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HEHI 2 Exam 2

Mood Disorders, Anxiety, OCD, Labor and Delivery

QuestionAnswer
Describe the various psychosocial etiologies of depression. Children who experience loss Anger turned inward Social role strain. Hopelessness Learned helplessness Behavioral theory
A client presents to the ED. You suspect he is experiencing a major depressive episode . Why? He reports that his wife recently asked for divorce, his stomach and head hurt, he is pacing, tearful and irritable with the staff. He wants to die and tells you he no longer enjoys anything. He is no longer eating, sleeping, or having sex for 2 weeks
Before a client can be diagnosed with a major depressive episode, they must meet what criteria? 5+ symptoms present during same 2 week period where one is: (depressed mood OR anhedonia) -10% weight change -altered sleep -psychomotor agitation/retard -fatigue -guilt/worthlessness -poor concentration -suicidal ideation
Beck's Cognitive theory of depression teaches us that... A negative self view combined with pessimistic world view and negative reinforcement lead to repetitive, unintended, and difficult to control negative thoughts
When taking a patient's history, you learn that the patient's mother had Bipolar disorder. This leads you to... Assess for bipolar in your patient because he has 5-10x more likely to develop Bipolar
There are several biologic theories of depression. Explain 4. Genetic predisposition Neuroendocrine- increased cortisol and decreased TSH Altered sleep cycles Abnormal neurotransmitters- low serotonin and norepinephrine
While the exact mechanism of bipolar disorder is unknown, you teach your client about the associated neurotransmitters explaining that. There is a combination of ways the neurotransmitters can appear, frequently high dopamine and norepinephrine or low serotonin and high norepinephrine
What is the continuum of depression? Where on the scale would you place major depressive episode? Transient (everyday disappointments) Mild (normal grief) Moderate (dysthymic disorder) Severe (Major depressive episode/disorder)
Draw the mood disorders comparison graph including Bipolar 1, Bipolar 2, Mania, Hypomania, Dysthymia, Cyclothymia, Euthymia, and Major depression.
You explain to a patient that he has Bipolar 2 instead of Bipolar 1. He asks what that means. You say.. Bipolar 2 is less severe than Bipolar 1. While both are characterized by major depressive episodes, bipolar 2 involves HYPOmania (increased activity without psychosis) while bipolar 1 involves mania or mixed episodes (altered thought process).
What is the difference between dysthymia and cyclothymia? Dysthymia is moderate depression while cyclothymia cycles between hypomania and dysthymia (almost like a mild form of bipolar 2)
A client asks you how he can know when he's going to have another major depressive episode. He also want's to know if he will ever be "normal" again and how long it will last. You tell him.. A few weeks before full onset he may experience anxiety and mild depressive symptoms Most people return to their normal level of functioning but 20-30% have symptoms that persist for months or years that can be distressing but don't meet full criteria
A mom is worried that her 3 year old may have Major depression. What are some expected findings? Feeding problems, failure to thrive, won't play, changed emotions, delay in speech and gross motor, aggression, accident proneness, phobias
Adolescents are quite different than adults and have their own criteria for major depression. What are some common symptoms? How do you know it isn't just hormonal changes? Inappropriate anger Social isolation Sexual misconduct Substance abuse Apathy **Must last for several weeks
T/F: Depression is often misdiagnosed in older adults because memory loss, insomnia, and loss of appetite are related to other illnesses common in this age group (dementia) True. Note that patients with depression will tell you if they cannot remember something while patients with dementia will usually make something up.
What is persistent depressive disorder (dysthymic disorder)? When does it occur? How common is it? 3-5% of people have a depressed mood for at least 2 years with no break in symptoms more than 2 months (children/teens at least 1 year) Onset: childhood -> early adult Often occurs with anxiety
What is the diagnostic criteria for Dysthymic disorder (persistent depressive disorder) 2 year period of depressed mood Significant distress in functional areas AND 2+ -Appetite changes -Sleep changes -low energy -low esteem -hopelessness -low concentration/decision making
You suspect an adolescent or child may have dysthymia because.. They are irritable, cranky, depressed, have low esteem and social skills, Very pessimistic and serious with limited social interaction and poor academic performance
In 2013, the DSM 5 developed a new diagnosis of Disruptive Mood Dysregulation Disorder. Why? What is it? How does it usually evolve? Purpose: prevent over-diagnosis and treatment of Bipolar in children Presentation: persistently irritable and frequent extreme behavioral dyscontrol Usually turns into unipolar depression or anxiety disorder
You need to assess a patient with a mood disorder (depression). What are your top 3 priorities? (in order) 1) Suicide risk 2) Risk to others 3) History of current episode --Mood and cognitive changes (rule out Bipolar) --Behavioral and physical changes (extreme) --GAF (ability to function) 4) Physical exam 5) History 6) Support/coping
What are some expected mental status assessment findings for someone with depression? (appearance, behavior, mood, affect, intellect, thought process) Appearance- poor hygiene, no eyecontact, distracted Behavior- sluggish, agitated Mood- Sad, lonely, exhausted, hopeless Intellect- poor attention, indecisive, memory impairment Process- negative, slow, guilty, anxious, disorganized, suicidal
Diagnostically, the major difference between bipolar type 1 and 2 is... Bipolar 1- history of manic or mixed episode with or without depression episode Bipolar 2- history of depressive episode and one hypomanic episode
T/F: In order to be diagnosed with Bipolar type 1, you must have had at least one episode of mania and one episode of depression False; you must have one manic or mixed episode with or without an episode of depression Bipolar 2 requires at least 1 depressive episode and 1 hypomanic episode with NO maWhinia or mixed episodes
Bipolar 1 and 2 occur in men and women equally often. Which is more common generally? Men are more likely to have a first episode of ____- while women tend to have ____. Most common demographic of bipolar is _____-. Suicide risk is __%. Bipolar 1 more common at 1% (0.5% is 2) Men- Manic Women- Depressed Demo: Divorced, single, non-college, older adolescence/young adult 20% suicide (during depressed/mixed- never manic)
A client is recently diagnosed with Bipolar after having their first episode of mania. They ask wht their prognosis is. You say... 50% have second episode within 2 years 90% have more than 1 episode, 40% > 10 7% have no more symptoms 50-60% have good control 40% chronic symptoms with functional decline
A client's mother insists that her daughter does not have Bipolar 1. Your job is to explain the diagnostic criteria for mania. Go. 1+ week abnormally/persistently elevated expansive/irritable mood (+3 of these) -^ esteem/grandiosity -decreased sleep -Pressured speech -Flight of ideas -Distracted easily -Increase in goal directed activity -Risky behavior
A client comes into the ED behaving very oddly. They are convinced that they are Jesus and have very poor insight believing that they are fine. They tell you they just flew from across the country yesterday and intend to go to London tomorrow. You.. Suspect a manic episode, especially after they become physically violent or threatening
A parent of an adult client asks you what triggers these manic episodes in her daughter and what she can expect to experience. You tell her. Followed by psychological stressor with sudden onset, rapid escalation of symptoms over days Last weeks to months and 50% followed/preceded by major depressive episode Cognitive/Affective/Mood/Behavioral/ Physiological changes are expected
What are the common cognitive changes in mania? Grandiosity Easily distracted Flight of ideas Poor judgment Denial of danger
What are the common affective/mood changes in mania? Elevated mood Confident Euphoric Extroverted Intolerant Irritable Suspicious Lability
What are the common behavioral/physiological changes in mania? Decreased sleep Dehydration Poor nutrition/weight loss Increased energy Psychomotor agitation Impulsive Intrusive Aggressive Hyperactive Argumentative Poor hygiene Lack inhibition
What would you give a client with bipolar disorder to eat? Something portable like an apple or carrots
What makes hypomania different from mania? No marked impairment No hospitalization No psychotic features (delusions/hallucinations) Persistent elevated mood lasts at least 4 days (not 1 week)
A mother of an adult patient with bipolar 2 asks you to explain how her episodes of hypomania will go. You tell her... They start suddenly with rapid escalation over a day or 2, may last several weeks to months and are more abrupt and briefer than depression which may follow or precede hypomania 5-15% eventually develop Manic episode
T/F- It is uncommon for people to be diagnosed with bipolar 2 when they should have been diagnosed with biolar 1. False- About 5-15 % will eventually have a manic episode and thus meet Bipolar 1 criteria
What is a mixed episode? What are the criteria? What does it look like? 1) Meets criteria for both manic and major depressive episode (except duration) 2) cause impairment or need hospitalization to prevent harm or has psychotic features Rapid mood shifts, agitation, insomnia, change appetite, suicidal thoughts, psychosis
A mother of an adult patient with a mixed episode asks you how this happened, how long it will last and what to expect. You say... Can evolve from mania/MDE or occur on own May last weeks to months May stop with few/no symptoms or turn into MDE Uncommon to turn into manic episode
What is cyclothymic disorder? When does it begin? What is the risk of developing Bipolar after being diagnosed? How common is it? 2+ years of fluctuating mood between hypomania and depressive symptoms begins adolescence-> early adult 15-50% develop Bipolar affects 0.5% population
As the nurse, you are responsible for therapeutic management which involves the assessment of bipolar disorders. What are your 7 priorities in order? 1) Suicide 2) Risk to others 3) Mental status safety screen 4) History of current episode (mood/cog, behavior/physical changes, GAF) 5) Physical and health history 6) Focused history 7) Support/coping
When treating someone with a mood disorder, there are 3 phases. What are they and how long are they? What are your goals for treatment? Acute/Sub-acute (6-12 weeks) Continuation (4-9 months) Maintenance (1+ years) Stabilize, limit severity, limit duration, prevent relapse
Individuals with mania or depression have similar physiological needs. Explain nutrition needs, elimination, sleep and hygiene differences. Depression -may refuse to eat -constipation r/t lack of fluid, UTI -excessive sleeping -doesn't know dirty Manic -easily distracted, no time to care for self -constipation, UTI, anticholinergic SE -Encourage rest -too distracted for self care
Depressive disorders are usually treated with these meds while bipolar disorders are usually treated with these.. Depression -SSRI's, TCA's, MAOI's, Atypical antipsychotics, Anxiolytics for comorbidities Bipolar - LITHIUM CARBONATE -Antiepileptic/Anticonvulsants (Depakote is often first line treatment for bipolar) -Any adjunct therapies as needed
As the nurse the way you communicate with someone who is depressed versus someone who is manic differs greatly. Explain. Depressed -Make observations -Simple/concrete language -Allow them time -Listen -Avoid platitudes Manic -Be firm and calm - Short and concise language -Be consistent -Set limits -Use firm redirection
In a psychiatriac hospital, the milieu is considered to be very therapeutic. What needs are common to both depression and mania? How do they differ? Both - Safety- reduce harmful, sharp objects/hanging risks, safety contract, observation, restraint may be needed Depression -Increase stimuli, encourage exercise, limit sleeping Mania -Decrease stimuli, encourage rest, teach personal space
T/F= When considering restraint of a patient with mania or depression who poses a threat to himself or others, you should start with... Chemical restraint (medications) then move to seclusion restraint and only place in physical restraints last to allow for medications to take effect (1-4 hours usually)
Electroconvulsive therapy (ECT) involves inducing a generalized seizure to reset the brain. When would you use this? With what patient population? How effective is it? Are there any special considerations? 85% see improvement Extreme agitation/stupor Risks of other meds outweigh risk of ECT Hx of poor med response or + ECT response Major depressive disorder, Bipolar, Mania, Rapid cycling w/ bipolar (Short term memory impairment, insurance, sedation)
What are the adverse effects of ECT? Short duration of confusion and delirium 6 months of short term memory impairment Mild transient cardiac arrhythmias Death is possible but uncommon (risk 0.0002 per treatment)
The limbic system is known as the "emotional brain" because it has these functions... Appraisal (is this situation good/bad?), Response (based on perception), reversal of arousal (calm neurotransmitters, neutralize response) YIKES! (phew, I survived)
Anxiety results when neurotransmitter regulation occurs. Specifically, when _____ is released from post-synaptic sites or with high or low levels of ____ subtypes. Increased HR and oxygen use lead to increase in release of ______ which can also lead. GABA (calms until released) Serotonin subtypes can calm or excite Increased Norepinephrine can lead to anxiety
Which of the following is a criteria for evaluating the anxiety level in clients with an anxiety disorder? Ability to be assertive Attention span/concentration Ability to determine if behavior is appropriate Sleep patterns Attention span and concentration are specific to anxiety disorders
When assessing someone with anxiety, be sure to include these 5 things. Anxiety screening scales Attention span and concentration Physical and neuro exam Suicide assessment (20% attempt suicide) Psychosocial screening
With a patient who has an anxiety disorder and presents with heightened anxiety, what is your PRIORITY? Safety by reducing anxiety
A patient presents to the ED and is diagnosed with an anxiety disorder. What are some symptoms of this? Sweating, chest pain, muscle tension, heart palpitation and increased BP, nausea/diarrhea, dizziness, decreased sex drive, irritability
When treating a patient with anxiety, you should start with a _______ intervention before a ____ intervention. Behavioral first rather than cognitive so they feel a different physical response before they can look at their thoughts
There are many non-pharm interventions to treat anxiety. Name some. Behavioral therapies (systematic desensitization, flooding,aversion, thought stopping etc) Cognitive approaches (journaling, priority restructuring, cog. reframin, assertiveness training) Relaxation (mediation) Lifestyle (nutrition, hygiene, sleep)
List 5 drug classes (with advantages and disadvantages) for treating anxiety. Benzo (rapid, few heart effects, generic, SE, abuse) TCA and SSRI's (single dosing, antidepressant, delayed onset, cardiac effects, insomina) Busprione (few SE, no sedation, $$$$) Others can be used to treat symptoms but not disorder
Before diagnosing someone with any anxiety disorder, the nurse knows that the DSM-V states that these are common to ALL anxiety disorders. Anxiety, panic attacks or obsessions/compulsions NOT r/t medical condition NOT exclusive to delirium NOT better suited to another mental disorder SIGNIFICANT distress/impairment
What is panic disorder? Cause? Patient knows they have Disordered thinking patterns but they can't do anything about it (helpless) associated with malfunctioning NE system (increased) and decreased GABA with decreased frontal lobe involvement and increased Thalamus involvement
When do most people develop Panic disorder? Men/women? Comorbidities? 50% before age 24 2x women as men 30% abuse ETOH, 17% abuse illegal drugs 1/3 develop agoraphobia
You recieve SBAR from the night shift nurse and she tells you the patient is actively having a panic attack/ What are the common MSA findings you would expect? Appearance- pacing, can't sit still Mood- feels anxious Intelligence- decreased judgment Speech- pressured/mute Thought- I'm going to die, make it stop, i'm crazy, worried about next panic attack
While there are some common criteria to all anxiety disorders, the specific criteria for a diagnosis of panic disorder is... Recurrent, unexpected panic attacks 1+ attack has been followed by a month of concern for additional attacks or worry about implications of attacks (feeling crazy, losing control, having a heart attack)
A client has just been diagnosed with panic attacks. Which med should you plan teaching for (first choice medication)? Tricyclic antidepressant Benzodiazepine Antipsychotic Beta-blocker Tricyclic antidepressant- associated with regulating norepinephrine levels
When treating a patient wiht panic disorder, the nurse recognizes that her priorities are.. Safety Cognitive-behavioral therapy Decreasing anxiety through relaxation TCA's or SSRI's, possibly with Benzo combination
Specific phobias (another form of anxiety disorder) are higher in men/women, onset is usually ____-- and comorbidities include... Phobias can be caused by ____________.Common phobias? 2x likely in women, though more men seek help Onset usually in childhood/adolescence 25% comorbidity with depression and substance abuse Caused by psychosocial conditioned response or biological GABA deficiency Animals, environment, situation, injury
Social anxiety disorder (a social, not specific phobia) can include... Speaking in public, eating in front of others, using a public lavatory, writing in front of others, answering questions
A nurse knows that, aside from the general anxiety disorder criteria, a client diagnosed with a specific phobia must meet what criteria? Marked/persistent fear that is unreasonable and is cued by a specific object/situation Exposure to stimulus almost always provokes anxiety Stimuli is avoided or endured with intense anxiety
These non-pharm and pharmacological interventions are used to treat specific phobias... Basic anxiety reducing interventions + Systematic desensitization + Flooding PRN- Benzo's, beta-blockers (social) SSRI's
OCD has many categories. Name 4 broad categories. OCD Body dysmorphic disorder Hoarding disorder Trichotillomania and dermotillomania (hair and skin picking)
OCD affects ___% of the population, Men/women, and is comorbid with ____. It is also a major leading cause of ________. Etiology? 10-30% of the population, men and women equally, causes disability in est. market economies, and 67% comorbid depression
What causes OCD? What are the most common obsessions and compulsions? Psychosocial conditioned/distorted thoughts Biological- Low Serotonin, small caudate, limbic system involvement O- checking, order, counting, illness, violence C- touching, cleaning, avoidance, symmetry
T/F- As the nurse, it is your job to keep a patient with OCD from carrying out his compusive actions. False, this is used to alleviate anxiety and preventing him from doing it will increase anxiety and make compulsion stronger
A patient is diagnosed with OCD. Explain to him the difference between obsessions and compulsions? Obsessions- unwanted ideas, thoughts, impulses, or images that cause anxiety and distress Compulsions- unwanted repetitive behavior or mental acts to reduce anxiety but not for pleasure or gratification
Luvox (fluvoxamine) is only used to treat this... Obsessive-Compulsive disorder
How can you treat a patient with OCD? Behavioral therapy, cognitive restructuring Luvox, SSRI's, TCA's Cingulotomy (in extreme cases- 30% effective)
What is generalized anxiety disorder? How many seek treatment? Cause? Chronic, uncontrollable levels of anxiety for at least six months 1/3 seek treatment Caused by disordered thought patterns and likely includes serotonin system
What is the DSM-V criteria for a GAD diagnosis? Excessive anxiety for 6+ months about events Hard to control the worry 3+ Restlessness/Easily fatigued/Trouble concentrating/ Irritability/ Muscle tension/ Sleep disturbance
Teach a patient newly diagnosed with GAD about some Pharm and Non-Pharm interventions that are available to him. Cognitive-Behavioral therapy (works well), Cognitive reframing, Stress and lifestyle mgmt, support groups Buspar (only for anxiety, no euphoria) Valium TCA's? SSRI's?
Fetal monitoring can be important to ensure baby is doing well because labor can be very stressful and complications are possible. There are three types of fetal monitoring. List and describe. Intermittent auscultation- using fetoscope or doppler to periodically check on fetus heart rate External- Ultrasound transducer and Tocotransducer Internal- Spiral electrode (screwed into head) or intrauterine pressure cath (measures contractions exact)
When using a tocotransducer and ultrasound transducer for external fetal monitoring, placement is important. Which should be placed higher? Lower? Why? How do you know? Use Leopold's style to find the FHR Tocotransducer- up top b/c contractions picked up best at fundus Ultrasound transducer lower b/c baby HR is located lower
If you need to know the EXACT amplitude of a contraction, you need to use... What requirement must be met before using this? Intrauterine pressure catheter for exact, membranes must first be ruptured, same with spiral electrode to monitor HR
When looking at a FHR strip, the red vertical lines indicate ______, the upper pane displays _____ and the lower pane displays ________. To determine full picture of FHR, how long do you need to look? Lines- 1 minute intervals Upper- Fetal HR tracing Lower- Uterine activity Observe 10 minute strip to detect a pattern
When counting contractions on the FHR strip, you should consider the duration to be from ____ to ____- and frequency to be from _____ to _______. Duration- Beginning to end of 1 contraction Frequency- Beginning of one contraction to beginng of next
There are 5 key components being assessed by FHR monitoring. Name them and list WNL's. Baseline fetal HR- 110-160bpm Accelerations- good Decelerations- depends Variability- want moderate Contractions- see patterns
How do you determine baseline FHR? Look at 10 minute strip and draw line around where HR hovers, pick round number
You notice a fetal heart rate is tachycardic because the baseline is ______. Why might this be? What should your first nursing intervention be? baseline > 160 bpm Infection is #1 cause, take mom's temp immediately other causes are meds, dehydration, activity etc.
You notice a fetal heart rate is bradycardiac because the baseline is ______. Why might this be? What is your first intervention? Baseline <110 bpm Hypoxia, fetal distress, placental abruption (major cause) Supply oxygen
What are the 4 levels of variability in Fetal HR monitoring amplitude? What is each measured by? Which is best? Absent- amplitude range is undetectable Minimal- <5bpm variability Moderate- 6-25 bpm variability Marked- >25 bpm Moderate is best Count from peak to trough to determine, indicates neurological status (absent/minimal- bad, indicates neuro damage)
Changes in fetal heart rate can be described as periodic or episodic and can be accelerations or decelerations. What do those terms mean? Periodic- changes that only occur with contractions Episodic- changes that occur WITHOUT contractions Accelerations/decelerations- can be periodic or episodic increases in HR or decreases
You suspect a baby is having accelerations based on FHR monitoring. If the baby is older than 32 weeks, you would see _____. If the baby is younger than 32 weeks, you would seek ______. How often do you want them for reassuring strip? Older- 15bpm above baseline for 15 seconds Younger- 10 bpm above baseline for 10 seconds Lasts less than 2 minutes. More than 2 minutes is new baseline. Want to see accelerations within a 20 minute strip for reassuring strip
You notice a baby is having decelerations based on FHR monitoring. What are the 4 types of decelerations? How do you classify? Which are reassuring, which are not reassuring? Early- mirror contractions, last more than 30 sec, fine Late- slow >30, come after contraction, warning Variable- abrupt drop from onset to nadir (V/W) quick 15bpm drop 15+seconds, <30 Prolonged- >2minutes <10
What is the etiology of early decels? Are we concerned? What is the intervention? Head compression, not concerned, no interventions
What is the etiology of late decels? Are we concerned? What is the intervention? Uteroplacental insufficiency, baby isn't tolerating well and is slow to recover from contractions, Warning Re-position patient, IV bolus 500 mL, evaluate uterine activity, FHR baseline, variability, DC oxytocin, Notify MD/CNM
What is the etiology of variable decels? Are we concerned? What is the intervention? Cord compression, Warning Relieve cord compression by repositioning (knee/chest), check for cord prolapse, labor process, evaluate baseline FHR and variability Contact MD/CNM
What is the etiology of prolonged decels? Are we concerned? What is the intervention? May indicate maternal hypotension, cord prolapse, eclampsia, not enough O2, placental abruption
In terms of intrapartum fetal HR monitoring, what does VEAL-CHOP mean? Variable decels -- Cord compression Early decels -- Head compression Acceleration -- Ok Late decels -- Placental insufficiency
There are 3 categories of FHR strips. What are they and which is best indicator of healthy baby, which is worst? Note: Continuous FHR monitoring is NOT associated with better outcomes 1) is best 2) 3) expect medical intervention
What is the purpose of an APGAR score? What is the range? Only Indicates how well a newborn is transitioning to extra uterine life. Range 0-10 with 10 being the best and 0 being the worst
How frequently do you assess APGAR? 1 minute after birth, 5 minutes after birth, and every five minutes until stable
Whata re the signs and scores of APGAR? Activity- Absent, arms/legs extended, Active w/ flexed UE. Pulse- Absent, <100, >100, Grimace- No response, facial grimace, sneezes, coughs, pulls away. Appearance- Blue/gray, Pink body, blue extremeties, Pink. Respirations- Absent, shallow, good/crying
What does an APGAR of 0-3, 4-6, and 7-10 mean? 0-3-severe distress, 4-6- moderate difficult, 7-10- adjusting without difficulty
Assign an APGAR- 1 minute, Arms and legs extended, HR 90, sneezes, acrocyanosis, shallow irregular breaths. 6
What factors place a newborn at a higher risk for morbidity/mortality? Low birth weight, Small/Large for gestational age, intrauterine growth restriction, Pre-term or post-term
What is hyperbilirubinemia? What causes it? Is this an issue? Excessive bilirubin accumulates in the blood as RBC’s are destroyed but the bilirubin remains unconjugated b/c liver cannot hand it so it remains insoluble and cannot be eliminated in stool or urine and can cause neurotoxicity
How does the body dispose of bilirubin? When hemoglobin breaks down, the unconjugated bilirubin binds to albumin and is processed by the liver and is excreted in urine and stool. When it is not conjugated with albumin, it is not water soluble so it remains in body and crosses BBB
What is the expected level of bilirubin in adults? At what point can you see jaundice? What are signs and symptoms of hyperbilirubinemia? What do you do? Normal 0.2-1.4 mg/dL, >5 is Jaundice. CNS depression or excitement , intellectual disability, cerebral palsy, ADD. Intervene ASAP to prevent neurotoxicity and death
What is Kernicterus? Yellow staining of brain cells when serum concentration of bilirubin reaches a toxic level, a post-mortem diagnosis.
In a newborn, what are some manageable reasons for hyperbilirubinemia? Physiologic, breast feeding, genetic predisposition (native American/Asian, birth injury resulting in increased RBC breakdown such as cephalohematoma which temporarily increases bilirubin.
What are some very concerning reasons for hyperbilirubinemia in the newborn? Liver is unable to secrete conjugated bilirubin, disease process, hemolytic disease.
A newborn develops jaundice within the first 24 hours of life. As the nurse, you should suspect… Sepsis or hemolytic disease. This is really bad.
A newborn develops jaundice on day 2-3. As the nurse, you should suspect… usually physiologic anemia, adjusting is a little hard, usually mild and self limited.
What is breast milk jaundice? How long does it last? What is the difference between early and late breastfeeding jaundice? Early- within first 3 days, insufficient milk so hepatic clearance is reduced and baby has extra fluid while the breast milk comes in. Late- develops day 4-7, persists longer than physiologic jaundice with no other cause. Can persist for 13 weeks.
A mother is terrified that her baby is going to have brain damage b/c he had a head-birth trauma. Explain to her the difference between a caput succedaneum and a cephalohematoma. Caput- generalized edema of scalp, not brain damage, crosses sagittal suture, no blood. Cephalohematoma- bleed between skull and periosteum
When will you know if a baby has hyperbilirubinemia secondary to hemolytic disease? What causes this? Usually w/in first 24 hours, abnormal rate of RBC destruction due to Rh incompatibility or ABO incompatibility (mom O, baby is A or B)
How do you evaluate hyperbilirubinemia in a newborn? Serum blood level, when it appeared, estimated gestational age, how old? Family history, feeding method, hemolysis. Serum bilirubin progression.
A full term breast fed infant Is 14 hours old and has been feeding well. The serum bilirubin comes back at 16 mg/dl. You suspect… Potential for hemolytic disease b/c early appearance combined with high bilirubin.
Teach a new nurse the indicators of non-physiologic hyperbilirubinemia Jaundice in first 24 hours. Persistent jaundice, even with bottle feeds. TSB >12.9 in term bottle fed, >15 in preterm and full term breast fed. Bilirubin increase 5 mg/dl/day and conjugated bilirubin is >2.0 mg/dl
A mother is freaking out because her baby is jaundice. She wants to know how you’re going to treat it. Explain Phototherapy is the main treatment. Light helps excrete bilirubin by conjugating it. Can use an overhead light or a bili blanket.
You are the neonatal nurse for a newborn who is receiving phototherapy for jaundice. What do you need to be aware of? Frequently assess jaundice, expose skin, turn baby, shield eyes (remove q4 and with feeds), may need to stop breastfeeding for a while, make sure its eating enough, d/c teaching about bili blankets, encourage mom to pump
You are worried about baby’s skin under those phototherapy lights. It looks dry. The mom asks if you can put lotion on, you say… No, the lotion will cause him to burn. We can increase his fluid because he may be volume deficit
What is meconium aspiration? What causes it? When fetus is in distress, can cause passage of meconium before birth into amniotic fluid. IF aspirated during deliver, can lead to respiratory distress and failure b/c of airway obstruction, chemical pneumonitis, and surfactant dysfunction
As the nurse of an infant with meconium aspiration, how do you manage it? Ventilation, exogenous surfactant, IV fluids, systemic antibiotics, thermoregulation
What is sepsis? How are neonates affected by it? bacterial infection bloodstream, highly susceptible die/meningitis &permanent neruodeficits.Prenatal- acquired across the placenta if prolonged ruptured membranes. Perinatal- within 6 days of birth from maternal bacteria, E Coli, GBS. Postnatal- 7 +
The mother of a 20 day old neonate calls and tells you her baby is running a fever of 100.5. You tell her Bring that baby in for complete evaluation (spinal, blood cultures, in and out cath), admission, cultures, and antibiotics (broad spectrum Ampicillin, gentimiacyn, acyclovir)
As the newborn nurse, you know that a neonate with sepsis looks like Can be vague but usually fever (>100.4) or hypothermia , activity level change, feeding change, Apnea, color change, NVD, urine output change. Lethargic, poor perfusion, hypo/hyperventilation, cyanosis (impending doom)
T/F- An ill appearing infant should be considered septic until proven otherwise. You should give this baby early antibiotics and will treat for 10-21 days with IV antibiotics in the hospital if positive culture True
What is SIDS? Cause? Correlations? Sudden death in an infant under 1 year old, unknown cause. Peak age 2-4 months with 95% by 6 months. Higher incidenceof preterm, low birth weight, multiple births, and low APGAR. Mom is young, smokes, had poor prenatal care or substance abuse.
What sleeping environment increases risk for SIDS? Prone sleeping, pillows/soft bedding, non infant sleep surfaces, co-sleeping, tobacco smoke
Describe feeding habits and pacifier use and their affect on SIDS. Lower incidence of SIDS in breast-fed infants. Pacifier use in sleep may protect against SIDS
What is a prolapsed umbilical cord? How common is it? Mortality rate? Risk factors? Protrusion of the umbilical cord pas the presenting part though the cervical os. 36-345 deaths per 1000. Fetal malpresentation, PROM, Premature, LBW, long umbilical cord, multiple gestation, Cephalo-pelvic disproportion, low lying placenta, multiparity
What OB interventions place a woman at risk for cord prolapse? Manipulating or elevating the presenting part, amnioinfusion, external version, forceps/vacuum placement
What are the signs/symptoms of umbilical cord prolapse? Cord presentation, persistent, variable decels/bradycardia on the EFM. Feel cord on cervical exam
As the nurse, what do you do if there is an umbilical cord prolapse? Call for help! Notify PCP. Elevate fetal presenting part. Keep cord moist, Knee chest position, give O2, increase IV or start, prepare for delivery, educate mom and calm her
T/F- If there is a cord prolapse, an appropriate nursing intervention would be to just push the cord back in. False, may sever the cord or cut off O2 to baby which results in C-section
What is shoulder dystocia? How common? Risk factors? Impaction of fetal shoulders w/ maternal pelvis, head comes out anterior shoulder gets stuck. 3% pregnancies, turtle sign risk with fetal macrosomia, prior shoulder dystocia, previous mid-pelvic operative birth with estimated fetal weight of 4000 grams.
If a woman and baby suffered from shoulder dystocia during birth, you as the nurse should be prepared to educate mom about these complications Post-partum hemorrhage, 3rd/4th degree episiotomy. Brachial plexus/phrenic nerve injury , clavical/humerus fracture, cerebral hypoxia, death.
The acronym HELPERR is used to intervene with shoulder dystocia. What does that mean? Help-nursing, Evaluate for episiotomy-medical, Legs- McRoberts maneuver- nursing, Suprapubic Pressure- nursing, Enter manuvers- medical, Remove posterior arm- medical Roll patient to all fours- Nursing
T/F- Combining McRobert and suprapubic pressure may relieve more than 50% of shoulder dystocia cases True
What is the McRoberts Maneuver? Why do we use it? Thighs to chest to straighten sacrum and decrease angle of incline of symphysis pubis. Gives more room for baby to get out with shoulder dystocia
What is suprapubic pressure? Why use it? Apply suprapubic pressure with hand over anterior fetal shoulder with down and lateral motion to push the shoulder forward to try to get it out of the pelvis.
What is the Gaskin maneuver? Why do you use it? Position mom on all fours to help alleviate shoulder dystocia
When you have a shoulder dystocia baby, how long should you do the various manuvers for? Each position for 30 seconds then move on to the next one try and get baby out.
T/F- Shoulder dystocia babies often have a low 1 minute apgar. True
What is an amniotic fluid embolism? Cause? How common? Consequences? 1/40,000 pregnancies, an immune response resulting in sudden maternal hypoxia, cardiovascular collapse and coagulopathy. Maybe caused by intrauterine infection? Only 15% of mothers survive neurologically intact with 20-60% maternal mortality
What are the symptoms of amniotic fluid embolism that you should watch for in laboring mothers? Hypotension, fetal distress, pulmonary edema or ARD, cardiopulmonary arrest, cyanosis, coagulopathy (no clotting)
How do you treat anaphylactoid syndrome of pregnancy (amniotic fluid embolism)? Call rapid response, high O2, CPR, intubate, ventilate, IV, give blood product, monitor fetus for signs of crashing. Perform perimortem c-section ASAP after cardiac arrest (within 4 minutes)
What is the single most significant cause of maternal mortality world-wide with 1 death every 4 minutes? Many of these maternal deaths are preventable. It can occur antepartum, intrapartum, and postpartum. Obstetric hemorrhage
During pregnancy, there are many cardiac adaptations. Blood volume increased to ____L/minute and plasma volume by ___%. Clotting (increase/decrease). Fibrinolysis (increase/decrease)? Blood- 6-7 L/min and plasma 45%. Clotting increase (up to 400,000) and fibrinolysis decrease
What are the 4 classifications of pregnancy hemorrhage? What are the clinical manifestations of these? 1- 1000mL blood loss (none, dizziness, palpitations, minimal BP change. 2-1500mL, orthostatic hypo, tachycardia, tachypnea, weak, >3sec cap 3-2000mL, hypotension, tachy, cold, clammy, pale. 4- >2500 cardiogenic shock, bp absent, air hunger
How do you estimate blood loss for pph? Difficult w/amniotic fluid. Often underestimate by 30-50%. Visual inspection and VS- hypotension, dizziness, pallor, oliguria. Hct levels, weigh items convert gm to mL. Peri pad- 100cc, chucks 400cc
T/F, with PPH, O2 is released more freely into tissues, CO increases due to vasoconstriction, increased HR and mobilization of fluid from interstitial to intravascular space. True
T/F- With hemorrhage, the body increases stroke volume, blood is shunted from non essential body parts. Hyperventilation to compensate for metabolic acidosis and hypotension occur. True
As the nurse, you know that PPH can be very dangerous. What are the goals for treatment? Maintain S BP>90, adequate urinary output, normal mental status, treat hemorrhage
As the nurse, you notice that a woman is having substantial blood loss postpartum. You should… Call rapid response, place foley (expect UOP >30 ml/hr, check q1hour) Get large bore IV access, figure out cumulative blood loss totals. Notify blood bank for mass transfusion, check blood products w/ 2 liscened personnel
What can you do for a woman who is hemorrhaging after birth? Elevate LE to optimize CO, monitor VS frequently, monitor fetal status/prepare for delivery, monitor pain and notify anesthesia
What is abruption placentae? How common? Dangers? Premature separation of normally implanted placenta, can be revealed or concealed. Common in 1/100 pregnancies. Significant for perinatal morbidity and mortality depending on severity of abruption, blood loss, and gestational age
What causes placental abruption? Unknown, linked to previous placental abruption, cocaine, smoking, multiple pregnancy, Preeclampsia, trauma, PPROM, maternal thrombophiias, uterine malformation
There are 3 grades of placental abruption. What are the maternal and fetal effects of each? 1) Slight bleeding, uterine irritabilityl 2) Mild/moderate bleed tetanic/frequent contractions, ^HR, BP stable, EFM compromise. 3) Moderate/severe bleed uterus firm/painful, hypotension, low fibrinogen and thrombocytopenia, horrible fetal tracing/death
How do you diagnose placental abruption? Based on suspicion of presentation and symptoms, confirmed with placental inspection. (sever abdominal pain, hard abdomen, dark red blood loss doesn’t always correlate to visible blood)
What is placenta preva? Common? Causes? Placenta implants low in uterus over cervical os, 1/200 pregnancies. May be caused by endometrial scarring, HTN/smoking, increased placental mass. Over 35yo, multiparity, prior c-section, prior placenta previa, smoking, previous uterine surgery
What are the 4 types of placenta previa from most to least severe? Which require c-section? Total- covers internal os, Partial-implants near/partially covers os, Martinal-implants near but doesn’t cover os, Low-lying- near region of internal os. Total/Partial get C-section
As a nurse, you need to recognize the signs and symptoms of placenta previa. Go. Painless bright red blood b/c directly from placenta. Dx with transvaginal sonography
As the nurse, you know a patient with placenta previa has special needs. What are those? No cervical exams, monitor blood loss, assess maternal hemodynamic status, assess fetal well being, plan for c-section
What is placenta accreta? Increta? Percreta? common complications of placenta previa. Accreta is where chorionic villi adhere to myometrium, Increta is chorionic villi invade into myometrium, Percreta the chorionic villi grow through myometrium to other organs. Placenta stays attached after birth.
What is uterine rupture? Common? Causes? Layers of the uterus separate, 1% of pregnancies. Associated with uterine scars, multiparity, uterine distention
What are the signs of uterine rupture? Abnormal FHR tracing, Contractions change, abdominal pain even with epidural, loss of fetal station, can feel fetal body parts, vaginal bleeding, anxiety, shock, could be asymptomatic though.
What is expected blood loss after vaginal delivery? C-section? Vaginal >500 mL Cesarean>1000mL
80% of postpartum hemorrhage is caused by this. Some other causes are… Major- Uterine atony (massage the fundus!). Others- grand multiparity, overdistended uterus, prolonged labor, previous hx, full bladder
What are some likely causes of early and lage PPH? Early- trauma, uterine rupture, coag. Disorder. Late-Infection, retained placental fragments, coag. Disorder.
How quickly can a patient exanguinate from PPH? (note, blood flow to placental is 1000 mL/minute) Within 8-10 minutes
You are caring for a woman 1 hour post partum from vaginal delivery to a 10 lb baby. She calls out and says her peripad needs to be changed. You notice she is having significant bleeding. What is your first action? Call for help as you massage the fundus, give O2, take vitals q5-15, get blood type, call rapid response, administer utero tonics, place foley and 2nd large bore IV, educate mom.
What is preterm labor? How is it defined? Labor 20 -36 and 6/7 weeks gestation. Uterine contractions >cervical dilation of 2+ cm /effacement of 80% w/progressive cervical dilation &persistent regular, painful contractions 4 q20 min or those that occur q10 minutes or less for at least 30 minutes.
What is late, moderate, very and extreme preterm birth? Late- 34-36 weeks, Moderate- 32-34 weeks, Very-prior to 25-32 weeks, Extreme- Less than 25 weeks
What is low, moderately low, very low, and extremely low birth weight? Low- <2,500 grams, Moderate- 1,500-2,499 grams, Very-<1500 grams, Extremely low-<1000 grams
What is the difference between preterm birth and low birth weight? PTB- refers to length of gestation w/o consideration f birth weight. LBW- describes weight at time of birth regardless of gestational age.
What is the leading cause of neonatal death? It is also a major cause of early childhood M&M including pediatric neurodevelopmental problems. Preterm birth
T/f- There is no approved drug to prevent or treat preterm birth in the US. The drugs used off-label to treat PTL have not been shown to improve perinatal outcomes True
Preterm labor is a problem because there are many neonatal consequences of prematurity. List some. Underdeveloped lungs, Intraventricular hemorrhage , Necrotizing Entercolitis (bowel ischemia) & Gastroesophageal reflux ( aspiration). Patent ductus arteriosus, retinopathy, hyperbilirubinemia, hypothermia, hypoglycemia, feeding problems.
Preterm birth is medically indicated in about 25% of preterm births. What are some conditions where preterm labor is indicated? Preeclampsia, diabetes, placenta previa and abruption, Intrauterine growth restriction, fetal compromise, intrauterine fetal demise
T/F- Most preterm births occur in women who are less than 18 or older than 35, non-Hispanic black women, who have lack of education and lack of prenatal care with low SES. True
How does stress contribute to preterm birth? Release of cytokines leads to release of prostaglandins which stimulates uterine contractions
What are some medical risk factors for preterm birth? Infection/Inflammation, autoimmune disorders, thromboembolic disorders, renal disease, cardiovascular disease, anemia
T/F- ½ of all women experiencing PTL will not have any known risk factors while 2/3 of women who do have risk factors will not deliver early. True
What is required to diagnose a woman with Preterm Labor? Persistent uterine contractions and documented cervical change (cervical effacement>80 % or cervical dilation >2cm
What is fetal fibronectin? Where is it found? What is it a predictor of? glycoprotein produced by chorion found at junction of fetal membrane and uterus to keep baby in place. A negative result indicates that you probably will NOT have PTL. Is present in first and 3rd trimester but absent in second trimester, 25% accurate
How do we treat preterm labor? No standardized plan, educate patient on S&S and when to call, adequate hydration, modified bed rest, tocolytics/corticosteroids if indicated (Mag Sulfate, Indomethacin, Nifedipine)
Progesterone is a new therapy being given for preterm labor. When is it administered? Who is a candidate? More effective in Hx of PTbirth, administered weekly from 10-20 weeks until 36 weeks or vaginal progesterone suppository daily until 36 weeks. Unclear mechanism
T/F- Avoiding sexual activity may be recommended to prevent preterm birth. True, nipple stimulation stimulates uterine contractions and prostaglandins found in semen may stimulate contractions
What is cervical cerclage? When do you use it? What is it for? Stitching cervix together, used for cervical insufficiency, prophylactic cerclage, or rescue cerclage when cervical changes are detected
T/F- The viability threshold of a preterm baby depends on the gestational age with babies under 25 weeks having less than 50% chance and babies over 25 weeks having a higher chance as well as the capabilities of the NICU. True
What is premature rupture of membranes? (PROM)? Fetal membranes release amniotic fluid more than 1 hour before onset of labor (50% go into labor within 24 hours of PROM)
What is Preterm Premature rupture of membranes (PPROM)? Premature rupture of membranes before 37 weeks gestation
What is prolonged preterm premature rupture of membranes (PPProm)? Preterm premature ruputure of membranes lasting longer than 18-24 hours before delivery
What are the risks of Preterm Premature rupture of membranes (PPROM)? Prematurity, infection, cord accident, pulmonary hypoplasia (lungs are underdeveloped before 24 EGA b/c no stretching from amniotic fluid), Infection, abruption, Death
How do you diagnose Preterm Premature Rupture ofMembranes (PPROM)? Clinical suspicion (patient felt “gush” or constant trickle) Patient history, and Clinical testing (Fern-Dip Q-tip in pool, view with microscope, fern pattern Pool-Speculum, cough, fluid, Nitrazine-Paper turns blue combined are 93% accurate)
How is Preterm Premature Rupture of Membranes treated? Antibiotics, Labor inhibition to give corticosteroids in absence of infection, abruption, fetal distress etc. etc., Non stress test to check how baby is doing daily or 2x per week b/c baby can become septic quickly
A woman with Preterm Premature Rupture of Membranes is 22 weeks pregnant. What do you do? Educate her on the maternal and neonatal risks (perinatal mortality rate is high), observe for 24-48 hours, consider home management until fetus is viable is at all possible
A woman with Preterm Premature rupture of membranes is 28 weeks pregnant. What do you do? Conservative management if no infection, advanced labor, or placental abruption. Administer antibiotics and corticosteroids. Place on modified bed rest and perform fetal surveillance.
A woman is 32 weeks pregnant with Preterm Premature rupture of membranes. What do you do? Collect amniotic fluid to check lung maturity and infection. IF lungs are mature, consider delivery. If immature but no infection, consider delivery after corticosteroid therapy. If infection, give antibiotics and delivery
A woman is 34-36 weeks pregnant with Preterm Premature Rupture of Membranes. What do you do? Immediate labor induction and delivery due to increased risk of chorioamnionitis, neonatal infection
How is labor initiated after a pregnancy of uterine quiescence? Prostaglandins from the fetus, amniotic fluid, and decidua cause smooth muscle contraction and vasoconstriction, soften cervix and moderate hormones. Myometrium becomes receptive to oxytocin
A woman thinks she is going into labor. As an RN, you know that signs of labor include... Low back ache, Bloody show (mucous plug dislodged), Braxton Hicks contractions, Lightening (baby settles into pelvis), Diarrhea, weight loss, Nesting, rupture of membranes
What is the difference between prodromal and progressive labor? Prodromal- false, irregular contractions w/o cervical dilation, no bloody show, symptoms decrease with position change Progressive- true, contractions are regular, frequent, and duration/intensity increase, continue constantly, pelvic pressure
What are the stages and phases of labor? Stage 1- Phase 1 (Latent 0-3 cm) (Active 4-7 cm) (Transition 8-10 cm) Stage 2- Full cervical dilation _> delivery Stage 3- Delivery->Placental delivery (up to 30 minutes) Stage 4- 1 hour PP recovery
What are the 4 p's of labor? Passenger- Fetal head size, attitude, lie, presentation, position Powers- Contraction frequency, duration, intensity, mom pushing Passageway- Pelvic size and shape, cervix Psyche- mother's preparation, support, experiences
In terms of the labor passenger, what is molding? Fetal head shape and size adapts to pass through the maternal pelvis during labor and returns to normal within 24 hours
In terms of the labor passenger, what is presentation? What are the possible presentations? Which is best? The part of the body that enters into the maternal pelvis first Cephalic/Vertex- top of head first Breech- Frank (butt first), Complete (buddah) Footling (foot first) Other (shoulder, chin etc)
In terms of the labor passenger, what is fetal lie? What are the 3 classifications? Which is best? Relation of fetal spine to mother spine Longitudinal/Vertical- spines parallel (yay!) Oblique - slight angle between spines Transverse- fetus horizontal to mom (no vaginal delivery possible)
T/F- If a laboring mother finds out her baby is in transverse fetal lie, she can still have a vaginal delivery/ False
In terms of the labor passenger, what is fetal attitude? What is typical? Relationship to fetal parts to each other expressed as flexion or extension NORMALLY- fetal position is flexed (occiput presents 1st=smallest head measure) Head can be extended or hyperextended so brow/chin present first making for larger measurement
In terms of the labor passenger, what is fetal position? How is it expressed Relationship between presenting part (ie occiput) and the 4 quadrants of mom's abdomen 3 letters Location (R/L side of pelvis) Presenting part (Occiput, Sacrum, Mentum, Scapula) Location of presenting part/pelvis (Anterior, Posterior, Transverse)
What is the difference between engagement and station in fetal position? Explain the -5>+5 stations. Engagement- widest transverse diameter of presenting part passes through pelvic inlet Station- level of presenting part in relation to ischial spines with (-) being above and (+) below (ie +5 is ready to crowning)
What is important to consider in terms of the passageway for labor? Pelvic inlet, canal, suprapubic inlet, pelvic outlet, soft tissues, cervix/vagina/perineum, hormones to soften and increase elasticity and ripening through Braxton-Hicks
When do you consider a pelvis adequate? Fetal head is at station 0 so the widest part of head has passed through the inlet
What is the primary powers of labor? Uterine contractions which cause effacement and dilation of cervix, facilitate descent/rotation of fetus, lead to separation/expulsion of placenta, and compress blood vessels to prevent PPH
What is the ideal frequency, duration, intensity, resting tone for uterine contractions 1.5-3 minutes apart length of contraction 30-90 seconds (60sec goal) Intensity- want to be strong, increase as progress Resting tone is desirable to allow for uninterrupted placental blood flow
What is effacement? Dilation? In primagravida women, which happens first? Effacement- Shortening/thinning of cervix, expressed in % (not effaced is 0% at 1 inch) Dilation- Opening and enlargement of external cervical ox (1 finger=2 cm) Primagravida- effacement first, multigravida- together
Maternal Pushing is a needed power, in conjunction with contractions, to deliver a baby. When does this start? Glottis? Coaching/Physiologic? Start in second stage of labor, want open glottis to prevent impaired blood return, encourage physiologic and spontaneous pushing but some coaching may be needed
What is meant by including Psyche in the 4 P's of labor? How prepared is mom for this labor/birth? What does this pregnancy mean to her? Are there spiritual/cultural implications around the birth? Anxiety? Dread? Concerns? Fatigue? Fear? Support people? Other experiences with birth?
What are expected maternal physiologic responses to labor? Increased HR and BP, Increased RR, mild pH changes at different stages, decreased gastric motility and increased stomach emptying, Polyuria w/ proteinuria, Increased WBC and decreased blood glucose, increased clotting
T/F- Nursing interventions in the first stage of labor focus on relaxation, rest, easily digested food. True, not much you can do yet b/c no pushing yet
What is leopolds maneuvers? Nursing intervention to determine fetal position, estimate fetal weight and determine where to place fetal monitoring
T/F- You can palpate the intensity of contractions to mild (cheek) moderate (chin) and strong (forehead) True, how the abdomen feels determines intensity
T/F- Regardless of monitoring needs, all moms get at least a 10 minute EFM tracing. False, they get a 20 minute EFM tracing to check heart rate and contractions to see if its a reassuring strip
T/F- Perform cervical exams on a woman every 30 minutes. False- examine as needed because risk for infection increases after rupture of membranes
After amniotic membrane rupture, what does the nurse do first? Check fetal heart rate to see if they are tolerating it well, check for cord prolapse, and monitor for infection (fever on mom, tachycardia in fetus)
What is the major occurrence during the 2nd stage of labor? How long does it last? When do you become concerned? Urge to push! Baby descends with contractions, let mom pick her position to labor, Duration can range from minutes to hours (after 3 hours of active pushing, we are concerned for exhaustion)
What is laboring down? With mom's who have epidural, allowing contractions to do some extra work before encouraging her to push so baby is lower down in birthing canal
What position should women labor in? Whatever position they are most comfortable in.
What is crowning? What does it have to do with an episiotomy? Portion of presenting part is visible at opening of vagina, involves intense rectal pressure, sensation of stretching, tearing, or burning Create incision to enlarge vaginal outlet
What is a nuchal cord? Meconium at delivery? Birth complication with umbilical cord wrapped around neck Meconium means you check for aspiration b/c first BM occurred before birth
How common is the use of forceps or vacuum extraction? Complications? Why? Does it require anything special? 10-15% of births, Help deliver the head, can cause cephalohematoma which can lead to jaundice, woman may tear more Consent, empty bladder, pain management, prep and consent for C/Section, assess newborn/perineal immediately
What is the goal of the 3rd stage of labor? How long does it last? What is in your nursing assessment? Prompt separation and complete expulsion of the placenta, lasts from a few minutes up to 30 minutes When the placenta is ready to deliver, trickle of blood from vagina, another contraction, umbilical cord lengthens. Assess placenta, ensure intact
During the 3rd stage of labor, there are some potential complication like what? How can you prevent/treat those? Placenta retention, need to get those out to avoid infection and hemorrhage Encourage bonding, monitor for blood loss and VS/consciousness, maternal physical status
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