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Premature Rupture of Membranes (PROM)
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Premature Rupture of Membranes (PROM)
Definition
Premature rupture of membranes (PROM) is an event that occurs during pregnancy when the sac containing the developing baby (fetus) and the amniotic fluid bursts or develops a hole prior to the start of labor.
Definition
There are two types of PROM. One occurs at a point in pregnancy before normal labor and delivery should take place. This is called preterm PROM. The other type of PROM occurs at 36-40 weeks of pregnancy.
Definition
PROM occurs in about 10% of all pregnancies. Only about 20% of these cases are preterm PROM. Preterm PROM is responsible for about 34% of all premature births.
Etiology
The causes of PROM have not been clearly identified.
Some risk factors include: smoking, multiple pregnancies (twins, triplets, etc.) excess amniotic fluid (polyhydramnios). Amniocentesis - (a diagnostic test involving extraction
and examination of amniotic fluid) and cervical cerclage (a procedure in which the uterus is sewn shut to avoid premature labor).
Etiology
A condition called placental abruptio is also associated with PROM, although it is not known which condition occurs first.
In some cases of preterm PROM, it is believed that bacterial infection of the amniotic membrane causes it to weaken and then break.
Pathophysiology
• PROM is associated with malpresentation, possible weak areas in the amnion and chorion, subclinical infection, and, possibly, incompetent cervix.
• Basic and effective defense against the fetus contracting an infection is lost and the risk of ascending intrauterine infection, known as chorioamnionitis, is increased.
Pathophysiology
• The leading cause of death associated with PROM is infection.
• When the latent period (time between rupture of membranes and onset of labor) is less than 24 hours, the risk of infection is low.
Assessment
a. Evidence of fluid pooling in vaginal vault; nitrazine test positive
b. Amount, color, consistency and odor of fluid
c. Vital signs; elevated temperature may indicate presence of infection.
d. Fetal monitoring; tachycardia may indicate infection.
Medical Management
• Treatment of PROM depends on the stage of the patient’s pregnancy. In PROM occurring at term, the mother and baby will be watched closely for the first 24 hours to see if labor will begin naturally.
• If no labor begins after 24 hours, most doctors will use medications to start labor. This is called inducing labor. Labor is induced to avoid a prolonged gap between PROM and delivery because of the increased risk of infection.
Medications
CORTICOSTEROIDS
Corticosteroids decrease perinatal morbidity and mortality after preterm PROM. Corticosteroid is administered to hasten fetal lung maturity.
Medications
ANTIBIOTICS
Giving antibiotics to patients with preterm PROM can reduce neonatal infections may delay the onset of labor and reduce risk of infection in the newborn enough to allow the corticosteroid to have its effect.
Nursing ManagementA. Prevent infection and other potential
complications.
1. Make an early and accurate evaluation of membrane status, using sterile speculum examination and determination of ferning. Thereafter, keep vaginal examinations to a minimum to prevent infection.
2. Obtain smear specimens from vagina and rectum as prescribed to test for betahemolytic streptococci, an organism that increases the risk to the fetus.
Nursing Management
3. Determine maternal and fetal status, including estimated gestational age. Continually assess for signs of infection.
4. Maintain the client on bed rest if the fetal head is not engaged. This method may prevent cord prolapse if additional rupture and loss of fluid occur. Once the fetal head is engaged, ambulation can be encouraged.
Nursing ManagementB. Provide client and family education.
1. Inform the client, if the fetus is at term, that the chances of spontaneous labor beginning are excellent; encourage the client and partner to prepare themselves for labor and birth.
2. If labor does not begin or the fetus is judged to be preterm or at risk for infection, explain treatments that are likely to be needed.
Prognosis
• The prognosis in PROM varies. It depends in large part on the maturity of the fetus and the development of infection.
QUESTIONS
1. The nurse is evaluating a client who is 34 weeks pregnant for premature rupture of the membranes (PROM). Which findings indicate that PROM has occurred? Select all that apply:
i. Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry
ii. Acidic pH of fluid when tested with nitrazine paper
iii. Presence of amniotic fluid in the vagina
iv. Cervical dilation of 6 cm
v. Alkaline pH of fluid when tested with nitrazine paper
vi. Contractions occurring every 5 minutes
a. i, ii, iii, iv
b. i, iii, v
c. ii, iv, vi
d. iv, v, vi
Answer: B
Rationale: PROM is manifested by fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry; presence of amniotic fluid in the vagina and alkaline pH of fluid when tested with nitrazine paper
2. The fetal heart rate is checked following rupture of the bag of waters in order to:
a. Determine if there is utero-placental insufficiency
b. Check if the fetus is suffering from head compression
c. Check if fetal presenting part has adequately descended following the rupture
d. Determine if cord compression followed the rupture
Answer: B
Rationale: After the rupture of the bag of waters, the cord may also go with the water because of the pressure of the rupture and flow. If the cord goes out of the cervical opening, before the head is delivered (cephalic presentation), the head can compress on the cord causing fetal distress. Fetal distress can be detected through the fetal heart tone. Thus, it is essential do check the FHB right after rupture of bag to ensure that the cord is not being compressed by the fetal head.
3. A client tells the nurse that she suspects her amniotic membranes broke 2 hour ago. Because the goal of care for this client is to prevent infection, the care plan should include:
a. Assessing the fetal heart rate once every hour
b. Limiting vaginal examinations to once every hour
c. Assessing vital signs, especially temperature, every 4 hours
d. Confirming membrane rupture by using sterile speculum and cotton-tipped applicator to assess fluid.
Answer: D
Rationale: To prevent infection, the nurse must use sterile technique to assess amniotic fluid and thus confirm membrane rupture. The nurse should assess the fetal heart rate every 30 minutes because fetal tachycardia signals chorioamnionitis.
4. A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptures. When obtaining her history, what should the nurse ask about first?
a. The time of membrane rupture
b. The frequency of contractions
c. The presence of back pain
d. The presence of bloody show
Answer: A
Rationale: First, the nurse should ask the client when her membranes ruptured because the risk of perinatal infection increases with the time elapsed between membrane rupture and onset of contractions. After determining the time of membrane rupture, the nurse should ask about the frequency of contractions and find out whether the client has back pain or bloody show.
5. When PROM occurs, which of the following provides evidence of the nurse’s understanding of the client’s immediate needs?
a. The chorion and amnion rupture 4 hours before the onset of labor.
b. PROM removes the fetus most effective defense against infection
c. Nursing care is based on fetal viability and gestational age.
d. PROM is associated with malpresentation and possibly incompetent cervix
Answer: B
Rationale: PROM can precipitate many potential and actual problems; one of the most serious is the fetus loss of an effective defense against infection. This is the client’s most immediate need at this time. Typically, PROM occurs about 1 hour, not 4 hours, before labor begins. Fetal viability and gestational age are less immediate considerations that affect the plan of care. Malpresentation and an incompetent cervix may be causes of PROM.
6. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert?
a. Endometritis
b. Endometriosis
c. Salpingitis
d. Pelvic thrombophlebitis
Answer: A
Rationale: Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Endometriosis does not occur after a strong labor and prolonged rupture of membranes. Salpingitis is a tubal infection and could occur if endometritis is not treated. Pelvic thrombophlebitis involves a clot formation but it is not a complication of prolonged rupture of membranes.
7. When a client states that her "water broke," which of the following actions would be inappropriate for the nurse to do?
a. Observing the pooling of straw-colored fluid.
b. Checking vaginal discharge with nitrazine paper.
c. Conducting a bedside ultrasound for an amniotic fluid index.
d. Observing for flakes of vernix in the vaginal discharge.
Answer: C
Rationale: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining whether a client has ruptured membranes.
8. A nurse is reviewing the physician's orders for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which physician's order should the nurse question?
a. Perform a vaginal examination every shift.
b. Monitor maternal vital signs every 4 hours.
c. Monitor fetal heart rate (FHR) continuously.
d. Administer ampicillin 1 gm as an intravenous piggyback (IVPB) every 6 hours.
Answer: A
Rationale: Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to administer an antibiotic, monitor maternal vital signs, and monitor the FHR.
9. Which of the following situations is most likely to produce sepsis in the neonate?
a. Maternal diabetes
b. Prolonged rupture of membranes
c. Cesarean delivery
d. Precipitous vaginal birth
Answer: B
Rationale: Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.
10.A primipara is admitted in early labor, and her membranes rupture. Which of the following assessments by the nurse is MOST important?
a. Determine the pH of the amniotic fluid.
b. Evaluate the mother’s blood pressure.
c. Check the monitor for decelerations.
d. Assess for a prolapsed cord.
Answer: D
Rationale: The nurse’s initial assessment is to check for a prolapsed cord
Care of Newborn with Birth Defects
Definition
• Birth defects are defined as abnormalities of structure, function, or body metabolism that are present at birth.
• These abnormalities lead to mental or physical disabilities or are fatal.
Etiology
Birth defects can be caused by genetic, environmental, or unknown factors.
Common Birth Defects
Cleft lip and palate Esophageal atresia/tracheoesophageal fistula Omphalocele/gastroschisis Diaphragmatic hernia Neural tube defects Congenital hydrocephalus Inborn Error of Metabolism ( Galactosemia,
Phenylketonurea)
Cleft Lip and Palate
• Congenital anomaly. Occurs as result of failure of soft tissue or bony structure to fuse during fetal development, and can be unilateral or bilateral
• Cleft lip occurs at about 6 weeks and cleft palate occurs at about 9 weeks gestation
Cleft Lip and Palate
• Any child with one closure defect needs to be assessed for other anomalies
• Cleft lip occurs in 1 in 1000 live births and is more common in males
• Cleft palate occurs in 1 in 2500 live births and the incidence in girls is double that of boys
Cleft Lip and Palate
Treatment
Surgical plastic repair
• Cheiloplasty - Early is better than later b/c lip is important to infant feeding; Also improved appearance allows for easier bonding (typically at 4–8 wks).
Treatment
• Palatoplasty - usually between 4 to 18 months, may be up to 24 mosdepending on severity of defect; May have to do repair in stages
• May need dental referral, speech therapy
Nursing Management
• Provide emotional support to parents as well as appropriate education; It is helpful to show parents pictures of babies after repair
• Breastfeeding is to be encouraged but mom may need to express milk for several days or weeks; The expressed milk is helpful in preventing the ear infections which is common to cleft palate babies
Nursing Management
Feeding (Pre-op)Cleft lip only -no big feeding problemsCleft palate: hold baby upright and feed
slowly -burp oftenMay use specialized feeder or
gavagefeedingsKeep suction equipment, bulb syringe at
bedsideAssess respiratory status continuously
during feedings
Nursing ManagementPost-op Care
Often only NPO for 4 hours after repairNo milk for first feedings -adheres to
sutures; Offer clear water after feeding to clean sutures
Cleft lip repairs may have Elbow restraints
Nursing Management
Post-op Care
Avoid crying (cuddle, provide analgesics), position on side lateral or on back
Assess circulation every 30 minutes; Avoid contact with sharp objects near surgical site
Tracheoesophageal Atresia or Fistula
Congenital or acquired communication between the trachea and esophagus
Often lead to severe and fatal pulmonary complications
Incidence of 1 case in 2000-4000 live births
Tracheoesophageal Atresia or Fistula
Most patients are diagnosed immediately following birth or during infancy
Often associated with life-threatening complications, so they are usually diagnosed in the neonatal period
Causes
Congenital
No definite cause identified Trisomy 13, 18 and 21 are often
associated
CausesAcquired
Malignant disease Infection Ruptured diverticula Trauma. Postintubation TEF Prolonged mechanical ventilation with an
endotracheal or tracheostomy tube
Tracheoesophageal Atresia or Fistula
Clinical Manifestations
3C’s
Choking on 1st feedingCoughingCyanosis
Clinical Manifestations
Absence of stomach gas on prenatal ultrasound Copious, fine white frothy bubbles of mucus in the mouth and noseIn the presence of a TEF, abdominal
distention may occur secondary to collection of air in the stomach
Diagnostics
A. Prenatal diagnosis of congenital TEF:
1. Prenatal UTZPolyhydramniosAbsence of fluid-filled stomachSmall abdomenLower-than-expected fetal weightDistended esophageal pouch
Diagnostics
B. Postnatal Diagnosis of Congenital TEF
1. Plain chest radiographs
Tracheal compression and deviationAbsence of a gastric bubbleAspiration pneumonia in the posterior
segments of the upper lobeRecurrent or massive aspiration may
lead to acute lung injury in some patients
Diagnostics
B. Postnatal Diagnosis of Congenital TEF
2. Contrast studies
- detect spilling of the contrast into the trachea
3. Insertion of a nasogastric tube
Diagnostics
C. Diagnosis of acquired TEF
1. Instillation of contrast media into the esophagus
2. Direct visualization by flexible esophagoscopy or bronchoscopy
Diagnostics
Surgical Management
Surgical repair is required following confirmation of a diagnosis of TEF
Management
In healthy infants without pulmonary complications, primary repair is performed within the first few days of life
Repair is delayed in patients with low birth weight, pneumonia, or other major anomalies
Management
Initially, treat patients conservatively with parenteral nutrition, gastrostomy, and upper pouch suction until they are considered to be low risk.
Preoperatively, a cuffed endotracheal tube is placed distal to the fistula site in order to prevent reflux of gastric contents into the lungs
Management
The head of the bed is elevated, and oral secretions are frequently suctioned
A gastrostomy tube is placed to minimize gastroesophageal reflux
A jejunostomy feeding tube is placed for nutritional purposes
Abdominal Wall Defects - Omphalocele
Omphalocele is the herniationof abdominal contents through umbilical ring.
Abdominal Wall Defects - Omphalocele
Management:• Immediately after birth, sac covered with
sterile gauze soaked in normal saline• Preoperatively: Maintain NPO status,
administer IV fluids, monitor for signs of infection, handle infant carefully
Abdominal Wall Defects –Gastroschisis
Gastroschisis is the herniation of intestine, lateral to umbilical ring
Abdominal Wall Defects –Gastroschisis
Management Exposed bowel covered loosely in saline-soaked
pads, with abdomen wrapped in plastic drape Preoperatively: Care similar to that of
omphalocele, with surgery performed within several hours after birth
Postoperatively: Perform measures to control pain, infection, fluid and electrolyte imbalances; provide nutrition as prescribed
Neural Tube Defects
Failed closure of neural tube
May involve entire length of the neural tube or small portion
Incidence (more girls than boys) 50% or more is caused by folic acid
deficiency
Spina Bifida
Congenital defect of the neural tube-vertebral arches of the spinal vertebrae
Happens during embryological development
Spina Bifida
Spina Bifida
Nursing Management
• Protect sac by covering with sterile, moist, non adherent dressing; change every 2 to 4 hours to prevent infection. Prevent stool contamination
• Serial measurement of the head circumference is essential.
Nursing Management
• The infant should be referred immediately to a neurosurgeon experienced in dealing with such cases.
• Prone position• Aseptic technique
Hydrocephalus
Results in head enlargement (prior to fontanels closing), increased ICP ( water head baby)
Hydrocephalus
TYPES:
• Communicating: Result of impaired absorption within subarachnoid space
• Noncommunicating: Obstruction of cerebrospinal fluid (CSF) flow within ventricular system
Clinical Manifestations
• Bulging anterior fontanelle& split sutures.
• Eyes deviated downward “Sunset eyes”
• Distended scalp veins• High-pitched cry
• Irritability• Poor feeding• Increasing head
circumference• Change in level of
consciousness• Neurological reflexes
inappropriate
Treatment
• Placement of shunt within 6 months to drain CSF from the ventricles to another part of the body (VPS or VA shunt).
• Surgical closure of back lesion 24-48 hrs after birth
Nursing Care Management
• Watch for increased ICP signs and symptoms
• Prevent infection• Avoid scalp vein IV’s• Observe for abdominal distention• Family support• Education
Nursing Care Management
Preoperative interventionsNPO statusReposition head frequently to prevent
pressure sores
Postoperative interventions Position on unoperativeside to prevent
pressure on shunt valve & keep flatObserve for increased ICP; if present,
elevate head of bed 15 to 30 degrees
QUESTIONS
1. The nurse is seeing several pregnant women at a community health clinic. Which woman is at highest risk for having a low-birth weight infant or one with birth defects, and is in need of prenatal education?
a. A 25-year-old woman who smokes and drinks two beers a day
b. An 18-year-old woman who is in her eighth month and has gained 22 pounds
c. A 30-year-old woman who was 10 pounds overweight before becoming pregnant
d. A 32-year-old, unmarried middle class executive secretary
Answer: A
Rationale: Smoking during pregnancy can cause low birth weight, stillbirths, sudden infant death syndrome, cleft palates, and cleft lips. Alcohol use increases risk of low birth weight, developmental and behavioral abnormalities, spontaneous abortion, and stillbirth. Weight gains of less than 21 pounds during pregnancy; being underweight, not overweight before pregnancy; maternal age of 16 or younger or 35 and older; and low socioeconomic status are also some risk factors.
2. A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:
a. Because it is a state law
b. To detect cardiovascular defects
c. Because of her age
d. To detect neurological defect
Answer: D
Rationale: Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida. The test is not mandatory, as stated in answer A. It does not indicate cardiovascular defects, and the mother’s age has no bearing on the need for the test, so answers B and C are incorrect.
3. Which intervention would the nurse include in care of an infant following surgical repair of a cleft lip?
a. Administer pain medications as ordered.
b. Use a special feeding device with shorter nipples.
c. Position the infant in the supine position for feedings, to avoid aspiration.
d. Let the infant touch the suture lines as a means of self-comforting.
Answer: A
Rationale: Special feeding devices with long nipples usually are used, and the infant is fed in the sitting position to avoid aspiration. Some soft restraints may be used to prevent the infant from touching the suture line.
4. Which assessment finding would lead the nurse to suspect esophageal atresia in an infant?
a. Excessive crying
b. Abdominal distention
c. Hypotonicity
d. Excessive drooling
Answer: D
Rationale: The classic symptom in an infant with esophageal atresia is excessive drooling, often accompanied by cyanosis, choking, and coughing. Low blood pressure, excessive crying, and hypotonicity are not common signs of esophageal atresia.
5. Which intervention would not be included in the preoperative plan of care for an infant with an omphalocele?
a. Push the exposed abdominal contents back into the abdomen.
b. Assess for signs of other congenital anomalies.
c. Administer intravenous fluids.
d. Care for the infant in a radiant warmer.
Answer: A
Rationale: Care of an infant with an omphalocele (a congenital malformation where the abdominal contents herniate through the umbilical cord covered by a translucent sac) is aimed at protection of abdominal contents. Aggressive attempts at replacing the abdominal contents can lead to numerous problems, including increased abdominal pressure, impaired respiratory status, and bowel perforation. The goals should be to protect the infant from hypothermia, replace fluids, prevent infection, and look for other associated anomalies.
6. Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus?
a. Measuring head circumference
b. Obtaining skull X-ray
c. Performing a lumbar puncture
d. Magnetic resonance imaging (MRI)
Answer: A
Rationale: Measuring the head circumference is the most important assessment technique for recognizing possible hydrocephalus, and is a key part of routine infant screening. Skull X-rays and MRI may be used to confirm the diagnosis. A lumber puncture isn’t appropriate.
7. Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site?
a. Avoid touching the suture line, even when cleaning.
b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infant’s arms in soft elbow restraints.
Answer: D
Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such as objects as pacifiers, suction catheters, and small spoons shouldn’t be placed in a baby’s mouth after cleft repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair.
8. The student nurse is assigned to take the vital signs of the clients in the pediatric ward. The student nurse reports to the staff nurse that the parent of a toddler who is 2 days postoperative after a cleft palate repair has given the toddler a pacifier. What would be the best immediate action of the nurse?
a. Notify the pediatrician of this finding
b. Reassure the student that this is an acceptable action on the parent’s part
c. Discuss this action with the parents
d. Ask the student nurse to remove the pacifier from the toddler’s mouth
Answer: C
Rationale: Nothing must be placed in the mouth of a toddler who just undergone a cleft palate repair until the suture line has completely healed. It is the nurse’s responsibility to inform the parent of the client. Spoon, forks, straws, and tongue blades are other unacceptable items to place in the mouth of a toddler who just undergone cleft palate repair. The general principle of care is that nothing should enter the mouth until the suture line has completely healed.
9. The nurse is caring for a newborn boy who has hypospadias. His parents are planning to have the baby circumcised before discharge. When teaching the parents about their child's condition, the nurse should tell them:
a. the baby can still be circumcised as planned.
b. the foreskin will be needed at the time of surgical correction.
c. circumcision is necessary because the foreskin obstructs the urethral meatus.
d. circumcision will correct the hypospadias.• .
Answer: B Rationale: Circumcision is the surgical removal of the foreskin of the penis. In hypospadias, the urethral meatus is on the underside of the penis. A newborn with hypospadias shouldn't be circumcised because the surgeon may use the foreskin for surgical repair. The foreskin doesn't block the urethral meatus, which may be located near the glans, along the underside of the penis, or at the base. Circumcision doesn't correct hypospadias because the location of the urethral meatus isn't changed during circumcision
10.When performing a physical examination on an infant, the nurse notes abnormally low-set ears. This finding is associated with:
a. otogenous tetanus.
b. tracheoesophageal fistula.
c. congenital heart defects.
d. renal anomalies.
Answer: D Rationale: Normally, the top of the ear aligns with an imaginary line drawn across the inner and outer canthus of the eye. Ears set below this line are associated with renal anomalies or mental retardation. Low-set ears don't accompany otogenous tetanus, tracheoesophageal fistula, or congenital heart defects.
Prematurity
Definition
A preterm infant is usually defined as a live-born infant born before the end of 37 week of gestation with weight of less than 2,500 g (5 lb 8 oz) at birth
Incidence
Occurs approximately 7% of live births of white infants. In African-American infants, the rate is doubled to approximately 14%.
Risk Factors• Stress
Single women Low socioeconomic status Anxiety Depression Life events (divorce, separation, death) Abdominal surgery during pregnancy
• Occupational fatigue Upright posture Use of industrial machines Physical exertion Mental or environmental stress
Risk Factors• Excessive or impaired uterine distention
Multiple gestationPolyhydramniosUterine anomaly
• Cervical factors History of second trimester abortion History of cervical surgery Premature cervical dilatation or effacement
• Infection Sexually transmitted infections Pyelonephritis, appendicitis, Systemic infection
Risk Factors• Placental pathology Placenta previa Placenta Abruptio Vaginal bleeding
• Fetal factors Congenital anomaly Growth restriction
• Miscellaneous Previous preterm delivery Substance abuse Smoking Maternal age (<18 or >40)
African-American race Poor nutrition and low body
mass index Inadequate prenatal care Anemia (hemoglobin <10
g/dL) Excessive uterine
contractility Low level of educational
achievement Genotype
Preterm Infant
Alterations in Respiratory System
• Surfactant deficiency - Neonatal respiratory distress syndrome (RDS )
• Unstable chest wall - atelectasis• Immature respiratory centers - apnea• Small passages - obstructions• Unable to clear fluid -Transient Tachypnea
of the Newborn (TTN)
A 6-day-old, 28 weeks’ gestational age, 960-g preterm infant.
Preterm Infant
Cardiovascular• Difficulty transitioning from fetal to
neonatal circulatory pattern• Greater risk for the ductus arteriosis to
remain open• Fragile blood vessels (brain)• Impaired regulation of B/P
Mother breastfeeding her premature infant
Preterm Infant
Gastrointestinal• Lack neuromuscular coordination suck-
swallow-breath• Hypoxia shunts blood from the gut-
ischemia and intestinal wall damage • Risk for malnutrition -weight loss• Small stomach-compromised metabolic
function
Measuring gavage tube length
Auscultation for placement of gavage tube
Preterm Infant
Renal System
• Slow glomerular filtration rate• Reduced ability to concentrate urine• Risk: fluid retention, electrolyte
imbalance, drug toxicity
An 8-day-old, 30 weeks’ gestational age, 860-gram IUGR infant is “nested.” Hand-to-face behavior facilitates self-
consoling and soothing activities.
Preterm Infant
Immune system
• Deficiency of IgG • Impaired ability to produce antibodies• Thin skin- limited protection barrier
Preterm Infant
Central nervous system - Thermogenesis
• Long term disability due to injury• Difficulty maintaining temperature• Compounded by lack of brown fat
Infants who do not require resuscitation are immediately transferred in a heated incubator to the NICU. where:
Respiratory support. Temperature regulation. Nutrition. Prevent infection. Provide stimulation
Therapeutic management
Kangaroo (skin-to-skin) care facilitates a closeness and
attachment between parents and their premature infant.
Family bonding occurs when parents have
opportunities to spend time with
their infant.
QUESTIONS
1. A nurse in a newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs, if noted in the newborn infant, would alert the nurse to the possibility of this syndrome?
a. Tachypnea and retractions
b. Acrocyanosis and grunting
c. Hypotension and bradycardia
d. Presence of a barrel chest with acrocyanosis
Answer: A
Rationale: The newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is the bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is not uncommon in the first few hours of life.
2. A nurse in the newborn nursery is caring for a neonate. On assessment, the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse prepares to administer this therapy by:
a. Intravenous injection
b. Subcutaneous injection
c. Intramuscular injection
d. Instillation of the preparation into the lungs through an endotracheal tube
Answer: D
Rationale: The aim of therapy in respiratory distress syndrome is to support the disease until the disease runs its course, with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.
3. You’re assessing a neonate who has a persistent low body temperature. You should evaluate the neonate for which of the following conditions?
a. Infection
b. Thyroid disorder
c. Ocular hemorrhage
d. Developmental delay
Answer: A
Rationale: A neonate with an infection cannot maintain thermoregulation. An inability to maintain temperature may be the first sign of infection.
4. You’re caring for a 28-week preterm infant. You carefully monitor the infant’s oxygen levels to prevent which complication of Oxygen therapy?
a. Pulmonary hypertension
b. Respiratory distress syndrome
c. Retinopathy of prematurity
d. Patent ductus areteriosus
Answer: C
Rationale: Excessive oxygen administration to the preterm infant can cause retinal detachment and blindness or retinopathy of prematurity.
5. The physician has ordered indomethacin (Indocin) to be administered to a preterm neonate with patent ductus arteriosus. You explain to the parents that this drug is used to:
a. Slow the heart rate
b. Maintain peripheral oxygenation
c. Close the ductus
d. Increase cardiac output
Answer: C
Rationale: Patent ducuts arteriosus is persistence of the opening between the pulmonary artery and the aorta. Indomethacin is a prostaglandin inhibit that’s commonly prescribed for preterm neonates to close a patent ductus.
6. When taking care of Louella who smokes, your intervention should focus on: risk for fetal injury resulting from maternal smoking. You inform her about the hazards of smoking which include:
7. High incidence of premature birth
8. Increased incidence of SIDS
9. Heart defects
10. Low birth weight of infants
a. 1,2,4
b. 1,3,4
c. 1,2,3,4
d. 2,3,4
Answer: C
Rationale: Smoking puts the fetal life in danger, Prematurity; low birth weight; increased risk for sudden infant death syndrome; increasedrisk for bronchitis, pneumonia, developmental delays, heart defects are effects of maternal cigarette smoking.
7. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants?
a. Contains less lactose
b. Is higher in calories/ounce
c. Provides antibodies
d. Has less fatty acid
Answer: C
Rationale: Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest, therefore less residual is left in the infant's stomach.
8. Which of the following is the most appropriate intervention to reduce stress in a preterm infant at 33 weeks gestation?
a. Sensory stimulation including several senses at a time
b. tactile stimulation until signs of over stimulation develop
c. An attitude of extension when prone or side lying
d. Kangaroo care
Answer: D
Rationale: Kangaroo care is the use of skin-to-skin contact to maintain body heat. This method of care not only supplies heat but also encourages parent-child interaction.
9. A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is under the hood, it would be appropriate for nurse Gian to:
a. Hydrate the infant q15 min
b. Put a hat on the infant’s head
c. Keep the oxygen concentration consistent
d. Remove the infant q15 min for stimulation
Answer: B
Rationale: Oxygen has cooling effect, and the baby should be kept warm so that metabolic activity and oxygen demands are not increased.
10.The newborn boy, Willy, was being bathed in the nursery by the nurse. She did not have to look at Willy’s papers to know that he was close to term. She recognized several features characteristic of term babies. Which of these findings would indicate the likelihood of a term infant?
a. Abundant lanugo
b. Flat areola
c. Good flexion
d. Scarf sign that is past midline
Answer: C
Rationale: Term infants are characterized by a well-flexed body and good muscle tone. Abundant lanugo (a) is a characteristic of preterm infants, as is a flat areola (b), and a scarf sign past midline (d).
Gestational Diabetes
Description
Gestational diabetes is abnormal carbohydrate, fat, and protein metabolism that is first diagnosed during pregnancy, regardless of the severity.
GDB is a possible signal of an increased risk for type 2 diabetes later in life
Description
Gestational diabetes is further classified as:– Gestational diabetes characterized by an abnormal
glucose tolerance test (GTT) without other symptoms. Fasting glucose is normal and the diabetes is controlled by diet (A1).
– Gestational diabetes characterized by abnormal glucose tolerance test and elevated fasting glucose. This type of gestational diabetes must be controlled by insulin (A2).
Etiology
• Gestational diabetes is a disorder of late pregnancy (typically), caused by the increased pancreatic stimulation associated with pregnancy.
Risk Factors
Obesity Age over 25 years old History of large babies (10 lb or more) History of unexplained fetal or perinatal
loss History of congenital anomalies in
previous pregnancies Family history of diabetes
Pathophysiology
• In gestational diabetes mellitus (type III, GDM), insulin antagonism by placental hormones, human placental lactogen, progesterone, cortisol, and prolactin leads to increased blood glucose levels. The effect of these hormones peaks at about 26 weeks’ gestation. This is called the diabetogenic effect of pregnancy.
• The pancreatic beta cell functions are impaired in response to the increased pancreatic stimulation and induced insulin resistance.
Pathophysiology
• Pregnancy complicated by diabetes puts the mother at increased risk for the development of complications, such as spontaneous abortion, hypertensive disorders, and preterm labor, infection, and birth complications.
Pathophysiology
• The effects of diabetes on the fetus include hypoglycemia, hyperglycemia, and ketoacidosis. Hyperglycemic effects can include:
a. Congenital defects b. Macrosomia c. Intrauterine growth restriction d. Intrauterine fetal death e. Delayed lung maturity f. Neonatal hypoglycemia g. Neonatal hyperbilirubinemia
Assessment Findings Poor obstetric history, including spontaneous
abortions, unexplained stillbirth, unexplained hydramnios, premature birth, low birth weight or birth weight exceeding 4,000 g (8lb, 13 oz), and birth of a newborn with congenital anomalies. Common clinical manifestations include: Glycosuria on two successive office visits
Recurrent monilial vaginitis Macrosomia of the fetus on ultrasound Polyhydramnios
Laboratory and diagnostic study findings.
• Fasting blood sugar test will reveal elevated blood glucose levels.
• A 50-g glucose screen (blood glucose level is measured 1 hour after client ingests a 50-g glucose drink) reveals elevated blood glucose levels. The normal plasma threshold is 135 to 140 mg/dL.
Laboratory and diagnostic study findings
• A 3- hour oral glucose tolerance test (performed if 50-g glucose screen results are abnormal) reveals elevated blood glucose levels. (Table 1)
• The glycosylated hemoglobin (HbA 1c) test (measures glycemic control in the 4 to 8 weeks before the test is performed; The upper normal level of HbA1c is 6% of total hemoglobin.
Screens for fetal (and later, neonatal) complications, including:
Maternal serum alpha-fetoprotein level to assess risk for neural tube defects in newborn.
Ultrasonography to detect fetal structural anomalies, macrosomia, and hydramnios.
Nonstress test (as early as 30 weeks), contraction stress test, and biophysical profile because of risk of unexplained intrauterine fetal demise in the antepartum period.
Lung maturity studies (by amniocentesis) to determine lecithinsphingomyelin (L/S) ratio and to detect phosphatidylglycerol (PG); the adequacy of L/S and PG, predictor of the newborn’s ability to avoid respiratory distress
Nursing Management
1. Establish an initial database, and maintain serial documentation of test results throughout the pregnancy.
2. Provide client and family teaching. Assess the client’s understanding of GDM and its
implications for daily life. As needed, explain the effects of gestational diabetes on
the mother and fetus. Point out the need for frequent laboratory testing and
follow-up for mother and fetus, for example, to prevent infection and assess other potential complications.
Discuss and demonstrate insulin self-injection
Nursing Management
Demonstrate how to self-monitor blood glucose level. Explain that blood is generally tested daily before meals and at bedtime.
Explain the need to test urine for ketones, which are harmful to the fetus.
Point out the importance of keeping daily records of blood glucose values, insulin dose, dietary intake, periods of exercise, periods of hypoglycemia, kind and amount of treatment, and daily urine test results.
Nursing Management Discuss potential complications and their management.
– Diabetic ketoacidosis is a multisystem disorder resulting from hyperglycemia in which plasma glucose levels exceed 350 mg/dL.
– Hypoglycemia is a disorder caused by too much insulin, insufficient food, excess exercise, diarrhea, or vomiting.
(a) Discuss the management of hypoglycemia by administering 12 fluid oz of orange juice (or 20 g of carbohydrates) and waiting 20 minutes before repeating the procedure.
(b) Report the episode to the health care provider as soon as possible.
Explain the need for continued evaluation during the postpartum period until blood glucose levels are within normal limits.
HYPOGLYCEMIA HYPERGLYCEMIA
•Shakiness, dizziness•Sweating•Pallor, cold, clammy skin•Disorientation, irritability•Headache•Hunger•Blurred vision•Nervousness•Weakness, fatigue•Shallow respirations, but normal pulse rate•Urine negative for glucose and acetone•Blood glucose level below 60 mg/dL
•Fatigue•Flushed, hot skin•Dry mouth, excessive thirst•Frequent urination•Rapid, deep respirations, fruity odor•Depressed reflexes•Drowsiness, headache
Client and Family Teaching on the signs and symptoms of Hypoglycemia and
Hyperglycemia
Nursing Management
3. Arrange for the client to consult with a dietitian to discuss the prescribed diabetic diet and to ensure adequate caloric intake
CATEGORY KCAL/LB PER DAY
TOTAL GAIN
Adult 16.4 24-30 lb
Adolescent 20.5 30 lb
Underweight 22.7 30 lb
Obese 13.6 20 lb
Generally recommended Caloric Intake for Pregnant Diabetic Women
Nursing Management4. Address emotional and psychosocial needs. Intervene
appropriately to allay anxiety regarding diabetes and childbirth.
5. Prepare the client for intensive frequent intrapartum assessment, which may include:
Fetal monitoring Intravenous infusion of glucose, insulin, and oxytocin Evaluation for diabetic ketoacidosis (signs and symptoms include
altered level of consciousness, labored breath sounds, fruity breath odor, and ketonuria)
Intravenous fluid and electrolyte replacement therapy Invasive maternal cardiac monitoring
6. Identify and make referral to support groups and resources available to the client and family.
QUESTIONS
1. The antepartum patient is being routinely screened for gestational diabetes by administering 50 mg of glucose and testing the woman’s blood sugar in an hour. The patient asks for the normal glucose values an hour after taking the glucose. The nurse replies:
a. “It should be less than 140 or we do further testing.”
b. “Anything under 105 is acceptable.”
c. “We like to see a result between 130 and 165.”
d. “It is different for each individual.”
Answer: A
Rationale: In the glucose challenge test, which isused to screen for diabetes in pregnancy, a reading of 140 or over should be followed by the glucose tolerance test. A glucose level less than 105 is a good reading for a fasting blood glucose, and between 130 and 165 includes readings between 140 and 165, which are considered high. The blood sugar guidelines apply to all patients and are not different for each individual.
2. The nurse is doing a community blood glucose screening and gets a reading of 206 when testing an overweight woman. Upon questioning, the woman has a history of two macrosomic infants and complains of fatigue, constant hunger and thirst, as well as frequent urination. The nurse refers her for further screening and treatment, since it is likely she suffers from:
a. type I diabetes.
b. type II diabetes.
c. hypoparathyroidism.
d. Graves’ disease
Answer: B
Rationale: The woman’s blood sugar reading,weight, history of large babies and symptoms of fatigue, hunger, thirst, and frequent urination are all highly suggestive of diabetes. Type I diabetes usually presents earlier in life, and its symptoms are not as subtle. They are not usually overweight when diagnosed, nor do they have large babies. Hypoparathyroidism involves the body’s calcium/phosphorus balace, and Graves’ disease is a hyperthyroid condition.
3. A population group that should be given attention by the community health nurse is obese women who became pregnant. Obesity is responsible for what pregnancy complications?
a. Prematurity
b. Anemia
c. Gestational diabetes
d. Spontaneous abortion
Answer: C
Rationale: Gestational diabetes is a condition of abnormal glucose metabolism that arises during pregnancy. Obesity is one of the major risk factor of Gestational DM.
4. You’re assessing the neonate of a mother with diabetes. The neonate has a serum glucose level of 60 mg/dl. What other laboratory data do you anticipate the physician to order?
a. Serum chloride
b. Complete blood count
c. Serum magnesium
d. Serum calcium
Answer: D
Rationale: A neonate born to a mother with diabetes is at risk for calcium imbalance because he may have an immature parathyroid gland. Apnea, seizures, irritability and nervousness are common symptoms of both hypocalcemia and hypoglycemia.
5. Which of the following complications is not related to the presence of maternal diabetes mellitus?
a. Macrosomia
b. Birth trauma
c. Breech presentation
d. Congenital anomalies
Answer: C
Rationale: Fetal position is unrelated to the presence of maternal diabetes. Congenital anomalies, macrosomia and birth trauma are all associated with maternal diabetes mellitus.
6. A client with type 1 diabetes mellitus who’s a multigravida visits the clinic at 27 weeks gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus:
a. Weekly fetal movement counts are made by the mother.
b. Contraction stress testing is performed weekly.
c. Induction of labor is begun at 34 weeks’ gestation.
d. Nonstress testing is performed weekly until 32 weeks’ gestation
Answer: D
Rationale: For most clients with type 1 diabetes mellitus, nonstress testing is done weekly until 32 weeks’ gestation and twice a week to assess fetal well-being.
7. When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following instructions would be the priority?
a. Dietary intake
b. Medication
c. Exercise
d. Glucose monitoring
Answer: A
Rationale: Although all of the choices are important in the management of diabetes, diet therapy is the mainstay of the treatment plan and should always be the priority. Women diagnosed with gestational diabetes generally need only diet therapy without medication to control their blood sugar levels.
8. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
a. The client’s urine test is positive for glucose and acetone.
b. The client has 1+ pedal edema in both feet at the end of the day.
c. The client complains of an increase in vaginal discharge.
d. The client says she feels pressure against her diaphragm when the baby moves.
Answer: A
Rationale: Option A is an abnormal finding; it could indicate gestational diabetes (GDM) and hazard of placental insufficiency.
9. A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
a. Insulin requirements moderate as the pregnancy progresses
b. A decresed need for insulin occurs during the second trimester
c. Elevation in HCG decrease the need for insulin
d. Fetal development depends on adequate insulin regular
Answer: D
Rationale: Fetal development depends on adequate nutrition and insulin regulation. Insulin needs increase during the 2nd and 3rd trimesters, insulin requirements do not moderate as the pregnancy progresses, and elevated HCG elevates insulin needs, not decreases them.
10.The nurse is caring for a 26-year-old woman immediately after delivery of an 8 lb 4 oz baby girl. The patient’s history indicates she was diagnosed with type I diabetes mellitus (IDDM) at age 12. The nurse would expect which of the following changes to occur in the patient?
a. The blood sugar will fall due to a sudden decrease in insulin requirements.
b. The blood sugar will rise due to a rapid decrease in circulating insulin.
c. The blood sugar will gradually rise due to a decreased level of metabolic stress.
d. The blood sugar will gradually fall due to a decrease in food intake.
Answer: A
Rationale: Hormonal interference in glucose metabolism during pregnancy causes insulin requirements to increase then decrease after delivery
Breech Presentation
Introduction
• Breech presentation occurs in 3-4% of all deliveries. The occurrence of breech presentation decreases with advancing gestational age. Breech presentation occurs in 25% of births that occur before 28 weeks’ gestation, in 7% of births that occur at 32 weeks, and 1-3% of births that occur at term.
Perinatal mortality is increased 2- to 4-fold with breech presentation, regardless of the mode of delivery. Deaths most often are associated with malformations, prematurity, and intrauterine fetal demise.
Position of fetus in which buttocks alone (frank breech), buttocks and feet (complete breech), or one or both feet (footling) descend through the birth canal first.
Maternal implication cesarean birth may be required especially in primigirivda
Fetal implications Increased mortality Occurrence of prolapsed cord leading to asphyxia Birth trauma such a brachial palsy and fracture of the
upper extremities.
Definition
Predisposing Factors
prematurity, uterine abnormalities (eg, malformations,
fibroids), fetal abnormalities (eg, CNS
malformations, multiple gestations.
Types of breeches
• Frank breech (50-70%) - Hips flexed, knees extended
• Complete breech (5-10%) - Hips flexed, knees flexed
• Footling or incomplete (10-30%) - One or both hips extended, foot presenting
Positions
Assessment Findings
• Recognition of breech presentation on performing Leopold's maneuvers and vaginal examination
• Auscultation of fetal heart tones above umbilicus
• Presence of meconium without signs of fetal distress
Nursing Diagnosis
o Pain related to prolonged posterior pressure of fetal buttocks
o Risk for maternal or neonatal injury related to difficult to birth
o Risk for suffocation of fetus related to interruption in umbilical blood flow because of umbilical cord compression
Nursing Management1. Use measures to promote comfort
2. Monitor to FHR in upper quadrants
3. Watch of prolapsed cord if it occurs With a sterile gloved hand push the presenting part
off the cord. Place the client in the Trendelenburg position to keep
presenting part away from the cord. Keep prolapsed cord moist with sterile saline
4. Observe for frank meconium, results from contractions of the uterus on lower colon of the fetus not significant in breech birth
•
Nursing Management
5. Add piper forceps to the deliver setup if vaginal birth is anticipated.
6. Prepare clients for cesarean birth usually done in primigravidas
7. Teach mother and partner about the process of breech birth
QUESTIONS
1. You performed the Leopold’s maneuver and found the following: breech presentation, fetal back at the right side of the mother. Based on these findings, you can hear the fetal heart beat (PMI) BEST in which location?
a. Left lower quadrant
b. Right lower quadrant
c. Left upper quadrant
d. Right upper quadrant
Answer: B
Rationale: Right lower quadrant. The landmark to look for when looking for PMI is the location of the fetal back in relation to the right or left side of the mother and the presentation, whether cephalic or breech. The best site is the fetal back nearest the head.
2. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had:
a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation.
Answer: D
Rationale: This type of client has no obstetrical indication for a caesarean section as she did with her first caesarean delivery.
3. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas?
a. Above the maternal umbilicus and to the right of midline
b. In the lower-left maternal abdominal quadrant
c. In the lower-right maternal abdominal quadrant
d. Above the maternal umbilicus and to the left of midline
Answer: D
Rationale: With this presentation, the fetal upper torso and back face the left upper maternal abdominal wall. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. The other positions would be incorrect.
4. A patient is in labor and has just been told she has a breech presentation. The nurse should be particularly alert for which of the following?
a. Quickening
b. Ophthalmia neonatorum
c. Pica
d. Prolapsed umbilical cord
Answer: D
Rationale: In a breech position, because of the space between the presenting part and the cervix, prolapse of the umbilical cord is common. Quickening is the woman’s first perception of fetal movement. Ophthalmia neonatorum usually results from maternal gonorrhea and is conjunctivitis. Pica refers to the oral intake of nonfood substances.
5. An 18-year-old woman comes to the physician’s office for a routine prenatal checkup at 34 weeks gestation. Abdominal palpation reveals the fetal position as right occipital anterior (ROA). At which of the following sites would the nurse expect to find the fetal heart tone?
a. Below the umbilicus, on the mother’s left side.
b. Below the umbilicus, on the mother’s right side.
c. Above the umbilicus, on the mother’s left side.
d. Above the umbilicus, on the mother’s right side.
Answer: B
Rationale: Occiput and back are pressing against right side of mother’s abdomen; FHT would be heard below umbilicus on right side. Option C and D can be found on breech presentations.
6. A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Of the following interventions, which is the lowest priority in planning the nursing care of this client?
a. Measure fundal height.
b. Attach electronic fetal monitoring.
c. Prepare the client for a possible cesarean section.
d. Visually examine the perineum and vaginal opening.
Answer: A
Rationale: Intrapartum management and assessment require careful attention to maternal and fetal status. The fetuses should be monitored by dual electronic fetal monitoring, and any signs of distress need to be reported to the physician or health care provider. A cesarean section may be necessary if a fetus is breech. The nurse should examine the perineum and vaginal opening visually for signs of the cord, which sometimes will prolapse through the cervix.
7. During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
a. Right breech presentation
b. Right occipital anterior presentation
c. Left sacral anterior presentation
d. Left occipital transverse presentation
Answer: A
Rationale: If the fetal heart tones are heard in the right upper abdomen, the infant is in a breech presentation. If the infant is positioned in the right occipital anterior presentation, the FHTs will be located in the right lower quadrant, so answer B is incorrect. If the fetus is in the sacral position, the FHTs will be located in the center of the abdomen, so answer C is incorrect. If the FHTs are heard in the left lower abdomen, the infant is most likely in the left occipital transverse position, making answer D incorrect.
8. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
a. Anticipate the need for a Caesarean section
b. Apply the fetal heart monitor
c. Place the client in Genu Pectoral position
d. Perform an ultrasound exam
Answer: B
Rationale: Applying a fetal heart monitor is the correct action at this time. There is no need to prepare for a Caesarean section or to place the client in Genu Pectoral position (knee-chest), so answers A and C are incorrect. Answer D is incorrect because there is no need for an ultrasound based on the finding.
9. During the MCN class of Arianna, Breech presentation has been the topic. The following are types of breech presentation EXCEPT:
a. Footling
b. Frank
c. Complete
d. Incomplete
Answer: D
Rationale: Breech presentation means the buttocks of the fetus is the presenting part. If it is only the foot/feet, it is considered footling. If only the buttocks, it is frank breech. If both the feet and the buttocks are presenting it is called complete breech.
10.A nurse is working in the labor and delivery unit. The nurse assesses all the laboring clients and notes that one has a small baby in breech position, one has a large baby who is engaged, one has an average sized infant in a transverse lie, and the last has an average sized infant with a floating head. Which client will the nurse definitely have to prepare for a cesarean delivery? The client with the
a. small baby in breech position
b. large baby who is engaged
c. average sized infant in transverse lie
d. average sized infant with a floating head
Answer: C
Rationale: A transverse lie is a shoulder presentation and cannot be delivered in this position. All of the other infants could be delivered vaginally.
Care of Newborn with Infections
Introduction
Infants are at increased risk for infection due to the immaturity and relative inexperience of their immune system.
Preterm infants are at even higher risk because the majority of maternal antibodies are transferred during the latter weeks of gestation.
Maternal risk factors
Inadequate prenatal care, Poor nutrition Low socioeconomic status, Prolonged rupture of membranes Maternal fever Foul-smelling amniotic fluid Presence of a urinary tract infection.
Neonatal factors
antenatal or intrapartal asphyxia congenital abnormalities, male sex multiple gestations concurrent neonatal diseases, invasive diagnostic or therapeutic procedures Iatrogenic complications administration of medications that alter normal
microbial flora.
Sepsis
Newborns are at risk for infection by bacterial, viral, fungal, or protozoal microorganisms; the most common form is bacterial sepsis or bloodstream infection.
Bacterial sepsis is characterized by signs of systemic infection in the presence of bacteria in the bloodstream.
Patterns• Early onset or congenital• Nosocomial infection—late onset
Signs and Symptoms of Sepsis
• Lethargy or irritability• Hypotonia• Hypotension• Pallor, duskiness, or
cyanosis• Cool and clammy skin
• Temperature instability• Feeding intolerance• Hyperbilirubinemia• Tachycardia followed
by apnea/bradycardia
Diagnostic Evaluations
• Positive CSF, urine, and bacterial blood cultures are lab results that confirm the infant has an infection.
• Other abnormal results to observe in an infant suspected of sepsis are hypoglycemia, hyperglycemia, metabolic acidosis, thrombocytopenia, or hyperbilirubinemia.
• CBC – elevated WBC, low platelet count
Pathogens causing Sepsis1. Group B Strep (GBS)
GBS is by far the most serious cause of neonatal infection and mortality. GBS is a normal flora found in the vagina and gastrointestinal tract of 15% to 20% of women. It is not a sexually transmitted disease and normally does not cause any problems for the women who are colonized with it.
GBS infections can either be an early or late onset infection. The early onset infection is a result of transmission of the GBS bacteria from the mother to the fetus, usually during delivery. The infant will begin to present symptoms during the first 24-48 hours of life.
Pathogens causing Sepsis
2. Staphylococcus
Staphylococcal pathogens can cause mild to severe infections. Transmission may result in a localized infection from a scalp electrode, to more widespread infections such as osteomyelitis resulting in overwhelming sepsis.
The major source of this infection from staphylococcus comes from improper hand washing by the hospital staff. It is also associated with infections arising from umbilical catheters, endotracheal tubes, and central lines.
Pathogens causing Sepsis
3. Escherichia Coli
E. Coli is the most common cause of gram negative neonatal infection . This bacterium is found in the mother’s genital tract with a high incidence of colonization in the neonate. The pathogen can cause severe infections that may lead to respiratory distress, cardiovascular collapse, meningitis, multiorgan failure, and even death.
Management
• Antibiotic therapy is usually started before lab results confirm and identify the pathogen causing the infection. Antibiotic therapy is continued for 7 to 21 days if the cultures are positive, or it is discontinued in 3 days if cultures are negative.
• Careful monitoring of the infant’s vital signs and regulation of the thermal environment
• Supportive therapy for a septic infant starts with the administration of oxygen when respiratory distress or hypoxia becomes present
Nursing Considerations
• Constant assessment and documentation of subtle changes in the infant’s vital signs, physical assessments, feeding tolerance, responsiveness, and/or general behavior.
• Awareness of the potential routes for transmission of infectious pathogens will also help identify those infants at risk for developing sepsis.
Nursing Considerations
• Nurses must be aware of the side effects of the specific antibiotics and the proper administration guidelines.
• Providing an optimum thermoregulated environment and anticipating potential problems, such as dehydration or hypoxia.
• Precautions need to be implemented to prevent the spread of infections to other newborns.
Ophthalmia Neonatorum
An eye infection that occurs at birth or during the first month. The most common causative organisms are Neisseria gonorrhea and Chlamydia trachomatis.
Causes extremely serious form of conjunctivitis. If left untreated may cause corneal ulceration and destruction, resulting in opacity of the cornea and severe vision impairment.
Assessment
• The condition is generally bilateral• Conjunctiva – fiery red, with thick pus• Eyelids – edematous• This usually occurs on day 1 to day 4 of life.
Prevention
• Prophylactic instillation of erythromycin ointment into the eyes of newborns
- prevents both gonococcal and chlamydial conjunctivitis.
- delay administration until after first reactivity period so the child can see the parents clearly
Therapeutic Management
MEDICATIONS• Gonococci – Intravenous ceftriaxone and
penicillin• Chlamydia – an ophthalmic solution of
erythromycin
Management
Use standard and contact precautions when caring for the newborn
Irrigation of eyes with sterile saline solution – clear copious discharge (use sterile medicine dropper or bulb syringe)
The mother of the infant should be treated for gonorrhea and Chlamydia
Hepatitis B Virus Infection
Hepa B virus can be transmitted to the newborn through contact with infected vaginal blood at birth when the mother is positive for the virus.
A number of infants become chronic carries of the virus, who may develop liver cancer later in life.
Prevention
• Infants are now routinely vaccinated at birth
• If mother is identified positive of the virus, an infant is also administered immune serum globulin within 12 hours of birth to decrease possibility of infection.
HIV Infection
• Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) can be caused by placental transfer or direct contact with maternal blood during birth.
Assessment
• The disorder progress more rapidly in children and infants who receive the virus through placental transmission if they do not receive treatment.
• HIV positive by 6 months, develops clinical signs by 1-3 years of age.
Therapeutic Management
Zidovudine
Administered during pregnancy of HIV positive women.
Prevent infection due to decreased immune function.
QUESTIONS
1. A 2 day old neonate hasn’t been eating well, and has a temperature of 101˚F axillary. The nursery nurse anticipates that the physician will most likely prescribe which tests?
a. CSF and blood cultures and CBC
b. Urinalysis
c. Blood culture and a throat culture
d. CBC and ABG analysis
Answer: A
Rationale: The neonate is exhibiting signs and symptoms of sepsis. Effective treatment of sepsis can’t be initiated until the cause is identified. The physician will most likely prescribe CBC and obtain CSF and blood cultures to help identify the cause. Urinalysis would indicate whether a UTI is present but it won’t identify the cause. ABG analysis isn’t necesasary for this neonate at this time.
2. A client with HIV infection delivers a neonate. When assessing the neonate, the nurse is most likely to detect:
a. Skin vesicles
b. Limb dysmorphism
c. Conjunctivitis
d. hepatosplenomegaly
Answer: D
Rationale: A neonate with HIV infection typically hepatosplenomegaly, a distinctive facial dysmorphism, interstitial pneumonia, recurrent infections, behavioral deviations and neurologic abnormalities. The other options aren’t typical findings in neonates with HIV infection.
3. A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation?
a. By avoiding holding the eyelid open during medication instillation
b. By letting the medication drip onto the surface of the eye
c. By positioning the neonate so the head remains still
d. By holding the neonate in the football position
Answer: C
Rationale: after positioning the neonate securely so the head remains still, the nurse should hold the eyelid open and instill the medication into the conjunctival sac. Holding the neonate in the football position doesn’t secure the head.
4. The nursery nurse performs an assessment on a 1-day old neonate. During the assessment, the nurse notes discharge from both of the neonate’s eyes. The nurse should take which step to help determine whether the neonate has opthalmia neonatorum?
a. Do nothing; discharge is a normal finding in the eys of a 1-day old neonate.
b. Notify the physician immediately
c. Ask the physician for an ordr to obtain cultures of both of the neonate’s eyes
d. Obtain a nasal viral culture
Answer: C
Rationale: Ophthalmia neonatorum, caused by N. gonnorrhea, causes neonatal blindness if left untreated. The nurse should ask the physician for an order to obtain cultures of both eyes so antibiotic treatment can be initiated. Eye discharge is not normal in 1 day old neonate.
5. When caring for a neonate, what is the most important step the nurse can take to prevent and control infection?
a. Assessing frequently for signs of infection
b. Using sterile technique for all caregiving
c. Practicing meticulous hand washing
d. Wearing gloves at all time
Answer: C
Rationale: To prevent and control infection, the nurse should practice meticulous hand washing, scrubbing for 3 minute before entering the nursery, washing frequently during caregiving activities and scrubbing for 1 minute after providing care.
6. A client who has tested positive for the human immunodeficiency virus (HIV) delivers a girl. When she asks whether her baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond?
a. "Don't worry. It's too soon to tell."
b. "Chances are she'll be okay because you don't have AIDS yet."
c. "She may have acquired HIV in utero, but we won't know for sure until she's older."
d. "All babies born to HIV-positive women are infected with HIV, but your baby won't have symptoms for years."
Answer: C Rationale: Diagnosing AIDS in neonates is difficult because all neonates of women with HIV receive maternal antibodies and therefore initially test positive for HIV antibodies. However, not all such neonates actually are infected. The newborn of an HIV-positive mother has a 25% to 30% chance of developing HIV.
6. A nurse administers erythromycin ointment (0.5%) to the eyes of a newborn infant and the mother asks the nurse why this is performed. The nurse explains to the mother that this is routinely done to:
a. Prevent cataracts in the newborn infant born to a woman who is susceptible to rubella.
b. Protect the newborn infant's eyes from possible infections acquired while hospitalized.
c. Minimize the spread of microorganisms to the newborn infant from invasive procedures during labor.
d. Prevent ophthalmia neonatorum from occurring after delivery in a newborn infant born to a woman with an untreated gonococcal infection.
Answer: D
Rationale: Erythromycin ophthalmic ointment (Ilotycin ophthalmic)0.5% is used as a prophylactic treatment for ophthalmia neonatorum,which is caused by the bacterium Neisseria gonorrhoeae.
7. What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
a. The disease will incubate longer and progress more slowly in this infant
b. The infant is very susceptible to infections
c. Growth and development patterns will proceed at a normal rate
d. Careful monitoring of renal function is indicated
Answer: B
Rationale: : The infant is very susceptible to infections. HIV infected children are susceptible to opportunistic infections due to a compromised immune system.
8. Which finding might be seen in baby James a neonate suspected of having an infection?
a. Flushed cheeks
b. Increased temperature
c. Decreased temperature
d. Increased activity level
Answer: C
Rationale: Temperature instability, especially when it results in a low temperature in the neonate, may be a sign of infection. The neonate’s color often changes with an infection process but generally becomes ashen or mottled. The neonate with an infection will usually show a decrease in activity level or lethargy.
9. The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause:
a. Discoloration of baby and adult teeth.
b. Pneumonia in the newborn.
c. Snuffles and rhagades in the newborn.
d. Central hearing defects in infancy.
Answer: B
Rationale: Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia.
10.The nurse is caring for a neonate with an infection. The nurse would be MOST concerned if which of the following was observed?
a. Heart rate of 150 bpm.
b. Axillary temperature of 96°F (35.5°C).
c. Weight increase of 4 oz.
d. Respiratory rate of 65 at rest.
Answer: D
Rationale: A normal respiratory rate of a neonate is 30–50; Tachypnea is a sign of sepsis orhypoxia in a neonate
