2015 Maternal – Child Nursing Exam Study Guide
This study guide is based on my nursing class notes, various mnemonics, and other information I found on the web, although it is not all-inclusive. The page #’s listed are from my nursing class book: Maternal-Child Nursing 4th Edition by Mckinney, James, Murray, Nelson, and Ashwill. Jennifer Cook 5/8/2015
Maternal-Child Nursing Exam Study Guide Outline
Antepartum (Pg. 1 - 10) o Ethical Principals (Pg. 1) o Cultural Health Beliefs (Pg. 1) o Heredity and Environmental Influences on Development (Pg. 1) Teratogenic Drugs – Warfarin, etc. (Pg. 1) o Genetic Risk Factors (Pg. 2) X-Linked Recessive Disorders o Conception and Prenatal Development (Pg. 2 – 3) Parity Abbreviations (Pg. 2) Fetal Circulation (Pg. 3) o Pregnancy Adaptations (Pg. 4 – 5) Multifetal Pregnancy (Pg. 4) Reproductive System: Changes to the Uterus (Pg. 4) Braxton Hicks Contractions (False Labor) Hyperemia Chadwick’s Sign Goodell’s Sign Hegar’s Sign Changes to the Cardiovascular System (Pg. 4) Iron Deficiency Anemia Cardiac Output Position Effects of B/P Changes to Gastrointestinal System (Pg. 4) Esophagus - Pyrosis Confirmation of Pregnancy (Pg. 4) Nagele’s Rule – Calculating EDD Diagnostic Tests (Pg. 5 – 7) Ultrasound (Pg. 5) Triple Marker Screening or Multiple Marker Screen (Pg. 5) Chorionic Villus Sampling (Pg. 5) Amniocentesis (Pg. 6) Fetal Lung Maturity Testing (Pg. 6) Nonstress Test (Pg. 6) Contraction Stress Test (Oxytocin Challenge Test – OCT) (Pg. 67)
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Biophysical Profile (BPP) (Pg. 7) o Physiological Changes During Pregnancy (Pg. 8 - 10) Gestational Diabetes (Pg. 9 – 10) Hyperemesis Gravidarum (Pg. 10) Intrapartum (Pg. 10 – 29) o Fundal Height (Pg. 10) o Labor and Delivery (Pg. 10 – 11) Uterine Contraction Frequency, Duration, Intensity, and Interval o Stages of Labor (Pg. 11 – 13) o Mechanisms of Labor (Pg. 14 - 15) o Fetal Stations (Pg. 16) o Fetal Heart Rate (Pg. 16) o Complications of Pregnancy (Pg. 17) o Danger Signs in Pregnancy (Pg. 17 – 18) o RH Incompatibility (Pg. 19) o ABO Incompatibility (Pg. 20) o Hypertension During Pregnancy (Pg. 20 – 23) Classification (Pg. 20) Gestational HTN (Pg. 20) Preeclampsia (Pg. 21 – 22) Eclampsia (Pg. 23) o Bleeding Disorders During Pregnancy (Pg. 23 – 28) Spontaneous Abortion (Pg. 23 – 25) DIC – Disseminated Intravascular Coagulation Hypovolemic Shock Miscarriage Ectopic Pregnancy (Pg. 25) Hydatidiform Mole (Gestational Trophoblastic Disease) (Pg. 25 – 26) Placenta Previa (Pg. 26 – 27) Abruptio Placentae (Pg. 28) o Medications (Pg. 28 – 29) Anticonvulsant Medications (Pg. 28 - 29) Magnesium Sulfate Antihypertensive Medications (Pg. 29) Hydralazine Pain Medication Narcan (Naloxone) (Pg. 29) Labor Medications (Pg. 29) Oxytocin (Pitocin) Postpartum (Pg. 30 – 39)
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o Postpartum Adaptations (Pg. 30 – 31) Reproductive System Changes (Pg. 30 – 31) Descent of the Uterine Fundus (Pg. 30) Lochia (Pg. 30 – 31) o Postpartum Assessment (Pg. 32 - 33) Episiotomy (Pg. 33) o Postpartum Complications (Pg. 34) o Therapeutic Management of PP Hemorrhaging (Pg. 34) What To Do If Fundus Shifted to One Side o Postpartum Psychosis (Pg. 35) o Concurrent Disorders During Pregnancy (Pg. 35) Hypoglycemia Hyperglycemia o CHF (Pg. 36) o Rheumatic Heart Disease (Pg. 36) o Congenial Heart Disease (Pg. 36 – 37) o Classification of Heart Disease (Pg. 38) o Maternal Infections (Pg. 38 – 39) TORCH (Toxoplasmosis), etc. (Pg. 38) Viral Infections (Pg. 39) Nonviral Infections (Pg. 39) Newborn Care (Pg. 39 – 73) o Newborn Assessment (Pg. 39) Normal Newborn VS (Pg. 40) Apgar Scoring (Pg. 40 – 41) Respirations (Pg. 42) 1st Respirations (Pg. 42) WET FROGS (Pg. 42) Respiratory Distress Syndrome (Pg. 43) o Caused by Insufficient Surfactant in Lungs Cardiorespiratory Status (Pg. 43) Normal Respiratory Rate Thermoregulation & Temperature Assessment (Pg. 43 – 45) Identification (Pg. 45) Breastfeeding (Pg. 45) Hazards of Cold Stress (Pg. 45) Fluid Imbalance in Newborn (Pg. 46) Overhydration Head (Pg. 46) Caput Succedaneum
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Cephalematoma Moro Reflex (Startle Reflex) ( Pg. 47) Gestational Age (Pg. 47) Pediatric Lab Values (Pg. 47 – 51) Hepatic System (Pg. 51 – 52) Hyperbilirubinemia Vitamin K (Pg. 52) Eye Treatment (Pg. 52) o High Risk Newborn (Pg. 53 – 73) Hypoglycemia (Pg. 53) PKU (Pg. 53 - 54) Medications (Pg. 54) Alterations in Lymphatic and Immune System (Pg. 55 – 57) Rubeola (Pg. 55) Rubella (Pg. 55) Fifth Disease (Pg. 56) Infectious Mononucleosis (Pg. 56) Leukemia (Pg. 57) o Induction GI Alterations (Pg. 58 – 61) Esophageal Atresia w/Tracheoesophageal Fistula (Pg. 58) Hernias (Pg. 58) GERD (Pg. 58 - 59) Acute Infectious Gastroenteritis (Pg. 59) Appendicitis (Pg. 59) Pyloric Stenosis (Pg. 59) Intussusception (Pg. 60) Hirschsprung Disease (Pg. 60) Failure to Thrive (Pg. 60 – 61) Genitourinary System Alterations (Pg. 61) Cryptorchidism Cardiovascular (Pg. 61 – 65) Infective Endocarditis (Pg. 61) Rheumatic Fever (Pg. 61 – 63) Kawasaki Disease (Pg. 64) Sickle-Cell Disease (Pg. 65) Thalassemia (Pg. 65) Musculoskeletal System (Pg. 65 - 68) Sprains and Strains Jennifer Cook
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Hip Dysplasia (Pg. 65) o Pavlik Harness Muscular Dystrophy (Pg. 66) Juvenile Rheumatoid Arthritis (Pg. 67) o Stiffness – Gel Phenomenon o Lab Markers – C-Reactive Protein Endocrine or Metabolic Alterations (Pg. 68 – 73) Galactosemia (Pg. 68) Tay-Sachs Disease (Pg. 68 - 69) Hypothyroidism vs Hyperthyroidism (Pg. 70) Congenital Hypothyroidism (Pg. 70) Acquired Hypothyroidism (Pg. 70 -71) Hyperthyroidism (Grave’s Disease) (Pg. 71) Thyroid Basics (Pg. 72) Diabetes Insipidus (Pg. 73) Infectious Diseases (Pg. 73 – 74) o Lyme Disease (Pg. 73 – 74) Health of Child (Pg. 74 – 75) o Freud Stages of Development (Pg. 74 - 75) o Best Way for Nurse or N.P. to Assess 3 year Old (Pg. 75) o Epiglottitis (Pg. 75 - 76)
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Antepartum Ethical Principals
Cultural Health Beliefs American Indian: Avoid tying knots or making braids
Heredity and Environmental Influences on Development Teratogenic drugs "W/ TERATOgenic": Warfarin Thalidomide Epileptic drugs: phenytoin, valproate, carbamazepine Retinoid ACE inhibitor Third element: lithium OCP and other hormones Teratogenic drugs: major non-antibiotics Remember “TAP CAP� Thalidomide Androgens Progestins Corticosteroids Aspirin & indomethacin Phenytoin
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Genetic Risk Factors X-linked Recessive Disorders (More common than X-linked Dominant ones)  Examples: Colorblindness and Hemophilia
Conception and Prenatal Development Parity abbreviations (ie: G3 T2 P1 A0 L3) (Describes the outcomes of the total number of pregnancies (Gravida). Remember "To Peace And Love": T: of Term pregnancies P: of Premature births A: of Abortions (spontaneous or elective) L: of Live births
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Fetal Circulation: Umbilical Cord: 2 Arteries and 1 Vein. Cushioned by soft substance “Wharton’s Jelly.” Umbilical Vein carries freshly oxygenated and nutrient rich blood from placenta back to fetus. Remember: “Obvious problem for unwanted virtual devastating distress if successful regular fetal pulmonary artery development doesn’t ultimately articulate properly.” Obvious Potential For Unwanted Virtual Devastating Distress If Successful Regular Fetal Pulmonary Arterial Development Doesn’t Ultimately Articulate Properly
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Oxygenated blood from Placenta to Fetus through Umbilical Vein through Ductus Venosus combines with Deoxygenated blood from Inferior Vena Cava and Superior Vena Cava into the Right Atrium and most goes through the Foramen ovale bypassing Pulmonary arteries to the Aorta via the Ductus Arteriosus then Deoxygenated blood goes through the Umbilical Artery to the Placenta
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Pregnancy Adaptations Multifetal Pregnancy (Pg. 251 – 252)
Monozygotic Twins: “Identical” Twins Dizygotic Twins: “Fraternal” Twins (same or different sex)
Reproductive System: Changes to the Uterus
Braxton Hicks Contractions (False Labor) – Occurs throughout pregnancy Hyperemia – Causes a bluish purple color Chadwick’s Sign – Cervix, one of the earliest signs of pregnancy. Goodell’s Sign – Softening of the cervix. Hegar’s Signe – Thinning.
Changes to the Cardiovascular System
Iron Deficiency Anemia – occurs when: o Hgb < 11 g/dl or Hct < 33% in 1st trimester and 3rd trimester or o Hgb < 10.5 g/dl or Hct < 32% in 2nd trimester Cardiac Output – Most efficient in Lateral position and Least efficient in Supine Position. Position Effects of B/P o Less than 24 weeks gestation in the Sitting or Standing Position, Diastolic B/P decreases slightly but returns to pre-pregnant level by term. o Supine Hypotension – turn to Right Lateral Position.
Changes to Gastrointestinal System
Esophagus o Pyrosis (heart burn) – Reflux of acidic contents into esophagus. Take deep breaths and sip water for relief.
Confirmation of Pregnancy
Calculating EDD: Nagele’s Rule o Subtract 3 months, add 7 days to 1st day of last normal menstrual period (LNMP) and correct the year, if appropriate.
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Diagnostic Tests Ultrasound Women may need to drink water to fill the bladder before procedure to obtain better image of baby. Triple Marker Screening or Multiple Marker Screen (Pg. 305) Screens for fetal anomalies such as Trisomy 18 and 21 and Neuro Tube Defects. AFP, HcG, Estriol blood test. The test is considered positive if MSAFP and estriol are low and if hCG is high. Chorionic Villus Sampling (Pg. 305 - 306) Uses transcervical or transabdominal sampling to obtain villi to diagnose fetal chromosome or metabolic abnormalities. Tests for things such as Downâ&#x20AC;&#x2122;s Syndrome.
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Amniocentesis (Pg. 306 – 308) Aspiration of amniotic fluid from the amniotic sac for examination. It can be performed in the 2nd or 3rd trimester of pregnancy. The fluid can be tested to detect chromosomal abnormalities in fetal cells or other problems and to determine fetal lung maturity. Fetal Lung Maturity Testing (Pg. 307) It is recommended when non-emergency delivery is being considered before 38 weeks of gestation to reduce the risk of respiratory distress in the newborn. The lecithin/sphingomyelin (L/S) ratio is the best known test for estimating fetal lung maturity. Lecithin and sphingomyelin are lipoproteins that make up surfactant, which is present in the pulmonary alveoli of term infants. Surfactant keeps the alveoli open by reducing surface tension on their inner walls. The decreased surface tension prevents collapse of the alveoli when the infant exhales, reducing the effort of breathing. An L/S ratio greater than 2:1 (twice as much lecithin as sphingomyelin) generally indicates that surfactant is adequate and the fetal lungs are mature. An L/S ratio of 2:1 does not ensure fetal lung maturity; however, particularly for the fetus of a woman who has diabetes. Nonstress Test (Pg. 309 – 310) Identifies whether an increase in the FHR occurs when the fetus moves, indicating adequate oxygenation, a health neural pathway from the fetal central nervous system to the fetal heart, and the ability of the fetal heart to respond to stimuli. FHR accelerations without fetal movement are also considered a reassuring sign of adequate fetal oxygenation. IF the fetal heart does not accelerate w/movement; however, fetal hypoxemia and acidosis are concerns. Contraction Stress Test (Oxytocin Challenge Test – OCT) (Pg. 310 – 311) Can be done if NST findings are nonreactive, although the next step is usually an ultrasound examination for a BPP. The concern is that if fetal oxygenation is only marginally adequate when the uterus is at rest, it will be decreased further during contractions generated w/oxytocin infusion or nipple stimulation.
Contraindications: o Preterm labor or women who have a high risk for preterm labor. o Preterm membrane rupture o History of extensive uterine surgery or classic uterine incision for cesarean birth. o Placenta Previa Interpretation: o Negative (reassuring): No late or significant variable decelerations. o Positive (nonreassuring): Late decelerations follow 50% or more of contractions, even if fewer than three contractions occur in 10 minutes.
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o Equivocal-suspicious: Intermittent late or significant variable decelerations. o Equivocal-hyperstimulation: FHR decelerations occur in the presence of excessive contractions (more frequent than every 2 minutes or lasting longer than 90 seconds). o Unsatisfactory: Fewer than three contractions within 10 minutes or a tracing that cannot be interpreted. Biophysical Profile (BPP) (Pg. 311 – 313) Unlike only the NST and CST’s, which assess only fetal heart activity, the BPP assesses a total of five parameters of fetal well-being: the NST, fetal breathing movements, gross fetal movements (large trunk movements), fetal tone (small or fine body movements such as limb or hand extension and flexion or sucking movements), and amniotic fluid volume. Normal values for each suggest adequate neurologic function and oxygenation. The amount of amniotic fluid provides important information about long-term hypoxia. If the hypoxemia is prolonged, blood flow to the fetal kidneys and lungs, which produce most amniotic fluid, may virtually cease. Therefore, oligohydramnios indicates prolonged fetal hypoxia and strongly suggests fetal compromise. H Y P O X I A
↓ ↓ ↓ ↓
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Late decelerations appear (first sign) Accelerations disappear (next sign) Fetal breathing movement stops Fetal movement ceases (late sign) Fetal tone absent (fetus already compromised)
P
↓
H
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Physiological Changes During Pregnancy
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Gestational Diabetes (Pg. 613 – 616) Gestational diabetes mellitus is an impaired tolerance to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level during pregnancy should fall between 70 and 110 mg/dL. Symptoms of diabetes mellitus may disappear a few weeks following delivery. However, approximately 50% of women will develop diabetes mellitus within 5 years.
Risks Associated w/Gestational Diabetes: o Spontaneous abortion, which is related to poor glycemic control. o Infections (urinary and vaginal), which are related to increased glucose in the urine and decreased resistance because of altered carbohydrate metabolism. o Hydramnios, which can cause overdistention of the uterus, premature rupture of membranes, preterm labor, and hemorrhage. o Ketoacidosis from diabetogenic effect of pregnancy (increased insulin resistance), untreated hyperglycemia, or inappropriate insulin dosing. o Hypoglycemia, which is caused by overdosing in insulin, skipped or late meals, or increased exercise. o Hyperglycemia, which can cause excessive fetal growth (macrosomia). o Obesity o Maternal age older than 25 years o Family history of diabetes mellitus o Previous delivery of an infant that was large or stillborn Assessment: o Subjective: Hypoglycemia (nervousness, headache, weakness, irritability, hunger, blurred vision, tingling of mouth or extremities) Hyperglycemia (thirst, nausea, abdominal pain, frequent urination, flushed dry skin, fruity breath) o Objective: Hypoglycemia Shaking Clammy pale skin Shallow respirations Rapid pulse Hyperglycemia Vomiting Excess weight gain during pregnancy
Gestational Diabetes think FETAL Fetal and maternal well-being (monitor ongoing) Expect insulin requirements to ^during second and third trimester The medication of choice: Insulin (Limited use of glyburide (DiaBeta) at present Anticipate vaginal delivery as long as adequate placental profusion Jennifer Cook
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Look for hypoglycemia during PP (Insulin requirements will decrease) Hyperemesis Gravidarum (Pg. 589 – 590) Is persistent, uncontrollable vomiting that begins in the first weeks of pregnancy and may continue throughout pregnancy. The cause of HEG is not known, but is thought to be associated w/PUD, Helicobacter pylori (H. pylori). Hyperemesis gravidarum is excessive nausea and vomiting (related to elevated hCG levels) that is prolonged past 12 weeks of gestation and results in a 5% weight loss from prepregnancy weight, electrolyte imbalance, acetonuria, and ketosis. Hyperemesis gravidarum may be accompanied with liver dysfunction. There is a risk to the fetus for intrauterine growth restriction (IUGR) or preterm birth if the condition persists.
Hyperemesis Gravidarum Think Vomit V/N uncontrolled; > first trimester Observe Labs; BM; Wt Meals: Sm/Frequent; Low fat; ^carbs; Liquids between meals; Sit up after meals; Dietician consult I/O Strict; From all sources Tx: Vit B6; Antiemetics; Steroids; IV fluids; Parenteral Nutrition
Intrapartum How to Measure Fundal Height (Pg. 250 – 251)
Bladder must be empty to avoid elevation of the uterus by a full bladder. Lies on back w/knees slightly flexed. Palpate top of fundus Stretch tape measure from top of symphysis pubis over abdominal curve to top of fundus.
Labor and Delivery Uterine Contraction (Pg. 318) Frequency – Beginning of 1 contraction to the beginning of the next contraction. Duration – length, Intensity – strength, Interval – period between the end of one contraction and the beginning of the next.
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Stages of Labor (Pg. 329 â&#x20AC;&#x201C; 335) True vs. False Labor (See Table on pg. 329)
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Mechanisms of Labor (Pg. 329)
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Fetal Stations (Pg. 330)
Fetal Heart Rate (Pg. 251) Should be between 110 and 160 bpm (See Chart below). If FHR is heard in the Upper quadrant of the abdomen, it suggests that the fetus is in a breech presentation. Internal Fetal Heart Rate Monitor is put on: after amniotic sac has ruptured. If no heartbeat detected, immediate action by the nurse is: Improve fetal O2, scalp rub, and/or tell mom to turn on left side.?
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Complications of Pregnancy (Pg. 576 – 604)
Danger Signs in Pregnancy
Vaginal Bleeding Visual Disturbances Chills or Fever Persistent Vomiting Painful Urination Escape of fluid from Vagina Swelling of Fingers, Face, or Around eyes Continuous Pounding H/A Persistent or Severe Abdominal Pain or Epigastric Pain Convulsions Change in Fetal Movement
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RH Incompatibility (Pg. 601 – 604)
Test – Indirect Coombs test determines whether they are sensitized (have developed antibodies) as a result of previous exposure to Rh positive blood. TX – RhoGam administered at 28 weeks gestation.
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ABO Incompatibility (Pg. 604) Occurs when the expectant mother is blood type O and the fetus is blood type A, B, or AB. Blood types A, B, and AB contain a protein component (antigen) that is not present in type O blood. Neonatal morbidity can range from uncomplicated hyperbilirubinemia to more severe anemia. No specific prenatal care is needed, but the nurse must be aware of the possibility of ABO incompatibility. At birth, cord blood is taken to determine the blood type of the newborn and fully screened for jaundice, which indicates hyperbilirubinemia.
Hypertension during Pregnancy (Pg. 590 – 591)
Gestational HTN (Pg. 590 – 591) o Gestational Hypertension (PIH) think Peace Promote rest/quiet environment Ensure high protein intake (1g/kg/day)
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Antihypertensive drugs: Aldomet (methyldopa) first line in pregnancy Convulsions (Mag Sulfate) Evaluate: BP; Urine output; Respirations; Patella reflex
Preeclampsia (Pg. 591 – 596) o A systolic B/P of > 140 mm Hg or diastolic B/P of > 90 mm Hg occurring after 20 weeks of pregnancy that is accompanied by significant proteinuria (> 0.3 g in a 24 hour urine collection, which usually correlates w/a random urine dipstick evaluation of > 1 +). It is a result of generalized vasospasm. Generalized edema can be a sign, but is also related to normal pregnancy. o Symptoms (precursors for seizures): Continuous H/A Drowsiness Mental Confusion Poor Cerebral Perfusion Epigastric Pain or Upset Stomach (indicate distention of hepatic capsule and often warn that seizure is imminent).
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Decreased Urinary output indicates poor perfusion of kidneys and may precede acute renal failure.
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Eclampsia o Potentially preventable extension of severe preeclampsia marked by onset of one or more generalized seizures. o Magnesium is the drug of choice to control eclamptic seizures. (See Medications below)
Bleeding Disorders During Pregnancy (Pg. 576 - 583) Early Bleeding (Pg. 576 – 583)
Spontaneous Abortion (Pg. 576 – 579) o Spontaneous abortion: definition "Spontaneous abortion" has less than 20 letters [it's exactly 19 letters]. Spontaneous abortion is defined as delivery or loss of products of conception at less than 20 weeks gestation.
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o o o o o
Threatened – vaginal bleeding occurs. Inevitable – membranes rupture, and cervix dilates. Incomplete – some products of conception have been expelled, but some remain. Complete – all products of the conception are expelled from the uterus. Missed – fetus dies during the first half of pregnancy but is retained in the uterus. Major Concerns: Infection Disseminated Intravascular Coagulation (DIC) (Pg. 578) – A defect in coagulation that may occur if the fetus is retained for a prolonged period. Although DIC may occur w/other pregnancy complications, such as abruption placentae (pg. 585) or HTN (pg. 590), the coagulation defects may occur in the absence of pregnancy. o Recurrent (habitual abortion) – three or more consecutive spontaneous abortions. Hypovolemic Shock – rapid pulse, lightheadedness, syncope, falling B/P are nursing priorities when a woman is bleeding heavily. The nurse should also observe for tachycardia (often the earliest sign of hypovolemia), a falling B/P (late sign), pale skin and mucous membranes, confusion, restlessness, and cool and clammy skin.
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Ectopic Pregnancy (Pg. 579 – 581) – implantation of a fertilized ovum in an area outside the uterine cavity. More than 95% of ectopic pregnancies are in the fallopian tube, usually the ampulla, or middle part of the tube.
Hydatidiform Mole (Gestational Trophoblastic Disease) (Pg. 581 – 582) o Occurs when the trophoblasts (peripheral cells that attach the fertilized ovum to the uterine wall) develop abnormally. As a result of the abnormal growth, the placenta, but not the fetus, develops. It is characterized by proliferation and edema of the chorionic villi. The fluid-filled villi form grapelike vesicles that may grow large enough to fill the uterus to the size of an advanced pregnancy if not diagnosed and treated. The mole may be complete, w/no fetus present, or partial, in which fetal tissue or membranes are present. Malignant change and proliferation of residual trophoblastic tissue (gestational trophoblastic neoplasm, or choriocarcinoma) is a life-threatening complication.
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Late Bleeding (Pg. 583 – 589) – after 20 weeks of pregnancy
Placenta Previa (Pg. 583 – 585) o Implantation of the placenta in the lower uterus, near the fetal presenting part. Marginal Partial Total
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Abruptio Placentae (Pg. 585 – 587) o Separation of a normally implanted placenta before the fetus is born (called abruption placentae, placental abruption; or premature separation of the placenta) occurs when there is bleeding and formation of a hematoma on the maternal side of the placenta. As the clot expands, further separation occurs. o The major danger for the woman is hemorrhage and consequent hypovolemic shock and clotting abnormalities such as DIC (pg. 578). The major dangers for the fetus are related to anoxia, blood loss, and preterm birth.
Medications Magnesium Sulfate (Pg. 595)
Indications o Prevention and Control of seizures in severe preeclampsia. o Prevention of uterine contractions in preterm labor
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Anticonvulsant Medications (Pg. 594)
Magnesium Sulfate is the drug most commonly used to prevent seizures.
Antihypertensive Meds (Pg. 595) If the woman’s systolic B/P is > 160 mm Hg or her diastolic blood pressure is > 110 mm Hg, the risk for stroke or CHF is higher. Hydralazine (Apresoline) is commonly used because of its record of safety. The major advantage of this medication over other antihypertensives is that it is a vasodilator that increases cardiac output and blood flow to the placenta. Other antihypertensive medications such as nifedipine (a calcium channel blocker) or labetalol (a beta-adrenergic blocker) may be used. Pain Meds (Pg. 395 – 410)
Narcan (Naloxone) – reverses opioid-induced respiratory depression. Small doses may be given to the woman to reduce pruritus from epidural opioids. It is occasionally needed w/neonatal resuscitation.
Labor Meds Oxytocin (Pitocin) (Pg. 416 – 418) Stimulates Uterine contractions Jennifer Cook
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Postpartum Postpartum Adaptations Reproductive System Changes Descent of the Uterine Fundus (top of the uterus) (Pg. 434)
Immediately after birth, located midline, halfway between symphysis pubis and umbilicus. The fundus descends by approximately 1 cm, or one fingerbreadth, per day, so that by the 14th day it is in the pelvic cavity and cannot be palpated abdominally.
Lochia (Pg. 434 – 435)
Amount on Perineal Pad – (Pg. 435) o Scant (less than 1 inch in 1 hour) o Light (1-4 inches in 1 hour) o Moderate (4-6 inches in 1 hour) o Large (saturated pad in 1 hour) o Excessive (saturated pad in 15 minutes)
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(Important: Always check the pad underneath the client)
Color o Lochia rubra (Red 1st 3 days) o Lochia serosa (Pink or brown tinged Days 4-10) o Lochia alba (Creamy white/yellow; Days 11-3 to 6 weeks) S/S That Should be Reported o Resumption of bright red color o Passage of clots o Foul Odor
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Postpartum Assessment Uterus â&#x20AC;&#x201C; Fundus firm/midline. Immediately fundus will be several finger breadths above U then descends into pelvis 1 finger breadth/day. Higher if multipara; Massage if boggy.
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Episiotomy (Pg. 423 â&#x20AC;&#x201C; 424)
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Postpartum Complications
Therapeutic Management of PP Hemorrhaging
Massage fundus if boggy Once firm, express clots by applying form gentle pressure on fundus in direction of vagina. Do not attempt to express clots if fundus is not firm. If shifted to 1 side, assist w/urination or catheterize Medications that can increase uterine tone and control bleeding o Pitocin (Rapid IV Infusion) o Methergine (IM, do not give if HTN) o Prostaglandins (IM or into uterine muscle) o Antibiotics if PP infection is suspected.
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Postpartum Psychosis
Impaired ability to recognize reality, communicate, and relate to others. Classified as either Depressed or Manic Type Rare Condition Psychiatric Emergency when behavior exhibits: o Agitation o Irritability o Rapidly shifting moods o Disorientation o Disorganized Behavior o Sometimes Delusions/Hallucinations At danger of suicide and/or infanticide Never leave client w/these symptoms alone or alone with infant. Immediate medical attention and hospitalization.
Concurrent Disorders During Pregnancy (Pg. 607 – 631) Hypoglycemia (Pg. 616)
S/S: o o o o o o o
Shakiness (tremors) Sweating Pallor; cold, clammy skin Disorientation, irritability H/A Hunger Blurred Vision
Hyperglycemia (Pg. 616)
S/S: o o o o o o o
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Fatigue Flushed, hot skin Dry mouth, excessive thirst Frequent urination Rapid, deep respiration; odor of acetone on the breath Drowsiness, H/A Depressed reflexes
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CHF (Pg. 616 – 617)
S/S: o o o o o o o
Cough (frequent, productive, hemoptysis) Progressive dyspnea w/exertion Orthopnea Pitting edema of legs and feet or generalized edema of face, hands, or sacral area Heart palpitations Progressive fatigue or syncope w/exertion Moist rales in lower lobes, indicating pulmonary edema
Rheumatic Heart Disease (Pg. 618) This is a heart disease complication that sometimes follows a streptococcal pharyngitis infection (strep throat). Congenital Heart Disease (Pg. 618)
Left-to-Right Shunt o Atrial Septal Defect o Ventricular Septal Defect o Patent Ductus Arteriosus
Right-to-Left Shunt o Tetralogy of Fallot
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o Eisenmenger Syndrome o Mitral Valve Prolapse
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Classification of Heart Disease (Pg. 619)
Maternal Infections (Pg. 624 – 631)
TORCH
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Viral Infections o Cytomegalovirus o Rubella o Varicella-Zoster Virus o Herpesvirus Serotypes 1 and 2 o Parvovirus B19 o Hepatitis B o HIV Nonviral Infections o Toxoplasmosis o Group B Streptococcus Infection o TB
Newborn Care Newborn Assessment
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Respirations (Pg. 483 – 485)
Lung Development o Surfactant secretion increases during labor and immediately after birth to reduce surface tension within alveoli. What Causes 1st Respiration o 1st breath forces remaining fetal lung fluid out of alveoli allowing air to enter the lungs. o 1st breath requires much larger negative pressure. o Initiated by factors that stimulate the respiratory center in Medulla Chemical: Hypoxia; partial pressure of O2; pH; partial pressure of carbon dioxide. Mechanical: Fetal chest compressed by birth canal recoils Thermal Factors: Temp change stimulates receptors in skin. Sensory: Tactile stimuli during birth stimulates skin receptors; stimulated by sound, light, smell, and pain. o What Keeps the Respirations Going Surfactant allows alveoli to remain partially open between respirations. Subsequent breaths require less effort than the 1st one Infant cries causing increased pressure within lungs. Causes remaining fetal lung fluid to move into interstitial spaces to absorb May take as long as 24 hours for all of fluid to be absorbed.
WET FROGS
Wheezing? (Or abnormal breath sounds)
Effort of Breathing? (Struggling?)
Tachypnea? (Resp > 60/min)
Flaring of the nares? (That continues longer than a few hours of birth)
Retractions? (Caving in between ribs with respirations)
Oxygen Saturation? (Central Cyanosis; lips; mucous membranes; trunk)
Grunting? (Sound with respirations; heard with or without stethoscope)
Seesaw Respirations (Chest falls when abdomen rises) or Asymmetry (Decreased movement on 1 side of chest)
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Respiratory Distress Syndrome (Preterm Infants) Caused by Insufficient surfactant in lungs Cardiorespiratory Status (Pg. 483 – 485)
Airway: Free of mucous? Respiratory Rate (30 to 60/minute) o Assessed every 30 minutes until stable for 2 hours o Normal: pause for 5 to 10 seconds followed by rapid resp for 10 to 15 seconds o Abnormal To pause for 20 seconds or longer Any cyanosis; pallor; bradycardia or decreased muscle tone Breath Sounds o Listen to anterior and posterior o May have moist rales especially if cesarean birth o Report abnormalities to HCP Heart Sounds o Should range between 120-160 bpm o With crying may increase to 180 bpm o When sleeping may decrease to 100 bpm
Thermoregulation & Temperature Assessment (Pg. 485 – 486) Temperature – Assessed soon after birth then probe is attached to abdomen (between umbilicus and xyphoid process) if under Radiant warmer.
Why are newborns susceptible to heat loss o Thin Skin o Blood vessel close to surface o Little subcutaneous (white) fat Methods of Heat Loss o Evaporation: Air Drying Wet diaper Regurgitated milk on shirt Hair wet from bath Insensible water loss from lungs o Conduction: Contact w/cooler object. Cold hands Metal scale with thin paper liner o Convection: From infant to cooler surroundings Blanket loose or off
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Open door to hall Air conditioner o Radiation: Transfer of heat to cooler objects Signs of Inadequate Thermoregulation o Axillary temp < 36.3 C to > 36.9 C (<97.3 F to > 98.4 F) o Abdominal skin temp < 36 C to > 36.5 C (<96.8 F to > 97.7 F) o Poor feeding or feeding intolerance o Irritability followed by lethargy o Weak cry or suck o Decreased muscle tone o Skin pale, cool to touch, mottled or acrocyanotic o Hypoglycemia o Respiratory distress o Poor weight gain if chronic Prevent Heat Loss o Before Birth – preheat radiant warmer o Dry neonate immediately o Wrap in blanket o Dry hair and cover head o Skin-to-skin with mother o Put under radiant warmer or skin-to-skin with mom Complications of Heat Loss o Hypoglycemia o Metabolic Acidosis o Pulmonary Vasoconstriction o Impaired surfactant production o Hyperbilirubinemia Bathing – Receives 1st bath when temp is stable
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Identification ID bands are placed on the mother, the infant, and the father or other support person at the infant’s birth to ensure that an infant is never given to the wrong person. Breastfeeding Show the mother, if she has problems Hazards of Cold Stress
Increased O2 need Decreased surfactant production Respiratory distress Hypoglycemia Metabolic acidosis Jaundice
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Fluid Imbalance in Newborn (Pg. 477)
Dehydration Signs of Imbalance o Urine output < 2 mL/kg/hr o Urine specific gravity > 1.01 o Weight loss greater than expected o Dry skin and mucous membranes o Sunken anterior fontanel o Poor tissue turgor o Blood: elevated sodium, protein, and hematocrit levels Overhydration o Urine output > 5 mL/kg/hr o Urine specific gravity < 1.002 o Edema o Weight gain greater than expected o Bulging fontanels o Moist breath sounds o Difficulty breathing o Blood: decreased sodium, protein, hematocrit levels
Head (Pg. 487)
Caput Succedaneum: Area of soft localized edema that crosses suture lines; results of pressure against mother’s cervix during birth or from vacuum extractor.
Cephalhematoma: Bleeding between the periosteum and skull from pressure during birth; Firm, usually not present at birth but develops within first 24 to 48 hours.
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Moro Reflex (Startle Reflex) (Pg. 491) Clapping of hands can elicit this response. Gestational Age (Pg. 504) Small for gestational age (SGA) (Below the 10th percentile) Pediatric Lab Values (Textbook, Pg. 473) Hematology Test
Age Red Cell Count
Hematocrit
Hemoglobin
MCH
MCHC MCV
White Cell Count
Differential (manual) Neutrophils Jennifer Cook
0-1 month 1-2 months 2-3 months 3-6 months 6 months-1 year 0-1 month 1-2 months 2-3 months 3-6 months 6 months-1 year 0-1 month 1-2 months 2-3 months 3-6 months 6 months-1 year 0-1 month 1-3 months 3-6 months 6 months-1 year 0-6 months 6 months-1 year 0-1 month 1-3 months 3-6 months 6 months-1 year 0-1 month 1-3 months 3 months-1 year 1-2 years 2-4 years 0-1 month 1-3 months
Range 3.90-5.90 3.10-5.30 2.70-4.50 3.10-5.10 3.90-5.50 42-65 33-55 28-41 29-41 31-41 13.4-19.9 10.7-17.1 9.0-14.1 9.5-14.1 11.3-14.1 31-37 27-36 25-35 23-31 28-36 32-36 88-123 91-112 74-108 70-85 9000-30000 5000-19500 6000-17500 6000-17000 5500-15500 1000-20000 1000-9000
Units millions/mm3
%
gm/dL
pg
g/dL RBC femtoliters
mm3
mm3
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Lymphocytes
Monocytes
Eosinophils
Basophils
3-6 months 6 months-5 years 5-18 years 0-1 month 1-3 months 3-6 months 6 months-1 year 1-2 years 2-5 years 5-18 years 18+ years 0-1 month 1-3 months 3-12 months 1-2 years 2-5 years 5-18 years 18+ years 0-1 month 1-3 months 3 months-1 year 1-2 years 2-5 years 5-18 years 18+ years 0-1 month 1 month-5 years 5-18 years 18+ years
1000-8500 1500-8500 1700-7500 2000-11000 2500-16500 4000-13500 4000-10500 3000-9500 2000-8000 1250-3380 875-3300 540-1800 350-1365 300-875 300-850 275-775 28-825 130-860 270-900 150-585 180-525 180-510 165-465 40-650 40-390 0-400 0-140 7-140 10-136
mm3
mm3
mm3
mm3
Chemistry - Assays with Separate Male/Female Ranges Test Age Male Female Albumin 0-4 days 2.8-4.4 2.8-4.4 4 days-14 years 3.8-5.4 3.8-5.4 14-18 years 3.2-4.5 3.2-4.5 Alpha Fetoprotein, Non0-13 days 5,000-105,000 5,000-105,000 Pregnant 14-30 days 300-60,000 300-60,000 1 month 100-10,000 100-10,000 2 months 40-1,000 40-1,000 3 months 11-300 11-300 4 months 5-200 5-200 5 months 0-90 0-90 Jennifer Cook
Units g/dL g/dL g/dL ng/mL ng/mL ng/mL ng/mL ng/mL ng/mL ng/mL
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Calcium (Total)
Phosphatase, Alkaline
Progesterone
Test Testosterone, Total (Male)
Testosterone, Total (Female)
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6-11 months 1 year 2 years 3+ years Birth-30 days 31 days-1 year 1-6 years 7-12 years 13-15 years 16-18 years 1-30 days 31 days-1 year 1-3 years 4-6 years 7-9 years 10-12 years 13-15 years 16-18 years < 2 years old 2-9 years old 10-17 years old
0-60 0-17 0-12 0-9 8.5-10.6 8.7-10.5 8.8-10.6 8.7-10.3 8.5-10.2 8.4-10.3 75-316 82-383 104-345 93-309 86-315 42-362 74-390 52-171 0.87-3.37 < 0.2 adult levels generally achieved by puberty
0-97 0-41 0-12 0-9 8.4-10.6 8.9-10.5 8.5-10.5 8.5-10.3 8.4-10.2 8.6-10.3 48-406 124-341 108-317 96-297 69-325 51-332 50-162 47-119 0.87-3.37 0.20-0.24 adult levels generally achieved by puberty
ng/mL ng/mL ng/mL ng/mL mg/dL mg/dL mg/dL mg/dL mg/dL mg/dL U/L U/L U/L U/L U/L U/L U/L U/L ng/mL ng/mL
Age <1 month 1-5 months 6-24 months 2-5 years 6-9 years 10-11 years 12-13 years 14-15 years 16-18 years
Range 75-400 14-363 < 37 < 19 < 13 3-327 29-432 40-778 238-1048
Units ng/dL ng/dL ng/dL ng/dL ng/dL ng/dL ng/dL ng/dL ng/dL
Tanner stage 1 Tanner stage 2 Tanner stage 3 Tanner stage 4 Tanner stage 5 Up to 30 days 1-5 months 6-24 months 2-3 years
< 15 3-432 65-778 180-763 188-882 20-64 < 20 <9 < 20
ng/dL ng/dL ng/dL ng/dL ng/dL ng/dL ng/dL ng/dL ng/dL
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Test Iron (Transferrin) Saturation Total Protein
4-5 years 6-7 years 8-9 years 10-11 years 12-13 years 14-15 years 16-18 years
< 30 < 13 1-8 3-32 3-50 6-52 9-58
ng/dL ng/dL ng/dL ng/dL ng/dL ng/dL ng/dL
Tanner stage 1 Tanner stage 2 Tanner stage 3 Tanner stage 4-5
< 17 < 40 5-63 6-58
ng/dL ng/dL ng/dL ng/dL
Age
Male 20-50
Female 15-50
Units %
Birth-31 days 1-6 months 6 months-1 year 1-18 years
4.1-6.3 4.7-6.7 5.5-7.0 5.7-8.0
4.2-6.2 4.4-6.6 5.6-7.9 5.7-8.0
g/dL g/dL g/dL g/dL
Chemistry - Assays with Genderless Ranges Test Age Range Carbon dioxide (CO2 Cordblood 15-20 content=bicarb+dissolved CO2) Child 18-27 Creatinine Premature 0.3-1.o Neonates 0.2-0.9 2-12 months 0.2-0.4 Note: There are gender-specific 1-2 years 0.2-0.5 ranges only for ages 16 years 3-4 years 0.3-0.7 and older. 5-6 years 0.3-0.7 7-8 years 0.2-0.6 9-10 years 0.3-0.7 11-12 years 0.3-0.9 13-15 years 0.4-0.9
Glucose Iron
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Males 16 years + Females 16 years+ 0-1 month 1 month-adult Birth-4 months 5-23 months 24-35 months 3-11 years
0.6-1.2 0.5-1.0 40-99 65-99 110-270 30-70 20-124 53-119
Units mEq/L mEq/L mg/dL mg/dL mg/dL mg/dL mg/dL mg/dL mg/dL mg/dL mg/dL mg/dL mg/dL mg/dL mg/dL mg/dL mcg/dL mcg/dL mcg/dL mcg/dL
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N-terminal-pro-BNP
Percent Saturation
Phosphorus
Potassium Sodium Uric Acid
Test Calcium (ionized)
Test Bilirubin
12 years+ 0-30 days 1-11 months 12-35 months 3-6 years 7-14 years 15-18 years Newborn 4-10 months 3-10 years Newborn-11 months 12 months-15 years 16+ years <10 days >10 days Premature 0-2 years 2-12 years 12-14 years
Use adults ranges 263-6500 37-1000 39-675 23-327 10-242 6-207 65 25 30 4.2-9.0 3.2-6.3 2.7-4.5 3.5-6.0 3.5-5.0 130-140 2.0-7.0 2.0-6.5 2.0-7.0
pg/mL pg/mL pg/mL pg/mL pg/mL pg/mL % % % mg/dL mg/dL mg/dL mEq/L mEq/L mEq/L mg/dL mg/dL mg/dL
Critical Care Age Neonatal
Range 4.2-5.9*
Units mg/dL
Range <1.8 < or = 6.0 < or = 6.0
Units mg/dL mg/dL mg/dL
< or = 8.0 < or = 7.0
mg/dL mg/dL
< or =12.0 < or =12.0 < 1.0
mg/dL mg/dL mg/dL
Special Care Nurseries Age cord 24 hrs Preterm Term 48 hrs Preterm Term 3-5 days Preterm Term 1m-adult
Hepatic System (Pg. 474) Conjugation of Bilirubin ď&#x201A;ˇ
Major function of liver
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Liver may not be mature enough to prevent jaundice during 1st week of life. o Hyperbilirubinemia Jaundice (yellowing of skin) Excessive bilirubin in blood Occurs in 60% of term newborns and 80% of preterm infants Can lead to Kernicterus and Bilirubin encephalopathy Source and Effect of Bilirubin o After birth, not as many RBCs needed o Hemolysis of Erythrocytes (RBC’s) occurs Major source of bilirubin o Bilirubin released in an unconjugated for (indirect bilirubin which is fat soluble and not water soluble) Causes jaundice then Staining of tissues in brain then Acute bilirubin encephalopathy then Kernicterus (become chronic) o Must be changed to Direct to be excreted (conjugated; water soluble form)
Vitamin K
Cannot synthesize Vitamin K in intestines without bacterial flora Deficient in clotting factors Prevents bleeding problems One dose IM within 1st hour of birth Given in lateral aspect of thigh
Eye Treatment
Prevents ophthalmia neonatorum in case mother is infected with gonorrhea Types o Erythromycin (0.5%) ophthalmic ointment (most common) o Tetracycline (1%) ophthalmic ointment can be used May temp blur vision Mild inflammation
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High Risk Newborns
Hypoglycemia (Pg. 728 – 729)
Infants of Diabetic mother at risk for hypoglycemia S/S (sometimes none) may include o Jitteriness or tremors o Rapid respirations o Low temperature o Poor muscle tone Assess Blood Glucose Level per protocol Feed early to prevent Hypoglycemia Feed immediately if hypoglycemia is present
Phenylketonuria (PKU) (Pg. 733, 1380 and 1381)
Autosomal Recessive Disorder; Genetic Metabolic Disorder Caused by deficiency of enzyme needed to convert phenylalanine to tyrosine Lacks liver enzyme Phenylalanine Hydroxylase
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Unable to convert phenylalanine Toxic levels of phenylalanine in blood causes CNS injury S/S include o Digestive problems; vomiting o Hypopigmentation of hair/skin/irises o Hyperactive behavior o Progresses to seizures o Musty odor to urine o Intellectual impairment – Long term consequences of untreated PKU
Medications Narcan (Naloxone) (Pg. 401)
Reverses opioid induced respiratory depression
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Alterations in Lymphatic and Immune Systems Rubeola (OrdinaryMeasles) (Pg. 1009-1015)
S/S o Respiratory symptoms o Elevated temp o 3 C’s (Lasts for 1 to 4 days) Coryza (profuse runny nose) Cough Conjunctivitis o Koplik spots appear Small blue-white dots with red base on buccal mucosa (molar area) Lasts 3 days then slough off o Rash appears Deep-red; macular rash; face and neck spreads downward; blanches; turns brown; lasts 6 to 7 days.
Rubella (Pg. 1015 – 1016)
S/S
o Includes: Forscheimer’s sign: Petechiae (tiny, pin-point size red or purple spots) on soft palate. o Others Most common Complication: Sensorineural deafness
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Fifth Disease (Pg. 1016 – 1017)
S/S o Asymptomatic before rash o Some symptoms in some children may include: H/A Runny nose Malaise Mild fever o Facial rash: “Slapped Cheek” appearance o Red Maculopapular Rash Trunk and extremities Appears 1 to 4 days after facial rash Fades in center first “Lacy” appearance Lasts 2 to 39 days Reappears with heat, exercise, warm baths, rubbing, stress
Infectious Mononucleosis (Pg. 1022) Severe swelling of pharynx/tonsils can compromise respirations
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Leukemia (Pg. 1273 – 1280) Abnormal proliferation of immature WBC’s (blasts) compete w/normal cells for space/nutrition
Combo Chemotherapy (Phases: Induction; Consolidation; and Maintenance) usually outpatient basis o Induction: Remission (< 5% immature blast cells in bone marrow) usually 1 month Serum electrolytes stabilized before chemotherapy intitiation During Chemo: WBC’s breakdown releasing Uric acid which compromises kidney function; allopurinol and IV fluids w/sodium bicarbonate given to counteract. o Consolidation: Maintain remission prevent disease in extramedullary o Maintenance: Lower doses of chemo to prevent reoccurrence. Total treatment average: 2 ½ years girls and 3 ½ years boys.
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GI Alterations Esophageal Atresia w/Tracheoesophageal Fistula (Pg. 1071 – 1076) Excessive oral secretions, coughing, choking: 3 C’S of TEF – coughing, choking, and cyanosis.
Congenital malformations: Esophagus terminates before it reaches stomach and/or fistula is present causing an unnatural connection w/trachea. Cause unknown 50% born w/TEF have other anomalies. Clinical and Surgical Emergency R/T risk for aspiration, management focuses on preventing aspiration. If TEF is suspected, keep HOB elevated.
Hernias (Pg. 1076 – 1077)
Hiatal (Pg. 1077, table) – Protrusion of abdominal structure (stomach) through the esophageal hiatus o Clinical manifestations: vomiting, coughing, wheezing, short periods of apnea, failure to thrive. Congenital Diaphragmatic Hernia (CDH) (Pg. 1077, table) o Opening in diaphragm where abdominal contents herniate into the thoracic cavity during prenatal development. Findings depend on severity Abdominal organs in chest Diminished/absent breath sounds on affected side Bowel sound may be heard over chest Cardiac sounds may be heard on right side of chest Respiratory distress soon after birth Management Place child in semi-Fowler position on affected side w/HOB elevated Maintain patency of NG Tube Umbilical Hernia (Pg. 1078) o Soft, skin covered protrusion of intestine around umbilicus
GERD (Pg. 1076 – 1081) Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media related to pooled secretions in the nasopharynx during sleep are the hallmarks of GERD. In addition, the infant w/pathologic GERD can experience weight loss, failure to thrive, irritability, discomfort, and abdominal pain. Severe GERD can result in hematemesis or melena and anemia. Frequently, Jennifer Cook
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respiratory illness or asthma is associated w/GERD, and the child may experience coughing, choking, asthma, wheezing, pneumonia, apnea, or bradycardia. Diagnostic tests include ambulatory PH studies. Acute Infectious Gastroenteritis (Pg. 1086 – 1090)
Caused by o Viruses o Bacteria o Parasites o Ingested w/contaminated food/water o Person-to-person contact Manifestations o Diarrhea of varying amount and consistency o Vomiting o Abdominal Pain o Dehydration can be a severe complication of this Care o Do not give OTC medication without calling M.D. o Avoid high-fat or high-sugar foods. Can continue breast milk or formula.
Appendicitis (Pg. 1090 – 1091) Sudden relief of pain – BAD SIGN – Appendix may have ruptured – Notify MD Immediately Pyloric Stenosis (Pg. 1095 – 1097) Circular area of muscle surrounding pylorus hypertrophies and obstructs gastric emptying (Obstructive Disorder).
Assessment o Movable, palpable, firm, olive-shaped mass in RUQ Hydration Status o No tears o Weak cry o Depressed fontanel o Poor skin turgor o Dry mucous membranes
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Intussusception (Pg. 1097 – 1099) Telescoping of a portion of bowel into another (usually terminal ileum into the ascending colon).
Assessment o Parent may relate acute, intermittent abdominal pain o Usually health child may present screaming and flexing legs in severe pain. o N/V o Distention o Hypo-Hyperactive bowel sounds o Palpable abdominal Mass Sausage shape in RUQ while RLQ is empty (Dance Sign) o Passage of “currant jelly” looking stools o Fever o Increased HR o If septic, change in LOC/blood pressure/respiratory distress = EMERGENCY.
Hirschsprung Disease (HD) (Pg. 1099 – 1102)
Congenital Aganglionosis (megacolon). Absence of parasympathetic ganglion cells in rectum/distal colon 1 in 5000; 4:1 male/female; hereditary; down’s syndrome Absence of meconium stool in neonate within 24 hours Chronic constipation (mechanical constipation) pellet like or ribbon stools w/foul smell. Absence of ganglionic cells in sample confirm diagnosis
Failure to Thrive (FTT) (Pg. 1493 – 1494)
Suspect FTT if: o Body weight falls below 5th percentile on growth charts Organic FTT Caused by: o An underlying physical problem Non-Organic FTT Possibility Causes o Poverty o Maternal depression o Poor Social support system o Poor bonding o Maladaptive interactions between child/mother o Irritable, resistant to touch infant o Maladaptive parent/infant relationship w/impaired skills in responding to infant’s needs o Infant has difficulty eliciting attention and appropriate care
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o Infant exhibits feeding difficulties o Parental anxiety w/difficulty in bonding emotionally w/child
Genitourinary System Alterations Cryptorchidism (Pg. 1126 – 1127)
Undescended or hidden testes Occurs when one or both testes fail to descend through the inguinal canal into scrotal sac.
Cardiovascular Infective Endocarditis (Pg. 1224 – 1226)
Lab Values o Elevated Erythrocyte Sedimentation Rate (ESR) detects nonspecific inflammation. o C-Reactive Protein: Normally undectectable: high level indicates acute infection or inflammation.
Rheumatic Fever (Pg. 1229 – 1231) Inflammatory condition, possibly autoimmune origin. Effects connective tissue. Occurs 2 to 6 weeks following untreated or partially treated Group A beta-hemolytic streptococcal infection of the upper respiratory tract “pharyngitis, sore throat.”
Assessment o Arthritis: Most Common Symptom Tender/warm/erythematous joints Occurs especially in large joints (Elbows, knees, ankles, and wrists) o Carditis: Most Dangerous Symptom o Subcutaneous non-tender nodules over joints o Increased C-Reactive Protein
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Kawasaki Disease (Pg. 1231 â&#x20AC;&#x201C; 1233)
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Sickle-Cell Disease (Pg. 1244 – 1250)
Thalassemia (Pg. 1250 – 1252) Genetic disorder (autosomal recessive) involving abnormal synthesis of alpha or beta chains of Hgb that alters red blood cell membrane decreasing the life of the cell. Musculoskeletal System Sprains and Strains (Pg. 1350 – 1351)
Therapy – RICE (rest, ice, compression, elevation)
Hip Dysplasia (Pg. 1358 – 1363)
Pavlik Harness – Maintains hips in flexion, abduction, and external rotation position. o Nursing Considerations (Pavlik Harness or Spica Cast) Monitor skin integrity under harness and around cast Assess for lower extremity circulation and pain o Parent Teaching Proper application of Pavlik harness Protect child’s skin and legs under harness Inspect skin for redness and irritated areas Reposition child often A long t-shirt or onesie should be placed under halter to reduce rubbing Diaper should go under the harness
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Muscular Dystrophy (Pg. 1367 â&#x20AC;&#x201C; 1369)
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Juvenile Rheumatoid Arthritis Autoimmune Inflammatory Disease (Pg. 1369 – 1372)
Can also be known as Juvenile Idiopathic Arthritis (JIA) One of the most common chronic diseases in children Leading cause of childhood disability Manifestations o Intermittent joint pain lasting > 6 weeks o Swelling in one or more joints Painful Stiffness Worse in am or after rest (“Gel Phenomenon”) Warm to touch Erythematous Limited ROM Diagnosis o Physical Exam includes Lab Markers such as C-Reactive Protein (CRP) Drug Therapy o Includes Methotrexate
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Endocrine or Metabolic Alterations Galactosemia (Pg. 1382)
Deficiency of galactose 1 phosphate uridylyl-transferase Prevents the conversion of galactose to glucose in lactose digestion so infants cannot digest milk properly
Tay-sachs Disease (Pg. 1382)
Causes an abnormal buildup of gangliosides in the neurons A defect in lipid metabolism Leads to mental retardation and other neurological defects Child generally appears normal in 1st few months At 6 months, begins to lose head control and is unable to sit or roll over Progressive neurological deterioration occurs o Macrocephaly o Seizures o Blindness o Deafness No cure or treatment
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Hypothyroidism vs. Hyperthyroidism
Congenital Hypothyroidism (Pg. 1383 – 1386)
Thyroid gland does not produce sufficient thyroid hormone to meet the body’s metabolic needs. Infant w/low T4 and elevated TSH greater than 100 mU/L is considered to have primary hypothyroidism until proven otherwise Mild Hypothyroidism: Newborn w/TSH level 20 to 100 mU/L Present from birth Affects 1 in 4000 live births in the US
Acquired Hypothyroidism (Pg. 1385)
Unlike congenital hypothyroidism, it is often reversible depending on the cause. S/S
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o Goiter o Dry, thick skin o Coarse, dull hair o Fatigue o Cold intolerance o Constipation o Weight gain o Decreased growth rate when grafted on a growth chart o Edema of face, eyes, and hands o Irregular or delayed menstruation Primary Hypothyroidism o Elevated TSH and Low T4
Hyperthyroidism (Grave’s Disease) (Pg. 1386 – 1387)
Autoimmune Disease Excessive thyroid hormones are produced by enlarged thyroid gland Affects 1 in 5000 children Elevated serum T4 Suppressed TSH levels
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Diabetes Insipidus (DI) (Pg. 1387 – 1389)
Central DI o Idiopathic (Unknown)
Infectious Diseases Lyme Disease (Pg. 1031)
Medications include: Doxycycline, amoxicillin, or cefuroxime.
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Health of Child Freud Stages of Development
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Best Way for N.P., Nurse, or M.D. to assess a 3 year old: Listen to the momâ&#x20AC;&#x2122;s heart 1st. Epiglottitis
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References http://www.atitesting.com/ati_next_gen/FocusedReview/data/datacontext/RM%20MN%20RN% 208.0%20Chp%209.pdf McKinney, E. (2013). Maternal-child nursing (Fourth ed.). St. Louis, Missouri: Elsevier/Saunders.
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