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HIGH RISK PREGNANCY

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Adolescent Pregnancy: Contributing Factors

Peer pressure Self-esteemLack of role modelsGain attentionMediaPovertyRite of passage

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Implications of Adolescent Pregnancy

Socioeconomic:

• reliance on welfare

• cycle repeats itself

Maternal health:

• CPD

• PIH

• anemia

• nut deficits

• mortality

Fetal Health:

• LBW

• prematurity

• resp complications

• cp

• cognitive deficits

• death

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Adolescent Pregnancy: Assessment

Risksfundal height# of sexual partnersknowledge of infant care/needsfamily unit/support systembaseline VS/weight

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IMPLICATIONS OF DELAYED PREGNANCY

Pre-existing conditionsPreterm labor SGA/LBWIUGR (Intra Fetal Growth Retardation)PIH AbruptionC-sectionUterine fibroids PP hemorrhageChromosomal abnormalities

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DELAYED PREGNANCY: ASSESSMENT

Pre-existing conditionsFundal heightAnxietyPsychosocial issues

(career vs baby)

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Hemorrhage

It is the rapid loss of more than 1% of body weight in blood.

Results in:¨ Inadequate tissue perfusion¨ Deprivation of glucose and oxygen

to the tissues¨ Build up of waste products

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Antepartum hemorrhage

Bleeding that occurs anytime during pregnancy

Early – before 20 weeks AOG

e.g. abortionLate – bleeding after 20 weeks AOG

e.g. abruptio placentae, placenta previa

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Intrapartum hemorrhage

Bleeding that occurs during labor

e.g. uterine rupture

uterine inversion

abruptio placentae

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Postpartum hemorrhage

Blood loss greater than 500ml in a vaginal delivery or 1000ml in a CS birth

Early – occurs during the first 24 hours after delivery

Late – occurs 24 hours after vaginal delivery

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Abortion

Most common bleeding disorder of early pregnancy

Termination of pregnancy before age of viability

A fetus who is less than 24 weeks gestation or weighing less than 600 gms is not viable

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Early and Late Abortion

Early Abortion: termination of pregnancy before 12 weeks

Late Abortion: termination of pregnancy that occurs between 12 to 20 weeks

Spontaneous Abortion

Threatened Inevitable Incomplete Complete Missed Habitual

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TYPES OF SPONTANEOUS ABORTIONS

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Spontaneous Abortion Management

Threatened

Inevitable

Notify MD/MW Check fetus by Utz Bedrest, no sexual activity

for 2 weeks after bleeding stops No false reassurance Tocolysis

§ Check by Utz for complete vs. incomplete

§ Analgesics for D&C§ Save & count pads§ IV oxytocin

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Spontaneous Ab Mgmt, cont.

Incomplete

Missed

HospitalizationBefore 14 wks – D&C After 14 wks – Pitocin or

Prostaglandins

D & CMonitor for DIC Monitor for infection

Spontaneous Abortion Management

Complete

- Observe

- May give oxytocin

Habitual

- Cervical Cerclage

(Suturing of cervix)

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Post Abortion Education

Bleeding, cramping X 1-2 wksvaginal rest X 1 wk temp BID

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Incompetent Cervix

S&S

• Painless cervical dilatation

• Increased pelvic pressure

• Bloody show (pink stained)

• Urinary frequency

• PROM & discharge of amniotic fluid

Treatment

• Cerclage

• Bed rest

• √ FHT

• Avoid coitus & Vaginal douche

• Tocolytics

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Ectopic Pregnancy

It is the implantation of the zygote outside the uterine cavity or in an abnormal location inside the uterus.

Causes: narrowing of tubes, infection

Site: Fallopian tube, cervix, ovary and rare in the abdomen

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SITES OF ECTOPIC PREGNANCY

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S & S Ectopic Pregnancy

Amenorrhea, with positive PTAbdominal PainVaginal SpottingRupture↓ hCG levelsNo gestational sac on utz

Severe lower abd pain

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Surgical Management of Ectopic Pregnancy

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Hydatidiform Mole

Also called “molar pregnancy” or “H-mole”

Disorder of the placenta characterized by degeneration of the chorion and death of the embryo.

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S & S Hydatiform MoleVaginal bleeding

anemia uterus size,

crampsNo FHT’s N/VElevated serum or

urine HCGTherap. Mgmt: vacuum aspiration & curettage

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Placenta Previa

It is a condition that may occur during pregnancy when the placenta implants in the lower part of the uterus and obstructs the cervical opening to the vagina (birth canal).

Placenta Previa Asian and African ethnicity is high risk Associated with mothers who are

smoking and using cocaine Complications: Greater risk for post

partum hemorrhage, hypovolemic shock and preterm labor

Causes: Increased parity, maternal age, prior cesarean births, multiple gestation

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s/sx:

Spotting during the first and second trimesters

Sudden, painless, and profuse vaginal bleeding in pregnancy during the third trimester (usually after 28 weeks)

Uterine cramping may occur with onset of bleeding

The uterus is usually soft and relaxed.

Management:

Bleeding is an emergency Assess the amount of blood loss Bed rest with oxygenation as

prescribed Side lying or T-berg position No IE or rectal exams Keep IV line & have blood available

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Abruptio Placenta

Premature separation of a normally implanted placenta after 20 weeks of gestation and before delivery of the fetus

Common among hypertensive, high parity, old age, alcoholic mothers

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S&S Abruptio Placentae• Vag bldg

(unless concealed)

• abd & low back pain

• uterine resting tone

• uterine irritability

• uterine tenderness

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Med Mgmt of Abruptio Placentae

Mom stable,

fetus immature

bedrest

tocolytics

bleeding,

fetal distress

Emergency CS

Degree of Separation Grade Criteria

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0 – No symptoms of separation. Slight separation occurs after birth.1 – Minimal separation, enough to cause bleeding and changes in v/s. No fetal distress2 – Moderate separation. There is evidence of fetal distress and uterus is painful on palpation3 – Extreme separation, maternal shock or fetal death will result

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DICPlacental Bleeding

Thromboplastin release

Clot formation (systemic response)

clotting factors (fibrinogen, plts, PTT)

inability to form clots

profuse bleeding

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Hemorrhagic Conditions: Abruption & DIC

• Bleeding

• Pain

• VS/FHR

• Uterine Activity

• OB Hx

• Fundal Ht

• Lab Data (H/H, coags)

• Emotional response

ASSESSMENT

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Uterine Atony

The failure of the uterus to contract maximally after the delivery of the baby and placenta, resulting in heavy uterine bleeding.

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Causes:

Multiple gestation, high parity

Fetal macrosomia

Polyhydramnios

General anesthetics

Prolonged labor, precipitous labor, augmented labor

Infection (chorioamnionitis)

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S/Sx:

Excessive bleeding at the time of delivery

soft uterus

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Uterine Inversion

uterus literally turn inside out such that the top of the uterus (the fundus) comes through the cervix or even completely outside the vagina

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Treatment:

Initial treatment consists of bimanual compression, uterine massage.

Uterine contraction medications: Oxytocin, Methylergonovine, and Prostaglandins

Surgery: uterine vessel ligation or hysterectomy (the latter is rarely used)

Blood and fluids must be replaced as needed.

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Retained placental Fragments

Late post partal hemorrhage Fragments may become necrosed & fibrin

may be deposited. A placental polyp can form, separate, and sudden bleeding can occur

Caused by abnormal placental implantation or careless delivery of placenta

S/Sx: vaginal bleeding, boggy fundus

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Hypertensive Disorders of Pregnancy

Hypertension – BP reading in 2 occasions of at least 140/90 or a rise of 30mm/Hg systolic and 15mm/Hg diastolic

Gestational Hypertension – BP 140/90mmHg develops for the first time during pregnancy, but there is no proteinuria and within 12 weeks postpartum the BP is normal

Chronic HPN – presence of HPN before pregnancy or HPN that developed before 20 weeks AOG in the absence of H-mole that persists after 12th wk postpartum

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Pregnancy Induced Hypertension

HPN that develops after the 20th week of gestation to a previously normotensive woman.

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The Pathological Processes of Pre-eclampsia

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S&S Pre-eclampsia

Rapid wt gainedema of hands & faceproteinuriahyperreflexic DTR’svisual disturbancesepigastric pain

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Treatment of Pre-eclampsia

Bedrest protein diet document fetal

activity weekly NST

Bedrest, stimuli Meds

Apresoline for severe HPN

MgSO4 (anticonvulsant & antihypertensive)

Delivery

Mild: diastolic < 100, trace to 1+ proteinuria, no H/A

Severe: diastolic > 110, 3+ proteinuria, U/O, H/A, visual disturbances

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S&S Eclampsia/HELLP Syndrome

Eclampsiafacial twitchingtonic-clonic szpulmonary edemacirc/renal failure

HELLP SyndromeRUQ painn/vedema H/H, plts liver enzymes

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Treatment of Eclampsia/HELLP Syndrome

BedrestMeds

MgSO4Valium or Phenobarb (if Mg not effective, not

within 2 hr of delivery)Hydralazine (for severe ↑ B/P)steroids to fetal lung maturity

Delivery

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Assessment: Hypertensive Disorders of Pregnancy

Prenatal:wt, B/P, U/A, visual disturbances

Hospitalized Client:daily wthourly u/o, dipstick urine Q4HVS, FHR LOC, DTR’s

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Risk Control Strategies for Hypertensive Disorders of Pregnancy

Seizure precautionsmonitor for s/s Mg toxicity(RR<12, absent

DTR’s, sweating, flushing, confusion, B/P)

Ca gluconate Mg levelsIV MgSO4 D/C MgSO4 for RR < 12 or

absent DTR’s renal function (30 mL/hr)

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Premature Labor/Rupture of Membranes

S&S contractions cramps backache diarrhea Vaginal

discharge ROM

Treatment Tocolytics IV hydration bedrest steroids, if needed

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Nursing Care for PTL/PROM

AssessmentThorough history bleeding ROM

TeachingInfection

ControlComplete bed

rest without bathroom privileges

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Postterm Pregnancy

S&S Wt loss uterine size Meconium in Amniotic

fluid

Risks fetal mortality cord compression meconium aspiration LGA shoulder dystocia

CS episiotomy/laceration depression

Treatmentfetal surveillance

NST, CST, BPP Q wkmom monitors mvmt

InductionPitocin (10-20U/L) @ 1-2 mU/min every 20-60

min

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Disorders of Amniotic Fluid

PolyhydramniosS&S

uterine distentiondyspneaedema of lower extremities

Treatment therapeutic amniocentesis

OligohydramniosRisks

cord compressionmusculoskeletal deformitiespulmonary hypoplasia

TreatmentAmniotic infusion

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Risks of Multifetal Gestation

PIHGDMPPHAnemiaUTIPlacenta previaCS

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(Fetal) S&S Rh Incompatibility

HyperbilirubinemiajaundiceKernicterus (severe neuro d.o. r/t bili)

anemiahepatosplenomegalyHydrops fetalis

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Sequence of Assessments for Rh SensitizationBlood Test for Type & Rh Factor

Rh-negative Rh-positive

No further testingIndirect Coombs

Give RhoGAM

Repeat frequently Titer increasing

amniocentesis ( bilirubin)Titer not increasing

continue to monitorNo change

retest prn

Elevated

retest, U/S

intrauterine transfusion or early delivery

+-

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Management of Rh Incompatibility

PreventionRhoGAM at 28

weeks (unsensitized women only)

Postpartum direct Coomb’sRhoGAM to mom

if baby is Rh+ (within 72 hrs of birth)

Prenatal

• per algorithm

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Hyperemesis Gravidarum

S&S U/Owt lossketonuriadry mucous membranespoor skin turgor

TreatmentIVF, TPNantiemeticsSmall frequent feedingsToast, unsalted crackers

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Glucose Tolerance Test

1 GTT (24 - 28 wks)

drink 50g glucose,

if 1 BS > 140

3 GTT• hi carb diet X 2

days, then NPO after MN

• FBS, then drink 100g glucose,

• 1, 2, 3 BS

Gestational Diabetes is diagnosed with FBS > 105 or with 2 of the following BS results:

1 > 190, 2 > 165, 3 > 145

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Effects of Pre-Existing DM

Maternal risk of:PIHCystitisDKASpont Abortion

Fetal risk of:

Cardiac defectsMacrosomia orIUGRPolycythemiahyperbilirubinemia

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Treatment of Pre-existing DM

Team approachMonitor glycosylated Hgb ADiet: 50% carb, 20% prot, 30% fat Insulin TIDHourly glucoses during labor NST’s weekly (starting at 28-30 wks)Amnio ( lung maturity)

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Effects of Gestational Diabetes

Maternal EffectsUTIhydramniosPROM/preterm laborshoulder dystociaCSHPN

Fetal Effectsmacrosomiahypoglycemia at birthRespiratory Distress Syndrome

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Treatment of Gestational Diabetes

30 to 35 cal/kg/day (3 meals, 2 snacks)Insulin FBS,NST, BPP Q weekglycosylated Hgb AAmniocentesis ( lung maturity)

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Diabetes: Patient Education

Glucose monitoring insulin administration

type, onset, peak, duration, times, sites, injection technique

diet s/s hypoglycemia

tremors, pallor, cold/clammy skingive milk & crackers or glucagon injection

s/s hyperglycemiafatigue, flushed skin, thirst, dry mouth, check glucose, call MD for insulin order

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Cord Prolapse

the umbilical cord drops (prolapses) through the open cervix into the vagina ahead of the baby.

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Causes:

Premature delivery of the baby Delivering more than one baby per

pregnancy (twins, triplets, etc.) Excessive amniotic fluid Breech delivery (the baby comes

through the birth canal feet first) An umbilical cord that is longer than

usual

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Iron deficiency anemia

Approximately 20% of women, 50% of pregnant women, and 3% of men are iron deficient.

Iron is an essential component of hemoglobin, the oxygen-carrying pigment in the blood.

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S/SX

Pale skin color Fatigue Irritability Weakness Shortness of breath Unusual food cravings (pica) Decreased appetite (especially in children) Headache - frontal Blue tinge to sclerae (whites of eyes) Microcytic, hypochromic cells

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Treatment:

120 to 180mg of iron dailyFerrous sulfateDiet high in iron

e.g. green leafy vegatables, meatIf anemia is severe, Dextran is given

IM.

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Folic Acid Deficiency

Folic acid is necessary normal formation and nutrition of RBC’s.

Deficiency leads to formation of large and immature RBC’s that have shorter life span than normal RBC’s.

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S/Sx:

NauseaVomitingAnorexiaTreatment:® Folic acid supplement 1mg/day accompanied

oral iron® Dietary supplements® e.g. dark green leafy vegetables, dried beans

and peas, enriched grain products

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Postpartum Blues

also known as baby blues transient condition that affects up to 80

percent of new mothers just after delivery

Symptoms peak at the fifth day and resolves within two weeks

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S/Sx:

may include abrupt mood swings from happiness to sadness

anxiety irritabilitydecreased concentrationinsomniaTearfulnesscrying spells that can occur for no apparent

reason

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Treatment:

Treatment for postpartum blues is focused on providing support for the mother and her family

reassurance that her feelings are quite normal and experienced by many other women postpartum

It is important that mothers make time for adequate sleep and rest, eat a well-balanced diet, and allow others to care for the baby at night if possible.

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Postpartum Depression

occur within the first month after delivery, but may also occur up to one year after delivery

may be related to the abrupt withdrawal of estrogen and progesterone levels after birth that are much higher during pregnancy

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S/Sx:

Insomnia or excessive sleep

Fatigue

Change in appetite with weight loss or weight gain

Loss of interest or pleasure in life

Decreased libido (sex drive)

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Con’t. of S/Sx:

Excessive worry or anxiety

Intense irritability and anger, short temper

A sense of being overwhelmed or unable to care for the baby

Difficulty making decisions

Not bonding with the baby, leading to further shame and guilt

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Sickle Cell Disease

Maternal Effectspain jaundicePyelonephritisPIH/preeclampsialeg ulcersCHF

Fetal EffectsIUGR/SGAskeletal changes

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Systemic Lupus Erythematosis

Maternal effectsfatiguemuscle/joint painwt lossrashproteinuriaPIH/preeclampsia/

HELLPPG loss

Fetal effectsIUGRpreterm delivery

Treatment

• PO or IV Steroids

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Effects of Pregnancy on Heart Disease

Increase blood volumeSystemic vascular resistance drops

significantly by 25% during pregnancy lowering systolic and diastolic blood pressure

The gravid uterus can dramatically affect venous return to the heart in some positions

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S/Sx:

Dyspnea, orthopneaPalpitationsChest painSyncope with exertionNeck vein distention

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Management:

Regular prenatal visitsECGEchocardiogramFrequent rest periodsDiet

e.g. iron, protein and minerals

Na

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Problems with POWER, PASSAGE AND PASSENGER

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Shoulder Dystocia

painful, difficult, prolonged labor and birth resulting in failure to efface, and/or descend within an expected time frame

a.monitor uterine contraction frequency, intensity, duration

b.observe effacement, dilitation and descent

c.observe uterine resting tone for hypertonus

d.monitor fetal heart rate for non-reassuring pattern

e.observe fetal presenting part for molding, asyncliticism

f.monitor maternal coping skills

g.monitor amniotic fluid

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Management:

a.evaluate fetal status for size, position and reassuring heart rate

b.evaluate pelvic parameters for adequacy, empty bladder

c.evaluate uterine activity for frequency, intensity and duration

d.provide sedation and rest if appropriate in latent phase, ambulation in active phase, maternal repositioning to turn fetal head position, and hydration

e.prepare for pitocin augmentation if in active phase

f.provide adequate physical and emotional support for pain

g.provide pain relief if appropriate h.prepare for cesarean birth if appropriate i.prepare for shoulder dystocia if

macrosomic j.prepare for neonatal resuscitation if

necessary

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Sexually Transmitted Disease

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Candidiasis

Caused by the fungus “Candida” estrogen which causes vaginal pH to

be less acidicThick, cream cheese-like vaginal

dischargeExtreme pruritusTreatment: Monistat (Miconazole)

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Trichomoniasis

Protozoan infection: Trichomonas vaginalis

Yellow-gray frothy vaginal dischargeTreatment: Metronidazole (can be

teratogenic)Topical clotrimazole

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Chlamydia Trachomatis

Chlamydia (gram-negative)Heavy-gray white vaginal dischargeTreatment: erythromycin and amoxicillin

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Syphilis

Caused by spirochete “Treponema Pallidum”

Painless ulcer (chancre)Treatment: benzanthine penicillin G

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Herpes Simplex Virus Type 2

Painful, small, pinpoint vesicles surrounded by erythema on the vulva or in the vagina 3 to 7 days after exposure

Treatment: Acyclovir (zovirax)

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Gonorrhea

Caused by: Neisseria gonorrhoeaeClap diseaseYellow-green vaginal dischargeTreatment: oral cefixime or Ceftriaxone

Sodium IM

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Human Papilloma Virus

Condyloma AcuminatumCauliflower-like lesionsTreatment: Tricloroacetic acid or

bichloroacetic acid

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AIDS

Maternal Effectsvaginal

candidiasisPIDgenital herpesPCP

Fetal EffectsAsymptomatic at

birthCandidal diaper

rashthrushdiarrhearecurrent

bacterial infections

developmental delay

Treatment:

ZDV (zidovudine) during PG, L&D

ZDV to neonate for 6 wks

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Preterm Newborn

Neonate born before 37 weeks of gestation

Assessment includes:¨ Body temperature below normal¨ Poor suck and swallowing reflex¨ Minimal creases in the soles and

palms

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Con’t. Assessment:

¨ Extends extremities and cannot maintain flexion

¨ Testes are undescended in boys¨ Labia are narrow in girls¨ Lanugo is present in skin and in the

hair

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Postterm Infant

A neonate born after 42 weeks of pregnancy

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Assessment:HypoglycemiaDry and cracked skin without

lanugoFingernails long and extended

over ends of the fingersProfuse scalp hairMeconium staining possibly

present on nails and umbilical cord

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Small for gestational age

A neonate who is plotted at or below the 10th percentile on the intrauterine growth curve

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Assessment

Fetal distressLowered or elevated body

temperatureHypoglycemiaSigns of polycythemia

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Large for gestational age

A neonate who is plotted at or above the 90th percentile on the intrauterine growth curve

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Assessment

Gestational ageBirth trauma or injuryRespiratory distressHypoglycemia

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Respiratory Distress Syndrome

A serious lung disorder caused by immaturity and inability to produce surfactant, resulting in hypoxia and acidosis

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Assessment

TachypneaNasal flaringExpiratory gruntingRetractionsDecreased breath soundsPallor and cyanosisApnea

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Meconium Aspiration Syndrome

Caused by hypoxia in utero

Vagal reflex relaxation of the rectal

sphincter

Release of meconium into the amniotic

fluid

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S/Sx:

Tachypnea

Retractions

Cyanosis

Barrel chest

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Mgt.

SuctioningAssisted ventilationThermal neutral environment

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Sudden Infant Death Syndrome

Contributory factors:®Viral respiratory infection®Distorted familial breathing patterns®Possible lack of surfactant in alveoli®Sleeping prone rather than on the

side or back

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Fetal Alcohol Syndrome

caused by maternal alcohol use during pregnancy

Syndrome causes mental and physical retardation

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Congenital Rubella

Caused by Rubella virus

Causes congenital fetal malformations if the mother is infected in the first trimester

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S/Sx:

ThrombocytopeniaCataractsHeart diseaseDeafnessMicrocephalyMotor and Cognitive impairment

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Opthalmia Neonatorum

Eye infection at birth or during the first month of life

Caused by: Neisseria gonorrhoeae

Chlamydia Trachomatis

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S/Sx:

Conjunctiva becomes fiery red Thick pus present Edematous eyelids

If left untreated, it causes opacity of the cornea and severe vision impairment

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Treatment:

If gonococcal infection is present, IV cetriaxone and penicillin is given.

If chlamydia is identified, erythromycin ophthalmic solution is used.

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The Infant of a Diabetic Mother

Macrosomic babies

Caudal regression syndrome (hypoplasia of lower extremities)

Cushingoid (fat and puffy)

Lethargic

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Management:

Early feeding with formula

Infusion of glucose

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The Infant of A Drug-Dependent Mother

SGA Irritability Disturbed sleep patternsShrill, high pitched cryTachypneaTremors

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Cocaine

CNS stimulant and peripheral sympathomimetic

Maternal effects:Increased BPDecreased uterine blood flowIncrease vascular resistance

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Fetal Effects of Cocaine

Neurobehavioral depressionThis includes the ff:LethargyPoor suckWeak cryDifficulty arousing

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Heroine

CNS depressant Maternal effects:Decreased BPIncreased uterine bleeding

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Spontaneous Abortion Matching – Choose all that apply.

1. 1. Initial symptom is vaginal bleeding

2. 2. Membranes rupture and cervix dilates

3. 3. Some, not all, products of conception are expelled.

4. 4. Treatment includes D&C

5. 5. All products of conception passed

6. 6. All unsensitized Rh neg women should receive RhoGAM

7. 7. May be treated with bedrest

8. 8. Retained dead fetus

9. 9. May be complicated by DIC

10. 10. Pregnancy may continue

A. Threatened abortion

B. Inevitable abortion

C. Incomplete abortion

D. Complete abortion

E. Missed abortion

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Which of the following socioeconomic factors contributes to the high incidence of adolescent pregnancy?

A. lack of adequate birth control

B. poverty

C. lack of information on safe sex

D. availability of public assistance for unmarried mothers

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When caring for a woman with mild preeclampsia, the nurse would be concerned with which finding?

a. +4 proteinuria

b. +2 dependent edema in ankles

c. Blood pressure 156/100

d. +2 DTR’s, absent clonus

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The nurse is preparing to infuse magnesium sulfate to treat preeclampsia. In implementing this order the nurse understands the need to:

a. Prepare a solution of 20 g MgSO4 in 100cc D5W

b. Monitor maternal VS, FHR and uterine contractions every hour

c. Expect the maintenance dose to be approximately 4g/hr

d. Discontinue the infusion and report a respiratory rate of < 12 breaths/minute

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The primary expected outcome for care associated with the administration of MgSO4 would be met if the woman:

a. Exhibits a decrease in both systolic and diastolic blood pressure

b. Experiences no seizures

c. States that she feels more relaxed and calm

d. Urinates more frequently, resulting in a decrease in pathologic edema

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A primigravida at 10 weeks gestation reports slight vaginal spotting without passage of tissue and mild uterine cramping. When examined, no cervical dilation is noted. The nurse caring for this woman should:

a. Anticipate that the woman will be sent home and placed on bedrest with instructions to avoid stress or orgasm

b. Prepare the woman for a dilatation and curettage

c. Notify a grief counselor to assist the woman with the imminent loss of her fetus

d. Tell the woman that the doctor most likely will perform a cerclage to help maintain the pregnancy

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CASE STUDY I

A G3P2 woman, at 38 wks gestation, arrives at the obstetric unit with c/o painless vaginal bleeding.

1. What is the nursing priority at this time?

2. What assessments are necessary?

3. What is the most likely etiology of the bleeding?

4. What is the expected treatment for Anne?

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CASE STUDY II

A G1P0 woman, at 35 wks gestation, is visiting the midwife for a routine prenatal visit. On assessment, the nurse finds that she has gained 8 lbs in the past month.

1. What is the significance (if any) of this weight gain?

2. What other assessments should the nurse make at this time?

3. What is the required treatment for this client?

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CASE STUDY IIIA 22 y.o. G1P0 who has a history of IDDM X 6 yrs and whose LMP was 12 wks ago arrives at the prenatal clinic.

1. How will this client’s diabetes be affected by her pregnancy?

2. What changes will she most likely have to make to adjust to her pregnancy?

3. What routine assessments will be made at each prenatal visit?

4. What tests will be required as the pregnancy progresses?

5. What fetal effects occur with pre-existing diabetes?

6. How will L&D be altered by pre-existing diabetes?

7. What possible newborn complications could occur with pre-existing diabetes?

8. What nursing care will the infant require?

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MATH PROBLEM

For induction, Pitocin is ordered – 10 Units in 500 mL to start at 2 mU/min and increase by 1 mU/min every 20 minutes until effective contractions are achieved.

At what rate will the nurse start the IV? By how much will the rate be increased every 20 minutes?

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THE END