Discuss how her husband will undergo similar emotional and psychosocial adaptations to their pregnancy and impending parenthood.Discuss the concept COUVADE.Describe the three phases of paternal adjustment to pregnancy and the developmental tasks he must accomplish:> Announcement phaseaccept biologic reality of pregnancy> Moratorium phaseaccept the reality of the pregnancy> Focusing phaseactive involvement in pregnancy and in relationship with the baby by negotiating with partner the role he will play during childbirth and preparing for fatherhood

Teach Lechandra the importance of nutrition for herself, her developing baby, and family.- Emphasize the hazards of not meeting the nutrient requirements for pregnancy for herself and her baby including anemia, increased risk for complications, low birth weight and intrauterine growth restriction, and inadequate development of fetal body structures including the brain.

CHAPTER 11 CASE STUDYS

Chapter 11: High Risk Perinatal Care: Preexisting ConditionsClass III Cardiac DisorderQuestionsAngie is a 30-year-old pregnant woman at 4 weeks' gestation. She has been diagnosed with a Class III cardiac disorder for several years. Her cardiac condition has remained stable. Both she and her husband Jim desperately want to have one child and are "willing to take a chance." They state that they will work together with each other and with the health care team to do all they can to ensure Angie's safety and that of their baby. Both Angie and Jim come from large, supportive families who are all available to "pitch in and help whenever they are needed." To make an informed decision regarding pregnancy, Angie and Jim need to be fully aware of the complications Angie and their fetus will face as a result of her cardiac status. What are these complications? Correct AnswerCardiac disease is a major cause of nonobstetric maternal mortality with cardiac decompensation and myocardial infarction (heart attack) major concerns; spontaneous abortion, preterm labor and birth, and intrauterine growth restriction are also possible as a result of circulatory changes related to cardiac insufficiency.

Angie is a 30-year-old pregnant woman at 4 weeks' gestation. She has been diagnosed with a Class III cardiac disorder for several years. Her cardiac condition has remained stable. Both she and her husband Jim desperately want to have one child and are "willing to take a chance." They state that they will work together with each other and with the health care team to do all they can to ensure Angie's safety and that of their baby. Both Angie and Jim come from large, supportive families who are all available to "pitch in and help whenever they are needed." Describe the factors that should be emphasized when assessing Angie during her pregnancy. Correct AnswerHolistic approach should be used to identify factors that could place stress on Angie's heart including those related to lifestyle and emotions:- Health history interview should gather information related to Angie's personal medical history and that of her family with emphasis on cardiovascular problems; factors that increase stress on the heart such as infection, anemia, and edema; current cardiovascular and pulmonary status; medications taken; psychosocial status including role responsibilities, emotions and concerns, support system, and family expectations regarding pregnancy and parenting; and the birth plan.- Physical examination emphasizes in-depth cardiopulmonary assessment including scrutiny for signs of cardiac decompensation; assessment should include vital signs; heart and lung sounds; edema; changes associated with pregnancy including discomforts, especially if they are stressful; and weight gain.- Laboratory and diagnostic testing including complete blood count, blood chemistries, urinalysis, electrocardiogram, and pulse oximetry in addition to the usual testing completed during a low-risk pregnancy.- Fetal assessment includes fetal heart rate, sonography to monitor growth, daily fetal movement counts, and non-stress testing.- The couple should be fully informed of findings and taught about what to observe for when at home including the effect that stress can have on cardiac function; include warning signs in teaching.

Angie is a 30-year-old pregnant woman at 4 weeks' gestation. She has been diagnosed with a Class III cardiac disorder for several years. Her cardiac condition has remained stable. Both she and her husband Jim desperately want to have one child and are "willing to take a chance." They state that they will work together with each other and with the health care team to do all they can to ensure Angie's safety and that of their baby. Both Angie and Jim come from large, supportive families who are all available to "pitch in and help whenever they are needed." Angie is at high risk for cardiac decompensation, especially at 28 to 32 weeks' gestation. Identify the signs and symptoms Angie would exhibit and experience if cardiac decompensation occurred. Correct AnswerSigns and symptoms of cardiac decompensation:- Increasing fatigue; difficulty performing and experiencing dyspnea with usual activities- Frequent cough; productive of frothy sputum- Irregular, weak, rapid pulse; palpitations- Progressive generalized edema with swelling of face, feet, legs, and fingers- Crackles at bases of lungs- Orthopnea, increasing dyspnea; feeling of smothering- Cyanosis of lips and nail beds

Angie is a 30-year-old pregnant woman at 4 weeks' gestation. She has been diagnosed with a Class III cardiac disorder for several years. Her cardiac condition has remained stable. Both she and her husband Jim desperately want to have one child and are "willing to take a chance." They state that they will work together with each other and with the health care team to do all they can to ensure Angie's safety and that of their baby. Both Angie and Jim come from large, supportive families who are all available to "pitch in and help whenever they are needed." What specific prenatal care management recommendations should the nurse implement related to Angie's Class III cardiac status? Correct AnswerCare management usually includes:- Reduce workload on heart by balancing periods of activity with periods of rest in a lateral position; activity restrictions are individualized to the woman's condition and progress- Identification of stressors and determine appropriate coping strategies- Infection prevention- Balanced nutrition for appropriate weight gain of approximately 24 lb (excessive weight gain will increase cardiac workload) and for prevention of anemia; sodium may be restricted to reduce fluid retention- Measures such as fiber, fluids, and stool softener to prevent constipation- Ensure appropriate use of medications: - Cardiac medications such as digitalis and propranolol to strengthen heart activity and enhance cardiac output - Diuretics such as furosemide to reduce fluid retention - Anticoagulant therapy with heparin to prevent clot formation - Stool softeners to prevent constipation - Iron and vitamin supplementation- Appropriate monitoring and trending of laboratory results to identify baseline parameters and pick up potential problems during the course of the pregnancy.

Teach Angie and Jim signs of cardiac decompensation and thrombophlebitis; fully discuss treatment regimen.

Mobilize family members and home care agency referrals as needed.

Prepare Angie and Jim for hospitalization at some point during her pregnancy, especially with the occurrence of cardiac decompensation.

Angie is a 30-year-old pregnant woman at 4 weeks' gestation. She has been diagnosed with a Class III cardiac disorder for several years. Her cardiac condition has remained stable. Both she and her husband Jim desperately want to have one child and are "willing to take a chance." They state that they will work together with each other and with the health care team to do all they can to ensure Angie's safety and that of their baby. Both Angie and Jim come from large, supportive families who are all available to "pitch in and help whenever they are needed." Describe the intrapartal care management recommendations related to Angie's Class III cardiac status. Correct AnswerCare management during labor and birth should emphasize:- Assessment for cardiac decompensation because parturition is another time of risk- Prevention of cardiac decompensation by reducing stress on the heart: - Decrease anxiety - Implement effective pain control with epidural anesthesia recommended - Position on side to enhance cardiac output; this position is also effective for bearing-down efforts during the second stage - Facilitate birth with controlled open glottis pushing and appropriate use of forceps/vacuum extraction and episiotomy - Antibiotic prophylaxis to prevent infection - Care and management with a maternal fetal medicine specialist at a obstetrical facility that is equipped to handle high-risk clients.

- Encourage Angie and Jim to prepare for labor by participating in childbirth preparation: private classes in their home or video classes or real-time classes online if Angie cannot attend regular classes.

Angie is a 30-year-old pregnant woman at 4 weeks' gestation. She has been diagnosed with a Class III cardiac disorder for several years. Her cardiac condition has remained stable. Both she and her husband Jim desperately want to have one child and are "willing to take a chance." They state that they will work together with each other and with the health care team to do all they can to ensure Angie's safety and that of their baby. Both Angie and Jim come from large, supportive families who are all available to "pitch in and help whenever they are needed." Angie successfully gave birth to a baby girl at 36 weeks' gestation. She is at high risk for cardiac decompensation during the first 24 to 48 hours following birth. What prevention measures should be implemented? Correct AnswerCare management during the postpartum period should emphasize:- Assessment for cardiac decompensation since the circulatory and fluid balance changes during the first 48 hours after birth place Angie at risk for cardiac decompensation- Prevention of decompensation: - Gradually increase activity from bedrest to out of bed as desired; balance rest and activity; observe effects of activity on Angie's cardiopulmonary status. - Reduce stress by preventing complications such as infection and hemorrhage, keeping the couple informed, encouraging relaxation measures, assisting with activities of daily living, using pain relief and comfort measures, and beginning discharge planning early. - Ensure adequate nutrition. - Supervise interaction and care of the newborn; observe the effect of newborn care on Angie's cardiopulmonary status. - Use measures to facilitate urinary and bowel elimination to prevent urinary retention, bladder distension, and constipation. - Advise not to breastfeed because energy expenditure with breast feeding may be too great for Angie. - Continued monitoring in a high-risk unit post delivery that has available resources to intervene if complications ensue during this critical period.Organize home care by helping Angie and Jim mobilize their support system and by making needed referrals to home care agencies that can help them with her care, care of their baby, and care of their home.Counsel to consider sterilization, especially if cardiac decompensation occurred with this pregnancy.

CHAPTER 11 CASE STUDIES 2Chapter 11: High Risk Perinatal Care: Preexisting Conditions

Pregestational DiabetesQuestionsStacey, a 23-year-old newly married woman, was diagnosed with diabetes when she was 16 years old. Her diabetes has been fairly stable for several years, though she occasionally experiences glucose control problems requiring reevaluation of her insulin dosage and diet. Stacey and her husband Garrett are planning to become pregnant in about a year. Explain why Stacey and her husband Garrett should seek preconception care as soon as possible. Correct AnswerPreconception care addresses many issues regarding a healthy lifestyle and becoming physically, emotionally, and psychosocially ready for pregnancy and parenting; males and females should participate in this care.

Preconception care is designed for health promotion and maintenance; it focuses on risk assessment and management and encourages behaviors that will promote health and well-being in preparation for pregnancy; optimum physical and psychosocial readiness for pregnancy should be the outcome.

Potential mothers and fathers should participate in preconception care because each contributes to the creation of the newborn.

Components include:- General teaching related to health promotion including nutrition; weight; exercise and rest; avoidance of harmful substances (drugs, alcohol, tobacco); use of safer sex practices; and family and psychosocial considerations- Risk factor assessment including medical history, reproductive history, psychosocial history, financial resources, and environmental conditions at home and work- Interventions including anticipatory guidance, treatment and stabilization of medical conditions in this case Stacey's diabetes, nutrition and weight management, stress reduction, exercise, and referrals to community resources as appropriate

Because optimal outcome of pregnancy hinges on maternal glycemic control, it is important that Stacey's health be assessed and her diabetes be regulated in preparation for pregnancy. Inclusion of pregnancy hormones affecting increased insulin resistance will impose challenges during the course of pregnancy, and as such the client should be closely monitored and be in "good" glycemic control before the onset of pregnancy.Preconception care for the woman with pregestational diabetes should emphasize:- Establishing an ideal time for pregnancy and establishing glycemic control before conception; strict control before conception and in the early weeks of gestation reduces the risk for congenital anomalies; this is important because Stacey has a history of occasional glucose control problems that required reevaluation of insulin dosage and diet- Determining if any vascular complications are present and to what degree because pregnancy can increase the severity of these complications- Involving Stacey and Garrett because both should be aware of the risks involved with pregnancy, pregnancy's effect on the diabetes and diabetes on the pregnancy, and the aspects of management of Stacey's pregnancy that will be necessary and why they are critical to ensure her health and that of her potential fetus

Stacey, a 23-year-old newly married woman, was diagnosed with diabetes when she was 16 years old. Her diabetes has been fairly stable for several years, though she occasionally experiences glucose control problems requiring reevaluation of her insulin dosage and diet. Stacey and her husband Garrett are planning to become pregnant in about a year.The nurse prepares to explain to Stacey and Garrett the maternal and fetal/newborn risks and complications that are associated with pregestational diabetes, emphasizing that maintaining glucose control within an acceptable range is critical to reduce these complications. What maternal and fetal/newborn complications should this nurse describe to Stacey and Garrett? Correct AnswerMaternal risks and complications: pregnancy-induced hypertension (PIH), hydramnios, ketoacidosis, infection, hypoglycemia, preterm labor and birth, accelerated progress of vascular changes associated with diabetes, dystocia related to macrosomia

Fetal/newborn risks and complications: congenital anomalies, alteration in size either macrosomia or intrauterine growth restriction, fetal hypoxia related to circulatory insufficiency in placenta, preterm birth with increased risk for respiratory distress syndrome, neonatal hypoglycemia, polycythemia with neonatal hyperbilirubinemia

Stacey, a 23-year-old newly married woman, was diagnosed with diabetes when she was 16 years old. Her diabetes has been fairly stable for several years, though she occasionally experiences glucose control problems requiring reevaluation of her insulin dosage and diet. Stacey and her husband Garrett are planning to become pregnant in about a year.One year later, Stacey does become pregnant. She is now 4 weeks pregnant. Describe what the nurse should tell Stacey about how insulin needs will change during pregnancy. Correct AnswerEmphasize that they are expected to change as a result of adaptations to pregnancy:- Amount required decreases during the first half of pregnancy and increases during the second half of pregnancy- Multiple doses, usually twice a day before breakfast and dinner, of a combination of intermediate- and short-acting (regular insulin) insulin are usually required- Blood glucose levels will determine how much each type of insulin should be administered; it is usually monitored four times a day: before breakfast, lunch, and dinner, and at bedtime Emphasize that she may be more prone to hypoglycemia (first half) and ketoacidosis (second half). Effects of hormones of pregnancy on insulin resistance should be acknowledged. Emphasize importance of monitoring blood glucose levels and urine for ketones to ensure that insulin dosage and nutritional intake are appropriate.

Stacey, a 23-year-old newly married woman, was diagnosed with diabetes when she was 16 years old. Her diabetes has been fairly stable for several years, though she occasionally experiences glucose control problems requiring reevaluation of her insulin dosage and diet. Stacey and her husband Garrett are planning to become pregnant in about a year.At her second prenatal visit, Stacey's glycosylated hemoglobin was 5%. Explain what this finding indicates. Correct AnswerThis test measures the percentage of hemoglobin saturated with glucose and therefore reflects glucose control over time (over the past 3 months); a low percentage indicates good control; the finding of 5%, which is less than 7%, indicates good diabetic control. The higher the percentage of hemoglobin that is saturated with glucose, the less there is available to transport oxygen to the fetus.

Stacey, a 23-year-old newly married woman, was diagnosed with diabetes when she was 16 years old. Her diabetes has been fairly stable for several years, though she occasionally experiences glucose control problems requiring reevaluation of her insulin dosage and diet. Stacey and her husband Garrett are planning to become pregnant in about a year.

How should Stacey's diet be modified to meet the requirements of pregnancy? Correct AnswerNutritional requirements are increased using her prepregnancy diet as a foundation; increase should maintain acceptable blood glucose levels, achieve recommended weight gain, and prevent ketoacidosis and hypoglycemia; a diet is designed for each woman on the basis of her needs and following specific guidelines related to pregnancy.- Eat a well-balanced diet emphasizing complex carbohydrates, dietary fiber, and protein.- Divide daily food intake among three meals and two to four snacks.- Eat on a regular basis; avoid skipping meals or snacks.- Eat a substantial bedtime snack to prevent a drop in blood glucose during the night.- Avoid foods high in fats, refined sugar; avoid alcohol and caffeine.

Stacey, a 23-year-old newly married woman, was diagnosed with diabetes when she was 16 years old. Her diabetes has been fairly stable for several years, though she occasionally experiences glucose control problems requiring reevaluation of her insulin dosage and diet. Stacey and her husband Garrett are planning to become pregnant in about a year.Stacey and Garrett may experience increased stress as a result of the change in Stacey's diabetes associated with pregnancy. What measures could the nurse use to help prevent or reduce Stacey and Garrett's level of stress? Correct AnswerFull explanations of changes to expect and why they occur can reduce Stacey and Garrett's worry that something is wrong or her diabetes is getting worse.

Plan for more frequent prenatal visits and provide a telephone contact to facilitate discussion of concerns. Encourage healthy lifestyle measures such as exercise, infection prevention, and relaxation measures to prevent complications from occurring the would further increase stress.

Involve Garrett in the health care regimen designed for Stacey. Identify stress reduction measures they can do together.

Stacey, a 23-year-old newly married woman, was diagnosed with diabetes when she was 16 years old. Her diabetes has been fairly stable for several years, though she occasionally experiences glucose control problems requiring reevaluation of her insulin dosage and diet. Stacey and her husband Garrett are planning to become pregnant in about a year.

During the third trimester Stacey asks the nurse if she will be able to breast-feed her baby. What should the nurse tell Stacey? Correct AnswerBreast-feeding is safe and could even facilitate glucose control during the postpartum period.

Care must be taken to carefully monitor blood glucose level because insulin needs are decreased as a result of birth and the removal of insulin antagonists, thereby increasing the risk for hypoglycemia; poor metabolic control can delay lactogenesis and decrease milk production; and stabilization of glucose control normally takes time.

Maintain integrity of the nipples and areola because a woman with diabetes is more prone to infection and could develop mastitis and yeast infection, especially if glucose is in poor control.

Stacey, a 23-year-old newly married woman, was diagnosed with diabetes when she was 16 years old. Her diabetes has been fairly stable for several years, though she occasionally experiences glucose control problems requiring reevaluation of her insulin dosage and diet. Stacey and her husband Garrett are planning to become pregnant in about a year.

Following a successful uncomplicated vaginal birth, Stacey's primary health care provider advises her to avoid another pregnancy for at least 2 years. Stacey plans to use a diaphragm as her method of contraception. This will be her first time using this method. What should the nurse emphasize in the teaching given Stacey regarding birth control in the postpartum period and the method she has chosen? Correct AnswerEmphasize the need to have the diaphragm fitted when healing is complete at 6 weeks following birth.

Tell Stacey and Garrett to use condoms and spermicide until the diaphragm can be fitted; caution them to wait until Stacey is fully healed to have intercourse because Stacey is more prone to infection.

Review principles for effective use of a diaphragm with special emphasis on measures to prevent infection:- Demonstrate and assist Stacey to practice insertion and removal of the diaphragm.- Discuss the use of spermicide with the diaphragm to enhance effectiveness (both sides prior to use and into the vagina prior to another act of intercourse); spermicide will also counteract vaginal dryness related to estrogen deprivation associated with lactation.- Tell Stacey when she can insert the diaphragm (up to 6 hours before intercourse) and how long to keep it in (at least 6 hours but no longer than 8 hours).- Empty the bladder before insertion.- Discuss infection control measures including washing hands before and after handling diaphragm and methods to use to care for the diaphragm properly.- Describe care of diaphragm: wash with warm water and mild soap after use, dry thoroughly, dust with cornstarch (rinse off before use), and store in its case; it should always be inspected for defects before use. Tell Stacey about refitting after a weight change of 10 to 15 lb, after 2 years of use, and after vaginal birth.

CHAPTER 12 CASE STUDYChapter 12: High Risk Perinatal Care: Gestational Conditions

Preeclampsia

Case # 6 Pregnant woman with preeclampsiaQuestionsRofonzo is a 36-year-old recently divorced primigravida at 30 weeks' gestation. She weighs 120 lb with a body mass index (BMI) of 22, which indicates a normal height-to-weight proportion. Rofonzo's health history is negative for chronic health problems. She is an active career woman who experiences a moderate to sometimes severe level of stress with her job. Her diet consists of many fast foods to "save time," especially when she has to eat on the run or while working. Rofonzo was diagnosed with mild preeclampsia. When the diagnosis is explained, she states that her mother and one of her sisters had a blood pressure (BP) problem when they were pregnant.

How should the nurse explain preeclampsia to Rofonzo? Correct AnswerDefinition of preeclampsia: preeclampsia is a pregnancy-specific condition in which hypertension develops after 20 weeks of pregnancy in a woman whose BP had been within a normal range; it can affect many body systems (multisystem) and is characterized by spasms of the blood vessels (vasospastic) that make it difficult to impossible for the blood vessels to dilate to accommodate the increased amount of blood produced during pregnancy. She can experience a variety of signs and symptoms that can intensify and worsen as the disease process advances from mild to severe. The only cure is having her baby, but a variety of treatment measures have been found to be successful in controlling the progress of the disease until it is time for her baby to be born.

Rofonzo is a 36-year-old recently divorced primigravida at 30 weeks' gestation. She weighs 120 lb with a body mass index (BMI) of 22, which indicates a normal height-to-weight proportion. Rofonzo's health history is negative for chronic health problems. She is an active career woman who experiences a moderate to sometimes severe level of stress with her job. Her diet consists of many fast foods to "save time," especially when she has to eat on the run or while working. Rofonzo was diagnosed with mild preeclampsia. When the diagnosis is explained, she states that her mother and one of her sisters had a BP problem when they were pregnant.

What clinical manifestations did Rofonzo most likely exhibit to lead to this diagnosis? Correct AnswerAssessment findings associated with mild preeclampsia can include:- Hypertensionblood pressure greater than 140/90 and mean arterial pressure greater than 105 mm Hg on two occasions 6 hours apart- Proteinuria of 2+ to 3+ using a dipstick or proteinuria of 0.3 g or > in 24-hr urine- Generalized edema, which includes upper body edema (puffy eyelids, face, fingers); it is reflected as an excessive weight gain (>0.5 kg/week in second and third trimester or a sudden weight gain of 2 kg/week at any time)- Transient headache, irritability, and changes in affect (mood) can occur- Reduced placental perfusion can occur affecting the fetus

Rofonzo is a 36-year-old recently divorced primigravida at 30 weeks' gestation. She weighs 120 lb with a body mass index (BMI) of 22, which indicates a normal height-to-weight proportion. Rofonzo's health history is negative for chronic health problems. She is an active career woman who experiences a moderate to sometimes severe level of stress with her job. Her diet consists of many fast foods to "save time," especially when she has to eat on the run or while working. Rofonzo was diagnosed with mild preeclampsia. When the diagnosis is explained, she states that her mother and one of her sisters had a blood pressure problem when they were pregnant.

What risk factors for this disorder does Rofonzo present? Correct AnswerRisk factors presented by Rofonzo include age > 35, unmarried, poor diet, stressful career, first pregnancy, and family history.

Additional risk factors not present in this situation include age < 18, weight of < 100 lb or obesity; African-American ethnicity; first pregnancy with a new sexual partner; presence of chronic disease processes such as diabetes, hypertension, renal disease, vascular disease, and systemic lupus erythematosus; hydatidiform mole; pregnancy complications such as multifetal pregnancy, large fetus, and polyhydramnios; and previous history of preeclampsia.

Rofonzo is a 36-year-old recently divorced primigravida at 30 weeks' gestation. She weighs 120 lb with a BMI of 22, which indicates a normal height- to-weight proportion. Rofonzo's health history is negative for chronic health problems. She is an active career woman who experiences a moderate to sometimes severe level of stress with her job. Her diet consists of many fast foods to "save time," especially when she has to eat on the run or while working. Rofonzo was diagnosed with mild preeclampsia. When the diagnosis is explained, she states that her mother and one of her sisters had a BP problem when they were pregnant.

When assessing Rofonzo, the nurse must be alert for signs that her mild preeclampsia is progressing to a more advanced stage. What clinical manifestations would indicate a worsening condition? Correct Answer- Blood pressure at 160/110 mm Hg or higher on two occasions 6 hours apart with Rofonzo on bed rest- Continued weight gain with more noticeable upper body edema and possibly signs of pulmonary edema- Proteinuria 5+ or greater in a 24-hr urine or 3+ or > on 2 random urine samples collected at least 4 hours apart; diminished urinary output- Hyperreflexia with deep tendon reflexes (DTRs) 3+ or greater and possible ankle clonus- Severe headaches, irritability, and changes in affect (mood swings); alteration in vision (blurring, photophobia); epigastric pain- Laboratory test values: elevated serum creatinine, angiotensin sensitivity test (AST), hematocrit; thrombocytopenia- Fetal signs related to diminished placental perfusion: alteration in fetal heart rate (FHR) and pattern including decrease in variability, bradycardia, and late decelerations; intrauterine growth rate (IUGR); change in pattern of fetal movements- Oliguria < 500 mL/24 hr- Pulmonary edema or cyanosis. Signs and symptomatology leading to progression of eclampsia manifesting in seizure activity. Development of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome and DIC.

Rofonzo is a 36-year-old recently divorced primigravida at 30 weeks' gestation. She weighs 120 lb with a BMI of 22, which indicates a normal height-to-weight proportion. Rofonzo's health history is negative for chronic health problems. She is an active career woman who experiences a moderate to sometimes severe level of stress with her job. Her diet consists of many fast foods to "save time," especially when she has to eat on the run or while working. Rofonzo was diagnosed with mild preeclampsia. When the diagnosis is explained, she states that her mother and one of her sisters had a BP problem when they were pregnant.

Because her preeclampsia is mild at this point, Rofonzo's health problem will be managed on an outpatient--home care basis. She is instructed to record her daily health status in a diary. What should the nurse tell Rofonzo to include in her diary? What are Rofonzo's learning needs with regard to the recommendation that she maintain a daily diary of her health and well-being? Correct AnswerItems to include in each daily entry in her diary: BP, weight (taken at same time/day in similar clothing), signs of edema, protein in urine, fetal movement count, presence of any warning signs, general feeling related to well-being and being able to cope with and implement the treatment regimen, and how she is implementing the treatment regimen.

In order to ensure adequacy and usability of the findings recorded in the diary, the nurse should teach Rofonzo each aspect of the health assessment, how to perform the assessment accurately, and how to interpret findings in terms of being expected or a sign of worsening preeclampsia:- BP: Use same arm and a sitting position; support arm on table at heart level; rest before taking BP.- She should weigh herself using the same scale, wearing the same clothes, at the same time each day (morning, after voiding, before breakfast).- Use clean-catch specimen and dipstick when assessing for protein in urine; use first voided specimen and following timing exactly for reading results on the dipstick.- Provide Rofonzo with a checklist of clinical manifestations that includes signs of a worsening condition.- Count daily fetal movements (Cardiff count to 10 can be used).

Rofonzo is a 36-year-old recently divorced primigravida at 30 weeks' gestation. She weighs 120 lb with a BMI of 22, which indicates a normal height-to-weight proportion. Rofonzo's health history is negative for chronic health problems. She is an active career woman who experiences a moderate to sometimes severe level of stress with her job. Her diet consists of many fast foods to "save time," especially when she has to eat on the run or while working. Rofonzo was diagnosed with mild preeclampsia. When the diagnosis is explained, she states that her mother and one of her sisters had a BP problem when they were pregnant.

Describe the major components of Rofonzo's care management at home. Correct AnswerComponents of home care:

- Daily self-assessment of health status: BP (no tobacco or caffeine use 30 minutes before assessment), weight and edema, urine, signs of advancing condition

- Daily assessment of fetal movement/activity- Activity restriction ranging from bed rest with bathroom privileges to specified periods in bed and resting out of bed; when in bed, a lateral position is recommended to enhance uteroplacental and renal perfusion- Nutrition: balanced diet with 60 to 70 g of protein, 1200 mg of calcium, adequate zinc, magnesium, and vitamins; no sodium restriction but avoid highly salted foods; include roughage and fluid (8 to 10 eight-ounce glasses each day) to enhance elimination; avoid alcohol- Stress management; Rofonzo will need strategies to cope with the sudden change in her lifestyle now that her career is on hold; members of her support group need to be identified and enlisted to help her; home care services may be required- Health insurance and economic support issues may need to be addressed

Rofonzo is a 36-year-old recently divorced primigravida at 30 weeks' gestation. She weighs 120 lb with a BMI of 22, which indicates a normal height-to-weight proportion. Rofonzo's health history is negative for chronic health problems. She is an active career woman who experiences a moderate to sometimes severe level of stress with her job. Her diet consists of many fast foods to "save time," especially when she has to eat on the run or while working. Rofonzo was diagnosed with mild preeclampsia. When the diagnosis is explained, she states that her mother and one of her sisters had a BP problem when they were pregnant.State three priority nursing diagnoses related to Rofonzo's health problem and its impact on her pregnancy and her lifestyle/career. Correct AnswerConsider circulatory changes, anxiety level, interference with role performance, risk for maternal and fetal injury, ineffective individual/family coping, interrupted family processes, and powerlessness.

Rofonzo's health assessment, which will indicate her unique circumstances, will guide the nurse in setting the priority of the nursing diagnoses identified. Rofonzo herself should be a part of the identification of nursing diagnoses and the designation of priority, especially with regard to coping, role performance, family processes, and powerlessness.

Rofonzo is a 36-year-old recently divorced primigravida at 30 weeks' gestation. She weighs 120 lb with a BMI of 22, which indicates a normal height-to-weight proportion. Rofonzo's health history is negative for chronic health problems. She is an active career woman who experiences a moderate to sometimes severe level of stress with her job. Her diet consists of many fast foods to "save time," especially when she has to eat on the run or while working. Rofonzo was diagnosed with mild preeclampsia. When the diagnosis is explained, she states that her mother and one of her sisters had a BP problem when they were pregnant.

Rofonzo's condition advances to severe preeclampsia, and she is admitted to the hospital. A magnesium sulfate intravenous infusion is initiated.

A. State the primary expected outcome associated with this medication.B. What is the recommended infusion rate?C. What are the priority nursing assessments and frequency of assessment for Rofonzo while she is receiving magnesium sulfate therapy?D. Identify the signs Rofonzo would exhibit related to magnesium toxicity.E. What emergency readiness measures should be implemented and available related to Rofonzo's current health status? Correct AnswerA: Magnesium sulfate acts as a central nervous system depressant and is given to prevent or control seizures; therefore the primary expected outcome is that seizures do not occur or are controlled. Magnesium sulfate also acts as a smooth muscle relaxant in the hopes of decreasing uterine activity.

B: Magnesium sulfate is given in a loading dose first followed by a maintenance infusion; a controller pump should be used to ensure accuracy and safety. The loading dose is 4 to 6 g in 100 mL of 5% dextrose in water over 15 to 20 minutes; it is piggy backed to a primary infusion; monitor BP and pulse every 5 minutes during the loading dose. Maintenance infusion of 2 g/hour; piggy back a solution of 40 g of magnesium sulfate in 1000 mL of 5% dextrose in water or lactated Ringer solution to a primary infusion.NOTE: Hospital protocols may vary somewhat from the guidelines stated earlier.

C: Components of assessment- BP, pulse, MAP, respiratory rate, FHR pattern, and uterine contractions every 15 to 30 minutes- Intake and output, proteinuria, level of consciousness, DTRs, clonus, presence of headache, visual disturbances, and epigastric pain at least every hour; urinary output must be at least 120 mL in 4 hours, edema- Serum levels of magnesium every 4 to 6 hours; level should be maintained between 6 and 8 mg/dL- Expected effects and potential toxic effects of magnesium sulfate should be the foundation for the assessment findings gathered and documented

D: CNS depression is the basis for signs of magnesium toxicity; these signs include:- Respiratory rate of fewer than 12 breaths per minute- Absence of DTR- Severe hypotension- Serum magnesium level above therapeutic level- Decreased urine output < 120 mL/4 hr

E: Seizure prevention and precaution measures:- Environmental modification: quiet, nonstimulating, subdued lighting- Padding of side rails; bed in low position- Loose clothing should be worn- Suction and oxygen administration equipment at bedside and ready for use- Call button within reach- Emergency antiseizure medications at or near bedside: magnesium sulfate, amobarbital, diazepam- Be prepared to take action if a grand mal convulsion occurs

Treatment readiness for magnesium toxicity: calcium gluconate 10% should be available at the bedside during the course of clinical therapy. Treatment readiness for hypertension: hydralazine or labetalol may be given if diastolic pressure is 105 to 110 mm Hg or higher. Determination of mode of delivery must be anticipated and ability to do an emergency delivery in view of clinical progression must be evident.

ORAL CONTRACEPTIVEDrug that inhibits ovulation; contains progestins alone or in combination with estrogen.

OXYTOCIN CHALLENGE TESTA stress test for the assessment of intrauterine function of the fetus and the placenta. It is performed to evaluate the ability of the fetus to tolerate continuation of pregnancy or the anticipated stress of labor and delivery. A dilute IV infusion of oxytocin is begun, regulated by an infusion pump. The uterine activity is monitored with a tocodynamometer, and the fetal heart rate is monitored with an ultrasonic sensor as the uterus is stimulated to contract by the oxytocin. The amount of solution infused is increased as necessary to cause the uterus to contract for 30 to 40 seconds three times every 10 minutes. The fetal heart rate is observed for variability and for the timing of any marked variation from the normal in relation to uterine contractions. Decelerations of the fetal heart rate in certain repeating patterns may indicate fetal distress. One quarter of the infants diagnosed by this method as being in distress are normal. Therefore other tests of fetal well-being are recommended before performing an emergency cesarean section or induction of labor

CHAPTER 10 DEFINITIONSBODY MASS INDEX (BMI)A method of evaluating the appropriateness of weight for height, calculated by the following formula: BMI = Weight Height2

PHOSPHATIDYLGLYCEROL (PG)A phospholipid component of surfactant; its presence in amniotic fluid indicates fetal lung maturity

BIOPHYSICAL PROFILEMethod for evaluating fetal status during the antepartum period based on five fetal variables: fetal heart rate variability, fetal breathing movements, gross movements, muscle tone, and amniotic fluid volume.

PHYSIOLOGIC ANEMIA OF PREGNANCYDecrease in hemoglobin and hematocrit values caused by dilution of erythrocytes by expanded plasma volume rather than by an actual decrease in erythrocytes or hemoglobin.

CHORIONIC VILLUS SAMPLINGTranscervical or transabdominal sampling of chorionic villi (projections on the outer fetal membrane) for analysis of fetal cells. CONTRACTION STRESS TESTMethod for evaluating fetal status during the antepartum period by observing the response of the fetal heart to intermittent stress of uterine contractions.

5 PS 5 FACTORS affecting labor (powers, passage, passenger, maternal position, and maternal psychologic response).

NONSTRESS TESTA method for evaluating fetal status during the antepartum period by observing for accelerations of the fetal heart rate.

Chapter 11DIABETIC KETOACIDOSISMetabolic consequence of severe insulin deficiency; marked by hyperglycemia, acidosis, and ketosis.

CHAPTER 12 DEFINITIONSDILATION AND CURETTAGE (D&C)Chapter 12Stretching the cervical os to permit suctioning or scraping of the walls of the uterus. The procedure is performed in abortion, to obtain samples of uterine lining tissue for laboratory examination, and during the postpartum period to remove retained fragments of placenta.CERCLAGEEncircling of the cervix with suture to prevent recurrent spontaneous abortion caused by early cervical dilation.

CHRONIC HYPERTENSIONHypertension that is present before the pregnancy or develops before 20 weeks of gestation. Hypertension initially diagnosed during pregnancy that persists longer than 12 weeks postpartum is also classified as chronic hypertension.

DISSEMINATED INTRAVASCULAR COAGULATION (DIC)A pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both, and clotting.DISSEMINATED INTRAVASCULAR COAGULOPATHYA grave coagulopathy resulting from the overstimulation of clotting and anticlotting processes in response to disease or injury, such as septicemia, acute hypotension, poisonous snakebites, neoplasms, obstetric emergencies, severe trauma, extensive surgery, and hemorrhage. The primary disorder initiates generalized intravascular clotting, which in turn overstimulates fibrinolytic mechanisms; as a result the initial hypercoagulability is succeeded by a deficiency in clotting factors with hypocoagulability and hemorrhaging. Diagnosis is based on the presence of degradation products.

ECLAMPSIAOnset of seizure activity or coma in a woman with preeclampsia who has no history of preexisting pathology that can result in seizure activity.

ECTOPIC PREGNANCYImplantation of the fertilized ovum outside of the uterine cavity; locations include the uterine tubes, ovaries, and abdomen.

EFFACEMENTCervical thinning.

GESTATIONAL HYPERTENSIONOnset of hypertension without proteinuria after week 20 of pregnancy.

GESTATIONAL TROPHOBLASTIC DISEASE (GTD)A spectrum of diseases that includes benign hydatidiform mole and gestational trophoblastic tumors, such as invasive moles and choriocarcinoma.

GLYCOSURIAGlucose in urine that occurs when the blood glucose level exceeds the renal threshold and glucose spills into the urine.

GLYCOSYLATED HEMOGLOBINA laboratory test used to evaluate long-term blood glucose control by measuring glycosylation (glucose attachment to a protein) of a portion of the hemoglobin molecule in red blood cells; offers a 3-month average of blood glucose control.

HELLP SYNDROMELaboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction, characterized by hemolysis (H), elevated liver enzymes (EL), and low platelet count (LP). It is not a separate illness.

HOMOZYGOUSHaving two identical alleles for a genetic trait.

HETEROZYGOUSHaving two different alleles for a genetic trait.

HYDRAMNIOSExcessive volume of amniotic fluid (more than 2000 ml at term). Also called polyhydramnios.

HYPEREMESIS GRAVIDARUMExcessive vomiting during pregnancy that causes weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria.

INTENSITY (OF CONTRACTIONS)Strength of a contraction at its peak.

INTRATHECALWithin the spinal column.

KARYOTYPEA picture of a cell's chromosomes, arranged from largest to smallest pairs

PLACENTA PREVIAAbnormal implantation of the placenta in the lower uterus, at or near the cervical os.

PREECLAMPSIAPregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a woman who previously had neither condition.

Chapter 6LANUGOFine, soft hair covering the fetus.

KETONE, KETOACIDAn acid produced in response to starvation (in the diabetic child, a result of insulin deficiency); produced from fat stores, which can be used for energy by some tissues when glucose is unavailable.

MULTIPLE-MARKER SCREENINGAnalysis of maternal serum for abnormal levels of alpha-fetoprotein, human chorionic gonadotropin, and estriols that may predict chromosomal abnormalities of the fetus; often called
triple-screen or quad screen. Addition of tests such as inhibin A have improved accuracy of the results, leading to alternate names for the package of tests.

NUCHAL CORDUmbilical cord around the fetal neck

OLIGOHYDRAMNIOSAbnormally small quantity of amniotic fluid (less than 500 ml at term).

REDUCED CERVICAL COMPETENCE (PREMATURE DILATION OF THE CERVIX)Passive and painless dilation of the cervix during the second trimester. In the past, this condition was called cervical incompetence.

VERSIONTurning the fetus from one presentation to another before birth, usually from breech to cephalic.

Chapter 7MULTIGRAVIDAA woman who has been pregnant more than once.

PRIMIPARAA woman who has delivered one pregnancy of at least 20 weeks.

PRIMIGRAVIDAA woman who is pregnant for the first time.

PARITYNumber of pregnancies that have progressed to 20 or more weeks at delivery, whether the fetus was born alive or was stillborn; refers to the number of pregnancies, not the number of fetuses.

MULTIPARAA woman who has delivered two or more pregnancies at 20 or more weeks of gestation.

NULLIGRAVIDAA woman who has not completed a pregnancy with a fetus or fetuses beyond 20 weeks GESTATION

NULLIPARAA woman who has never completed a pregnancy beyond a spontaneous or elective abortion.

OPERCULUMPlug of mucus that fills the cervical canal during pregnancy; acts as a barrier against bacterial invasion

PELVIC INFLAMMATORY DISEASE (PID)An infectious process that most commonly involves the uterine tubes, causing salpingitis; the uterus, causing endometritis; and, more rarely, the ovaries and peritoneal surfaces.

TERMA pregnancy from the beginning of week 38 of gestation to the end of week 42 of gestation.

TERM INFANTAn infant born between the beginning of week 37 and the end of week 42 of gestation.

Chapter 10

CHAPTER 13 DEFINITIONS

ATTITUDERelationship of fetal body parts to one another, such as flexion or extension.

BIPARIETAL DIAMETERThe largest transverse diameter of the fetal head and an important indicator of head size. At term it measures approximately 9.25 cm.

BLOODY SHOWMixture of cervical mucus and blood from ruptured capillaries in the cervix. Bloody show often precedes labor and increases with cervical dilation.

ENGAGEMENTDescent of the widest diameter of the fetal presenting part to at least a zero station (level of the ischial spines in the maternal pelvis).

FETAL LIEThe relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. The two primary lies are longitudinal and transverse.

POSITIONRelation of a fixed reference point on the fetus to the quadrants of the maternal pelvis.

PRESENTATIONFetal part that first enters the pelvic inlet; also, the presenting part.

STATIONMeasurement of fetal descent in relation to the ischial spines of the maternal pelvis. See also engagement.

Chapter 14

EFFLEURAGELight stroking, usually of the abdomen, in rhythm with breathing during contractions.

OPIOID (NARCOTIC) AGONIST-ANTAGONIST ANALGESICSMedications that combine agonist activity (activates or stimulates a receptor to perform a function) and antagonist activity (blocks a receptor or medication designed to activate a receptor) to relieve pain without causing significant maternal or fetal or newborn respiratory depression.

OPIOID (NARCOTIC) ANTAGONISTSMedications that reverse the central nervous system depressant effects of an opioid, especially respiratory depression.

Chapter 15EARLY DECELERATIONa visually apparent, gradual decrease in and return to baseline fetal heart rate Associated with contractions; caused by fetal head compression. Generally the onset, nadir, and recovery of the deceleration correspond to the beginning, peak, and end of the contraction.NADIRLowest point, such as the lowest pulse rate in a series.LATE DECELERATIONA visually apparent, gradual decrease in and return to baseline fetal heart rate associated with contractions; caused by disruption of oxygen transfer. The deceleration begins after the contraction has started and the nadir of the deceleration occurs after the peak of the contraction. The deceleration usually does not return to baseline until after the contraction ends.

PROLONGED DECELERATIONA visually apparent decrease (may be either gradual or abrupt) in fetal heart rate of at least 15 beats/min below the baseline and lasting more than 2 minutes but less than 10 minutes.

UTERINE RESTING TONEDegree of uterine muscle tension when the woman is not in labor or during the interval between labor contractions.

VALSALVA MANEUVERForced expiration against a closed airway, which when released, causes blood to rush to the heart and overload the cardiac system.

MONTEVIDEO UNITSA method to quantify intensity of labor contractions with internal uterine activity monitoring. The baseline intrauterine pressure for each contraction in a 9-minute period is subtracted from the peak pressure. The resulting net pressures (peak minus baseline) are added to calculate Montevideo units, or MVUs.

VARIABILITYIrregular waves or fluctuations in the baseline FHR of two cycles per minute or greater. There are four possible categories of variability: absent, minimal, moderate, and marked.

VARIABLE DECELERATIONA visually apparent abrupt decrease in fetal heart rate below the baseline; caused by compression of the umbilical cord. The decrease is at least 15 beats/ min or more below the baseline, lasts at least 15 seconds, and returns to baseline in less than 2 minutes from the time of onset.

Chapter 16FIRST STAGE OF LABORBegins with the onset of regular uterine contractions and ends with complete cervical effacement and dilation. It consists of three phases: latent, active, and transition.

FOURTH STAGE OF LABORThe first 1 to 2 hours after birth. During this time maternal organs undergo their initial readjustment to the nonpregnant state and the process of parent / child bonding and attachment begins.

FOURTH TRIMESTERFirst 12 weeks after birth, a time of transition for parents and siblings.

FREQUENCY (OF CONTRACTIONS)Time from the beginning of one contraction to the beginning of the next, measured in minutes.

FUNIC SOUFFLESynchronous with the fetal heart rate and caused by fetal blood coursing through the umbilical cord, may also be heard, as well as the actual heartbeat of the fetus.

LATENT PHASE (OF FIRST STAGE LABOR)Phase in the first stage of labor when the cervix dilates from 0 to 3 cm.

LATENT PHASE (OF SECOND STAGE LABOR)Period of rest and relative calm (sometimes called ''laboring down'') early in the second stage of labor. During this phase the fetus continues to descend passively through the birth canal.

LIGHTENINGDescent of the fetus toward the pelvic inlet before labor.

LOCHIA RUBRARed vaginal discharge that occurs immediately after childbirth; composed mostly of blood.

LOCHIA SEROSAPink or brown-tinged vaginal discharge that follows lochia rubra; composed largely of serous exudate, blood, and leukocytes.

SECOND STAGE OF LABORBegins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. It is composed of two phases: latent and active pushing (descent).

THIRD STAGE OF LABORBegins with birth of the baby and ends when the placenta is expelled.

TRANSITION PHASEPhase in the first stage of labor when the cervix dilates from 8 to 10 cm.

NITRAZINE TESTCommercial paper strip to determine pH of a fluid sample by color; swabs also used to determine Ph

Chapter 4

METRORRHAGIABleeding from the uterus at any time other than during the menstrual period.

Chapter 24MILK EJECTION REFLEXRelease of milk from the alveoli into the ducts. Also called the letdown reflex.

Chapter 17LATE PRETERM BIRTHBirth that occurs between 34 and 36 weeks of gestation.

UTERINE TACHYSYSTOLEMore than five contractions in 10 minutes, averaged over a 30-minute window. The term applies to both spontaneous and stimulated labor.

PREMATURE RUPTURE OF MEMBRANESSpontaneous rupture of the membranes before the onset of labor. The gestation may be term, preterm, or postterm.

TOCOLYTICA drug that inhibits uterine contractions.

Chapter 22NEVUS FLAMMEUSPermanent purple birthmark; also called port-wine stain.

MECONIUMA material that collects in the intestines of a fetus and forms the first stools of a newborn. It is thick and sticky, usually greenish to black, and composed of secretions of the intestinal glands, some amniotic fluid, and intrauterine debris, such as bile pigments, fatty acids, epithelial cells, mucus, lanugo, and blood. With ingestion of breast milk or formula and proper functioning of the GI tract, the color, consistency, and frequency of the stools change by the third or fourth day after the initiation of feedings. The presence of meconium in the amniotic fluid during labor may indicate fetal distress and may lead to a lack of oxygen and developmental delays.

NEVUS SIMPLEX (SALMON PATCH, STORK BITES, TELANGIECTATIC NEVI)Flat, pink areas on the nape of the neck, forehead, or eyelids resulting from dilation of the capillaries.

Chapter 25PERIODIC BREATHINGCessation of breathing lasting 5 to 9 seconds followed by 9 to 15 seconds of rapid respirations without changes in color or heart rate.

Chapter 21PLACENTA ACCRETAA placenta that is abnormally adherent to the uterine muscle. If the condition is more advanced, it is called placenta increta
(the placenta extends into the uterine muscle) or placenta percreta (the placenta extends through the uterine muscle).