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CARE OF THE MOTHER AND CHILD

SICK OR WITH PROBLEMS (NCM 109)


Lecture / 2nd Year 2nd Semester (Midterms) Bathan, S.
Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients
MAIN TOPIC the Sustainable Development global goal of 70 maternal
deaths per 100,000 live births.
Sub-Topic  There has been significant progress since 2000. Between
Under Sub-Topics 2000 and 2017, South Asia achieved the greatest overall
percentage reduction in MMR, with a reduction of 59
IMPORTANT / MUST REMEMBER per cent (from 395 to 163 maternal deaths per 100,000
live births). Sub-Saharan Africa achieved a substantial
Additional Notes reduction of 39 per cent of maternal mortality during
this period.

Key Facts
NATIONAL HEALTH SITUATION IN THE PHILIPPINES ON
MATERNAL AND CHILD NURSING  Every day in 2017, approximately 810 women died from
preventable causes related to pregnancy and childbirth.
 The Philippines has made significant investments and
 Between 2000 and 2017, the maternal mortality ratio
advances in health in recent years. Rapid economic
(MMR, number of maternal deaths per 100,000 live
growth and strong country capacity have contributed to
births) dropped by about 38% worldwide.
Filipinos living longer and healthier. However, not all the
 94% of all maternal deaths occur in low and lower
benefits of this growth have reached the most
middle-income countries.
vulnerable groups, and the health system remains
 Young adolescents (ages 10-14) face a higher risk of
fragmented.
complications and death as a result of pregnancy than
 Health insurance now covers 92% of the population.
other women.
Maternal and child health services have improved, with
 Skilled care before, during and after childbirth can save
more children living beyond infancy, a higher number of
the lives of women and newborns.
women delivering at health facilities and more births
being attended by professional service providers than Causes
ever before.
 Access to and provision of preventive, diagnostic and Women die as a result of complications during and following
treatment services for communicable diseases have pregnancy and childbirth. Most of these complications develop
improved, while there are several initiatives to reduce during pregnancy and most are preventable or treatable. Other
illness and death due to noncommunicable diseases complications may exist before pregnancy but are worsened
(NCDs). Despite substantial progress in improving the during pregnancy, especially if not managed as part of the
lives and health of people in the Philippines, woman’s care. The major complications that account for nearly
achievements have not been uniform and challenges 75% of all maternal deaths are (4):
remain.
 severe bleeding (mostly bleeding after childbirth)
 Deep inequities persist between regions, richand the
poor, and different population groups. Many Filipinos  infections (usually after childbirth)
continue to die or suffer from illnesses that have well-  high blood pressure during pregnancy (pre-eclampsia
proven, cost-effective interventions, such tuberculosis, and eclampsia)
HIV and dengue, or diseases affecting mothers and  complications from delivery
children. Many people lack sufficient knowledge to  unsafe abortion.
make informed decisions about their own health. Rapid
The remainder are caused by or associated with infections such as
economic development, urbanization, escalating climate
malaria or related to chronic conditions like cardiac diseases or
change, and widening exposure to diseases and
diabetes.
pathogens in an increasingly global world increase the
risks associated with disasters, environmental threats,
and emerging and re-emerging infections
PHILIPPINES
STATISTICS ON MCN
Chart and table of the Philippines infant mortality rate from 1950
Worldwide to 2021. United Nations projections are also included through the
year 2100
 Maternal mortality refers to deaths due to
complications from pregnancy or childbirth. From 2000  The current infant mortality rate for Philippines in 2021
to 2017, the global maternal mortality ratio declined by is 18.392 deaths per 1000 live births, a 2.25% decline
38 per cent – from 342 deaths to 211 deaths per from 2020.
100,000 live births, according to UN inter-agency  The infant mortality rate for Philippines in 2020 was
estimates. This translates into an average annual rate of 18.815 deaths per 1000 live births, a 2.2% decline from
reduction of 2.9 per cent. While substantive, this is less 2019.
than half the 6.4 per cent annual rate needed to achieve
Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

 The infant mortality rate for Philippines in 2019 was - In humans, each cell, with the excemption of the
19.239 deaths per 1000 live births, a 2.16% decline from sperm and ovum, contains 46 chromosomes (44
2018. autosomes and 2 sex chromosomes)
 The infant mortality rate for Philippines in 2018 was - Spermatozoa and ova each carry 23 chromosomes
19.663 deaths per 1000 live births, a 3.96% decline from (1/2)
2017. - For each chromosome in the sperm cell, there is a
like chromosome of similar shape and size and
According to UNICEF function in the egg cell (AUTOSOME)

 160 women for every 100,000 births die.


 Roughly over 11 women die every day.
 7 out of 10 deaths occur at childbirth or within a day
after delivery.
 4 out of 10 deaths are due to complications and
widespread infections
 For every death, 40 more women get sick.
 8 out of 10 births in rural areas are delivered outside a
health facility

WESTERN VISAYAS

- The Center for Health Development (CHD) in Western


Visayas has admitted the need to double their efforts to
address the high rate of childhood mortality in the
region.
- Results of the 2017 National Demographic and Health • Alelles – 2 like genes
Survey (NDHS), conducted by the Philippine Statistics
Authority (PSA), showed that 31 percent of 1,000 • Phenotype – refers to his or her outward appearance or
pregnancies of at least seven months duration are the expression of the genes
stillbirth; 33 percent of 1,000 live births do not reach
• Genome –complete set of genes present. (46 XX or 46
their first month of life; 38 percent die before their first
XY)
birthday; and 46 percent of children die before reaching
their fifth birthday. • Genotype – refers to his or her actual gene composition.
- The result is higher than the national childhood
mortality rate, which is 22 percent for under-five Nature of Inheritance: Dominant and Recessive Pattern
mortality, 21 percent for infant, and 14 percent for
• The principle of inheritance of disease are the same as
neonatal mortality.
those that govern genetic inheritance of other physical
- Neonatal mortality refers to children who die before
characteristics, such as eye or hair color.
their 28th day while infant mortality refers to those who
die before they reach one year old. • These principles are discovered and described by
Gregor Mendel, an Austrian naturalist.

• Gregor Mendel – founder/father of modern science


GENETIC AND GENETIC COUNSELING genetics
NATURE OF INHERITANCE • Mendelian Laws – studies at garden of ---
 Genes Mendelian Laws
- are the basic units of heredity that determine both
the physical and cognitive characteristics of people. • A person who has two like genes for a trait on two like
- Composed of segments of DNA (deoxyribonucleic chromosomes (homozygous)
acid), they are woven into strands in the nucleus of
all body cells to form chromosomes. • If gene differs (heterozygous)

• Dominant – dominant in their action over others; if


paired with other genes

• Recessive – not dominant gene

• Mendelian laws permits the prediction of inheritance of


traits such as eye color or the chance that a child born to
parents with a certain genotype will be born with a
disorder.

• If the father is homozygous dominant (has 2 dominant


genes for brown eye color) and the mother is
homozygous recessive (has 2 genes for blue eye color) it
can be predicted that their children have a 100% chance

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

of being a heterozygous for a trait (brown eyed – • There is usually a history of the disorder in other family
phenotype) that will carry a recessive gene for blue eyes members
(genotype).
Example:
• If the father is heterozygous (has one dominant and one
recessive gene), a child born to this couple has equal • HUNTINGTON DISEASE
chance to have brown eyes or blue eyes – A progressive neurologic disorder that usually
• Suppose the mother is heterozygous, and the father is manifests symptoms between 35 and 45 years
homozygous dominant, the chances are equal that their of age and is characterized by loss of motor
child will be homozygous dominant like the father or control and intellectual deterioration.
heterozygous like the mother. All the children’s – Analyzing a specific gene in chromosome 4
phenotype will be brown eyes
– No cure
• Suppose both parents are heterogenous:
• FACIOSCAPULOHUMERAL muscular dystrophy
There is a 25% chance of their child to being
homozygous recessive (appearing blue eyed), 50% – A disorder that result to muscle weakness
chance of being heterozygous (appearing brown eyed)
and 25% homozygous dominant (appearing brown eyed)

This is how 2 brown eyed parents can produce a blue


eyed child.

INHERITANCE OF DISEASE

AUTOSOMAL DOMINANT DISORDERS (ADD)

– More than 3,000 ADD are known only a few • OSTEOGENESIS IMPERFECTA
are commonly seen.
– A disorder in which bones are exceedingly
– Most of them cause structural defects. brittle

– With ADD, either a person has 2 unhealthy


genes (homozygous dominant) or is
heterozygous, with the gene causing the
disease stronger than the corresponding
healthy recessive gene for the same trait.

Rule (ADD)

• A person who is heterozygous for an ADD mates with a


person who is free of the trait:

– 50% chance – child will have the disorder or


would be disease-free and carrier-free.

• 2 heterogenous people with a dominantly inherited • MARFAN SYNDROME


disorder to choose each other, because of they do,
their chances of having children free from the disorder – A disorder of connective tissue in which the
decline. child is thinner and taller than normal and may
have associated heart defects.
– There would only be 25% chance of a child’s being
disease and carrier-free. 50% chance that the child
would have the disorder, 25% chance that the child
would be homozygous dominant (incompatible
with life.

WHEN ASSESSING THE FAMILY GENOGRAM:

- pictorial and genetic disorder tree (?)


- allows user to visualize hereditary and ---pattern
*…+

• One of the parents of a child with the disorder also will


also will have the disorder (vertical transmission)

• The sex of the affected individual is unimportant in


terms of inheritance
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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

 Karyotyping.
For karyotyping, a sample of peripheral venous blood or
a scraping of cells from the buccal membrane is taken.
Cells are allowed to grow until they reach metaphase,
the most easily observed phase. Cells are then stained,
placed under a microscope, and photographed.
Chromosomes are identified according to size, shape,
 AUTOSOMAL RECESSIVE DISORDERS and stain; cut from the photograph, and arranged.
– Biochemical or enzymatic
– Do not occur unless 2 genes for a disease are
 Maternal Serum Screening.
present (homozygous recessive pattern)
Alpha-fetoprotein (AFP) is a glycoprotein produced by
– Examples: Cystic fibrosis, adrenogenital
the fetal liver that reaches a peak in maternal serum
syndrome, albinism, Tay-sachs disease,
between the 13th and 32nd week of pregnancy. The
galactosemia, phenylketonuria, limb-girdle
level is elevated with fetal spinal cord disease (more
muscular dystrophy and RH factor
than twice the value of the mean for that gestational
incompatibility.
age) and is decreased in a fetal chromosomal disorder
GENOGRAM such as trisomy 21.

• Both parents are disease free but both are heterozygous  Chorionic Villi Sampling.
in genotype. CVS is a diagnostic technique that involves the retrieval
and analysis of chorionic villi from the growing placenta
• The sex of the affected individual is unimportant
for chromosome or DNA analysis. The test is highly
• The family history for the disorder is negative accurate and yields no more false-positive results than
does amniocentesis.
• A known common ancestor between the parents
sometimes exist.  Amniocentesis.
Amniocentesis is the withdrawal of amniotic fluid
through the abdominal wall for analysis at the 14th to
SCREENING AND DIAGNOSTIC TESTING 16th week of pregnancy. Because amniotic fluid has
reached about 200 mL at this point, enough fluid can be
Pre-pregnancy: withdrawn for karyotyping of skin cells found in the fluid
as well as an analysis of AFP or acetylcholinesterase. If
 DNA analysis or karyotyping of both parents and an
no acetylcholinesterase, a breakdown product of blood,
already affected child (provides a picture of the family’s
is found in the specimen, it confirms that an elevated
genetic pattern and can be used for prediction in future
AFP level is not a false-positive reading caused by blood
children)
in the fluid.
GENETIC DISORDER SCREENING AND DIAGNOSTIC TEST
 Percutaneous Umbilical Blood Sampling. PUBS, or
cordocentesis
is the removal of blood from the fetal umbilical cord at
about 17 weeks using an amniocentesis technique. This
allows analysis of blood components as well as more
rapid karyotyping than is possible when only skin cells
are removed.

 Fetal Imaging.
Magnetic resonance imaging (MRI) and ultrasound are
diagnostic tools used to assess a fetus for general size
and structural disorders of the internal organs, spine,

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

and limbs. Because some genetic disorders are


PREGNANCY COMPLICATIONS
associated with physical appearance, both of these
methods may be helpful. Ultrasound is used HYPEREMESIS GRAVIDARIUM
concurrently with amniocentesis.
- Excessive nausea and vomiting that persists beyond
 Fetoscopy. 12weeks of gestation and which leads to
Fetoscopy is the insertion of a fiberoptic fetoscope complications like DHN(dehydration), weight loss
through a small incision in the mother’s abdomen into and acidosis from starvation and alkalosis from loss
the uterus and membranes to visually inspect the fetus of HCL acid in vomitus
for gross abnormalities. It can be used to confirm an - Some theories point to high levels of HCG and to
ultrasound finding, to remove skin cells for DNA ambivalent attitude towards pregnancy
analysis, or to perform surgery for a congenital disorder
SIGNS AND SYMPTOMS
such as a stenosed urethra.
- Excessive N/V not relieved by ordinary remedies
 Preimplantation Diagnosis. persisting beyond 12 weeks
Preimplantation diagnosis is possible for in vitro - Signs of DHN: thirst, dry skin, increased PR, weight
fertilization procedures. It may be possible in the future loss, concentrated and scanty urine
for a naturally fertilized ovum to be removed from the
uterus by lavage before implantation and studied for MANAGEMENT
DNA analysis this same way. The ovum would then be
 When a pregnant woman suffers from severe N/V, and
reinserted or not, depending on the findings and the
shows signs of DHN, hospitalization is necessary. This is
parents’ wishes. This would provide genetic information
to correct DHN and fluid and electrolyte imbalances by
extremely early in a pregnancy.
administration of IV Fluids
 When condition has improved:
CANDIDATES FOR REFERRAL FOR GENETIC TESTING OR o Introduce food gradually starting with clear
COUNSELING: liquids
o Give small frequent feedings
• A couple who has a child with a congenital disorder or o Do not serve foods with strong odour, spicy
an inborn error of metabolism. and greasy
o Do not force patient to eat, remove food if
• A couple whose close relatives have a child with a
nausea and vomiting recurs when food is
genetic disorder such as chromosomal disorder or an
introduced
inborn error of metabolism.
o See to it that the patient is relaxed and
• Any individual who is a known carrier of a chromosomal comfortable in meal time
disorder.  Nursing Responsibility
o Check doctor orders, what fluids and prepare
• Any individual who has an inborn error of metabolism or it
chromosomal disorder. o Record/document colour of vomitus
• A consanguineous couple.

• Any woman older than 35 years of age and any man ECTOPIC PREGNANCY
older than 55 years of age. - Any gestation located outside the uterine cavity
• Couples of ethnic background in which specific illnesses - The zygote implants in an abnormal location
are known to occur. outside the uterus (extrauterine pregnancy is 2nd
leading cause of bleeding in early pregnancy)
LEGAL AND ETHICAL ASPECTS OF GENETIC SCREENING AND
COUNSELING

• Legal responsibilities of genetic testing, counselling and


therapy:

– Participation by couples or individuals in


genetic screening must be elective.

– People desiring genetic screening must sign an


informed consent for the procedure

– Results must be interpreted correctly yet


provided to the individuals as quickly as Causes Of Ectopic Pregnancy
possible,
1. Mechanical Factors – factors that delay the passage of
– After genetic counseling, persons must not be ovum in the oviducts and prevent it from reaching the
coerced to undergo procedures such as uterus in time of implantation
abortion or sterilization.

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

Signs and Symptoms of Ectopic Pregnancy


 Previous Ectopic Pregnancy
1. Pain
 Previous operation on the tube
- Pelvic and abdominal pain on the side affected tube
 Tumors that distort the tube
when tube is not yet ruptured
 Past induced abortions
- Sudden severe knife-like pain (most common
symptom when the tube ruptures)
2. Functional Factors – external migration of the ovum
- Pain radiating to the neck and shoulder
- Menstrual reflux
- Cervical pain during IE
- Altered tubal motility – IUD, contraception,
2. Amenorrhea with some degrees of spotting or bleeding
morning after pill
(amount of bleeding may not reflect the actual amount
of blood loss as blood tends to collect in the peritoneal
3. Assisted Reproduction
cavity) Blood is usually dark brown
- Ovulation induction (clomid)
- Signs of Amenorrhea:
- Gamete intrafallopian transfer (is a tool of assisted
3. Signs of shock
reproductive technology against infertility. Eggs are
- Cyanosis, Pallor, cold clammy skin, rapid pulse, low
removed from a woman’s ovaries, and placed in
BP
one of the fallopian tube along with the man’s
- Cullen’s Sign – blush discoloration of the umbilicus
sperm
due to the presence of blood in the peritoneal
- IVF
cavity
- Ovum Transfer – this procedure begins with
- BP decreases and PR increases dramatically when
ovulatory drugs being administered to the woman
changing position from supine to sitting
to stimulate the maturation of multiple ova. The
- Oliguria – absence of urine
couple engages in sexual intercourse just prior to
the predicted time of ovulation. Diagnostic Aids

- Culdocentesis (aspiration of body fluids from the


4. Failed Contraception cul-de-sac of Douglas)
- IUD
- Oral contraceptives
- Condoms/diaphragm
- Tubal ligation (16 to 50%)
- Hysterectomy

Kinds Of Ectopic Pregnancy

 Tubal (ampulla)
 Ovarian (mgt; cystectomy or oophorectomy)
 Cervical (due to IVF or embryo transfer
o Painless vaginal bleeding
o Distended thin-walled cervix
o Dilated external os
o Seldom goes beyond 20w gestation - Ultrasound (reveals presence of gestational sac
 Abdominal outside the uterine cavity)
 Broad Ligaments - Colpotomy (direct visualization of the oviducts and
 Tubo-uterine ovaries) is atype of incision made in the back wall
 Tubo-abdominal of the vagina. During a tubal ligation, the doctor
can use a colpotomy also vaginotomy as one of the
 Tubo-ovarian
ways to reach your fallopian tubes *…+

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

 If ruptured, removal or repair of ruptured tube


o Many physicians choose to remove the
ruptured tube because the presence of scar if
tube is repaired and left can lead to another
tubal pregnancy.
o Responsibility: signed consent

Management

 If not yet ruptured, therapeutic abortion is performed


by:
- Salpingostomy
- Salpingotomy Prevent and treat hemorrhage which is the main danger of
- Fimbrial evacuation (milking and suctioning of the ectopic pregnancy:
FT)
- Blood transfusion
- Medical Management:
- Place flat on bed with legs elevated (trendelenburg)
o Methotrexate, sometimes combined w/
- Extra blanket to keep warm
surgery to treat an ectopic pregnancy. In
- Monitor VS, IO and amount of blood loss
this case, the medicine removes fetal
- Prevent infection as the woman who lost so much
cells left behind after surgery. To treat
blood is susceptible to infection
ectopic pregnancy, methotrexate is
- Contraception must be started upon discharge
typically given as an injection (a shot) in
from hospital. Ovulation begins as early as 12 days
to a muscle
or 3 weeks after resection of EP
o Usually occurs during 2-3 days of
treatment

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

HYDATIDIFORM MOLE (H-MOLE) Complications of H-mole

- Molar pregnancy occurs when the placenta  Gestational Trophoblastic tumors (persistent
develops into an abnormal mass of cysts rather trophoblastic proliferation after H-mole) they are 3
than becoming a viable pregnancy kinds
- Molar pregnancy is a type of gestational o Choriocarcinoma
trophoblastic disease (gtd)  Most severe malignant complication
- In a complete molar pregnancy, there’s no embryo that involve the transformation of
or normal placental tissue chorion into cancer cells that evades
- In partial molar pregnancy, there’s an abnormal and erode blood vessels and uterine
embryo and possibly some normal placental tissue. muscles. This leads to sloughing and
This embryo begins to develop but is malformed necrosis of the endometrium,
and can’t survive bleeding and infection. The cancer
cells can spread to the other parts of
Symptoms the body via the blood and lymph.
- Rapid growth of the uterus (out of proportion to  Invasive Mole
the actual AOG) o The mole is locally invasive and is
- Uterus bigger than dates (though many can be the characterized by excessive formation of
same size or even smaller) trophoblastic villi that penetrates the
- Persistent nausea and vomiting (due to elevated myometrium. Develops during the first
HCG levels) 6months after H-mole.
- Bleeding or spotting in the first or second trimester
(spotting or heavy, intermittent or continuous,  Placental Site Trophoblastic Tumor
usually light) – common sign o Composed of cytotrophoblastic cells arising
- No fetal heart tones or fetal movement from the site of the placenta
- Pelvic pressure o These cells produce both prolactin and HCG
- Hypertension may become a problem in the second o Main symptom is bleeding
trimester (signs of preeclampsia bfore 24 weeks: o May follow an abortion, normal pregnancy
HPN, edema, and proteinuria) and H-Mole
- SOB (late, life threatening indication of an o Major protein secreted is HPL
embolism) o Management of all Trophoblastic Tumor is
- Enlarged, tender ovaries (ovarian cysts) HYSTERECTOMY
- Passage of “grape-like” vesicles with bleeding (4th
month)
- UTZ reveal a mass of fluid-filled vesicles instead of INCOMPETENT CERVIX
developing fetus
 Mechanical defect of the cervix wherein there occurs
Management painless cervical dilation in the 2nd trimester or early in
the 3rd trimester, followed by a prolapse and ballooning
- Dilatation and curettage (D&C) to remove the
of the membranes in the vagina, then rupture of
mole. If woman is >40 years old, hysterectomy is
membranes, expulsion of fetus
done since she has a higher chance of developing
 This abnormality, which may be congenital or acquired,
choriocarcinoma
is the most common cause of habitual abortion
- Methotrexate (for 1yr to prevent the development
of malignant or cancer cells in the uterus
o Other anticancer drugs used: Actinomycin
D, vinblastine
- The woman is monitored for HCG level for 1yr. HCG
should be negative for 2-6weeks after removal of
mole
o HCG level is monitored every 2weeks
until normal ---then monthly for
6months---then every 2months for
another 6 months
o When HCG level is normal, it is monitored
monthly for 6months and then every
2months until 2 years. Signs and Symptoms
- Chest x-ray every 3months for 6months (lungs are
 First sign is painless vaginal bleeding accompanied by
common site of metastasis of choriocarcinoma)
cervical dilation
- The woman is advised not to get pregnant for one
 Rupture of membranes and passage of amniotic fluid
year (contraceptive methods should NOT BE PILLS -
follows cervical dilation and then loss of the products of
-- contains estrogen which promotes regrowth of
conception
chorionic villi)

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

Management PLACENTA PREVIA

 Cervical cerclage or suturing of the cervix between 14  Is the abnormal implantation of placenta near or over
and 16 weeks gestation to prevent cervical dilatation the internal os
o Prerequisite  Is the most common bleeding disorder of the third
 Cervix not dilated beyond 3cm trimester
 Intact membranes
 No vaginal bleeding and uterine Types of Placenta Previa
cramping
 Low lying placenta
o Types of Cervical Cerclage
 Marginal placenta
 Shirodkar suture – permanent
 Partial placenta
suture which is left in place for
 Complete placenta
subsequent pregnancies, fetus is
delivered by CS Causes
 Mc Donald Suture – temporary
suture remove starting 38-39 weeks  Multiparity
gestation, fetus is delivered vaginally  Multiple pregnancy
 Advance Maternal Age (over 35 years old)
 Smoking
 Previous CS and abortion
 Condition that make implantation in the upper fundal
portion of the uterus undesirable: previous molar
pregnancy
 Abnormal placenta:

Signs and Symptoms

1. Painless vaginal bleeding (most significant sign near the


end of early 3rd trimester)
2. UTZ reveals….

Management

 CS is the delivery of choice for all kinds of PP primarily


for the welfare of the mother
 Assess extent of blood loss:
o Visual estimates (most often but most
inaccurate)
o BP and Pulse
o Tilt test
o Uterine Flow (urine blood flow is sensitive to
blood volume changes. If there is massive
blood loss, urine output will be decreased or
absent)
After Suturing the cervix:
 Manage bleeding episodes:
 Place woman on bed rest for 24hrs o Keep woman on NPO
 Observe for bleeding, uterine contractions, and rupture o Monitor VS, FHR, Vaginal bleeding
of bag of water o Maintain on absolute bed rest
 If bag of water ruptures – the sutures are removed o Start IV replacement therapy and BT as
 If uterine contraction occurs – the woman is given necessary
tocolytics (ritodrine(Yutopar)) to stop the contraction  Watchful bleeding (delay delivery until fetus is mature
 Post op care: restrict activities for the next 2 weeks enough(
including coitus o Fetus still immature to be delivered
o Woman is placed on bed rest
o Ritodrine hcl and MG SO4 to prevent labor
o Amniocentesis to determine lung maturity
o NO IE is performed in diagnosed PP

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

ABRUPTIO PLACENTA o Bright red vaginal bleeding is usual is in overt


type
- Premature separation of normally implanted o If the woman develops shock because of
placenta after 20w of gestation and before delivery bleeding, it is usually out of proportion to the
of fewtus amount of blood loss
- Also called ablatio placenta, placental abruption o Board-like abdomen caused by accumulation
and accidental haemorrhage. of blood behind the placenta with fetal parts
Causes hard to palpate
o Abnormal tenderness due to distension of the
 Maternal HPN (chronic or pregnancy-induced) – most uterus with blood. Sharp pain over the fundus
common as the placenta separates
 Advanced maternal age o Signs of shock and fetal distress if bleeding is
 Grand multiparity – more than 5 pregnancies severe
 Trauma to the uterus
Management
 Sudden release of amniotic fluid that cause sudden
decompression of the uterus  When AP is suspected or diagnosed, hospitalization is a
 Short umbilical cord must
 Cigarette smoking and cocaine abuse  Bed rest on side-lying position for optimum placental
 Uterine leiomyoma esp. if located at the placental site perfusion
 Monitor VS, FHT (fetal heart tone), Amount of blood loss
Types of AP
(face mask O2 if fetal distress is present)
 Placenta separated from the uterus – internal bleeding –  Delivery:
external bleeding o Vaginal delivery if no sign of fetal distress,
bleeding is minimal and VS is stable
o CS if bleeding is severe, fetal distress present
and fetus cannot be delivered immediately
with vaginal method

Complications

 Couvelaire uterus or uterine apoplexy – infiltration of


blood into the uterine musculature results in the uterus
becoming hard and purplish. The uterus in this
condition, loses its contractility
 Hemorrhage and shock (treated by blood transfusion)
 Disseminated Intravascular coagulopathy
1. Covert/Central/Concealed AP
 Renal failure – degeneration of the structure of kidney
 Separation begins at the center of placenta attachment
occur as a result of shock
resulting in blood being trapped behind the placenta,
 Infection
bleeding then is internal and not obvious
2. Overt/Marginal/External AP
 Separation begins at the edges of the placenta allowing
blood to escape from the uterine cavity
 Bleeding is external

Classification according to Placental Separation

 Grade 0 – no symptoms, diagnosed after delivery when


placenta is examined and found to have a dark,
adherent clot on the surface
 Grade 1 – some external bleeding, no fetal distress, no
shock, uterine tetany and tenderness may or may not be
noted
 Grade 2 – external bleeding, uterine tetany, uterine
tenderness, fetal distress
 Grade 3 – internal and external bleeding, uterine tetany,
maternal shock, fetal death, DIC (disseminated
intravascular coagulopathy)

Signs and Symptoms

(vary depending on the type of AP or manner of separation)

 Vaginal Bleeding
o Dark red vaginal bleeding is the usual
manifestation in the covert type
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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

PREGESTATIONAL CONDITIONS Vulnerable Groups are Pregnant Women

High Risk Pregnancy  Physiologic problem such as concurrent illness with


malnutrition
Factors that categorize a pregnancy as high risk:
 Mothers who are too young, too old, pregnant too
 Psychological frequently
 Socio-demographic  Presence of physical deformity
 Physiological  Psychological/mental illness/mental retardation
 Marginalized
 Poverty
 Unemployment
 Lack of Education
 Exposure to teratogens due to occupation
 Victims of abuse or domestic violence, rape, incest
 Single or separated mothers

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

UNDERSTANDING THE CARDIOVASCULAR SYSTEM Risks

Cardiovascular system includes: heart, arteries, arterioles, Reducing Risk for Cardiovascular Diseases
capillaries, venules, veins
 Avoid tobacco
The Heart  Cut back on saturated fat and cholesterol
 Maintain a healthy weight
- Muscular, four chambered pump
 Modify dietary habits
- Contracts 100,00 times per day
 Exercise regularly
- Two upper chambers: atria
 Control diabetes
- Two lower chambers: ventricles
 Control blood pressure
- Tricuspid, pulmonary, mitral and aortic valves
o Systolic – upper
o Diastolic – lower
 Manage stress

Risks you cannot control:

 Heredity
 Age
 Gender
 Race

PHYSIOLOGICAL CONSIDERATION WITH HEART DISEASE IN


PREGNANCY

- The most important changes in cardiac function


occurs in the first 8weeks of pregnancy with
maximum changes at the 28 weeks

RHEUMATIC HEART DISEASE

 Results from rheumatic fever which affects connective


tissue - Maternal weight and basal metabolic rate also
 Causes scarring and may result in stenosis and/or affect cardiac output
regurgitation - Later in pregnancy, COP is higher when women is in
the lateral recumbent position than when she is in
the supine
- During labor, COP increases moderately in the first
stage of labor and appreciably greater in the
second stage
- COP also increase in the immediate postpartum
period

Heart

 The heart is displaced upward and to the left with lateral


rotation on its axis
 Resting pulse increase by about 10bpm. There is some
changes in the cardiac sounds include:
o An exaggerating splitting of the first heart
sound with increase loudness of both
components, no definite changes in the aortic
and pulmonary elements of the second sound,
and a loud easily heard third sound
 Systolic murmur is heard in 90% of cases
 Soft diastolic murmur transiently in 20%
 Continuous murmur arising from the breast vasculature
in 10% of cases

P a g e 12 | r l y n o t f a y e
Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

HEART DISEASE c. Avoid high altitudes, smoking areas, alcoholic


beverages
- Normal hemodynamic of pregnancy that adversely d. Prevent Infection
affect the client with heart disease e. Provide instructions on danger sign of heart
1. Oxygen consumption increased 10% to 20%; related to failure:
needs of growing fetus i. Cough with rales (first sign of
2. Plasma level and blood volume increase; RBCs remain impending HF)
the same (physiologic anemia) ii. Increasing dyspnea, tachycardia,
rales, edema
Functional or Therapeutic Classification of Heart Disease during f. Medications:
Pregnancy i. Iron Supplementation to prevent
anemia
 Class I: No limitation of physical activity; no symptoms ii. Digitalis to strengthen myocardial
of cardiac insufficiency or angina contraction and slow down heart
 Class II: Slight limitation of physical activity; may rate
experience excessive fatigue, palpitation, angina, or iii. Nitro-glycerine to relieve chest pain
dyspnea; slight limitation as indicated iv. Antibiotics to prevent and treat
 Class III: Moderate to marked limitation of physical infection
activity, dyspnea, angina, and fatigue occur with slight v. Diuretics maybe prescribed in case
activity, and bed rest is indicated during most pregnancy of heart failure
 Class IV: marked limitation of physical activity, angina,
Nursing intervention prenatal period:
dyspnea, and discomfort occur at rest; pregnancy should
be avoided; indication for termination of pregnancy  Teach client to recognize & report signs of infection,
importance of prophylactic antibiotics
Diagnosis of Heart Disease
 Compare vital signs to baseline
Some clinical indicator of heart disease during pregnancy  Instruct in diet to limit weight gain 15lbs, low Na+, Fe,
Protein
Symptoms  8-10hrs of sleep

- Progressive dyspnea or orthopnea Take Note


- Nocturnal cough
- Hemoptysis  Remember a pregnant woman with heart disease should
- Syncope with exertion avoid infection, excessive weight gain, edema and
- Chest pain anemia, because these conditions increase the workload
of the heart
Prenatal Period Assessment  Breastfeeding is allowed if there are no sign of cardiac
- Evidenced of cardiac decompensation especially when decompensation during pregnancy, labor, and
blood volume peaks (28-32w) puerperium
- Cough and dyspnea
- Edema
- Heart murmur PRE-GESTATIONAL DIABETES
- Palpitations
- Rales  A known diabetic becomes pregnant
- Weight gain  Hyperglycemia presents throughout pregnancy and not
just in the 2nd half as occurs in GDM
Diagnostics  More prone for certain complications

- ECG Diabetes Mellitus


- 2-D Echo
- Chest Xray - A hereditary endocrine disorder characterized by
inadequate or lack of insulin production that results in
Management impaired glucose absorption and metabolism resulting
to hyperglycemia
1. Prenatal
a. Promotion of rest (class I and II) Signs and symptoms
i. 8 hours of sleep at night and
frequent rest periods during the day 1. Hyperglycemia – in DM, the pancreas does not produce
ii. Light work only in the house enough insulin. Thus the glucose is unable to enter the
b. Diet cells and accumulate in the bloodstream resulting in
i. High in iron, proteins, minerals and hyperglycemia
vitamins 2. Glycosuria – When blood glucose level goes beyond the
ii. Limit sodium intake, avoid foods renal threshold for sugar, glucose pills in the urine.
with high sodium content 3. Polyuria – glucose attracts water so that when it is
iii. Weight gain of no more than 24lbs exerted in the kidney, it brings along with it large

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

amounts of water resulting in the woman excreting - Infants of mothers with GDM are vulnerable to several
large amounts of urine chemical imbalances such as:
4. Polydipsia- excretion of large amounts of fluid in the o Low calcium
body leads to dehydration. Excessive thirst is an o Low Magnesium
important symptom of dehydration
5. Weight loss – since glucose cannot be utilized as a Major Problem of Gestational Diabetes
source of energy, the body uses its protein and fats 1. Macrosomia – refers to a baby that is considerably
stores in the muscles and adipose tissue resulting to larger than normal
weight loss 2. Birth Injury
6. Ketoacidosis – breakdown of protein and fats result to 3. Hypoglycemia – refers to low blood sugar in the baby
excessive formation of ketone bodies that the body immediately after birth
cannot excrete right away causing them to accumulate 4. Respiratory distress (difficulty of breathing)
What is Gestational Diabetes

- Is a condition in which the glucose level is elevated and


other diabetic symptoms appear during pregnancy in a
woman who has not previously been diagnosed with
diabetes. In most cases, all diabetic symptoms disappear
following delivery.

Risk Factors of GDM

 Obesity
 Age over 25 years old
 Hx of large baby (over 10lbs or more)
 Hx of unexplained fetal or perinatal loss
 Hx of congenital anomalies in previous pregnancies
 Fx Hx of diabetes (one close relative or 2 distant
relatives)
 Member of a population with a high risk of diabetes
(native American, Hispanic, Asian)

Effects of Diabetes

1. Mother
 Increased tendency to preeclampsia, UTI and
candidiasis
 Higher incidence of dystocia because of large
infants
 Increased risk for postpartum haemorrhage
due to over distention of the uterus
 Hydramnios
 Maternal Mortality
 Diabetic retinopathy
 Diabetic Nephropathy
 Preterm Delivery
2. Infant
 Macrosomia
 Hydramnios
 Prematurity
 IUGR
 Hypoglecemia and hypocalcemia
 Predisposition to DM later in life as the
disease is hereditary

Possible Complications for the Baby:

- Unlike type 1 diabetes, gestational diabetes generally


does not cause birth defects. Birth defects usually
originate sometime during the first trimester of
pregnancy. They are more likely in woman with pre-
existing diabetes, who may have changes in blood
glucose during that time.
- Women with GDM generally have normal blood sugar
levels during the critical first trimester

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

d. Glucosuria
e. Strong family history of diabetes
2. Low Risk – screen at 24 to 28 weeks
a. Age <25 years
b. Normal weight before pregnancy
c. Ethnicity with low prevalence
d. No known first degree relatives with diabetes
e. No history of abnormal glucose tolerance
f. No history of poor obstetric outcome

Diagnostic Tests for DM

1. Glycosylated haemoglobin
 Provides information about blood glucose
level during the previous 3 months
 Because glucose in the bloodstream attaches
to some of the haemoglobin and stay attached
during the 120-day lifespan of the RBC

2. Glucose Challenge Test (GCT)


 Another name: Glucose Screening Test
 Done 24-28 weeks
 Blood is drawn 1 hour after you drink sweet
liquid containing glucose (50g)
 No need to fast
 If blood glucose level is high (140 or >) need to
return for ORAL GLUCOSE TOLERANCE TEST
 If blood glucose is 200 and >, possibility of
type 2 diabetes

3. Universal Screening Procedure

4. Oral Glucose Tolerance Test (OGTT)


 Fasting for at least 8 hours
 Blood is drawn after fasting
 Drink the liquid containing glucose
 Blood is drawn every hour for 2-3 hours
 High blood glucose levels at any two or more
blood test times means you have GDM
 Test Values for Pregnancy:

Gestational Diabetes Screening

1. High Risk – screen as early as feasible


a. Marked obesity
b. Previous unexplained fetal demise
c. Personal history of GDM
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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

because they are teratogenic and may cause


fetal and newborn hypoglycaemia
o Combined fast acting and intermediate acting
(Humulin is the insulin of choice during
pregnancy becase it is least allergenic)
o 2/3 in the morning, 1/3 at dinner administered
SQ 30 minutes before meals

REMEMBER!

 Hypoglycaemia could occur in persons undergoing


insulin therapy during the peak action hour of insulin:
o Short acting or regular insulin – after 2-3
hours of injection
o Intermediate or Lente – after 6-8 hours of
injection
o Long-acting or ultralente – after 16-18 hours
of injection
 Signs of hypoglycaemia are:
dizziness, weakness, blurring of
vision
 Give a hypoglycemic person a GLASS
OF ORANGE JUICE
 Home blood glucose monitoring
o 4x a day (upon rising in the morning, before
breakfast, lunch and dinner)
o Observe for UTI and VTI particularly
candidiasis
o Fetal well-being assessment:
 Uteroplacental function test (NST,
CST)
 Amniocentesis to determine fetal
lung maturity

DELIVERY with GDM

Prenatal Management – Early hospitalization and labor induction is performed to


deliver the baby before it becomes too large to pass the
- Diagnosis (suspect DM in Woman) birth canal
o With fx hx of DM – If cervix is not yet ripe, baby is macrosomic and fetal
o With hx of unexpected repeated abortions and distress occur, CS is performed
still births – Regular insulin is given on the day of delivery not long
o With glycosuria acting insulin because insulin requirement drop
o Obese immediately after the delivery. The woman may not
o Hx of giving birth to large infants require insulin in the first 24 hrs postpartum and her
- Diet (Goal: maintain FBS of 90mg/dl and PBBS of 120 insulin requirements usually fluctuates during the next
mg/dl) few days
o 1,800 to 2,400 cal/day
o Teach and instruct client to: Postpartum
 Reduce saturated fat
– Recurrence of diabetes may occur in subsequent
 Reduce cholesterol
pregnancies
 Increase dietary fiber
– Women who developed GDM have higher tendency to
 Avoid fasting and feasting
develop overt diabetes later in life
- Exercise that use upper body muscles or those exercises
– Newborn care:
which place little mechanical stress.
o Keep warm because of poor temperature
o Brisk walking or arm exercise while seated in a
mechanism of baby
chair for atleast 10 mins after each meal
o Observe respiration
o Exercise lower bld glucose and decrease the
– Observe signs of hypoglycaemia (shill cry, weakness) ->
need for insulin
give glucose water (small tube in the mouth)
- Insulin Therapy
– Observe for signs of hypocalcemia (tetany, tremors) ->
o Insulin requirements increases during
give calcium gluconate
pregnancy (highest in the 3rd trimester)
– Observe for congenital anomalies (esophageal atresia,
o Oral hypoglycemic are contraindicated during
neural tube defects)
pregnancy (Diamicron and Tolbutamide)

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

Nursing Management: - Birth defects are preventable

 Assessment of glucose Maternal Effects


 Nutrition counselling
 Malnutrition
 Education about the disease process and management
 Bone marrow suppresion
 Education about glucose monitoring(taken before
insulin) and insulin (taken before meals) administration  Increased incidence of infections
 Assessment of the fetus  Liver disease
 Support Neonatal Effects
 FOLIC ACID:
o all women of reproductive age should  Fetal alcohol spectrum disorders (FASD/FAS)
consume at least 0.4mg of folic acid  Physical and Mental Illness
o high risk women should consume 4mg/day
 reduces the risk of neural tube
defects
o newer evidence suggest a lower risk of facial
clefting and congenital heart disease

Intrapartum Management:

 Absolute requirements:
o Dextrose containing IV fluid
o Insulin
 Hourly glucose monitoring
 Continuous fetal heart rate monitoring
 Continuous tocodynametry
 Manage labor as normal
 Fetal Assessment:
o AFP
o Fetal activity Monitoring
Fetal Alcohol Syndrome 4 Major Criteria:
o NST
o Biophysical profile 1. Characteristic facial abnormalities
o Ultrasound 2. Brain structural neauro, functional deficits (lack of
coordination and poor fine motor skills)
3. Growth deficiencies (low birth weights)
SUBSTANCE ABUSE 4. Maternal alcohol use during pregnancy
 Small eyes
 Inability to meet help  An exceptionally thinner upper lip
 Major role obligations  A short, upturned nose
 Increase in legal problem  Smooth skin surface between the nose and upper lip
 Risk-Taking behaviour:
o Being firm is one thing but “laying down the
law” in a moralistic way can close of lines
o Failing to set expectations – teens who know
their parents disapprove of drug use are less
likely to use and vice versa. Dr. Lee says it’s
best to let kids know how a parent feel about
drugs before they hit their teenage years
o Assuming experimentation is no big deal –
experimentation doesn’t necessarily lead to
addiction, and some parents figure that
there’s nothing especially worrysome about a
Pathophysiology
child trying drugs or alcohol. Infact, even
dabbling in substance abuse can cause big – Cocaine is a small enough molecule to pass across the
problems, such as car accidents, sexual assault placental barrier into the bloodstream of the fetus
and serious overdoses. It’s not a normal rite of – The skin of the fetus is able to absorb the chemical
passage directly from the amniotic fluid until the 24th week of
 Exposure to hazardous situations because of an pregnancy. Cocaine can also show up in breast milk and
Addicting Substance affect the nursing baby

Alcohol Use in Pregnancy Cocaine Use In Pregnancy (Maternal Effects)

- Maternal Effects  Seizures and hallucinations


- Neonatal Effects  Pulmonary edema
- “No alcohol, no alcohol harm”  Respiratory failure
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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

 Cardiac problems o In utero exposure to MDMA is associated with


 Spontaneous first trimester abortion, abruption a neuro and cardiotoxicity and impaired motor
placenta, intrauterine growth restriction (IUGR), functioning
preterm birth and stillbirth
– Human Immuno – deficiency virus (HIV)
Cocaine Use In Pregnancy (Fetal Effects) - Virus that infects cell (CD4 / t cells) of the immune
 Decreased birth weight and head circumference, altered system
brain development - Progressive deterioration can lead to immune deficiency
 Genito-urinary malformations Acquired Immunodeficiency Syndrome (AIDS)
 Low apgar scores at birth
 Feeding difficulties - Most advance stage of HIV infection
 Neonatal effects from breastmilk: - Occurrence of opportunistic infections or HIV related
o Extreme irritability cancers
o Vomiting and diarrhea
o Dilated pupils and apneam Transmission

Heroine Use in Pregnancy = Smack or Junk (opiate)  Unprotected sexual intercourse


 Blood transfusion
 Street (illegal) drug made from the opioid morphine  Sharing of contaminated needles, syringes, surgical
o Can easily cross the placental barrier equipment or other sharp instruments
o Can be injected, smoked snorted or sniffed  Transmitted between mother & child during
 CNS depressant – alters perception and produces pregnancy, childbirth, & breastfeeding =
euphoria PERINATAL TRANSMISSION
 Maternal Effects:
o Poor nutrition and iron-deficiency anemia
o Preeclampsia- eclampsia
o Breech position
o Placenta previa / abruptio placenta
o Higher incidence of STIs and HIVs
o Preterm Labor / PROM / Meconium Staining
 Fetal Effects:
o Withdrawal suptomss after birth appears
72hrs (NAS)
 Tremors (trembling)
 Irritability (excessive crying)
 Sleep problems Risk Factors
 High-pitched crying
 Multiple sexual partners
 Tight muscle tone
 Hyperactive reflexes  Bisexual partners
 Seizures  Intravenous drug use
 Yawning, stuffy nose, and sneezing Stages of HIV
Neonatal Abstinence Syndrome

– Group of problems that occur in a newborn who was


exposed to addictive opiate drugs while in the utero
– Set of behavioural and physical signs in the newborn
resulting from abruptly cutting off a baby’s opiods
supply once born
– Usually occur within the first 1-3 days after birth
– May appear up to a week after birth

Marijuana

– Psychoactive compounds in marijuana easily crosses the


placenta, exposing the fetus to perhaps 10 percent of
the THC – tetrahydrocannibol – that the mother
receives, and higher concentrations if the mom uses pot
repeatedly

MDMA (Ecstacy / club drugs) methlyenedioxymethamphetamine

– Stimulant drug related to amphetamine producing some


of the mind-altering effects more commonly linked to
the use of drugs called hallucinogens
– Moderately teratogenic

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

Diagnosis

module 1: quiz 1

Submissions
HIV and Pregnancy

- Perinatal transmission
Here are your latest answers:
- Transmitted between mother & child during pregnancy,
childbirth & breastfeeding Question 1
A disorder resulting from a 5: missing portion of
Factors which increase the risk of transmission
Chromosome abnormal cat-like cry.
 Smoking
 Substance abuse
Response: Cri-du-chat
 Vit A deficiency
Correct answer: Cri-du-chat
 Malnutritions
 STD Score: 1 out of 1 Yes
 Clinical stage of HIV
 Labor Question 2
 Breastfeeding
When do most patients tend to develop
Therapeutic Management gestational diabetes during pregnancy?
Response: Usually during the 2-3 trimester of
pregnancy
Correct answer: Usually during the 2-3 trimester
of pregnancy
Score: 1 out of 1 Yes

Question 3
The human cells contains 46 chromosomes:
_____ are autosomes
Response: 44
Correct answer: 44
Score: 1 out of 1 Yes

Question 4
Which of the following nursing interventions is
appropriate for a nursing diagnosis of Excessive
Fluid Volume related to compromised regulatory
systems?
Response: Monitor intake and output every hour
and record
Correct answer: Monitor intake and output every
hour and record
P a g e 19 | r l y n o t f a y e
Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

Score: 1 out of 1 Yes Question 10


Trisomy 18 syndrome is?
Question 5
The human cells contains 46 chromosomes and Response: 47xx18
____are sex chromosomes. Correct answer: 47xx18
Response: 2 Score: 1 out of 1 Yes
Correct answer: 2
Question 11
Score: 1 out of 1 Yes It is a murmur that is heard with active carditis
and accompanies severe mitral insufficiency.
Question 6
Your patient is 36 weeks pregnant and has Response: Apical pansystolic murmur
gestational diabetes. Which lab result shows that Correct answer: Apical diastolic murmur
she is euglycemic?
Score: 0 out of 1 No
Response: Blood glucose 55 mg/dL
Question 12
Correct answer: Blood glucose 82 mg/dL
A disorder in which bones are exceedingly brittle.
Score: 0 out of 1 No
Response: Osteogenesis imperfecta
Question 7 Correct answer: Osteogenesis imperfecta
Which of the following diagnostic results would
reveal a prolongation of the PR interval, which is Score: 1 out of 1 Yes
a nonspecific finding, but counts as a minor
Question 13
manifestation in the Jones diagnostic criteria in a
A parturient had a consult with her obstetrician.
patient with heart disease?
She has a history of heart disease. She verbalized
Response: Electrocardiogram that during ordinary activity at home she feels
excessive fatigue, palpitation, and dyspnea but
Correct answer: Electrocardiogram
comfortable when at rest. What classification of
Score: 1 out of 1 Yes the heart disease is the parturient belong?

Question 8 Response: Class II


You're providing an educational class for Correct answer: Class III
pregnant women about gestational diabetes.
Select the CORRECT statement about the role and Score: 0 out of 1 No
function of insulin in the body
Question 14
Response: “Insulin is a hormone secreted by the Trisomy 13 syndrome
beta cells of the pancreas.”
Response: 47XY13
Correct answer: “Insulin is a hormone secreted by
Correct answer: 47XY13
the beta cells of the pancreas.”
Score: 1 out of 1 Yes
Score: 1 out of 1 Yes
Question 15
Question 9
Turner's syndrome
A progressive neurologic disorder characterize by
loss of motor control and intellectual Response: 45XO
deterioration. _____
Correct answer: 45XO
Response: Huntington disease
Score: 1 out of 1 Yes
Correct answer: Huntington disease
Question 16
Score: 1 out of 1 Yes Turner's syndrome
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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

Response: 45XO Correct answer: Chromosome


Correct answer: 45XO Score: 1 out of 1 Yes
Score: 1 out of 1 Yes Question 22
Fragile X-syndrome
Question 17
A person who is heterogenous for an Autosomal Response: 47XXY
Dominant Disorder and mates with a person who
Correct answer: 46XX23q
is free of the trait 50% chance the child will have
the disorder or would be disease-free, Score: 0 out of 1 No
Response: True Question 23
Correct answer: True A disorder of connective tissue in which the child
is thinner and taller than normal and may have
Score: 1 out of 1 Yes associated with Heart defects.
Question 18 Response: Marfan syndrome
A 36-year-old pregnant female is diagnosed with
Correct answer: Marfan syndrome
gestational diabetes at 28 weeks gestation, the as
the nurse educating the patient about her Score: 1 out of 1 Yes
condition. Which statement of the patient
demonstrates that she understands the health Question 24
teaching of the nurse about gestational diabetes? Basic unit of heredity

Response: “It is important I try to get my fasting Response: Genes


blood glucose around 70-95 mg/dL and <140 Correct answer: Genes
mg/dL 1 hour after meals.”
Score: 1 out of 1 Yes
Correct answer: “It is important I try to get my
fasting blood glucose around 70-95 mg/dL and Question 25
<140 mg/dL 1 hour after meals.” A 32-year-old female is diagnosed with
gestational diabetes. As the nurse you should
Score: 1 out of 1 Yes
know what test is used to diagnose a patient with
Question 19 this condition?
Klinefelters syndrome Response: Hemoglobin A1C
Response: 47XXY Correct answer: 3 hour glucose tolerance test
Correct answer: 47XXY Score: 0 out of 1 No
Score: 1 out of 1 Yes
Question 26
Question 20 Which of the following medications is not
Cri-du-chat indicated for a parturient client with heart
disease?
Response: 46XX5p
Response: Prophylactic Antibiotics
Correct answer: 46XX5p
Correct answer: Coumadin
Score: 1 out of 1 Yes
Score: 0 out of 1
Question 21
Segments of DNA that are woven into strands in
the nucleus of all body cells to a
Response: Chromosome

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Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

AIDS – acquired immune deficiency syndrome Prevention

- Can take many years to develop - Administration of Rh (Anti-D) globulin (Rhogam) within
- Eventually kills or impairs more and more cells in the the 1st 72 hours after delivery to woman who
immune system and body loses ability to fight off o Have delivered Rh positive babies
common infections such as: diarrhea or colds o Have had untypable pregnancies such as:
- Can die from diseases that are usually not dangerous for ectopic pregnancies, still birth,
people with healthy immune system o …

*Boost and protect their immune system

*mostly transfers via bodily fluids

Appearance of Conditions that sufficiently indicates AIDS

- Presence of opportunistic infections: Kaposi’s sarcoma,


pneumocystis carinii
- Dementia: CNS complications
- Presence of a disease that is due to a deficiency in the
immune system

Kaposi Sarcoma (KS)

- A cancer that causes patches of abnormal tissue to


grown under the skin, lining of the mouth, nose, and
throat, lymph nodes or in other organs. These patches *Antigen – substance that prompts your body to trigger an
or lesions are usually red or purple, they are made of immune response against it
cancer cells …
*Antibodies – Y-shaped proteins that the body produces when it
Pneumocystis Carinii detects antigens

- A cause of diffused pneumonia in immunocompromised Notes:


host. Even in fatal cases, the organism and disease
remain localized to the lung. - Destruction of RBC results in the formation of indirect
bilirubin
- Indirect bilirubin must be converted first to direct
bilirubin by the liver cells before it can be excreted in the
Hemolytic Disease body
- The liver is immature at birth so it cannot convert large
- Haemolytic dx of the newborn is either cause by RH
amount of bilirubin formed during hemolysis of RBC
incompatibility or ABO incompatibility
- Expect urine….
- The mother produced antibodies against the fetal blood
resulting in destruction or hemolysis of fetal RBC which
Remember:
in turn lead to severe fetal anemia..
- Suspension of breastfeeding during the first 24 hours to
prevent pregnanediol (breakdown product of
progesterone excreted in breast milk) from interfering
with the conjugation of indirect bilirubin to direct
bilirubin
- Phototherapy speeds up the maturation of RBC to
prevent accumulation of indirect bilirubin
- Expect stool to be loose and bright green due to
excessive bilirubin excretion and the skin to be dark
brown (bronze baby syndrome)

- If the fetus in subsequent pregnancies is RH+, the HEMATOLOGIC DISORDERS AMND PREGNANCY
antibodies is already present in the maternal blood 1. A woman with Iron deficiency anemia
stream will attack and destroy the fetal RBC resulting to - Most common anemia of pregnancy
fetal anemia - Condition in which you you do not have enough healthy
- The breakdown of RBC also cause the formation of red blood cells to carry adequate O2 to your body
bilirubin, the build-up of which can lead to jaundice and tissues
possible brain damage. - Low numbers ot properly functioning RBC in the body
- WHO and American College of Obstetricians and
*baby is exposed to bili light
Gynecologists define anemia in pregnancy as:

P a g e 22 | r l y n o t f a y e
Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

Good food sources of iron include the following:

 Meats – beef, pork, lamb, liver and other organ meants


 Poultry – chicken, duck, turkey, liver (esp. dark, meat)
 Fish – shellfish, including clams, mussels, oysters,
Risk Factors sardines and anchovies
 Leafy greens of cabbage family, such as broccoli, turnip
 Poor diet and poor nutrition greens and collards
 Heavy menses  Legumes – lima beans and green peas, dry beans beans
 Pregnancies at close intervals/successive pregnancies and epas, black-eyed peas, canned baked beans
 Unwise reducing programs  Yeast-leavened the whole wheat bread and rolls
 Iron-enriched white bread, pasta, rice and cereals
Signs and Symptoms

 Easy fatigability
 Sensitivity to cold 2. Anemia from Acute Blood Loss
 Proneness to infection  Caused by several bleeding disorders/complications of
 Dizziness pregnancy. These include: ECTOPIC PREGNANCY,
ABORTION, PLACENTA PREVIA, H-MOLE AND
Laboratory Findings ABRUPTIO PLACENTA
 Erythrocyte hypochromia – means that the RBC have *Pregnant woman to undergo CS - required to have onhand
less color than normal when examined under a bag of blood
microscope. This usually occurs when there is not
enough of the pigment that carries oxygen Management
(haemoglobin) in the RBC
 If the HGB level is more than 7g/dl, iron replacement
 Microcytosis – condition defined as a mean corpuscular
therapy until 3mos after anemia has been corrected
volume less than 80um3 (80fL) in adults. The most
 For massive haemorrhage: blood transfusion of whole
common causes of microcytosis are iron deficiency
blood, packed RBC, and plasma expanders to restore
anemia and thalassemia trait
normal blood volume.
 Low serum ferritin levels (ferritin is a protein that
contains iron and is the primary form of iron stored *if packed RBC is not available – plasma expanders can be use but
inside of cells. Normal ferritin levels range from 12-300 is only temporary. After a few days packed rbc should still be
nanograms per millilitre of blood (ng/ml) for males and transfused
12-150 ng/ml for females
 Elevated serum iron bindings capacity (blood test to see 3. Effects of FAD on Pregnancy
if you have too much or too little iron in your blood…\
 No sustainable bone marrow  Abortion
 Abruption placenta
Management  Neural tube defects

 Iron oral supplementation (200mg of elemental iron Predisposing Factors


daily in the form of:
o Ferrous sulphate  Long term use of oral contraceptive
o Ferrous fumarate  Poor nutrition
o Ferrous gluconate  Multiple pregnancies
 Inform about possible S/E – tarry  Successive pregnancies
stool, constipation, GI discomfort
Signs and Symptoms
 Take 1 hour before meals or 2 hours
after meals for better absorption  Nausea
 Never take with milk but with citrus  Vomiting
juice  Anorexia
 If given in liquid form, use straw to
avoid straining of the teeth Management
 If given IM – Ztracj technique to
prevent staining. Do not massage  Folic acid supplementation of 1mgday accompanied oral
after injection iron (RDA for all women – 0.4 mg/day)
 Oral iron should be continued until 3  Vitamin supplements containing 400mcg of folic acid are
months after anemia has been now recommended for all women of childbearing age
corrected and during pregnancy
 Increase intake of Vit C to enhance  These supplements are needed because natural food
absorption sources of folate are poorly absorbed and much of the
 Increase intake of iron rich foods: vitamins is destroyed in cooking
(lean meat, liver, dark green, leafy
*Nursing role – to ensure that they take their vitamins
vegetables)

P a g e 23 | r l y n o t f a y e
Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

Food sources of Folate  Sickling of RBC – when they sickle, they break down
prematurely which can lead to anemua
 Leafy, dark green vegetables  Anemia can cause shortness of breath, fatigue, and
 Dried beans and peas delayed growth and development in children
 Citrus fruits and juices and most berries  Rapid breakdown of RBC may also cause yellowing of
 Fortified breakfast cereals the eyes and skin, which are signs of jaundice
 Enriched grain products

3. A woman with sickle cell anemia


 Recessively inherited haemolytic anemia caused by
an abnormal amino acid in the beta chain of the
haemoglobin
 RBC are irregular or sickle cell shaped – cannot
carry as much haemoglobin
 In pregnancy, blockage to the placental circulation
can directly compromise the fetus, causing low
birth weight and possibly fetal death
 Fluid intake should be monitored – at least 8 Particularly serious complication of sickle cell disease is
glasses daily
 Exchange transfusion throughout pregnancy  High blood pressure in the blood vessels that supply the
 Women are generally interested at birth whether lungs (pulmonary hypertension)
their child has inherited the disease.  Pulmonary hypertension occurs in about one-third of
adults with sickle cell disease and can lead to heart
Sicke cell anemia (sickle cell disease) – a disorder of the blood failure
 Sickling is promoted by conditions associated with……….
caused by an inherited abnormal hemoglobin (the oxygen carrying
protein within the red blood cells) the abnormal hemoglobin Diagnosis
causes distorted (sickled appearing under a microscope) RBC
 The disease can be confirmed by specifically quantifying
Major features and symptoms of sickle cell anemia include: the types of haemoglobin present using a haemoglobin
electrophoresis
 Fatigue and anemia  Prenatal diagnosis (before birth) if sickle cell anemia is
 Pain crisis possible using amniocentesis or chorionic vilus sampling.
 Dactylitis (swelling and inflammation of the hands The sample obtained is then tested for DNA Analysis of
and/or feet) and arthritis the fetal cells
 Bacterial infections  Sickle cell anemia tends to stabilize without specific
 Sudden pooling of blood in the spleen and liver treatments
congestion  Blood transfusion is usuallt reserved for those patients
 Lung and heart injury with other complications including pneumonia, lung
 Leg ulcers infarction, stroke, severe leg ulceration, of late
 Aseptic necrosis and bone infarcts (death of portions of pregnancy
bone)  Folic acid is given as a supplement
 Treatments: hematopoietic stem cell transpiration
 Eye damage
 Red blood cell exchange (this process removes some of
Sickle cell anemia maternal complications the sickle blood cells and replaces then with normal
(non-sickle) blood cells. It is done when the sickle cell
 Vasco-occlusive crisis (occurs when the microcirculation crisis is so severe
is obstructed by sickled RBCs causing ischemic injury to
the organ supplied and resultant pain What causes pain pathophysiology….
 Infections
 Congestive heart failure
 Renal failure

Sickle cell anemia fetal complications

 Fetal death, prematurity, IUGR


 Treatment:
o Folic acid
o Prompt treatment of infections
o Prompt treatment of vaso-occlusive crisis

 Characteristic features of this disorder include a low


number of red blood cells (Anemia) repeated infections,
and periodic episodes of pain

P a g e 24 | r l y n o t f a y e
Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

ABORTION HYPERTENSIVE DISORDERS OF PREGNANCY

- The termination of pregnancy before viability (before  Pregnancy Induced Hypertension


20weeks gestation from LMP or before the fetus weighs – HPN that develops after the 20th week of
500grams) gestation to a previously normotensive
woman
Causes of Abortion – PIH includes: preeclampsia, eclampsia,
 Fetal cause: gestational HPN
o Abnormal development of zygote, embryo or
fetus a. Preeclampsia
– HPN that develops after 20weeks
 Maternal factors:
AOG accompanied by proteinuria
o Congenital or acquired condition of the
and edema
mother and environmental factors that had
b. Eclampsia
adversely affected pregnancy outcome
– HPN, proteinuria, edema + seizures
o DM, incompetent cervix, exposure to radiation
c. Gestational HPN
and infection
– Develops during pregnancy or during
Types of abortion the 24 hours after delivery which is
not accompanied by proteinuria,
edema and convulsions and
disappears within 10days after
delivery

Predisposing Factors

 Said to be the disease of primipara (higher incidence in


primiparas below 20 and above 35 years)
 Low socio-economic status
 Previous HPN of pregnancy: H-mole, DM, multiple
pregnancy, polyhydramnios, renal disease, heart disease
 Hereditary
D and C – dilatation and curettage (?)
Effects of Preeclampsia and Eclampsia

1. Cardiovascular changes
 Decrease cardiac output
 Hemoconcentration (increased concentration of cells
and solids in the blood usually resulting from loss of
fluid to the tissues)
 Failure of blood volume to expand to normotensive
women
 Thrombocytopenia (condition…)
 Increased levels of clotting factors (prolonged thrombin
time)

 Abnormal formation of RBC (mishappen and short life


span)

2. Endocrine and Metabolic changes


 Increased levels of the following hormones:
o Renin – enzyme secreted by kidney (also
possibly by the placenta) that is part of
physiological system that regulates blood
pressure. In the blood, renin acts on a protein

P a g e 25 | r l y n o t f a y e
Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

known as angiotensinogen, resulting in the Management


release of angiotensin I
o Angiotensin II – elevates BP  Ambulatory Management
o Aldosterone – promotes sodium reabsorption o Home management is allowed only if:
and fluid retention  BP is 140/90 or below
o Antidiuretic Hormone – decrease the amount  No proteinuria
of urine  No FGR
o HCG  The patient is not a young primipara
 Bed rest
 Increased ECF volume – edema  Diet high in protein and carbohydrates with moderate
sodium restriction
3. Renal Changes  Hospitalization if condition worsens
 Reduced renal perfusion and glomerular filtration  Provide detailed instructions about warning signs:
 Elevated creatinine, uric acid urea o Epigastric pain
 Decrease excretion of calcium in the kidney o Visual disturbances
 Decreased urine output o Severe headache
 Proteinuria o Nausea and Vomiting

Complication of preeclampsia and eclampsia  Hospital Management:


o Hospitalization if BP is above 140/90
 AP
o Bedrest is one of the most important principle
 Cerebral haemorrhage
because it reduces BP and promote diuresis:
 Hepatic failure
 Rest in left lateral recumbent
 Acute renal failure
position to promote blood supply in
 Prematurity
the placenta and fetus
 Perinatal death
 Room should be dim, quite, away
 Maternal death
from areas of activity. Avoid bright
Signs and Symptoms of Preeclampsia lights such as flashlights
 Restrict visitors to allow patient to
rest
 Leave BP cuff on patient’s arm so as
not to disturb the patient when
placing it every BP Check
 Medications
o Hydralazine – antihypertensive drug given IV
when diastolic pressure reaches 110mmHg or
higher
o Magnesium sulphate – DOC to treat and
prevent convulsions
o Diuretics are not given and IVF administration
is limited

 Monitor patient closely:


Signs and Symptoms of Eclampsia o VS and FHT continuously
o Blurring of vision, severe headache and
 All signs and symptoms of preeclampsia epigastric pain
 Convulsion followed by coma (main difference of o Urine output (pt should be in an indwelling
eclampsia to preeclampsia) catheter)
 Ologuria o Weigh daily (same time each day using the
 Pulmonary edema same scale)
o Lab Test: proteinuria, creatine, haematocrit

P a g e 26 | r l y n o t f a y e
Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients

 Fetal monitoring to check status of fetus:


o Fetal movement counting
o Non-stress test
o Biophysical profile (combined UTZ and NST to
observe for fetus)
o Doppler flow studies
 Safety Measures
o Raised padded siderails at all times to keep
the women from falling if convulsion occurs
o Put bed at lowest position
o Have emergency equipment available:
 Padded tongue blade
 Suction apparatus
 Mg SO4
 Calcium gluconate
 Oxygen
 Delivery
o The cure of PIH is termination of pregnancy or
delivery
o Signs and symptoms usually disappear once
pregnancy is terminated in mild preeclampsia
o Conservative management (wait until the
fetus is mature before attempting delivery)
A 21-year-old client, 6 weeks pregnant, is diagnosed with
o In severe cases, labor induction is performed hyperemesis gravidarum. This excessive vomiting during
regardless of gestational age pregnancy will often result in which of the following?
o The preferred method is vaginal delivery
o Labor is induced by amniotomy or oxytocin
administration 24 hours after the last Response: . electrolyte imbalance
convulsion and when condition of the woman Correct answer: . electrolyte imbalance
is stable. Local or pudendal anesthesia is used
o If labor induction is unsuccessful and fetal Score: 1 out of 1 Yes
distress is so severe that the fetus needs to be
Question 2
delivered asap, CS is performed A pregnant client at 26 week’s gestation takes a 1-hour
o Thiopental succinylcholine, nitrous oxide and glucose tolerance test as a part of a recommended
oxygen is used for general anesthesia screening for gestational diabetes. A result of greater than or
 Postpartum Care equal to what number of mg/dl indicates the need for further
o The danger of convulsion exist until 24 hour testing?
after delivery, MgSO4 is continued until the Response: : 140
immediate 24hours postpartum
o Watch for uterine relaxation and increased Correct answer: : 140
lochial flow if the woman is receiving MgSO4 Score: 1 out of 1 Yes
o Ergot products are contraindicated because
they are hypertensive Question 3
o 2 years rest before next pregnancy to A primigravida client’s baseline BP at her initial visit at 12
decrease likelihood of PIH to recure on weeks gestation was 110/70 mm Hg. During an assessment
subsequent pregnancy at 38 weeks gestation, which of the ff data would indicate
mild preeclampsia?
Response: : Weight gain of 2 lbs/week in the 2nd trimester
Correct answer: : Weight gain of 2 lbs/week in the 2nd
trimester
Score: 1 out of 1 Yes

Question 4
A client is being admitted to the antepartum unit for
hypovolemia secondary to hyperemesis gravidarum. Which
of the following factors predisposes a client to the
development of this?
Response: Gestational trophoblastic disease
Correct answer: Gestational trophoblastic disease
Score: 1 out of 1 Yes

Question 5

P a g e 27 | r l y n o t f a y e
Unit 1 - Framework For Maternal And Child Health Nursing Focusing On At-Risk, High Risk And Sick Clients
During a home visit to a teenage client at 34-weeks’ A woman has been diagnosed as having pregnancy-induced
gestation diagnosed with mild preeclampsia, assessment hypertension. Which of the following is the most typical
reveals that the client has gained 2 lbs in the past week and symptom of this?
her current BP is 140/90. Which of the following assessment
findings would provide further evidence to support the client’s Response: Protein in urine
diagnosis?
Correct answer: Protein in urine
Response: mild edema in hands and face
Score: 1 out of 1 Yes
Correct answer: mild edema in hands and face
Question 12
Score: 1 out of 1 Yes In Hyperemesis Gravidarum, there is severe nausea and
vomiting. What would be the implication of this?
Question 6
The physician orders IV magnesium sulfate for a Response: increased HCG level
primigravida client with severe preeclampsia. Which of the
Correct answer: increased HCG level
following medications would the nurse has readily available
at the client’s bedside? Score: 1 out of 1 Yes
Response: Calcium gluconate
Question 13
Correct answer: Calcium gluconate The nurse can anticipate to a reasonable degree of certainty
that microorganisms most likely responsible for cystitis/UTI
Score: 1 out of 1 Yes is:

Question 7 Response: Escherichia coli


A pregnant client with UTI is instructed on measures to
Correct answer: Escherichia coli
prevent the infection. Which statement by the client indicates
a need for further teaching? Score: 1 out of 1 Yes
Response: : “After bowel movement, I will wipe from back to
Question 14
front.”
. A pregnant client with lower UTI asks the nurse, “How did I
Correct answer: : “After bowel movement, I will wipe from get this infection?” The nurse should explain that in most
back to front.” instances, cystitis is caused by:

Score: 1 out of 1 Yes Response: stasis of urine in the bladder


Correct answer: stasis of urine in the bladder
Question 8
A woman with severe preeclampsia is being treated with an Score: 1 out of 1 Yes
IV infusion of magnesium sulfate. This treatment is
considered successful if: Question 15
A teenage primigravida with severe preeclampsia is in active
Response: seizures do not occur
labor. Her mother is at the bedside. Which of the following
Correct answer: seizures do not occur would alert the nurse that the client may be about to
experience a seizure?
Score: 1 out of 1 Yes
decreased contraction intensity
Question 9
.During pregnancy a diabetic person need for insulin is Response: :decreased temperature
typically ?:
Correct answer: Epigastric pain
. Score: 0 out of 1 No
Response: decreases during the first trimester and increases
Question 16
in the second and third
. The nurse knows that the most important thing the client
Correct answer: decreases during the first trimester and with lower UTI needs to learn to clear the infection is which
increases in the second and third of the following?

Score: 1 out of 1 Yes Response: : to drink up to 3L of fluid each day


Correct answer: : to drink up to 3L of fluid each day
Question 10
A primigravida client’s baseline BP at her initial visit at 12 Score: 1 out of 1
weeks gestation was 110/70 mm Hg. During an assessment
at 38 weeks gestation, which of the ff data would indicate
mild preeclampsia?
Response: : Weight gain of 2 lbs/week in the 2nd trimester
Correct answer: : Weight gain of 2 lbs/week in the 2nd
trimester
Score: 1 out of 1 Yes

Question 11

P a g e 28 | r l y n o t f a y e

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