Chapter 26 A Alpha-fetoprotein (AFP) enzyme blood test 1. Increase identifies fetus with neural tube defects (spina bifida, anencephaly); may indicate multiple pregnancy; followed by ultrasonography and amniocentesis when increased for two samples; done at 14 to 16 weeks’ gestation 2. Nursing care: food or fluid restrictions are not required 1. Identifies multiple pregnancy, placental location, and gestational age by measurement of biparietal diameters; visualizes organ formation 2. Nursing care: encourage fluids; teach to refrain from voiding before test, when performed during first 20 weeks’ gestation, to improve visualization C Chorionic villi sampling (CVS) 1. Supplies chromosomal data; done at 10 to 12 weeks’ gestation; sonogram before test to determine placental location, uterine position, and relative placement of neighboring organs (bowel, blood vessels) 2. Nursing care: instruct to drink fluid to fill bladder; after test monitor for uterine contractions and vaginal discharge; teach to monitor for infection 1. Amniotic fluid detects gender, chromosomal or biochemical defects, fetal age; reveals lecithin to sphingomyelin (L/S) ratio (2:1 ratio indicates lung maturity); phosphatidylglycerol (PG) after 35th week (indicates fetal lung maturity); increased bilirubin level (for Rh incompatibility); amniotic fluid index; biophysical profile of fetus; sonogram before test to locate placenta, fetus, and area of amniotic fluid suitable for aspiration 2. Nursing care: instruct to void; assess fetal heart rate (FHR) during and after test; after test monitor for uterine contractions, vaginal discharge; teach to rest and monitor for infection 1. Monitors accelerations of FHR in response to fetal movement over 30- to 40-minute period a. Reactive: indicates fetal well-being; baseline FHR 110 to 160 beats/min; 2 accelerations in 10 minutes, each increasing FHR by 15 beats/min and lasting 15 seconds b. Nonreactive: indicates nonreassuring prognosis: criteria not met (see above) c. Unsatisfactory: result cannot be interpreted; test repeated in 24 hours 3. Nursing care: explain test; explain why fasting is unnecessary; document fetal monitor recordings; evaluate physiologic and emotional responses to test and its results F Contraction stress test (CST) 1. Demonstrates if fetus can withstand decreased oxygen during a contraction; contraction produced by exogenous oxytocin or manual stimulation of nipples or moist heat a. Negative: indicates fetus should survive labor; no late decelerations with minimum of three contractions in 10 minutes b. Positive: repetitive late decelerations with more than half of contractions indicate nonreassuring prognosis because of uteroplacental insufficiency; consideration of early intervention c. Suspicious: late decelerations occurring in less than half of contractions; repeat in 24 hours 3. Nursing care: explain procedure; obtain signed consent if needed; instruct to void before test; monitor fetal heart rate for 30 minutes before; monitor after for possible initiation of labor; evaluate physiologic and emotional responses to test and its results 1. Assesses fetal breathing movements, gross body movements, tone, amniotic fluid volume, FHR reactivity during NST; each category is assigned a score of 2; used for fetus who may be compromised 2. Score of 8 to 10 indicates healthy fetus 3. Nursing care: initiate care related to amniocentesis; provide emotional support; evaluate response H Maternal assessment of fetal activity 1. Client counts number of fetal movements in specified time period; reflects vitality of fetus 2. Nursing care: teach how to monitor movements; report fewer than 3 movements in 8 hours, fewer than 10 movements in 12 hours, or no movements in morning 1. Capillary blood taken from fetal scalp in utero tested for pH; done during labor when fetal heart patterns are nonreassuring 2. If acidotic, immediate birth is indicated 3. Nursing care: cleanse vaginal area to avoid contamination during test J Fetal acoustic stimulation test (FAST) or vibroacoustic stimulation test (VST) 1. Buzzing (FAST) or vibration (VST) created over head of fetus through maternal abdomen for 1-second and 1-minute intervals for 5 minutes 2. Reactive test: FHR accelerates; indicates fetal well being 3. Nursing care: explain test is noninvasive; obtain baseline FHR before test A Reasons for high-risk pregnancy 1. Physical development: not yet completed; bone growth may be incomplete; increased levels of estrogen may close epiphyses 2. Preeclampsia: common complication because of poorly developed vascular system in placenta; possible inadequate adolescent nutrition 3. Developmental tasks of adolescence not yet achieved B Factors contributing to incidence of adolescent pregnancy 1. Inadequate coping mechanisms 2. Need to enhance self-concept 3. Belief in own invulnerability 4. Need for immediate gratification: focus on present, not future; lack of concern for long-term consequences 5. Need for attention, closeness, and/or idealized or idolized love 6. Lack of knowledge about conception or contraception 7. Indulgence in risk-taking behavior; sexual acting out 8. Change in concepts of morality; variety of family configurations; increase in dysfunctional families 1. Establish a trusting relationship 2. Refer to appropriate agencies and resources 3. Promote problem-solving abilities 5. Provide prenatal education; encourage consistent prenatal care 6. See Chapter 25, Nursing Care of Women during Uncomplicated Pregnancy, Labor, Childbirth, and the Postpartum Period; Nursing Care during the Prenatal Period, Nursing Care during the Intrapartum Period; and Nursing Care during the Postpartum Period A See Chapter 25, Nursing Care of Women during Uncomplicated Pregnancy, Labor, Childbirth, and the Postpartum Period; Nursing Care during the Prenatal Period, Nursing Care during the Intrapartum Period; and Nursing Care during the Postpartum Period B Assess for prenatal antiretroviral (ARV) therapy; offer ARV when in labor to decrease risk of transmission C Avoid procedures that may increase risk of transmission (e.g., fetal scalp sampling, artificial rupture of membranes) D Teach importance of formula feeding rather than breastfeeding (may not be an option for mothers in developing countries) A Frequency increasing; related to higher incidence of fertility drug use B Increasing rate of elective fetal reduction to decrease risk of fetal death; greater incidence of twin births; lower incidence of triplet and higher-order births C High probability for developing preterm labor, gestational hypertension, hyperemesis gravidarum, iron or folate anemia, dystocia, twin to twin transfusion, postpartum uterine atony D High risk for fetuses being born with congenital anomalies and intrauterine growth restriction (IUGR) E Monozygotic (identical) twins: develop from one fertilized ovum and are of same gender, race, heredity, parity; maternal age has no influence on incidence F Dizygotic (fraternal) twins: develop from two ova, each of which is fertilized by a different sperm; may be same or different genders; familial predisposition; increased incidence in women who are African-American, multiparous, and younger than 35 years of age A Origin: 50% had rheumatic fever (incidence expected to decrease as incidence of rheumatic fever decreases); congenital and mitral valve disorders are next most common B Adverse effects of hemodynamics during pregnancy 1. Oxygen consumption increased 10% to 20%; related to needs of growing fetus 2. Plasma level and blood volume increase; red blood cells (RBCs) remain same (physiologic anemia) 3. Peak cardiac output at about 28 weeks 4. After birth, extravascular fluid shifts into intravascular compartment with increased workload of heart C Functional (therapeutic) classification of heart disease during pregnancy 1. Class I: no limitation of physical activity; no clinical manifestations of cardiac insufficiency or angina 2. Class II: slight limitation of physical activity; may experience excessive fatigue, palpitation, angina, or dyspnea; slight limitations as indicated 3. Class III: moderate to marked limitation of physical activity; dyspnea, angina, and fatigue with slight activity; bed rest during most of pregnancy 4. Class IV: marked limitation of physical activity; angina, dyspnea, and discomfort at rest; indication for termination of pregnancy 1. Prenatal period: vital signs, weight gain, dietary patterns, emotional outlook, knowledge about self-care, clinical findings of heart failure, stress factors (e.g., work, household responsibilities), medication regimen 2. Intrapartum period: vital signs (heart rate increases), respiratory changes (dyspnea, coughing, or crackles), FHR patterns 3. Postpartum period: clinical manifestations of heart failure or hemorrhage related to fluid shifts; intake and output (I&O) a. Administer prescribed medications: heparin; furosemide (Lasix), digoxin (Lanoxin), beta blockers, antidysrhythmics b. Monitor for heart failure (e.g., respiratory distress, tachycardia); may be precipitated by severe anemia; accelerated maternal heart rate in latter half of pregnancy results in increased cardiac workload (1) Balance activity and rest, avoid stress (2) Wear elastic stockings, elevate legs periodically (3) Continue supervision by health care provider specializing in cardiology (4) Maintain appropriate dietary intake: adequate calories to ensure appropriate, but not excessive, weight gain; limited, not restricted, sodium intake (2.5 g/day) a. Observe progress of labor via clinical findings and electronic fetal/uterine monitoring b. Maintain continuous cardiac monitoring c. Encourage to remain in semi-Fowler or left-lateral position d. Assist to cope with discomfort; regional analgesia usually used e. Assist with birth (e.g., forceps or vacuum extraction) to avoid work of pushing 3. Postpartum: most critical because of increased circulating blood volume after birth of placenta a. Monitor for heart failure (increased cardiac output after birth of placenta may cause sudden bradycardia with cardiac arrest) b. Administer prescribed prophylactic antibiotics if history of rheumatic fever c. Encourage adequate rest (increased oxygen consumption during labor can deplete energy reserves) d. Institute early ambulation schedule; apply elastic stockings e. Determine newborn risks (e.g., intrauterine growth restriction, preterm birth, hypoxia) f. Plan for discharge; refer to agencies for family support if needed A Diabetes mellitus during pregnancy a. Type 1: complications include retinopathy, neuropathy, and coronary artery disease b. Type 2: complications may include retinopathy, neuropathy, and coronary artery disease; women with type 1 diabetes are at greater risk 2. Gestational diabetes mellitus (GDM) B Physiology of pregnancy that affects woman with diabetes 1. Vomiting, especially in first trimester, decreases carbohydrate intake, which reduces insulin need; may result in acidosis 2. Progression of hormonal influences a. Insulin production increases, but resistance to insulin occurs c. Exogenous insulin is required to maintain serum glucose level within acceptable range, especially in latter part of pregnancy 3. Basal metabolic rate increases; carbon dioxide combining power decreases; acidosis may result 4. Renal threshold for glucose decreases, glycosuria may result 5. During labor: muscular activity depletes glycogen; insulin need decreases 6. Postpartum period: involution and lactation further reduce insulin need; hypoglycemia may result C Hazards of diabetes during pregnancy 1. Increased incidence of fetal deaths, stillbirths, newborn anomalies 2. Neonatal deaths from hypoxia, hypoglycemia, congenital anomalies, preterm labor 3. Excessively large newborn; weight over 4000 g (macrosomia) with inadequate diabetic control 4. Hypertensive disorders, hydramnios 5. Frequent adjustments of insulin dosage because insulin needs vary throughout pregnancy 6. Frequent hospitalizations may be necessary a. Encourage preconception counseling; early, sustained prenatal supervision (1) Dietary and insulin regimens; encourage adherence (2) Clinical manifestation of hyperglycemia (acidosis), hypoglycemia (insulin reaction) (3) Blood glucose testing, insulin administration, record keeping (4) Reason for multiple tests to determine fetal well-being (e.g., ultrasound, stress/nonstress tests, biophysical profile, amniocentesis for phosphatidylglycerol levels and L/S ratio) c. Prepare for hospitalization, induction of labor, or cesarean birth if indicated d. Monitor fluid and electrolyte balance for signs of ketoacidosis during prenatal, intrapartum, and postpartum periods e. Monitor glucose levels for first 48 hours postpartum; may not remain diabetic if gestational diabetic 2. Care of neonate—infant of diabetic mother IDM a. Perform newborn assessment; inspect for congenital anomalies related to increased incidence in IDM b. Admit to neonatal intensive care unit (NICU) if necessary c. Keep warm (inadequate temperature control mechanisms) d. Observe respirations (distended stomach may impinge on diaphragmatic movement) e. Perform heel-stick blood specimen for glucose level; assess for hypoglycemia caused by excessive insulin production (blood glucose level 30 to 45 mg/dL) f. Observe for signs of: hypoglycemia (e.g., lethargy, poor sucking, irritability cyanosis, tremors, hypotonia, cyanosis); hypocalcemia (e.g., muscular twitching, tremors, seizure triggered by minor stimulus) g. Offer prescribed glucose water feedings to prevent acidosis; administer prescribed parenteral glucose if newborn has poor sucking reflex A Asthma (see Chapter 32, Nursing Care of Preschoolers Asthma) 1. Recurrent lower respiratory tract bronchospasms with airway inflammation and bronchoconstriction 2. Clinical findings: nonproductive cough, chest tightness, dyspnea, wheezing, shortness of breath 3. Impact on pregnancy: elevation of uterus in abdominal cavity impinges on thoracic cavity; maternal hypoxia causes impaired fetal gas exchange B Tuberculosis (see Chapter 7, Pulmonary Tuberculosis) 1. Infectious disease caused by Mycobacterium tuberculosis 2. Risk factors: being immunocompromised, living in substandard conditions 3. Clinical findings: lethargy, systemic infections, cough, night sweats, weight loss, and fever 4. Impact on pregnancy: elevation of uterus in abdominal cavity impinges on thoracic cavity; maternal hypoxia causes impaired fetal gas exchange 5. Screening test: purified protein derivative (PPD) skin test (Mantoux) a. Identification of triggers for attacks; limitation of exposure to respiratory tract pathogens b. Allergy desensitization if necessary c. Yearly influenza vaccination recommended by Centers for Disease Control and Prevention (CDC); may be administered during pregnancy because it does not contain live organisms d. Inhaled bronchodilators during exacerbations (e.g., albuterol [Proventil] and metaproterenol [Alupent]) e. Glucocorticoids when bronchodilators are ineffective to decrease inflammation and mucus secretions a. Isoniazid (INH) and rifampin (Rifadin); for resistance to isoniazid, ethambutol (Myambutol) may be substituted; treatment continued for 9 months b. Pyridoxine (vitamin B6) 50 mg/day c. Infants of untreated mothers at risk when cared for by mother after birth; transmission rate is 50% d. Uninfected infants may receive bacille Calmette-Guérin (BCG) vaccine 1. Health history to identify past record of respiratory disease, exposure to tuberculosis, clinical manifestations of tuberculosis 2. Results of PPD test, sputum cultures, and chest x-ray film if findings indicate possible infection 3. Case finding to limit spread of infection to family and community A Risk factors: increase with age, postponement of pregnancy B Incidence: breast most common; cervical, ovarian, melanoma, leukemia, lymphomas, and tubal and thyroid cancers C Moral dilemma for childbearing woman, family, and health team A Classification of hypertensive states a. Hypertension during pregnancy beginning in second trimester (20 to 24 weeks); disappears 6 weeks after birth b. May have edema or proteinuria; blood changes rarely occur in uncomplicated gestational hypertension
Nursing Care of Women at Risk during Pregnancy, Labor, Childbirth, and the Postpartum Period
Tests to Identify and/or Monitor High-Risk Pregnancy
Nursing Care of Pregnant Women with Special Needs
The Pregnant Adolescent
Data Base
Nursing Care of Pregnant Adolescents
Assessment/Analysis
Planning/Implementation
The Older Pregnant Woman (35 Years of Age or Older)
The Pregnant Woman with HIV
Nursing Care of Women with HIV
The Woman with a Multifetal Pregnancy
Data Base
Nursing Care of Pregnant Women with Preexisting Health Problems
Heart Disease
Data Base
Nursing Care of Pregnant Women with Heart Disease
Assessment/Analysis
Planning/Implementation
Diabetes Mellitus
Data Base
Nursing Care of Pregnant Women with Diabetes Mellitus
Planning/Implementation
Respiratory Disorders
Data Base
Nursing Care of Pregnant Women with Respiratory Disorders
Assessment/Analysis
Planning/Implementation
Cancer
Data Base (see Chapter 3, Integral Aspects of Nursing care, Neoplastic Disorders)
Nursing Care of Women with Complications during the Prenatal Period
Hypertensive Disorders of Pregnancy
Data Base
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