NUR3411C
Maternal Newborn
Study Guide: Test 1
Chapters 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
40-50 questions
Question types: Multiple choice, select all that apply, dosage calculation, bowtie, matrix,
trend, case study
This study guide is intended to be a tool, not all-inclusive of the examination's content.
Chapter 3 Assessment and Health Promotion
 Intimate Partner Violence
o Can be inflicted by women
o Physical or emotional abuse
o Sexual assault
o Isolation
o Controlling all aspects of the woman’s life
 Money
 Shelter
 Time
 Food
o Cycle of violence
 Phase 1: Tension building
 That her experiences increased tension, victim minimizes
problems
 Tension becomes intolerable
 Phase 2: Abusive incident
 Batterer highly abusive, incident occurs
 Phase 3: Honeymoon period
 Loving, apologetic, promises change
o Battering during pregnancy
 Rates range from 4% to 8% and may be as high as 20% in some
populations
 Incidence of intimate partner violence may escalate
 May happen for the first time during pregnancy
 Risk to the fetus includes increased rate of miscarriage, preterm birth,
and stillbirth
o History
 Biographic data
 Reason for seeking care
 Present health or history of present illness
 Past health
 Family history
 Screen for abuse
 Review of systems
 Functional assessment



o Physical examination
 General appearance
 Vital signs
 Objective data is recorded by body systems
 Findings are described in detail
o Cultural considerations and communication variations
 Trust that woman is expert on her life, culture, and experiences
 If asked with respect and genuine desire to learn, woman will tell
nurse how to care for her
 May be considered inappropriate for woman to disrobe completely
for physical examination
 In many cultures a female examiner is preferred
Menstrual Cycle
o Menarche and puberty
o Menstrual cycle
o Endometrial cycle
o Hypothalamic-pituitary cycle
o Ovarian cycle
 Corpus luteum = where the egg came from
o Other cyclic changes
Cultural Competency
Preconception Counseling and Risk factors
o Social, cultural, genetic
o Substance use and abuse
 Prescription drug use
 Illicit drug use
 Marijuana, cocaine, opiates, methamphetamine, phencyclidine
 Alcohol consumption
 Cigarette smoking
 Caffeine
o Nutritional problems
o Nutritional deficiencies
 Obesity
 Eating disorders
 Anorexia
 Bulimia nervosa
 Lack of exercise
o Stress
o Mental health conditions
o Sleep disorders
o Environmental and workplace hazards
o Risky sexual practices
o Risk for certain medical or gynecologic conditions
o Female genital mutilation
Chapter 4 Reproductive System Concerns
 Risk behaviors associated with STIs
 Signs, symptoms, causes and treatments of STIs (HPV, HSV, Gonorrhea, Chlamydia,
Trichomonas, Syphilis, HIV/AIDS) as well as BV, and vulvovaginal candidiasis
o Chlamydia
 Most frequently reported STI
 Infections often asymptomatic and highly destructive
 Screening and diagnosis
 Screening of asymptomatic and all pregnant women
 Management
 Drug therapy- doxycycline, azithromycin or amoxicillin
o Gonorrhea—Neisseria gonorrhoeae
 Oldest communicable disease
 Aerobic and gram-negative diplococci
 Screening and diagnosis
 Women are often asymptomatic
 Management
 Treatment with antibiotic therapy- Ceftriaxone IM &
azithromycin PO
 Drug-resistant strains on the rise
o Syphilis—Treponema pallidum, a motile spirochete
 Transmission by entry in subcutaneous tissue through microscopic
abrasions
 Transplacental transmission may occur at any time during pregnancy
 Infection manifests itself in distinct stages
 Primary - Chancre (painless papular lesion) at site of infection.
Inguinal lymph node edema can indicate internal lesions
 Secondary - Maculopapular skin rash on the palmar surface of
the hands and soles of the feet
 Tertiary - Damage to internal organs
o Manifestations: eye infections leading to blindness,
difficulty coordinating muscle movements, nervous
system infections leading to headache, numbness,
paralysis, dementia
 Screening and diagnosis
 Pregnant women- all screened in 1st trimester & repeated in
third trimester if high risk
 Serologic tests- VDRL & RPR
 Management
 Penicillin G IM in a single dose
 Sexual abstinence during treatment
o
o
o
Pelvic inflammatory disease (PID)
 Results from ascending spread of microorganisms from vagina and
endocervix to upper genital tract
 Caused by multiple organisms
 Most commonly involves:
 Uterine tubes (salpingitis)
 Uterus (endometriosis)
 At increased risk for:
 Ectopic pregnancy
 Infertility
 Chronic pelvic pain
Human papillomavirus (HPV)
 Most prevalent viral STI seen in ambulatory health care settings
 Genital warts (Condyloma acuminata)
 Cervical cancer
 Signs & Symptoms
 Irritating vaginal discharge with itching
 Dyspareunia, postcoital bleeding
 Small warts- cauliflower- like appearance
 Abnormal changes to the cervix detected by a Pap test
 Screening and diagnosis
 Physical inspection
 Pap smear
 21- 29 years old should have pap test every 3 years
 30-65 years old should have pap test and HPV test every 5 years
 Management
 Vaccine- ages 9-26 years, preferred at 11-12 years
 No therapy has been shown to eradicate
 Medications
 Bichloroacetic acid (BCA), imiquimod
 Trichloroacetic acid (TCA)
 Podophyllin – can’t use during pregnancy
 Counseling and education
Herpes simplex virus (HSV)
 Herpes simplex virus 1 (HSV-1)
 Transmitted nonsexually
 Herpes simplex virus 2 (HSV-2)
 Transmitted sexually
 HSV
o Initial infection is characterized by multiple painful lesions,
fever, chills, malaise, and severe dysuria
 Maternal infection can have adverse effects on both
the mother and fetus
 Increased miscarriage rates during the first trimester
 Association with cervical cancer has been observed
o Prevention is critical!


Viral hepatitis
o Hepatitis B virus
 Most threatening to fetus and neonate
 Disease of liver; often a silent infection
 Transmitted parenterally, perinatally, orally (rarely), and through
intimate contact
 Vaccination series
o Hepatitis C virus
 Most common bloodborne infection in the United States
 Risk factor for pregnant women is history of injecting intravenous
drugs
 Currently there is no vaccine
Human immunodeficiency virus (HIV)
o Heterosexual transmission now most common means of transmission in
women
o Estimated that 23% of new infections occur in women
o Transmission of HIV occurs primarily through exchange of body fluids
o Severe depression of cellular immune system associated with HIV infection
characterizes AIDS
o Symptoms include fever, headache, night sweats, malaise, generalized
lymphadenopathy, myalgias, anemia, nausea, diarrhea, weight loss, sore
throat, and rash
o Screening and diagnosis
 Antibody screening enzyme immunoassay (EIA), confirmation with
western blot or immunofluorescence assay
 All pregnant women in early pregnancy, repeat in third trimester if
high risk
o Counseling for HIV testing
 Perinatal transmission has decreased
 Discuss safe sex practices including barrier protection
 Nurses must consider confidentiality and documentation
o Pregnancy and HIV
 Transmission to infant may occur at any time
 Definitive diagnosis of children less than 18 months is done based on
lab evidence of HIV presence
 Proper treatment leads to <1% transmission to baby
 Antiretroviral therapy- given throughout pregnancy
 Triple-drug antiviral therapy or Highly active antiretroviral
therapy (HAART) may be given
 Lab monitoring- STIs, viral load, CD4 counts
 Vaccinations- hepatitis B, pneumococcal infection, influenza
 Cesarean versus vaginal birth depends on viral load

Vaginal infections
o Bacterial Vaginosis
 Caused by alteration in normal vaginal bacterial flora
 Common vaginal infection
 Signs and symptoms
 Thin, watery white or gray vaginal discharge
 Vaginal discharge has a "fishy" smell
 "Clue" cells are seen on wet-mount preparation
 Treatment
 Metronidazole (Flagyl), Tinidazole, Clindamycin
 Some available as vaginal creams and/or orally
o Candidiasis—Candida albicans
 Vulvovaginal candidiasis, or yeast infection, is second most common
type of vaginal infection
 Predisposition
 Antibiotic therapy
 Diabetes
 Pregnancy
 Obesity
 Diets high in refined sugars
 Use of corticosteroids
 Immunosuppressed states
 Common signs & symptoms
 Vulvar & Vaginal pruritus
 Vulvar and vaginal erythema and inflammation
 Thick, creamy, white, cottage- cheese-like discharge
 Management
 Fluconazole
o Over-the-counter agents
 Prevention
o Trichomoniasis—Trichomonas vaginalis
 Common Symptoms
 Yellow-green, frothy, malodorous discharge and vaginal
itching
 May have dysuria and dyspareunia
 Cervix bleeds easily (friable) and has tiny petechiae
 Can be asymptomatic
 Screening and diagnosis
 Specular examination
 Pap smear
 Management
 Metronidazole or tinidazole orally in a single dose
 Sexual transmission must be communicated to infected woman



o Group B streptococci
 Associated with poor pregnancy outcomes
 An important factor in neonatal morbidity and mortality
 Screening at 35 to 37 weeks of gestation
 GBS + or unknown:
 Treated with IV antibiotics in labor
 Penicillin G or Ampicillin
What STI are curable and what STIs are incurable
TORCH infections- can cause birth defects/death to the baby
o Toxoplasmosis
 Contracted via raw meat or handling of cat feces
 Manifestations- asymptomatic, fever, tender lymph nodes, malaise,
muscle aches
o Other (Hepatitis A, hepatitis B, syphilis, mumps, parvovirus b19, varicellazoster)
o Rubella (German measles)
 Contracted through children with the rashes or neonates exposed in
utero
 Manifestations- rash, mild lymphedema, fever, joint and muscle pain
o Cytomegalovirus
 Transmitted via droplet or bodily fluids
 Manifestations: asymptomatic or mononucleosis- like manifestations
o Herpes Simplex Virus
 Transmission to fetus is greatest during vaginal birth (when active
lesions present)
STI Prevention
o Safer sex practices
 Knowledge of partner, reducing partners
 Low risk sex
 Condom use
 Vaccination
Chapter 5 Infertility, Contraception and Abortion
 Types of contraceptives (IUD, Implants, Depo Provera, Sterilization, etc.)




Coitus interruptus (withdrawal)
Fertility awareness methods (FAMs)
o Rely on avoidance of intercourse during fertile periods
o FAMs combine charting menstrual cycle with abstinence or other
contraceptive methods
o Natural family planning (period abstinence)
o Calendar rhythm method
o Woman monitors fertile window
o Most fertile 5 days before ovulation until 1 day post-ovulation, so intercourse
is avoided or barrier protection is used cycle days 8-19 (for a regular length
cycle)
o Natural family planning (NFP), standard days method, cycle beads or
software program
o Calendar rhythm method (CRM) is based on premise that ovulation occurs at
day 14 of cycle (plus or minus 2 days)
o Billings method – spinnbarkeit (cervical mucous)
o Advantages
 Natural, noninvasive and inexpensive
o Disadvantages
 Requires extensive initial counseling
 Does not protect against STIs
o Effectiveness
 Couples must practice abstinence
 Low reliability
Barrier methods
o Spermicides
 Chemical barrier, causes the vaginal flora to be more acidic, which is
not favorable for sperm survival
o Condoms, male & female (STI protection)
 Prevent spread of most STIs
 Use only water soluble lubricants with latex condoms
o Diaphragm
 Must be fitted by a provider
 Use with spermicide to increase effectiveness
 Insert up to 6 hr prior to intercourse and leave in place for at least 6
hr after intercourse (no longer than 24 hours at a time)
o Cervical cap
 Insert up to 6 hr prior to intercourse and leave in place for at least 6
hr after intercourse (no longer than 48 hours at a time)
 Use with spermicide to increase effectiveness
o Contraceptive sponge
 Polyurethane sponge that contains spermicide that fits over the cervix
 Should be left in place for 6 hr after intercourse and provides
protection up to 24 hours
Hormonal methods
o Combined estrogen-progestin contraceptives (COCs)
 Oral contraceptives and side effects
 Transdermal contraceptive system
 Vaginal ring




Progestin-only contraceptives
o Oral progestins (mini pill)
 Orally, daily
 Continuous, no “pill free” week
 Considered safe to take while breastfeeding
o Injectable progestins
 Injected every 11 – 13 weeks
 Can decrease bone density, need adequate intake of calcium and vitamin D
 Weight gain, depression, and irregular bleeding are more common side
effects
 Return to fertility can be delayed greater than one year after discontinuation
 Not recommended for use for more than 2 years unless other methods are
not suitable
o Implantable progestins (Norplant)
 Implant inserted subdermally in woman’s upper underarm
 Impregnated with etonogestrel, a progestin
 Prevents ovulation; effective for 3 years
 Side effects: spotting, irregular bleeding, ovarian cysts, weight gain, acne,
hair loss, headaches, mood changes, depression
Sterilization
o Female
 Tubal occlusion
 Tubal reconstruction
o Male (vasectomy)
 Tubal reconstruction (reanastomosis)
What contraceptive method is acceptable for breastfeeding women
o Progestin-only pill (minipill) – oral
Emergency contraceptives- types and timing of administration
o Inhibits ovulation and the transport of sperm
o Used within 72 hours of unprotected intercourse
o Methods available in the United States
 High doses of estrogen or COCs
 Two days of levonorgestrel
 Insertion of the copper intrauterine device (IUD)
 Small, T-shaped device wrapped in copper inserted into the uterine
cavity
 Medicated intrauterine system loaded with progestational agent
(Mirena)
 IUD offers no protection against STIs or HIV
 Advantages: Long acting & reversible; effective for up to 10 years
(device dependent). High efficacy, next best to permanent
sterilization. Available hormone-free, and with progestin.
 Disadvantages: May cause cramping and irregular bleeding for first 3
to 6 months
 Woman must check for proper placement after each menses (string
check)
 Risks include perforation, PID, expulsion, discomforts and increased
bleeding




Combined hormonal contraceptives (also called combined oral contraceptives)
o Hormonal contraceptives, combined
 Contraindicated in pregnant clients, clients with cardiovascular disorders,
previous history of thromboembolic disease, acute or chronic liver disease
with abnormal function, presence of an estrogen-dependent carcinoma,
undiagnosed uterine bleeding, heavy smoking, gall bladder disease,
hypertension, diabetes and hyperlipidemia.
 Smokers over 35 years of age should not use
 Caution for decreased effectiveness when using with anticonvulsants and
some antibiotics
 Does not protect from STIs
 Very effective when used correctly
 Noncontraceptive benefits include relief of menstrual symptoms, lessened
cramps, decreased flow, improved cycle regularity (predictable
menstruation)
 Reduction in incidence of some cancers
 Educate regarding warning signs during use
o Warning signs (ACHES)
 A- abdominal pain- may indicate a liver or gall bladder problem
 C- chest pain or SOB- may indicate a clot in the heart or lungs
 H- Headaches (sudden or persistent)- may be caused by cerebrovascular
accident or hypertension
 E- Eye problems- may indicate vascular accident or hypertension
 S- Severe leg pain- may indicate a thromboembolic process

Assessment of female infertility
o Test or examination
 Evaluation of the anatomy (pelvic examination)
 Hormone analysis- prolactin, FSH, LH, estradiol, progesterone, thyroid
hormones
 Ultrasonography- visualize the reproductive organs
 Hysterosalpingography- radiologic procedure that uses dye to assess for
tubal patency
 Hysteroscopy- radiographic procedure to examine the uterus for defect,
distortion, or scar tissue
 Laparoscopy- procedure to visualize the internal organs
Assessment of male infertility
o Semen analysis
o Scrotal ultrasound- visualize the testes and abnormalities in the scrotum
Assisted reproductive therapies
o Intrauterine insemination
 Sperm is placed in the uterus at time of ovulation
o In vitro fertilization-embryo transfer (IVF-ET)
 Client’s eggs are collected, fertilized in the laboratory, then the embryo is
transferred into the uterus
o Ovum transfer (oocyte donation)
 Eggs are collected from a donor, fertilized and the embryo is transferred into
the client’s uterus
o Therapeutic donor insemination (TDI)
 Donor sperm is used to inseminate a person
o Embryo hosting/ Gestational carrier
 A person carries the pregnancy, has no genetic connection to the embryo
Chapter 6 Genetics, Conception, and Fetal Development
 Embryonic Stage
o Primary germ layers
 Ectoderm, Mesoderm & Endoderm
o Development of the embryo
 Day 15- 8 weeks is the embryonic stage
 At the end of the eight week all organ systems and external structures
are present
 Critical time in the development of the organ systems and main
external features
 Teratogens
o Teratogens – Remember TORCH
 Drugs
 Chemicals
 Infection
 Exposure to radiation
 Maternal conditions (Diabetes, PKU)
o Maternal nutrition
 Malnutrition


Genetics terms (Genotype, Phenotype, Karyotype, etc.)
o Genotype
 The genotype of a person is her or his genetic makeup. It can also
refer to the alleles that a person has for a specific gene
o Phenotype
 Phenotype is how a person looks (on the outside and inside the body)
due to his or her genes and the environment (for example, having a
certain eye color, being a specific blood type, or being a certain
height). Phenotype also can refer to how a person’s body functions,
for example, whether he or she has a certain disease.
o Karyotype
 A karyotype is an individual’s complete set of chromosomes. The term
also refers to a laboratory-produced image of a person’s
chromosomes isolated from an individual cell and arranged in
numerical order. A karyotype may be used to look for abnormalities in
chromosome number or structure.
Placental function and hormone production
o Structure
 Maternal-placental-embryonic circulation by Day 17
o Function
 Endocrine gland- produces hormones such as hCG, hPL, progesterone
 Metabolic function and waste
 Nutrient storage- carbohydrates, calcium, protein, iron
Chapter 7 Anatomy and Physiology of Pregnancy
 Definitions- gravidity, parity, term, preterm
o Gravidity
 Gravida: Woman who is pregnant
 Gravidity: Pregnancy
 Nulligravida: Woman who has never been pregnant
 Primigravida: Woman pregnant for first time
 Multigravida: Woman who has had two or more pregnancies
o Parity
 Parity: Number of pregnancies in which fetus or fetuses have reached
viability, not number of fetuses (e.g., twins) born. Whether the fetus is
born alive or is stillborn (fetus who shows no signs of life at birth)
after viability is reached does not affect parity
 Nullipara: Woman who has not completed a pregnancy with fetus or
fetuses who have reached stage of fetal viability
 Primipara: Woman who has completed one pregnancy with fetus or
fetuses who have reached stage of fetal viability
 Multipara: Woman who has completed two or more pregnancies to
stage of fetal viability
o Term
 Preterm: Pregnancy that has reached 20 weeks of gestation but before
completion of 37 weeks of gestation
 Late preterm: Pregnancy that has reached between 34 weeks 0 days
and 36 weeks 6 days gestation
 Early term: Pregnancy that has reached between
37 weeks 0 days and 38 weeks 6 days gestation
 Full term: Pregnancy that has reached between
39 weeks 0 days and 40 weeks 6 days
 Late term: Pregnancy that has reached between
41 weeks 0 days and 41 weeks 6 days
 Postterm: Pregnancy that has reached 42 weeks
0 days and beyond gestation
 Viability: Capacity to live outside the uterus; about 22 to 25 weeks
gestation are on the threshold of viability
 These very premature infants are vulnerable to brain injury

GTPAL- know what each letter stands for and how to write out GTPAL based on a
client’s history
o Two digits
 G—Gravida
 P—Para
o Five digits
 GTPAL
 Gravidity, term, preterm, abortions, living children
o G- 1
o P- 2
o G3P2002
 PREGNANT NOW, 2 TERM, 0 PRETERM, 0ABORTONS, 2 LIVING

Presumptive, probable, positive changes of pregnancy
o Signs of pregnancy

Presumptive

Those changes felt by the woman

Probable

Those changes observed by an examiner
o Positive pregnancy test
o Chadwick sign (blue cervix)

Positive

Those signs are attributed only to the presence of the fetus
o Hear fetal heart sounds
o Fetus on ultrasound
o Fetal movement

Changes in the following systems- respiratory, cardiovascular, integumentary
o General body systems

Cardiovascular system

Blood volume increases – 30-45%

Cardiac output increases – 30-50%

Blood pressure

Supine hypotensive syndrome

Circulation and coagulation times

Increases in various clotting factors

Increased risk of clots 5-7 fold

Respiratory system

Maternal oxygen demands increase

Maternal oxygen consumption increases 20-40% above pre-pregnancy levels

Size of the chest may enlarge to allow for lung expansion

Respiratory rate is unchanged or slightly increased

Renal system

GFR increases by 50% due to pregnancy hormones, increase in blood volume and
metabolic demands

Urinary output (volume) remains unchanged

Urinary frequency, urgency, nocturia, and bladder irritability are common in
pregnancy

Integumentary system

Chloasma or melasma (mask of pregnancy)

Linea nigra

Striae gravidarum

Musculoskeletal system

Changes in posture- lordosis

Pelvic joints relax

Diastasis recti abdominus

Risk of falls due to change in center of gravity

Neurologic system

Carpal tunnel syndrome

Headaches

Lightheadedness, faintness and syncope (common in early pregnancy)

Gastrointestinal system

Nausea and vomiting- due to increasing hCG levels

PICA- nonfood cravings

Constipation

Pyrosis (heartburn)

Endocrine system

The placenta becomes an endocrine organ that produces large amounts of hCG,
progesterone, estrogen, hPL and prostaglandins

Hormones function to maintain the pregnancy and prepare the body for delivery
Chapter 8 Nursing Care of the Family During Pregnancy



Nagele’s Rule
o Determine first day of last menstrual period (LMP), subtract 3 months, add 7 days
(plus 1 year if needed)
o Most women give birth from 7 days before to 7 days after EDB
Maternal Serum Alpha- fetoprotein- what does it test for? When is it tested?
o Multiple-marker or triple-screen blood test (alpha fetal protein)
o Follow up visit
o Fetal Assessment
o What is an Alpha-fetoprotein (AFP) Test? An AFP test is a test that is mainly used to
measure the level of alpha-fetoprotein (AFP) in the blood of a pregnant person. The
test checks the baby's risk for having certain genetic problems and birth defects. An AFP
test is usually done between 15 and 20 weeks of pregnancy
Common discomforts of pregnancy and interventions
o Nausea and vomiting- eat crackers or dry toast before rising in the morning; avoid
having an empty stomach, avoid spicy, greasy or gas- forming foods. Drink fluids
between meals
o Breast tenderness- wear a supportive bra
o Urinary frequency- empty the bladder frequently, decrease fluid intake before bed,
perform kegel exercises
o UTIs- wipe front to back, avoid bubble baths, wear cotton underwear, avoid tightfitting pants, consume plenty of water, urinate before and after intercourse, void
once you feel the urge, notify the provider if the urine is foul-smelling, bloody or
cloudy
o Fatigue- engage in frequent rest periods
o Heartburn- eat, small frequent meals, do not lie down immediately after eating
o Constipation- drink plenty of fluids, eat a high fiber diet, exercise regularly
o Hemorrhoids- a warm sitz bath, witch hazel pads, and application of topical
ointments
o Backaches- exercise regularly, perform pelvic tilt exercises, use proper body
mechanics, use the side-lying position
o Shortness of breath- maintain good posture, sleep with extra pillows, contact the
provider is manifestations worsen
o Leg cramps- Extend the affected leg with the knee straight and dorsiflex the foot.
Heat and massage may help
o Varicose veins and lower extremity edema- rest with legs and hips elevated, avoid
constricting clothing, wear supportive hose, avoid sitting and standing for long time
periods, not sit with the legs crossed. Sleep in the left lateral position, and exercise
moderately with frequent walking
o Gingivitis, nasal stuffiness, epistaxis- gently brush the teeth, follow good dental
hygiene, use a humidifier, use normal saline nose drops or spray
o Braxton Hicks contractions- position change and walking should relieve the pain. If
contractions increase in intensity and frequency with regularity, the client should
notify the provider (Braxton Hicks contractions are a tightening in your abdomen
that comes and goes. They are contractions of your uterus in preparation for giving
birth. They tone the muscles in your uterus and may also help prepare the cervix for
birth.)
o Supine hypotension- Lie in a side- lying position or semi- sitting position with the
knees slightly flexed

Danger signs of pregnancy
o First Trimester
 Burning on urination
 Severe vomiting
 Diarrhea
 Fever or chills
 Abdominal cramping or vaginal bleeding
 Miscarriage/etopic
o Second and Third Trimester
 Gush of fluid from the vagina prior to 37 weeks
 Vaginal bleeding – placenta privia/abruta
 Abdominal Pain
 Changes in fetal activity
 Persistent vomiting
 Severe headaches – gestational hypertension
 Elevated temperature – infection
 Dysuria – UTI
 Blurred vision – gestational hypertension
 Edema of the face and hands – gestational hypertension
 Epigastric pain – gestational hypertension
 Concurrent flushed dry skin, fruity breath, rapid breathing, increased
thirst and urination, headache – hyperglycemia
 Concurrent clammy, pale skin, weakness, tremors, irritability,
lightheadedness – hypoglycemia

Self-Care actions for health promotion- employment, exercise, travel, dental care,
activity, rest, sexual activity
Chapter 9 Maternal and Fetal Nutrition

BMI ranges and weight gain recommendations in pregnancy
o Energy needs
 Weight gain
 Body mass index (BMI) = weight/height2
 Underweight woman
 Body Mass Index (BMI) less than 18.5
 Recommended gain 28–40 lb (12.5–18 kg)
 Normal-weight woman
 Body Mass Index (BMI) 18.5–24.9
 Recommended gain 25–35 lb (11.5–16 kg)
 Overweight woman
 Body Mass Index (BMI) 25–29.9
 Recommended gain 15–25 lb (7–11.5 kg)
 Obese woman
 Body Mass Index (BMI) over 30
 Recommended gain 11–20 lb (5–9.1kg)
o Expected Weight Gain
 Normal weight
 Gain of 2.2–4.4 lb (1 to 2 kg) during the first trimester
 Average gain of 1 lb (0.5 kg) per week during the last two trimesters

Caloric needs in pregnancy and breastfeeding
o Calories
 First trimester- same as the non-pregnant state
 Second trimester- an additional 340 calories
 Third trimester- an additional 452 calories
o Protein
 Essential to basic growth
 Additional 25g in the second and third trimesters
o Omega 3 fatty acids
 LCPUFAs- DHA & AA
 Essential to fetal brain development and neurologic function
o Fluids
 Recommended daily intake 8-10 glasses (2.3L) of fluid
o Minerals and vitamins
 Iron
 Increased RBC mass & adequate iron transfer to fetus
 Patient Teaching Iron Supplementation p 222
 Calcium
 Bone and teeth formation
 Daily recommendation: 1000mg/day for 19-50 years of age &
1300 mg/day for those under 19 years
 Folic acid
 Neurologic development and prevention of neural tube defects
 Prior to pregnancy women of childbearing age should take 400
mcg of folic acid daily
 During pregnancy, women should take 600 mcg of folic acid
daily
o Nutrition needs during lactation similar to those during pregnancy (450-500
cal/day)
o Needs for energy (calories), protein, calcium, iodine, zinc, the B vitamins, and
vitamin C remain greater than nonpregnant needs

Foods to avoid in pregnancy
o Alcohol
 contraindicated in pregnancy
o Caffeine
 Limit intake to 200mg daily
 Can cause IUGR, SAB, infertility
o Artificial sweeteners
 Have not been found to have adverse effects on the mother and fetus
o No soft cheeses or foods that are unpasteurized
o No swordfish, shark, tilefish, or king mackerel
o Tuna to 6oz a week
o Do not restrict calorie intake to lose weight during pregnancy
o Avoid megadoses of vitamins

Maternal and fetal risks associated with abnormal weight gain
Chapter 10 Assessment of High-Risk Pregnancy



Fetal Movement Counts
o Daily fetal movement count (DFMC)
 Simple yet valuable method to evaluate the condition of the fetus
 Several methods can be used to count
 Once a day for 60 minutes
 2 to 3 times daily –ATI (2hrs after meals or before bedtime) (less
than 3per/hr = concern)
 10 movements in a 12-hour period
o
Non-stress test
o Widely used method of evaluating fetal status [alone or as part of biophysical profile
(BPP)]
o Adequately oxygenated fetus with intact fetal central nervous system should
demonstrate accelerated fetal heart rate (FHR) in response to fetal movement
o Requires electronic monitor to observe and record fetal heart rate accelerations
o Advantages
 Quick to perform
 Permits easy interpretation
 Inexpensive
 Can be done in an office or clinic setting
 No known side effects
o Disadvantages
 Sometimes difficult to obtain a suitable tracing
 Woman must remain relatively still for at least 20 minutes
 High false-positive rate
o Positioning options
 Reclining chair or in bed
 Left-tilted, semi-Fowler or side-lying position
o Avoid supine position
 Less fetal movement
 Maternal back pain
 Maternal shortness of breath
o Electronic fetal monitor to obtain data
 Fetal heart rate (FHR) tracing
 Fetal movement (FM)
o Monitor placed beneath woman's clothing
o Provide woman with privacy
o Results
 Shows at least two accelerations of FHR with fetal movements of 15
beats/min, lasting 15 seconds or more, over 20 minutes = reactive NST
 15x15 rule over 20 min
 In preterm fetuses (prior to 32 weeks), rate is 10 beats above baseline for 10
seconds in a 20 minute window
 10x10 rule over 20 min
 If reactive criteria are not met, than it is nonreactive
 For example, the accelerations do not meet the requirements (15 x 15 or 10
x 10)
 If data cannot be interpreted, or there was inadequate fetal activity,
than it is unsatisfactory
Biophysical Profile
o
o
o
o
o

Purpose is to either to identify the compromised fetus or to confirm the healthy fetus
Provides an assessment of placental functioning
Biophysical risks
 Genetic disorders
 ABO
 Multiple births
 Nutritional and general health status
 Young
 Multiple pregnancies
 Tobacco, drugs, alcohol
 Weight gain
 Medical or obstetric-related illness
 Poorly controlled diabetes mellitus
 Hypertensive disorders
 Advanced maternal age
Biophysical Profile (BPP) Indications
 Client presentation Vaginal bleeding evaluation
 Size- dates discrepancy
 Decreased fetal movement
 Preterm labor
 Possible ROM (ruptured membranes)
 Nonreactive NST (stress test)
Scoring Criteria
 Score of 2 assigned to each variable with normal finding
 Score of 0 assigned to each variable with abnormal finding
 Maximum score of 10
 Scores of 8 (with normal amniotic fluid) and 10 considered normal
 Reflect least chance of being associated with compromised fetus unless decreased
amount of amniotic fluid noted
 4-6 abnormal risk of asphyxia
 <4 asphyxia
Amniocentesis
o Studies can be performed on amniotic fluid, can be performed after 14 weeks, but depending
on indication, may be performed in later pregnancy
o US guidance used to identify fetal and placental positions, and pockets of amniotic fluid
o Provide information on
 Fetal health
 Genetic disorders
 Fetal health Fetal lung maturity (third trimester)
o Amniocentesis
 Fetal complications
 Death
 Hemorrhage
 Infection (amnionitis)
 Injury from needle
 Risks may be minimized by using ultrasound to direct the procedure
 Fetal lung maturity is determined by
 The lecithin/sphingomyelin (L/S) ratio
o A ratio of 2:1 indicates fetal lung maturity (2.5:1 or 3:1 if client is
diabetic)
 Presence of phosphatidylglycerol (PG)
o Absence of PG is associated with respiratory distress
o
o
o
Chorionic villus sampling (CVS)
 Earlier diagnosis and rapid results
 Performed between 10 and 13 weeks of gestation
 Removal of small tissue specimen from fetal portion of placenta
o Chorionic villi originate in zygote
o Tissue reflects genetic makeup of fetus
 Risks of CVS include:
o Failure to obtain tissue
o Rupture of membranes
o Leakage of amniotic fluid
o Bleeding
o Intrauterine infection
o Maternal tissue contamination of specimen
o Rh alloimmunization – cross contamination of – and +
o Spontaneous abortion
Percutaneous umbilical blood sampling (PUBS)
 Direct access to fetal circulation
 Insertion of needle directly into a fetal umbilical vessel under ultrasound
guidance
 In many centers has been replaced by placental biopsy
 Can be performed after 18 weeks gestation
 Detects certain genetic disorders, blood conditions, and infections
 Can also be used to deliver blood transfusions or medication to a baby via the
umbilical cord.
Maternal assays
 Alpha-fetoprotein (AFP) – just a screening test
 Maternal serum levels screened for neural tube defects (NTDs)
 80% to 85% of open NTDs and abdominal wall defects can be detected
early
 Recommended for all pregnant women between 16- 18 weeks gestation
 High levels can indicate a neural tube defect or open abdominal defect
 Low levels can indicate Down Syndrome
Chapter 11 High- Risk Prenatal Care: Preexisting Conditions

Diabetes mellitus/ GDM
o Diabetes mellitus
 The most common endocrine disorder associated with pregnancy
 Pregnancy complicated by diabetes considered high risk
 Diabetes can be successfully managed with a multidisciplinary approach
 Key to an optimal outcome is strict maternal glucose control
 10% of pregnancies
 Insulin dependent
o Classification of diabetes
 type 1 diabetes
 type 2 diabetes
 Gestational diabetes mellitus (GDM) is any degree of glucose intolerance with onset
or recognition during pregnancy
o Diabetes mellitus
 Maternal risks and complications
 Macrosomia – big baby
 Hydramnios – fluid levels increased
 Ketoacidosis
 Hyperglycemia
 Hypoglycemia
o Fetal and neonatal risks and complications
 Perinatal mortality risk increased – r/o cord event
 Congenital malformations
 Respiratory distress syndrome (RDS) – affects lung development
 Prematurity
 IUFD (intrauterine fetal demise)
o Assessment and nursing diagnosis
 Interview
 Physical examination
 Assess acute and chronic complications of diabetes
 Laboratory tests
 Baseline renal function
 UA and culture
 Glycosylated hemoglobin A
 Patient needs much more frequent monitoring
o Review self-monitoring
 Ideal blood glucose levels in pregnancy
 60-105 mg/dL before meals or fasting
 Less than or equal to 120 mg/dL 2hours after meals
o Antepartum care
 Diet and exercise
 Insulin therapy
 Self-monitoring blood glucose levels
 Urine testing
 Complications requiring hospitalization
 Fetal surveillance
 Daily kick counts
o Intrapartum care
 Glucose monitoring hourly
 Insulin infusion
 Avoid dextrose solutions
 May require a cesarean birth
o After birth care
 Insulin requirements decrease substantially
 Encourage breastfeeding

GDM
o
Care management
Screening for gestational diabetes mellitus
 Early pregnancy screening
 Screening at 24 to 28 weeks
o Women at average risk
 50-g, 1-hour OGTT at 24‒28 weeks' gestation (step 1)
 Oral glucose given at any time of the day
 No requirement for fasting
 If glucose level less than 140 mg/dL, they pass screening test (no step 2 needed)
 If glucose level equal to or greater than 140 mg/dL, than step 2 required,
 3-hour glucose test
o High Risk Factors
 Nonwhite women
 Prior history of GDM
 Prior birth of large-for-gestational-age LGA infant
 Marked obesity
 Diagnosis of polycystic ovarian syndrome
 Hypertension
 Glycosuria
 Strong family history of type 2 DM
 Stillborn
 Gestational age over 25
Iron deficiency anemia
o Most common medical complication of pregnancy
o Hemoglobin (Hb) levels below 11 g/dL
o Iron intake recommended in pregnancy is 27 mg/day
o Prevention
o Supplemental iron or folic acid during pregnancy
o Take iron supplements with vit C source and not with calcium source
o Iron-rich diet (legumes, fruit, green leafy vegetables, meat)
o Easily tired
o More susceptible to infection
o Increased chance of preeclampsia-eclampsia and postpartum hemorrhage
o Cannot tolerate even minimal blood loss during birth
o Possible delayed healing of episiotomy or incision



Substance abuse
o The continued use of substances despite related problems in physical, social, or
interpersonal areas
o Dual diagnosis
 Substance abuse plus another psychiatric disorder
o Damaging effects on the fetus are well documented
o Barriers to treatment
 Women fear losing custody of child and criminal prosecution
 Less than 10% of pregnant women receive treatment
 Substance abuse treatment programs do not address issues affecting pregnant
women
 Long waiting lists and lack of health insurance present further barriers to treatment
o Legal considerations
 Some states consider in-utero exposure to be abuse or neglect
 Healthcare practitioners possibly required to report positive results
 Legal mandating may impact provider-patient relationship
o
Screening
First prenatal visit
Past and present use
Include prescription and herbal substances
Nonjudgmental approach
Toxicology testing
 Urine
 Meconium
 hair
Assessment
 Additional assessment related to conditions more likely in women with substance
abuse issues
 Infections
 HIV
 Hepatitis
 Syphilis
 Common STIs
 Ultrasounds
 Gestational age
Interventions
 Medical management
 Education
 Consequences of drug use
 Monitoring
 Treatment programs
 Nursing interventions
 Low threshold for pain requires additional approaches to management
 Decreased involvement with infant requires advice and education
 Considerations for breastfeeding related to infant exposure
Follow-up care
 Assess safety of home environment
 Social services involved
 Availability of friends/family support systems
 Home care visits
If infant’s well-being is questionable, case will be referred to child protective services
agency





o
o
o
o
Chapter 12 High- Risk Prenatal Care: Gestational Conditions

Spontaneous abortiono Classifications
 Threatened – unexplained bleeding, cramping, backache; cervix closed
 Inevitable – bleeding & cramping increase; cervical os dilates, may
SROM(spontaneous rupture of membranes)
 Complete – all products of conception are expelled
 Incomplete – some products of conception (usually placenta) are
retained
 Missed – fetus dies in utero but is not expelled
 Recurrent pregnancy loss – occurs consecutively in 3 or more
pregnancies
 Septic abortion – infection is present
o Risk Factors
 Chromosomal abnormalities
 Advanced maternal age
 Premature cervical dilation
 Chronic maternal diseases (ex. DM)
 Maternal malnutrition
 Trauma or injury
 Substance use
 Chronic Maternal infections
 Anomalies in the fetus or placenta

o Nursing Care
 Perform a pregnancy test
 Observe color and amount of bleeding
 Avoid vaginal exams
 Assist with Ultrasound
 Administer medications and blood products as prescribed
 Retain passed tissue for examination
 Provide client education and support
 Refer to pregnancy loss support groups
 Labs
o Hgb & Hct
o Clotting Factors
o WBC
o Serum hCG levels (body will adjust levels if baby is
viable or not)
Vaginal bleeding- nursing interventions
o Hemorrhagic disorders in pregnancy are medical emergencies
o Maternal blood loss decreases oxygen-carrying capacity
 Increased risk for hypovolemia, anemia, infection, preterm labor, and
preterm birth
 Adversely affects oxygen delivery to fetus
 Fetal risks include blood loss or anemia, hypoxemia, hypoxia, anoxia,
and preterm birth
o
Cervical Insufficency
 Risk Factors

o
o
OB history of preterm births, late miscarriages, cervical trauma, congenital
structural defects of the uterus or cervix
 Diagnosis
 Ultrasound showing a short cervix (<25mm)m presence of cervical
funneling or effacement of the cervix
 Management
 cerclage
 Follow-up care
 Close monitoring of pregnancy
 Report sign/symptoms of preterm labor
Ectopic Pregnancy
 Incidence and etiology
 Fertilized ovum implanted outside uterine cavity
 Tubal rupture and hemorrhage
 Leading cause of infertility
 95% occur in uterine (fallopian) tube
o Most located on ampulla
 Clinical manifestations
o Abdominal pain
o Delayed menses
o Abnormal vaginal bleeding (spotting)
 Diagnosis
o Quantitative hCG levels
o Transvaginal ultrasound
 Medical management
o Medical
 Methotrexate- dissolves the pregnancy by destroying
rapidly dividing cells
o Surgical
 Salpingectomy- removal of the fallopian tube (performed
when tube has ruptured)
 Salpigostomy- remove the products of conception and
conserve the tube
Hydatidiform Mole
 Proliferation of trophoblastic cells creates placenta characterized by
hydropic (fluid-filled) grapelike clusters
 Types
o Complete – no maternal genetic tissue is present
o Partial – usually has triploid number of chromosomes (69)
 Consequences
o Loss of pregnancy
o Remote possibility of developing choriocarcinoma
 Signs and Symptoms
o Vaginal bleeding
o Often brownish (like prune juice) but it may be bright red
o Uterine enlargement greater than expected for gestational age
o Passage of hydropic vesicles (grapelike clusters)
o Serum hCG levels are markedly elevated
o Hyperemesis gravidarum
o Anemia due to blood loss
o Symptoms of preeclampsia before 24 weeks' gestation
o Absent fetal heart tones
o Low levels of AFP

Diagnosis and Treatment
o
o
o
o
o
Ultrasound
 Primary diagnostic tool
Therapy
 Suction curettage is most often successful for evacuation of
the mole
 Rh immune globulin administered to Rh-negative women
 Hysterectomy may be treatment of choice to reduce risk of
choriocarcinoma when no further pregnancies are desired
Follow-up Care
 Serum hCG weekly until the level decreases to normal for
three weeks, then monthly for 6- 12 months to detect GTD
Placenta previa
 Placenta implanted in lower uterine segment near or over internal cervical os
 Classification based on degree the internal cervical os is covered by placenta
 Complete placenta previa
 Marginal placenta previa
 Low-lying placenta previa
 Incidence and etiology
 Clinical manifestations
 Maternal and fetal outcomes
 Abnormal placental attachment
 Excessive bleeding
 Fetal risks include malpresentation, preterm birth, fetal anemia, and
congenital anomalies
 Risk Factors
 Prior cesarean birth
 High gravidity
 High parity
 Advanced maternal age
 Women of African and Asian descent
 Previous miscarriage
 Previous induced abortion
 Cigarette smoking
 Male fetus
 Nursing Assessment/Managaement
 Maternal assessment for painless, bright-red vaginal bleeding
o Most accurate diagnostic sign of placenta previa
o If this sign develops during the last 3 months of pregnancy,
placenta previa should always be considered until ruled out by
ultrasound examination
 Bleeding usually begins as scant and becomes more profuse
 Uterus is usually soft, relaxed and non-tender
 Bed rest if active bleeding, BR privileges allowed if no active bleeding
 IV fluids
 I&O
 Labs (CBC, Blood type & Rh, coagulation profile)
 Consider unengaged fetal presenting part (obstruction)
 Transverse lie is common
 Assessment of fetal status
 FHR: continuous external fetal monitoring
 Anticipate need for blood transfusion
 Assess maternal vital signs
 Every 15 minutes if no hemorrhage
 Every 5 minutes with active hemorrhage
 External tocodynamometer (contraction monitor)
 NO vaginal exams
Premature separation of placenta (Abruptio placentae)
 Grades

o

Grade 1
o Mild separation
 Grade 2
o Moderate separation
 Grade 3
o Severe separation
 Expected findings
 Sudden onset of intense uterine pain
 Bleeding, usually dark red
 Hypovolemia
 Hypertonic contractions
 Fetal distress
 Risk Factors
 Previous placental abruption
 Increased maternal age
 Increased parity
 Cigarette smoking
 Cocaine abuse
 Trauma
 Maternal hypertension
 Multifetal gestation
 PPROM or PROM
Cord insertion and placental variations
 Vasa previa
 Velamentous insertion of the cord
 Cord vessels begin in the branch at the membranes and then course to the
placenta
 Succenturiate placenta
 The placenta is divided into two or more lobes and not one mass
Hyperemesis gravidarum
 Definition: Excessive vomiting accompanied by dehydration, electrolyte imbalance,
weight loss, nutritional deficiencies and ketonuria
 Increased risk for intrauterine growth restriction, small for gestational age, or
preterm birth if the condition persists
o Risk factors
 Age < 30 years
 Multifetal gestation
 Diabetes
 Gastrointestinal disorders
 Family history of hyperemesis
 Clinical hyperthyroid disorders
 Psychosocial issues/ high stress levels
o Findings
 Weight loss
 Dehydration
 Dry mucus membranes
 Poor skin turgor
 Increased pulse rate
 Decreased blood pressure
o Labs
 Urinalysis
 Chemistry profile
 Thyroid test
 Complete Blood count
o
Nursing Care
 Determine severity of the problem








Monitor I&O
Assess skin turgor, mucus membranes
Monitor VS
Monitor weight
Nothing by mouth (NPO)
IV fluid administration
Pyridoxine (vitamin B6) alone or in combination with and doxylamine as initial
treatment
Corticosteroids treat refractory hyperemesis gravidarum


Preeclampsia/ Eclampsia
o Preeclampsia
 Pregnancy-specific syndrome
 Hypertension develops after 20 weeks of gestation in previously normotensive
women
 A vasospastic systemic disorder categorized as mild or severe
 Etiology
 Signs and symptoms develop only during pregnancy and disappear after
birth
 Associated high risk factors
 Family history of preeclampsia
 Multifetal pregnancy
 African-American race
 Obesity
 Before 19 and after 40 years old
 First pregnancy
 Preexisting medical or genetic conditions (DM, RA, SLE, Chronic HTN,
Chronic renal disease)
 Pathophysiology
 Progresses along a continuum from mild to severe
 Caused by disruptions in placental perfusion and endothelial cell
dysfunction
 Hypertension and vasospasm
 Decreased renal perfusion and glomerular filtration rate (GFR decrease)
 Decreased output and retention of sodium
 Increased serum levels of creatinine, BUN, uric acid
 Hyperreflexia
 Decreased placental perfusion
 Increased viscosity of blood
 Proteinuria greater than or equal to 1+
 Mild
 Few if any symptoms
 Diagnostic criteria
o Blood pressure elevated to ≥140/90 mmHg or higher
o Proteinuria is 1+ to 2+ on dipstick, or 300 mg in a 24 hr specimen
 Edema no longer considered diagnostic criterion
 Generalized edema may be present
 Severe
 May develop suddenly
 Epigastric pain RUQ
 Diagnostic criteria
o Blood pressure ≥160/110 mmHg on two occasions at least 6 hours
apart during bed rest
o Dipstick urine protein measurement 3+ or greater on two random
samples at least 4 hours apart
o Oliguria with urine output ≤500 mL in 24 hours
o Eclampsia
Seizure activity or coma in woman diagnosed
with preeclampsia
 No history of preexisting pathology
 Eclamptic seizures can occur before, during, or after birth
 Severe preeclampsia plus seizure activity
 Characterized by grand mal convulsion or coma
 May occur before onset of labor, during labor, or early in postpartum period
 Women may have one or more seizures
 Severe headache and epigastric pain
Severe gestational hypertension and severe preeclampsia
 Greater risk for pregnancy complications
 Expectant management
 Perinatologist services
 Antihypertensives
 Corticosteroids
 Intrapartum care
 Magnesium sulfate
 Control of blood pressure
Nursing Care
 Nurses should assess:
 VS (BP, pulse, respirations and temperature)
 Pulse oximetry
 FHR
 Urine output
 Urine for protein & specific gravity
 Daily weight
 Pulmonary edema
 DTRs
 Headache, visual disturbance, epigastric pain
 Abdominal rigidity (placental separation)
 LOC
 Monitor I&O
 Laboratory blood tests
 Emotional response and level of understanding
Nursing Care
 Maintain a quiet, low-stimulus environment in hospital; private room; limit visitors
 Woman should be in left lateral recumbent position
 Limit phone calls, bright lights, sudden loud noises
 Pad side rails of the bed
 Monitor effectiveness of medications
 Provide care during seizures
 Eclampsia
 Immediate care
 Maintain patient airway and safety during seizure
 Stabilize mother after seizure
 Magnesium sulfate
 Fetal status
 Prevention
 Prenatal care for assessment and early interventions

o
o
o



HELLP syndrome
o Laboratory diagnostic variant of severe preeclampsia involves hepatic
dysfunction, characterized by:
 Hemolysis (H)
 Elevated liver enzymes (EL)
 Low platelets (LP)
o Nonspecific symptoms reported
 N/V, flu- like symptoms, epigastric pain
 Worsen at night and improve during day
 AST&ALT increase
 Platelets <1000
 Can lead to DIC
o Associated with increased risk for:
 Pulmonary edema
 Acute renal failure
 Liver hemorrhage or failure
 Disseminated intravascular coagulation (DIC)
 Placental abruption
 Acute respiratory distress syndrome
 Sepsis
 Stroke
 Fetal and maternal death
Placenta previa vs. abruption (abruptio placentae)