Developmental Self Care Requirement: Childbearing Patient-Antepartum
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| Presumptive Signs of Pregnancy | Altered mensus, N/V, Urinary frequency, Breast tenderness, Quickening (Fetal movement), Excessive fatigue.
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| Physiological Changes of Pregnancy-Cardiovascular System | BV Increased by 30-50%, 1500ml, pulse up 10-15 bpm, Femoral vessel pressure, Supine Hypotensive Syndrome, 1/6 blood vl in vascular system of uterus, Normal physiologic Anemia.
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| Supine Hypotensive Syndrome | Vena cava pressure, Decreased blood flor to R atrium, S/S=low bp, dizziness, pallor & clamminess. Turn onto left side. NEVER LAY A PREGNANT WOMAN FLAT ON HER BACK.
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| Urinary Tract Changes | Enlarging uterus presses against bladder=urinary frequency, 1st and 3rd trimester, Increase for UTIs-progressing to pylonephritis.
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| Urinary Tract Changes Continued-Edema | Increased fluid volume and decreased venous return (from venous return)
Normal for legs and feet never for face (sign of danger).
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| Musculoskeletal Changes | Pelvic joints relax="waddling gait", Lumbar spinal curve "accentuates"
Leg cramps, Diastasis Recti-seperation of rectus abdominus muscle
Carpal Tunnel Syndrome- edema from increased steroidal sex hormones.
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| Water Metabolism | Increased water retension-needed for placenta, amniotic fluid, blood volume, fetus.
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| Weight Gain | Recommended: Ideal BMI 25-35 lbs, Overweight-15-25 lbs
Underweight-25-40+ the pounds needed to be at BMI.
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| Expected Weight Distribution | Baby - 7.5lbs, Breast - 2lbs, Maternal Stores - 7lbs, Placenta - 1.5lbs, Amniotic fluid - 2lbs, Uterus - 2lbs, Blood Increase - 4lbs, Body Fluid-4lbs.
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| Physiological Adaptations to Pregnancy-1st Trimester | 1st Trimester Tasks-seeking safe passage fpr self and infant, accepting the pregnancy (ambivalence, denial), confirmation of pregnancy makes it real.
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| Physiological Adaptations to Pregnancy- 2nd Trimester | 2nd Trimester Tasks: Ensuring acceptacne of fetus by others, seek comitment and acceptance of self as mother, quickening promotes bonding, seeking commitment.
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| Physiological Adaptations to Pregnancy- 3rd Trimester | 3rd Trimetster Tasks: learning to give of herself, anxiety about labor, birth, nesting.
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| Antepartum | Conception to onset of labor
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| Intrapartum | Labor to delivery of placenta
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| Postpartum | Delivery of placenta until maternal return to non-pregnant state (6 weeks)
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| Gestation | # of weeks pregnancy (42 max)
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| Gravida | Total # of pregnancies
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| Para | Total number of pregnancies carried past 20 weeks
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| Primigravida | 1st pregnancy
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| Multigravida | 2nd or greater pregnancy
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| Nullipara | no births >20 weeks
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| Multipara | 2 or more births >20 weeks
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| Fetal Demise | Fetus has died inside uterus >20 weeks
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| Fundus | Top of Uterus
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| GTPAL | G-# of pregnancies
T-# of term infants ≥37 weeks
P-# preterm infants born ≥20 weeks ≤37 weeks
A-# of pregnancies ending in abortion (spontaneous or therapeutic)
L-number of currently living children
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| Initial Antepartal Assessment | Confirm Pregnancy, High Risk Screening, Patient Education, EDD, EDC, EDB, Physical Exam, Antepartal Visits.
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| Physical Exam | Pelvic Adequacy, Fundal Height, Fetal wellbeing.
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| Antepartal Visits | Q4Wks <28 weeks, Q2Wks <36 weeks, Q Week 36 weeks-birth
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| High Risk Screening | Education level, economic level, culture/diversity, weight, social and personal, age, smoking, drug/alcohol use, poor diet, preexisting medical dx, OBGyn history, partner history.
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| Physical Risks of a 15 year old | CPD, PIH, Fe Deficiency, Anemia, LBW and premature, risk of exposure to taratogens (ETOH, drugs, cigarettes, STDs), prenatal care < risks
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| Nursing DX | 1. Risk for disturbed maternal/fetal dyad
2. Readiness for enhanced parenting
3. Readiness for enhanced knowledge
4. Rediness for enhanced childbearing process
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| Outcomes | 1. Engage in necessary alterations in lifestyle and ADLs
2. Identify s/s requiring medical intervention or evaluation
3. Verbilize realistic expectations and informations of parenting
4. Verbalize understanding of information gaines
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| Outcomes continued... | 5. Demonstrate healthy pregnancy free of complications
6. Engage in activities to prepare for birth process
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| Common Discomforts in 1st Trimester | -N/V, fatigue, breast tenderness, urinary frequency, increased vaginal discharge, nasal stuffiness & epitaxis (nose bleeds), ptya;osm (bitter tasting saliva)
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| Common Discomforts in 2nd and 3rd Trimesters | -Heartburn, ankle edema, varicose veins, hemorrhoids, constipation, backache, leg cramps, SOB, round ligament pain.
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| Fetal Activity Monitoring | Starts at 28 weeks- Cardiff Count -to-ten method - count fetal movements, 2-3 times a day, consistency (same time Qday 1 hour after meals), 20-30 minutes at a time, lie on left side.
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| Nutrition in Pregnancy | Protein-60g, Fat-30-40% of diet, CHO Complex-Carbs, Minerals (Ca-1000-1300mg, Fe-30mg, Vitamin D if < milk intake, Folic Acid-400mcg), B12-Vegetarians
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| Modified Food Guide for Vegetarians | Milk, yogurt, cheese-5 servings/day
Eggs- 1
Legumes-3
Nuts-1
Fruites/veges- 9
Breads, rice, grains - 8
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| Danger signs of pregnancy | Sudden gush of fluid
Vaginal bleeding
abdominal pain
absence or decreased fetal movement
fever
dizziness
persistent vomiting
severe headache
visual disturbances
edema of hands and face
muscular irritability, seizures, epigastric pain, oliguria
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| Teratogens to Avoid during Pregnancy | Medications-OTC and prescription (first trimester is highest risk), Tobacco-any decrease in amount is good for the fetus, Alcohol-no amount is safe, heavy drinking is associated with fetal alcohol syndrome, Caffine moderation, <200mg/day, Illegal drugs.
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| Purpose of Assessment of Fetal Well-being | Provide information such as: Normal growth, Placenta location, Presence of congenital anomolies, Fetal lung maturity.
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| Maternal Risks associated with Gestational Diabetes | Polyhydramnios-due to excessive fetal urination as a result of hyperglycemia. Preeclampsia or Eclampsia- due to vascular changes.
Ketoacidosis
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| Provide information such as:
Normal growth
Placenta location
Precense of congenital anomolies
Fetal lung maturity
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| Signs of Pregnancy- Positive Diagnostic Signs | Fetal Heart Beat, Palpated Fetal Movement, Visualization of the fetus via transvaginal ultrasound (4-5 weeks), Transvaginal ultrasound of gestation sac (10 days after implementation).
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| Signs of Pregnancy-Probably Objective Signs | Pigmentation of Skin, Abdominal Striae, Braxton Hicks Contractions
Uterine Souffle, Ballottement (Examiner pushes against cervix and fetus floats up then bounces back against cervix).
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| Maternal Physiological Changes of Pregnancy | Uterus Enlarges: Pear-watermelon; 5mL--5000mL capacity; Cervix- mucus plug;Godell's Sign; Chadwick's Sign; Ovaries- stop producing ova; hormone secretion changes; Vagina- secretions thicken & increase in acidity; Breasts enlarge; areola darkens; colostrum
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| Compression of Bladder | Urinary frequency caused by head compression, During 1st and 3rd trimesters.
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| Fetal Obesity Pregnancy Risks | 3x risk stillbirth;preterm birth;IUGR, LBW, LGA;shoulder dystacia;increase NICU admit;congenital heart anomalies;cardiac defects ^ 6.5%; neural tube ^ 20% for each 20lbs;multiple anomolies.
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| Maternal Obesity Pregnancy Risks | C/S, unsuccessful VBac, preeclampsia; gestational diabetes; thromboembolism; dysfunctional labor; wound complications; UTIs; hemorrhage; failed epidural placement
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| Paternal Tasks of Pregnancy | 1st Trimester-may feel left out
2nd-feels fetal movement, decides which behaviors from his own father he wants to imitate/discard, acceptance of changing roles and responsibilities
3rd-anxiety about labor & birth, developing relationship w/infant
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| Adolescent Pregnancy | 1 in 10 women, US among highest rates in world, many results in lower educational attainment and lifelong poverty.
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| Adolescent Pregnancy-Psychological tasks of adolescence conflict with tasks of pregnancy | Physcial Risk <15 years: CPD, PIH, Fe Deficiency Anemia, LBW & Premature, exposure to teratogens (ETHOL, drugs), prenatal care < risks
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| Pregnancy in Older Women | Later marriage, success with fertility treatments, even with control for other medial conditions 2x incidence of fetal death, ^ C/S, ^ incidence of chronic illnesses- HTN, DM
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| Antepartal Assessments | VS, weight, edema, uterine size/fundal height, fetal heart rate, fetal movement, U/A, labwork
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| Antepartal Assessment-Fetal Well Being | FFHR (8-12 wks), fetal movement, ultrasound (sac 5-6wks, FHR 6-7wks, fetal breathing 10-11wks, crown to rump <12wks, BPD (fetal head diameter, helps determine fetal growth)).
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| Antepartal Assessment-Estimated Pelvic Adequacy | Pelvic Inlet:diagonal conjugate-dist. from the lower posterior boarder of the symphysis pubis to the sacral promontory; 12.5cm; done vaginally.
Pelvic Outlet: Anteroposterior Diameter-dist. from lower border of the symphysis pubis to tip of sacrum; 9.5cm
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| Common Lab Tests | U/S-for dates, diagnostic of anomolies
Alpha-fetal protein (AFP)-if ^ may be nerual tube defect, if down may be downs
Fetal Nuchal Translucency
Triple Marker test-AFP. hCG, Estriol
Quad Screen-adds Inhibin A
Amnioscentesis for dx
Blood Type & Rh
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| Common Lab Tests Continued... | H/H-anemia if Hgb <11; Hct ≤ 32, Hepatitis B, HIV, Rubella titer-if < 1:10 need meruvax/MMR postpartum, Urinalysis, GTT, Group Strep B, STIs.
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| Planning/Implementation - Educative Supportive Nursing System | Promotion of normalcy/wellness; prevention of hazards: modify risks; antepartal education; community resources.
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| Planning/Implementation- Partially Compensatory Nursing System | Collaborate with health care team, Assist with medical treatment, Medication management/pharmacotherapy.
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| Fetal Activity Monitoring | Begin at 28 weeks-Cardiff Count-to-ten method: count fetal movement
2-3 times a day, consistency (same time every day; 1 hr after meals), 20-30 minutes at a time, lie of left side.
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| Types of Fetal Well-Being Assessments-Doppler Blood Flow Studies | Doppler Blood Flow Studies:Non invasive, Ultrasound test used to determine blood flow changes that occur in maternal and detal circulation, Evaluates post term, IUGR, effects nicotine.
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| Types of Fetal Well-Being Assessments-Non Stress Test | A "well" fetus=HR w/activity, Test results are reactive: ≥ 2 acceleration of FHR w/fetal movement (> 15 bpm) over 20 minutes
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| Types of Fetal Well-Being Assessments-Fetal Acoustic & Vibroacoustic Stimulation Tests | Acoustic = sound, Vibroacoustic=sound & vibration: a handheld batter operated device that is placed at the fetal head to initiate movement- done 3x, if no movement further tests are done.
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| Types of Fetal Well-Being Assessments-Biophysical Profile | Comprehensive assessment via U/S & NST: fetal breathing movement, fetal movements of body and limbs, fetal tone, amniotic fluid volume, reactive FHR with activity (reactive NST).
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| Types of Fetal Well-Being Assessments--Contraction Stress Test | Evaluate the response of the FHR during a uterine contraction: contraction stimulated via IV pitocin, natural stimulation (nipple, breast pump).
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| Types of Fetal Well-Being Assessments-Amniotic Fluid Analysis | Amnioscentesis-to obtain amniotic fluid for testing: Diagnostic- trisomy 21, Trisomy 18, Nerual Tube Defects, Evaluation of Fetal Maturity- L/S ratio 2:1.
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| Gestational Diabetes | Any Degree of glucose intolerance that has its first onset during pregnancy
Effects 18% pf pregnancies
High Risk: Hx of diabetes in family; previous hx of gest. diabetes; obesity; high risk for type I or II in future - 50%
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| Four Cardinal Signs of Gestational Diabetes | Polyuria, Polydipsia, Polyphagia, Weight Loss
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| Fetal Risks-Gestational Diabetes | Congenital Anomalies, Large for gestational age, hypoglycemia-after birth
RDS -high insuline levels inhibit surfactant, need L/S 3:1, PG
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| Bleeding Disorders of Pregnancy | 1st Half of Pregnancy: Miscarriage, Ectopic Pregnancy, Gestational Trophoblastic Disease
2nd Half: Placenta Previa, Abruptio placenta
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| Bleeding Disorders-Spontaneous Abortion | Majority are early and due to chromosomal abnormalities.Other causes: Teratogenic Drugs, Faulty Implantation, Weakened Cervix, Placental Abnormalities, Endocrine imbalances, Maternal Infections, Chronic maternal disease.
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| Bleeding Disorders-Treatment | Complete Abortion:
cervix dilates, S/S bleeding and cramping and back ache
ALL products of conception are expelled
Patient cannot try to get pregnant again for 6 weeks
Incomplete abortion: SOME of the products of conception are expelled; D&C
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| Ectopic Pregnancy | Assessment: Subj - +/- vag. bleeding, +/- abd pain, +/- shoulder pain, fainting, shock.
Objective: +/- adenexal mass, low hCG
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| Gestational Trophoblastic Disease (GTD) | -Pathogenic proliferation of trophoblastic cells
-Forms: Hydatidiform Mole-grapelike clusters in uterus; invasive mole; Choriocarinoma (cancer).
-S/S-vag. bleeding, high hCG, N/V, preeclampsia early, dramatic uterine enlargement
-Treatment-D&C
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| Hypermesis Gravidarium | -Excessive n/v & retching during pregnancy with weight loss
-Cause: high levels of hCG
-Signs:dehydration, electrolyte imbalances and weight loss
-Clinical management: control vomitting by medication and self-care measures
-restore electrolyte balanc
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| Hypertensive Disorders in Pregnancy | Classifications:
Gestational Hypertension
Pre-eclampsia-progressive
Eclampsia-seizures
Chronic hypertension
Chronic Hypertension with superimposed
Transient hypertension
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| Preeclampsia | Etiology: Woman's antibody system overwhelmed by fetal antigens, also genetic component
At Risk: Primigravida (5-6x), multiple gestation, obesity, < 16 years and > 35 years, hx of preeclampsia, GTD, DM, Rh, incompatibility, large placental mass (twins).
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| Signs of Preeclampsia | Hypertension >140/90, Proteinuria x2, Sudden Edema-facial and hand
-Most common hypertensive disorder in preg.
-2nd leading cause of maternal morbidity and mortality in US
-Usually Occurs after 20 weeks
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| Preeclampsia-Maternal Risks | -CNS Changes-hyperreflexia, headache & seizures, Cerebral Vasospasm, Cerebral Edema, Vasoconstriction, Seizures = Eclampsia.
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| Preeclampsia-Neonatal Risks | -SGA/IUGR, Fetal hypoxia, Placental abruption, Prematurity, Over Sedation (Due to maternal treatment w/magnesium sulfate), Magnesium Toxicity.
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| Mild Preeclampsia-Nursing Interventions | Monitor VS especially BP, DTRs, check clonus, Rest on Left Side, Weight qd, > protein in diet, Monitor FH, NST, CST, U/S to monitor status of placenta.
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| Severe Preeclampsia-Nursing Interventions | Same as mild interventions plus, Quiet Room, < stimulus, Bedrest on left side, Strict I&O, Magnesium Sulfate as ordered, Sedative, antihypertensive as ordered, Fluid and electrolyte replacement, Carticosteroids if needed.
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| HELLP Syndrome | H: Hemolysis, EL: Elevated Liverenzymes, LP: Low platelet count (<100,000mm)
S/S:n/v, flulike s/s, visual disturbances, headache, epigastric pain, clonus, increased reflexes
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| Magnesium Sulfate (MgSO4) | -A CNS Depressant & smooth muscle relaxant
-Dose: loading 4-6mg IV therapeutic range 4-8mg/dl
-Monitor BP, DTRs, R if <12-d/c med
-Calcium gluconate-antagonist for magnesium toxicity, Evaluation-diuresis within 24hours.
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| Rh Status | -First fetal exposure fine, subsequent pregnancies in jeopardy
-Rh negative moms need RhoGAM/Rhophylac at 28 weeks and within 72 hours postpartum if baby is Rh positive
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| Hydrops Fetalis | Result of Rh factor antigens attacking fetus blood in utero
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| Hyperbilirubinemia-Jaundice | 22nd consequence of Rh factor
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