, renal disease, and
multifetal pregnancies
The BPP is a scored test with five components, each worth two points if present.
A total score of 10 is possible if the NST is used. Thirty minutes are allotted
for testing, though less than 10 minutes are usually needed.
• Body movements: three or more discrete limb or trunk
movements= 2points
• Fetal tone: one or more instances of full extension and flexion of
a limb or trunk= 2points
• Fetal breathing: one or more fetal breathing movements of more
than 30 seconds= 2 points
• Amniotic fluid volume: one or more pockets of fluid measuring 2
cm= 2 points

NST: normal NST = 2 points; abnormal NST = 0 points

10. Obstetric terms-

o Para- The number of times a woman has given birth to a fetus of at least 20
gestational weeks (viable or not), counting multiple births as one birth event.
o Gravida- The total number of times a woman has been pregnant, regardless of
whether the pregnancy resulted in a termination or if multiple infants were born
from a pregnancy.
TPAL- T, term births; P, preterm births; A, abortions; L, living children
• T—the number of term gestations delivering between 38 and 42 weeks
• P—the number of preterm pregnancies ending >20 weeks or viability but before
completion of 37 weeks
• A—the number of pregnancies ending before 20 weeks or viability
• L—the number of children currently living

11. Amniocentesis- the sampling of amniotic fluid using a hollow needle inserted into
the uterus, to screen for developmental abnormalities in a fetus.

12. At Risk Pregnancy (Assessment, complications, and interventions/treatments)

Bleeding-
 o Abortions-

Spontaneous Abortion- (miscarriage)- termination of pregnancy before 20 weeks gestation.

• 1st trimester commonly due to fetal genetic abnormalities

• 2nd trimester more likely related to maternal conditions
• Nursing Assessment
• Vaginal bleeding
• Cramping or contractions
• Vital signs, pain level
• Client’s understanding
• Types
• Threatened
• Inevitable
• Incomplete
• Complete
• Missed
• Habitual

Ectopic Pregnancy
Pregnancy outside the uterus

S/S
Vaginal bleeding and pelvic pain
Shock

Management
Medical
Methotrexate
Surgical
Salpingectomy

Gestational Trophoblastic Disease (GTD)-

Pathologic proliferation of trophoblastic cells

Types
Hydatidiform mole (Molar pregnancy)
Complete mole
Partial mole
Invasive mole

Choriocarcinoma

Gestational Trophoblastic Disease (GTD)

 S/S
Bleeding
Uterine size
hCG
Interventions
Evacuation
Treatment of complications
Emotional support
F/U
Monitor serum hCG

CXR

o Incompetent cervix,
o Risk factors:
o Interventions
o US for cervical length
o Cerclage
o Cesarean delivery- suture left in place
o Vaginal delivery- suture removed before term

o Abruption- Abruptio Placentae

Early separation of placenta from uterine wall

S/S: May or may NOT have vaginal bleeding, rigid/hard abdomen, severe abdominal pain

Management- emergency!
Fetus mature–Cesarean section
Fetus immature–

Nursing care
Assess
Monitor
 o Placenta previa-

Placenta lies over or near the cervix

S/S
Painless vaginal bleeding,

Management
Fetus mature–Cesarean section
Fetus immature–bed rest, monitoring

Nursing care
Assess for bleeding, prepare for surgery
Monitor maternal vital signs, contractions, and fetal
well-being
 o Asthma- most common respiratory disease effecting pregnancy.

The primary goal of mgmt. during pregnancy is to maintain adequate oxygenation

of the fetus by preventing hypoxic episodes in the mother. Asthma should be
treated as aggressively in pregnant women as in nonpregnant women b/c the
benefits of averting an asthma attack outweigh the risks of medications. 4
important aspects of asthma treatment ensure optimal control:

 Close monitoring
 Education of clients
 Avoidance of asthma triggers
 Pharmacologic therapy

o Rh incompatibility-
RH factor- presence of Rh0 (D) antigen on the RBC.
When an Rh- woman and a Rh+ man conceive a child, Rh- gets pregnant
with Rh+ fetus. Cells from the fetus enter the woman’s bloodstream.
Woman becomes sensitized. Antibodies form to fight Rh+ blood cells. In the
next Rh+ pregnancy, maternal antibodies attack fetal RBCs. Confirmed by
positive antibody screen (indirect coombs’), fetal ascites on US exam.
Interventions are: Serial labs, US, amniocentesis, intrauterine transfer may
be necessary, prevention through administration of immune globulin
RhoGam as indicated.

o Anemia- reduction in RBC and oxygen carrying capacity.

 Sickle cell anemia is an autosomal recessive inherited condition that
results from a defective hemoglobin molecule (hemoglobin S). The
typical lifespan of sickled red blood cells (RBCs) is approximately 15
days compared to the 120-day lifespan of normal RBCs. Consequently,
women with sickle cell anemia suffer from moderate to severe anemia.
 Women with sickle cell disease can have more adverse maternal
outcomes such as preeclampsia, eclampsia, preterm labor and birth,
urinary tract infections, placental abruption, IUGR, low birth weight, and
maternal mortalities
 Thalassemia-Thalassemia is a group of hereditary anemias in which
synthesis of one or both chains of the hemoglobin molecule (alpha and
beta) is defective. Inheritance is autosomal recessive
 Additionally, frequent hemoglobin and ferritin levels should be
monitored to avoid iron overload. Identification and screening are
 important to plan care. The woman’s ethnic background, medical
history, and blood studies are analyzed.

o Amniotic fluid imbalances

 Polyhydramnios- also called hydramnios is a condition in which
there is too much amniotic fluid (more than 2,000mL) surrounding the
fetus between 32- and 36-weeks’ gestation. There are several causes
of polyhydramnios. Generally, too much fluid is being produced, there
is a problem with the fluid being taken up, or both. It can be
associated with maternal disease and fetal anomalies, but it can also
be idiopathic in nature. It is associated with maternal diabetes, and
fetal anomalies such as upper GI obstruction or atresias, NTD, and
anterior abdominal wall defects together with impaired swallowing in
fetuses with chromosomal anomalies, such as trisomies 13, 18, and
anencephaly. Overall, it is associated with poorer fetal outcomes b/c
of the increased incidence of preterm births, fetal malpresentation, and
cord prolapse. Polyhydramnios is suspected when uterine enlargement,
maternal abdominal girth, and fundal height are larger than expected for
the fetus’s gestational are.

Treatment may include close monitoring and frequent follow-up visits with the
healthcare provider if the polyhydramnios is mild to moderate. In severe cases in
which the woman is in pain and experiencing SOB, an amniocentesis or artificial
rupture of the membranes is done to reduce the fluid and the pressure. Removal of
fluid by amniocentesis is only transiently effective. A noninvasive treatment may
involve the use of a prostaglandin synthesis inhibitor (indomethacin) to decrease
amniotic fluid volume by decreasing fetal urinary output, but this may cause
premature closure of the fetal ductus arteriosus.

** There is an increase in C-section births for fetal labor intolerance, low 5-minute
Apgar scores, increased neonatal birth weight, congenital anomalies, and NB ICU
admissions for women with too much amniotic fluid at term.

o Oligohydramnios- is a decreased amount of amniotic fluid (less than

500mL) between 32- and 36-weeks’ gestation that is associated with poor
pregnancy outcomes. The volume of amniotic fluid increases in a linear
fashion until 38 weeks to a mean volume of 1,000 mL and then starts to
decrease. Oligohydramnios may result from any condition that prevents the
fetus from making urine or blocks it from going into the amniotic sac.
 Oligohydramnios occurs in about 4 in 100 pregnancies. It often occurs if the
pregnancy goes two weeks past the due date. This happens as the amniotic
fluid levels naturally decline. This condition puts the fetus at an increased
risk of perinatal morbidity and mortality. Reduction in amniotic fluid
reduces the ability of the fetus to move freely without risk of cord
compression, which increases the risk for fetal death and intrapartal
hypoxia.

This can be managed on an outpatient basis with serial US and fetal

surveillance through nonstress testing and biophysical profiles. If fetal well-
being is demonstrated with frequent testing, no intervention is necessary. If
fetal well-being is compromised, however, birth may be planned along with
amnioinfusion (the transvaginal infusion of crystalloid fluid for the lost
amniotic fluid). The fluid is introduced into the uterus through an intrauterine
pressure catheter. The infusion is thought to improve abnormal FHR patterns,
decrease cesarean births, and possibly minimize the risk of neonatal meconium
aspiration syndrome, but more studies need to be done to validate this.

o Gestational Diabetes- an endocrine d/o of carb metabolism which results

from an inadequate production or use of insulin. Associated risks (mom):
vaginitis/UTI’s, hydramnios, worsen diabetic retinopathy, Pre-eclampsia,
ketoacidosis. Fetal risks: congenital anomalies, macrosomia- birth injuries,
hypoglycemia, intrauterine growth restriction, respiratory distress
syndrome, polycythemia, hyperbilirubinemia. Insulin requirements
increase significantly during pregnancy, and during each trimester d/t
increased hormone levels and increased insulin resistance. Test to confirm
this is a 2-hr GTT performed during 24-28 weeks’ gestation. If the result is
abnormal, a 3-hr GTT is done next. Early detection is the key.
Education/counseling, diet, lifestyle changes, glucose monitoring, fetal
monitoring, monitor weight, testing urine and BS, US, medication for
glucose control,
o Hypertensive Disorders-

HTN in pregnancy

Types
Chronic Hypertension

BP elevation pre-pregnancy or before 20 weeks gestation

BP elevation persists 42 days postpartum

 • Interventions
• Prenatal visits
• Q 2 weeks through 28wks/ then q week until delivery
• Frequent rests (left side)
• Continue medical management of HTN:
• Diet- 2 gm Na
• Monitor BP at home
• Medication
• Aldomet
• Monitor for preeclampsia/ eclampsia
• Monitor fetal well-being

Gestational HTN

(previously known as: PREGNANCY-INDUCED HYPERTENSION)

Elevation in BP after 20 weeks and without proteinuria

BP returns to normal by 12 weeks postpartum

 Risk factors: primigravida
Maternal age > 35 yrs;
African American
Interventions
Medication
Aldomet (Methyldopa)
Labetalol
Monitor for preeclampsia/ eclampsia
Monitor fetal well-being

Preeclampsia
Pathophysiology
VASOSPASM and HYPOPERFUSION
Decreased brain and liver perfusion
Decreased uterine and placental perfusion
Decreased renal perfusion
Decreased output/ GFR
Increased sodium retention

Progressive mild to severe

Eclampsia= generalized seizures or coma
 S/S
H/A, blurred vision, hyperreflexia
Epigastric pain, elevated liver enzymes
Edema face, hands
N/V
mild severe
B/P: >140/90 >160/110
Proteinuria: 300mg/L - 1gm/L > 5gm/L
(1+ and 2+ dipstick) (3+ to 4+ dipstick)

Interventions
Mild p Interventions
Mild preeclampsia
Bed rest- left side
High protein diet
Monitor fetus
NST
Kick counts
Ultrasound/ biophysical profilereeclampsia
Bed rest- left
Interventions (con’t)
Severe preeclampsia
Bed rest
Anti-convulsant medication
IVF (with electrolytes)
Meds (monitor effects/ side-effects)
Corticosteroids
Antihypertensives

(generalized seizures or coma) Eclampsia

Interventions
Seizure
Medication
Magnesium sulfate
Diazepam if magnesium sulfate
unsuccessful
Minimize stimuli
Monitor CV, respirations
Monitor urinary output
Monitor fetus
Eclampsia
Chronic Hypertension w/ preeclampsia

HELLP Hemolysis
Elevated
Liver Enzymes
Low
Platelet count
Disseminated intravascular coagulation (DIC)

overactive clotting

HELLP syndrome is an acronym for hemolysis, elevated liver enzymes, and low platelet
count. It is a variant of the preeclampsia/eclampsia syndrome that occurs in up to 20%
of clients whose conditions are labeled as preeclampsia with severe features. Similar to
preeclampsia, the essential phenomenon in HELLP’s development is an abnormal
trophoblastic invasion due to inadequate maternal immune tolerance. Women with
HELLP syndrome are at increased risk for complications such as cerebral hemorrhage,
retinal detachment, hematoma/liver rupture, DIC, placental abruption, eclampsia, acute
renal failure, pulmonary edema, and maternal death. It is a life-threatening obstetric
complication considered by many to be a severe form of preeclampsia involving hemolysis,
thrombocytopenia, and liver dysfunction.
Management focuses on stabilization of blood pressure and assessment of fetal well-being to
determine the optimal time for birth. The treatment for HELLP syndrome is based on the severity
of the disease, the gestational age of the fetus, and the condition of the mother and fetus. The
mainstay of treatment is lowering of high blood pressure with rapid-acting antihypertensive
agents, prevention of convulsions or further seizures with magnesium sulfate, and use of steroids
for fetal lung maturity if necessary, followed by the birth of the infant and placenta

o PROM- Premature Rupture of Membranes- the spontaneous rupture of the

amniotic sac before the onset of labor. There are several conditions and
complications, such as infection, prolapsed cord, placental abruption, and
preterm labor. High-risk factors associated with PROM include low
socioeconomic status, multiple gestion, low BMI, tobacco use, history of
preterm labor, placenta previa, placental abruption, UTI, vaginal bleeding
at any time in pregnancy, illicit drug use, cerclage, and amniocentesis. If
 prolonged (>24 hrs), the woman’s risk for infection (chorioamnionitis,
endometritis, sepsis, and neonatal infections) increases and continues to
increase the longer the time since the sac ruptured. Fetal complications
include intrauterine infection, umbilical cord compression, placental
abruption.

Women with PROM present with leakage of fluid, vaginal discharge, vaginal
bleeding, and pelvic pressure, but they are not having contractions. PROM is
diagnosed by speculum vaginal examination of the cervix and vaginal cavity. Pooling
of fluid in the vagina or leakage of fluid from the cervix, ferning of the dried fluid
under microscopic examination, and alkalinity of the fluid as determined by nitrazine
paper (pH indicator) confirms the diagnosis.

The exact cause of PROM is not known but may be associated with vaginal bleeding,
placental abruption, microbial invasion of the amniotic cavity, and defective
placentation.

Treatment of PROM typically depends on the gestational age. Under no circumstances

is an unsterile digit cervical examination done until the woman enters active labor to
minimize infection exposure. If the fetal lungs are mature, induction of labor is
initiated. If the fetal lungs are immature, expectant management is carried out with
adequate hydration, reduced physical activity, pelvic rest, and close observation for
possible infection, such as with frequent monitoring of VS and lab test results (WBC).
Corticosteroids may be given to enhance fetal lung maturity if lungs are immature,
though this remains controversial.

Nursing assessment focuses on obtaining a complete health history and performing a

physical examination to determine maternal and fetal status. An accurate assessment
of the gestational age and knowledge of the maternal, fetal, and neonatal risks are
essential to appropriate evaluation, counseling, and management of women with
PROM. Also assess the color, amt, pH, and odor of the fluid.

Nursing management for the woman with PROM focuses on preventing infection and
identifying uterine contractions. The risk for infection is great b/c of the break in the
amniotic fluid membrane and its proximity to vaginal bacteria. Therefore, maternal
VS must be monitored closely. Temperature elevation, increase in pulse, monitor FHR
for tachycardia which can indicate maternal infection, or variable decelerations which
suggest cord compression. If WBC count is elevated, may be put on antibiotics.
Management of this emergency includes elevation of the presenting part to avoid cord
compression and C/S.
 o Prolapsed Cord- occurs when the cord drops through the open cervix into
the vagina before your baby moves into the birth canal. When this
happens, the cord is squeezed between your baby’s body and your pelvic
bones. This reduces your baby’s blood supply, leading to loss of oxygen to
your baby.

Infections-

Group B Strep (GBS)

Maternal: culture @ 35-37 wks; asymptomatic (treat during labor w/ IV

antibiotics)

NBN: (early onset) pneumonia, septicemia; (late onset) meningitis,

pneumonia

Chlamydia

Maternal: purulent discharge, urinary frequency, burning

NBN: conjunctivitis
Group B streptococcus (GBS) is a naturally occurring bacterium found in approximately
50% of healthy adults. It is a Gram-positive bacteria which colonizes in the
gastrointestinal and genitourinary tracts. Women who test positive for GBS bacteria are
considered carriers. Carrier status is transient and does not indicate illness.
Approximately 50% of pregnant women carry GBS in the rectum or vagina, thus
introducing the risk of colonization of the fetus during birth. Approximately one out of
every 100 to 200 newborns born to mothers who carry GBS will develop signs and
symptoms of GBS disease. Although GBS is rarely serious in adults, it can be life
threatening to newborns. GBS is the most common cause of sepsis and meningitis in
newborns and is a frequent cause of newborn pneumonia. Penicillin G is the treatment of
choice for GBS infection because of its narrow spectrum. The drug is usually administered IV at
least 4 hours before birth so that it can reach adequate levels in the serum and amniotic fluid to
reduce the risk of newborn colonization.

Gonorrhea-
 Maternal: STI, asymptomatic

NBN: gonorrhea neonatorum (Erythromycin opthalmic ointment)

Syphillis-

Maternal: STI, chancre sore (prenatal screening, PCN by 16wks to prevent

crossing placenta)

NBN: stillbirth, congenital cataracts; congenital syphillis

HIV-
• Impact of HIV on pregnancy:
 Self
 Fetus and newborn
• Nursing assessment
 HIV antibody testing
 Pretest and posttest counseling
 Testing for STIs
 H&P-Sexually acquired or bloodborn (i.e. needle sticks)
• Risk for Infection R/T inadequate defenses secondary to HIV-positive
status

Goals:
• Client will remain free of opportunistic infections during course of
pregnancy

 No signs of infection- chills, fever, sore throat

When a woman who is infected with HIV becomes pregnant, the risks to herself, her
fetus, and the newborn are great. Early identification of maternal HIV seropositivity
allows early antiretroviral treatment to prevent mother-to-child transmission, allows a
provider to avoid obstetric practices that may increase the risk for transmission, and
allows an opportunity to counsel the mother against breastfeeding (also known to
increase the risk for transmission) (USPSTF, 2019). However, such cases have
decreased in recent years in the United States, primarily due to the use of
antiretroviral therapy in pregnant women infected with HIV. The USPSTF (2019)
recommends that all pregnant women be offered HIV antibody testing, regardless of
their risk of infection, and that testing be done during the initial prenatal evaluation.
Testing is essential because treatments are available that can reduce the likelihood of
perinatal transmission and maintain the health of the woman. With perinatal
transmission, approximately half of children manifest AIDS within the first year of
life, and about 80% have clinical symptoms of the disease within 3 to 5 years (CDC,
2019p). Breastfeeding is a major contributing factor for mother-to-child transmission,
and the infected mother must be informed about this (March of Dimes, 2019h).

Current evidence suggests that cesarean birth performed before the onset of labor and
before the rupture of membranes significantly reduces the rate of perinatal
transmission. ACOG recommends HIV-positive women be offered elective cesarean
birth to reduce the rate of transmission beyond that which may be achieved through
ART. The standard treatment is oral antiretroviral drugs given daily until giving birth,
IV administration during labor, and oral zidovudine (AZT) for the newborn within 6
to 12 hours of birth (Jordan et al., 2019). The goal of therapy is to reduce the viral
load as much as possible, which reduces the risk of transmission to the fetus

Infection control issues at home

Safer sex precautions
Stages of the HIV disease process and treatment for each stage
Symptoms of opportunistic infections
Preventive drug therapies for the unborn infant
Avoidance of breastfeeding
Referrals to community support, counseling, and financial aid
Client’s support system and potential caregiver
Importance of continual prenatal care
Need for a well-balanced diet

Measures to reduce exposure to infections

o TORCH

Toxoplasmosis

Maternal: parasite contracted through cat feces; under-cooked meats

NBN: enlarged liver/spleen; jaundice; anemia; neurological deficits

Other (Hepatitis)
 Maternal: HAV- poor handwashing after defication, HBV- placental
transfer or through body fluids during delivery; prenatal HbsAg

NBN: preterm, intrauterine demise, hepatitis infection

Rubella

Maternal: maculopapular rash, lymph node enlargement, muscle aches/

pain

NBN: congenital cataracts, sensorineural deafness, heart defects, MR, CP

Cytomegalovirus (most common)

Maternal: asymptomatic

NBN: death, severe neuro

Herpes simplex:
Maternal: C/S if active lesions; acyclovir

NBN: microcephaly, MR, seizures, apnea, coma

Approximately 400 to 4,000 cases of toxoplasmosis occur in newborns

annually the United States (CDC, 2019l). Cats are the definitive
hosts of this parasite and shed it in their feces. It is transferred by
hand to mouth after touching cat feces while changing the cat litter
box or through gardening in contaminated soil. Consuming
undercooked infected meat, such as pork, lamb, or venison drinking
contaminated water, and eating unwashed fruits and vegetables can also
transmit this organism. A pregnant woman who contracts toxoplasmosis for the
first time has an approximately 30% chance of passing the infection to her fetus.
Toxoplasmosis acquired during pregnancy means high risk of damage for the
fetus in addition to preterm labor and stillbirth (March of Dimes, 2019g).
HBV can be transmitted through contaminated blood, illicit drug use, and sexual contact.
The virus is 100 times more infectious than HIV and, unlike HIV, it can live outside
the body in dried blood for more than a week. The fetus is at particular risk during
birth because of the possible contact with contaminated blood at this time.
Rubella, commonly called German measles, is spread by droplets or through direct
contact with a contaminated object. The risk of a pregnant woman transmitting this
virus through the placenta to her fetus increases with earlier exposure to the virus.
 Congenital rubella can manifest with a diverse range of symptoms in the newborn,
including congenital cataracts, glaucoma, cardiac defects, microcephaly, and hearing
and intellectual disabilities. Hearing impairment is the most common manifestation.
Cytomegalovirus is a member of the herpesvirus family, which includes herpes simplex
virus (HSV) types 1 and 2, varicella zoster virus, and Epstein–Barr virus. CMV is the
leading cause of congenital infection, with morbidity and mortality at birth.
HSV is a highly contagious, incurable, recurrent infection with high prevalence and rapid
acquisition. Infants born to mothers with primary HSV infections have a 30% to 50%
risk of acquiring the infection via perinatal transmission near or during birth.

o Special Populations-

o Teens-

Statistics

70 pregnancies* per 1,000 teen females occurred in 2005

(3% increase from 2005- 2006)

1 of 6 teen mothers will have another child within 1 yr

Healthy People 2020

 Goals-
Reduce number of teen pregnancies
from pregnancies per 1,000 per year
 Interventions

Adolescent pregnancy has a negative impact in terms of both health and social
consequences. For example, seven out of 10 adolescents will drop out of school. More
than 75% will receive public assistance within 5 years of having their first child. In
addition, children of adolescent mothers are at greater risk of preterm birth, low birth
weight, child abuse, neglect, poverty, and death. The younger the adolescent is at the
time of the first pregnancy, the more likely it is that she will have another pregnancy
during her teens.
The impact of adolescent pregnancy is evident in maternal and perinatal morbidity and
mortality. Adolescent pregnancy also reflects previous conditions such as malnutrition,
communicable diseases, and deficiencies in health care. The most important impact lies
in the psychosocial area; adolescent pregnancy contributes to a loss of self-esteem,
societal discrimination, a destruction of life projects, and the prolonging of poverty
• Physiological risks
 Preterm birth, LBW, anemia, STD
• Psychological risks
 Interruption of developmental tasks
• Sociological risks
 Long-term effects
 Dropping-out of school
 Prolonged dependency on parents

Single-parent status

Adolescent pregnancy also places the client at high risk for obstetric complications such
as preterm labor and births; low-birth-weight infants; STIs; poor maternal weight
gain; preeclampsia; iron-deficiency anemia; poor eating habits and inadequate
nutrition; and postpartum depression. For adolescents, as for all women, pregnancy
can be a physically, emotionally, and socially stressful time. The pregnancy is often
both the result of and cause of social problems and stressors that can be
overwhelming. Teen mothers often present with depression, social complexity, and
inadequate parenting skills. Nurses must support adolescents during the
transition from childhood into adulthood, which is complicated by the
emergence into motherhood. Assist the adolescent in identifying family and
friends who want to be involved and provide support throughout the
pregnancy.

o Abuse- Domestic
 Abuse is always about power!
 Abuser now has power over the pregnant client and the baby
 Abuse typically increases in frequency with pregnancy
 Often threaten to take custody of the baby if she leaves
 Consult crisis counselor
 Interview patient alone
 FNE if needed
 Social work referral for community resources
 Treat bodily injuries if needed
  State by state- is this child abuse?
 Empower the woman

o ETOH-

Most serious effects of FAS are the invisible symptoms of neurological damage from
prenatal exposure to alcohol:

 Attention deficits
 Memory deficits
 Hyperactivity
 Growth Defects
 Learning difficulty
 Poor impulse control
 Poor judgment
 Tobacco, Illicit drugs

Intake increases the risk of alcohol-related birth defects, including growth

deficiencies, facial abnormalities, central nervous system impairment, behavioral
disorders, and intellectual development

No amount of alcohol consumption is considered safe during pregnancy.

Damage to the fetus can occur at any stage of pregnancy, even before a woman knows
she is pregnant.

Cognitive defects and behavioral problems resulting from prenatal exposure are
lifelong.

Alcohol-related birth defects are completely preventable (ACOG, 2019f).

o Tobacco-
o Incidence
 1 in 4 women smoke
 11% during pregnancy
 Effects on pregnancy
 Spontaneous abortion
 Maternal hypertension
  Abruptio placentae
o Effects on fetus/ newborn
 LBW
 SGA
 Preterm delivery
 SIDS
Cognitive deficits
o Marijuana

• Incidence
 Most widely used illicit drug (THC)
 Correlation w/ ETOH and cigarette smoking
 Medical marijuana for nausea and appetite stimulant
• Effects on fetus
 SGA
 Preterm delivery
 Long-term neurological deficits?

Concentrated in the fat of breastmilk

o Illicit drugs-

Cocaine-
CNS stimulant produces feelings of pleasure, well
being and alertness.
• Effects on mother
 Hypertension
 Abruption
• Effects on fetus
 Prematurity, LBW

 CNS physical anomalies

Methamphetamines, addictive stimulant, produce same effects. Street.

Heroin

o Illegal, highly addictive opiate derived from morphine,

o can be sniffed, smoked or injected
o Maternal effects
 o Physical dependence
o Malnutrition
o Risky behaviors
o Effects on fetus/ newborn
o Hypoxia- MAS, stillborn, IUGR, LBW, infection
o Increased risk SIDS
Neonatal Abstinence Syndrome (NAS)

Synthetic opiate used for heroin addiction

Methadone use

• Synthetic opiate used for maintenance therapy of heroin addiction

 Benefits
 Improved maternal health
 Improved fetal growth
 Mother can breastfeed
 Risks
 More severe/ prolonged withdrawl for newborn

LBW, SIDS rates remain increase