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OB2 SAS 1-23 merged WITH ANS
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 1
LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT
CLIENT (PRE-GESTATIONAL CONDITIONSCARDIOVASCULAR DISORDERS AND PREGNANCY)
Materials:
Book, SAS, pen and notebook
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:
1. Define types and effects of cardiovascular disorders to
pregnancy, including preexisting factors that contribute to its
development such as cardiovascular disease.
2. Integrate knowledge of cardiovascular disorders to nursing
process to achieve quality maternal and child health nursing
care.
Reference:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
Cardiovascular Disorders and Pregnancy
(Please refer to Chapter 20 Nursing Care of a Family Experiencing a Pregnancy Complication from a Preexisting or Newly
Acquired Illness page 489.)
Effects of Pregnancy on Heart Disease
Blood Volume & Cardiac output
-Blood Volume peaks at 24-28 weeks
-Cardiac output increases 50%
-Heart must contract harder& faster
-Postpartum-blood circulating in the uterus & placenta returns to maternal circulation
*Team approach to care during pregnancy (internist, OB and nurse)
*Most dangerous period is in weeks 28 to 32, just after the BV peaks, earlier in more severe cases
Most Commonly Cause Difficulty During
Pregnancy
1. Valve Damage due to Kawasaki Disease or
Rheumatic Fever
2. Congenital Anomalies such as ASD or
Uncorrected Coarctation of Aorta
3. Aortic Dilatation
4. Marfan Syndrome
Risk Factors
1. Rheumatic fever- 90% of all cases
2. Congenital heart defects
3. Arteriosclerosis
4. Myocardial Infarction: pregnancy is
generally contraindicated with previous MI
and who have severe left ventricular
damage & heart failure
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5. Pulmonary disease
6. Renal diseases
7. Heart surgery
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Classification of Heart Disease (table 20.1 on page 487)
Class
Description
I
Uncompromised. Ordinary physical activity causes no discomfort. No symptoms of cardiac insufficiency and no
anginal pain.
II
Slightly compromised. Ordinary physical activity causes excessive fatigue, palpitation, and dyspnea or anginal
pain.
III
Markedly compromised. During less than ordinary activity, woman experiences excessive fatigue, palpitations,
dyspnea, or anginal pain.
IV
Severely compromised. Woman is unable to carry out any physical activity without experiencing discomfort.
Even at rest, symptoms of cardiac insufficiency or anginal pain are present.
From Criteria Committee of the New York Heart Association. (1994). Nomenclature and criteria for diagnosis of diseases
of the heart and great vessels (9th ed.). Boston, MA: Little, Brown & Co.
Prognosis & Management
1.
Woman with Artificial valve Prosthesis
a.
Pregnant women in the past was not advised to get pregnant to the increase blood volume and increase
work load of the heart.
b.
TO watch out for SUBCLINICAL BLEEDING/HEMOLYSIS
Observe the ff:
a. PETECHIAE
b. PREMATURE SEPARATION OF PLACENTA
2.
Women with Chronic Hypertensive Vascular Disorder
Women with chronic hypertensive vascular disease before pregnancy is usually associated with atherosclerosis or
renal disease and usually puts the mother and the fetus at risk.
3.
Women with Venous Thromboembolic Disease (DVT)
Increases with a combination of the ff:
1. Stasis of blood in the lower extremities from uterine pressure
2. Hypercoagulability (effect of elevated estrogen levels)
3. Vessel damage
AT RISK of DEVELOPING Deep Vein Thrombosis (DVT)
a.
Spontaneous Miscarriage
b.
Fetal death
c.
Hypertension of Pregnancy
d.
Antiphospholipid antibodies(aPLA)/Antiphospholipid Syndrome
PULMONARY EMBOLI
S/sx
Chest pain
Sudden onset of dyspnea
Hemoptysis
Tachycardia/Missed Beats
Dizziness
Fainting
Complications
Congestive heart failure (LSCHF)
Maternal dysrhythmias
Spontaneous abortion
Premature labor
Intrauterine growth retardation
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Assessment
Signs of Cardiac
Other Signs
Decompensation
ECG
moist cough
Syncope w/ exertion
Echocardiography
Pedal edema: signs of pulmonary
Cyanosis
Echocardiogram
edema
Clubbing of fingers
(ultrasound of the
Dyspnea, increasing with activity
Neck vein distention
heart)
Tachycardia
Cardiomegaly
Tachypnea
Pulmonary hypertension
Chest pains on exertion
Cyanosis
Persistent heart murmurs
*Safety alert: presence of severe dyspnea, syncope with exertion, hemoptysis, nocturnal tachycardia and angina
require prompt evaluation
Diagnostic Test
Criteria for establishing
diagnosis of Heart Disease
Persistent murmurs
Permanent cardiomegaly
Severe dysrhythmias
Severe dyspnea
*A pregnant woman w/ heart disease should avoid infection, excessive weight gain, edema and anemia because these
conditions increase the workload of the heart
Treatment/Management: Individualized
Frequent prenatal visits
7.
Iron supplement- prevent/treat anemia
Rest, physical and mental:
8.
Oxygen as necessary
a. Sleep at least 8-10 hours at night & 2 rest periods 9.
Anticoagulant-Heparin/Enoxaparin to prevent clot
during the day
formation with DVT and Pulmonary Emboli as
b. Instruct client to lie down for 30 mins after meals
complication
c. Allow only light work, no stair climbing, no
10.
Nitroglycerin- relieves angina by vasodilation
exhaustion
a. take: 5 min before effort
d. Activity limitation especially for Class 3 & 4
b. how often: q 5 mins up to 3 tabs, if the chest pain
3.
Severely affected clients may need to be admitted
is not relieved after 15 mins, go to ER
as early as mid-2nd trimester
c. take tablet while sitting down
4.
Digitalis. Withhold if PR <60bpm or >100bpm
d. storage: covered, replace every 3 months
5.
Diuretics. If Potassium-excreting (e.g. Furosemide Side Effects: hypotension, Headache, flushing, burning &
(Lasix))
stinging sensation under the tongue
SIDE EFFECTS: hypokalemia increases the risk for
types: tablet, patch, cream, sublingual
digitalis toxicity; report signs like bradycardia, N/V,
11.
Corticosteroid- help to reduce the formation of
diarrhea, colored vision deficiency (xanthopsia)
additional antibodies in aPLA
6.
Antibiotics-before any invasive procedure;
prophylaxis vs. Rheumatic Fever; treatment of bacterial
infection
1.
2.
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. A 26-year-old pregnant client has a history of Heart Disease and she told the doctor that ordinary physical
activity causes no discomfort and has no symptoms of cardiac insufficiency and no anginal pain . Which of the
following class of heart disease does the client has?
A. Compromised
B. Slightly compromised
C. Markedly compromised
D. Severely compromised
E. Uncompromised
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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2. A 28-year-old pregnant client has Uncorrected Coarctation of Aorta and she told the doctor that when she do
ordinary physical activity it causes excessive fatigue, palpitation, and dyspnea or anginal pain. Which of t he
following class of heart disease does the client has?
A. Compromised
B. Slightly compromised
C. Markedly compromised
D. Severely compromised
E. Uncompromised
ANSWER: ________
RATIO:________________________________________________________________________ ___________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. A pregnant patient was diagnosed when she was a child with Atrial Septal Defect and now pregnant, she went
to the hospital due to extreme fatigue, dyspneic and palpitations every time she takes the stairs or walk a couple
of meters. According to the Classification of Heart Disease which class does the patient belongs to?
A. Class 1
B. Class 2
C. Class 3
D. Class 4
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. A pregnant client is experiencing chest pain and was diagnosed with Chronic Hypertensive Vascular Disorder;
her doctor ordered a medication called Nitroglycerin. The following are correct statement regarding Nitroglycerin,
EXCEPT:
A. Nitroglycerin works by relaxing the smooth muscle and blood vessels in the body.
B. A vasodilator drug used for the treatment of chest pain and high blood pressure.
C. Nitroglycerin sublingual tablets should not be chewed, crushed, or swallowed.
D. It is taken within 5 mins up to 3 tablets and if the chest pain is not relieved after 15 minutes the patient will take a r est.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5. A 28 weeks pregnant woman came to the Outpatient Department for her prenatal check -up and was requested
to do Ultrasound of her heart. Which of the following diagnostic test is called Ultrasound of the Heart?
A. Electrocardiogram
B. Electrocardiography
C. Echocardiogram
D. Electroencephalogram
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. A pregnant client ask you what are the common causes of heart disorder in pregnancy. The following are most
common cause of cardiovascular disorder during pregnancy, EXCEPT:
A. Atrial Septal Defect
B. Uncorrected Coarctation of Aorta
C. Marfan Syndrome
D. Pulmonary Embolism
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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7. A 29 weeks pregnant came to the emergency room department due to severe dyspnea, hemoptysis, nocturnal
tachycardia and angina. What makes the client prompt actions means?
A. requires no intervention.
B. requires referral to her doctor.
C. requires immediate intervention.
D. requires rest and oxygen therapy
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. Althea, an 18 weeks pregnant client with an Aortic Dilatation was advised to decrease the workload of the
heart. The following conditions increases the workload of the heart.
A. Infection
B. Eupnea
C. Weight Loss
D. Vasodilation
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
9. A pregnant client is taking Furosemide for the treatment of her edema and she asked you what are the side
effects of Potassium-wasting diuretics. The following are side effects of potassium-wasting diuretics, EXCEPT:
A. Hyperkalemia
B. Hypokalemia
C. Bradycardia
D. Xanthopsia
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
10. A 28-year-old pregnant client has Marfan Syndrome and she told the doctor that during less than ordinary
activity, woman experiences excessive fatigue, palpitations, dyspnea, or anginal pain. Which of the following
class of heart disease does the client has?
A. Compromised
B. Slightly compromised
C. Markedly compromised
D. Severely compromised
E. Uncompromised
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among
yourselves. Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________ ________________
_____________________________________________________________________
3. ANSWER: ________
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RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
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PERIOD 1
8
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PERIOD 2
24
PERIOD 3
39
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AL STRATEGY: CAT: Student Response Cards
1. The instructor will give you response card and will explain the choices that was included with the card.
2. The Instructor will give a question to the class regarding information just covered in your lesson.
3. Hold up your card with the corresponding answer to the instructor’s question.
(For next session, review Chapter 20: Nursing Care of a Family Experiencing a Pregnancy Complication from a
Preexisting or Newly Acquired Illness-Endocrine Disorders and Pregnancy, p.511)
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 2
Materials:
LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT
CLIENT (PRE-GESTATIONAL CONDITIONS- MANAGEMENT
OF DIABETES MELLITUS)
Book, SAS, pen and notebook
LEARNING OUTCOMES:
Reference:
At the end of the lesson, the student nurse can:
1. Define diabetes mellitus in relation to pregnancy, including
pre-existing factors that contribute to its development.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate knowledge of diabetes mellitus in relation to
pregnancy and nursing process to achieve quality maternal and
child health nursing care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
(Please refer to Chapter 20: Nursing Care of a Family Experiencing a Pregnancy Complication from a Preexisting or
Newly Acquired Illness-Endocrine Disorders and Pregnancy, p.511)
DIABETES MELLITUS
Description:
-An endocrine disorder in which the pancreas cannot
produce adequate insulin to regulate body glucose levels
-Disorder in CHO, CHON and fat metabolism
Risk factors of DM
1. Family history
2. Rapid hormonal changes in pregnancy
3. Tumor/infection of the pancreas
4. Obesity
5. Stress
*Pregnancy is a diabetogenic state due to the profound
effect of hormones (HPL), which increases insulinresistance
Normal Metabolic changes in Pregnancy that Affect DM
1.
2.
3.
4.
5.
6.
Increase insulin antagonistic hormones: cortisol, estrogen, progesterone and human placental lactogen
Lowered renal threshold for sugar, increased Glomerular Filtration Rate is link to GLYCOSURIA
Excess glucose crosses placenta is link to LGA
Vomiting decreases CHO intake link to metabolic acidosis
Labor activity requires increased CHO intake
Hypoglycemia postpartum due to involution & lactation
Gestational Diabetes Mellitus (GDM)
-This is DM that develops during pregnancy and spontaneously resolves after delivery.
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MATERNAL COMPLICATIONS OF GDM
1. Predisposes to PIH, UTI,
2. Infections: candidiasis, UTI
3. Uteroplacental insufficiency
4. Dystocia due to large infant----CS delivery
5. Preterm Labor and Cephalopelvic Disproportion
6. Postpartum hemorrhage due to uterine atony
7. More difficult to control DM-hypo/hyperglycemia
8. Maternal mortality
9. Diabetic retinopathy
10. Diabetic nephropathy
FETAL COMPLICATIONS:
1. Macrosomia---birth injuries
2. Intrauterine Growth Restriction due to placental
insufficiency
3. Fetal hypoxia, IUFD, stillbirths
4. 1st trimester: spontaneous abortion or fetal
anomalies
5. Hydramnios
6. Prematurity
7. Neonatal hypoglycemia as soon as 1 hr
postpartum
8. Respiratory Distress Syndrome
9. Hyperbilirubinemia
10. Hypocalcemia
11. Birth defects: heart, brain & spine, kidney, GIT
Assessment Findings
1.
2.
3.
4.
5.
6.
7.
Family hx of DM, previous GDM
Previous LGA (4k or more)
Previous infant with congenital defects, hydramnios
Spontaneous abortion, fetal deaths, stillbirth
Obesity
Frequent candidiasis
Marked abdominal enlargement (hydramnios & LGA)
Signs of Hypoglycemia:
1. Sweating with cold, clammy skin
2. Pallor
3. Tremors, shakiness
4. Hunger & nausea
5. Irritability or impatience, anger
6. Confusion, indicating delirium
7. Tachycardia
8. Nervousness, anxiety
9. Sleepiness
10. Blurred vision
11. Seizures
12. unconsciousness
Diagnosis
1.
SCREENING TEST
At 26-28 wks for high-risk women
50g oral glucose challenge (if >140 mg/dl, needs 3-hr GTT)
2.
GLUCOSE TOLERANCE TEST(GTT)
100 g GTT bw wk 28-34
Glucose levels at 1,2 & 3 hrs
*Results: Gestational Diabetes Mellitus if FBS>95 or 2 results
are high
*Normal: FBS(95 mg/dl)
1h (180 mg/dl)
2h (155 mg/dl)
3h (140 mg/dl)
Nursing Implementation
1.
Participate in early detection.
2.
Encourage early prenatal mgt. & supervision
-Regular prenatal check-up
-Record dietary intake & monitor glucose levels
-Insulin when FBS is not consistent at < 105 mg/dL or
2-hr PPBS is not <120mg/dL
-Serial UTZ- from 28-34 wks if DM poorly-controlled or
with complications
SIGNS & SYMPTOMS of Hyperglycemia(N=80120mg/dL)
1. Glycosuria-blood glucose>150mg/dL
2. Polyuria
3. Polydipsia
4. Polyphagia
5. Weight loss: CHON & Fat stores are used for
energy
6. ketoacidosis
Treatment of Hypoglycemia
Consume 15-20 g glucose or simple CHO
Glucose tabs, 2 tbsp raisins, 4 oz(1/2 c juice or soda),
8 oz nonfat milk, 1 Tbsp sugar, honey or corn syrup,
hard candies, jellybeans or gumdrops
Recheck blood glucose after 15 mins.
*emergency drug: GLUCAGON IM into buttock, arm
or thigh to stimulate liver to release stored glucose
into the bloodstream
DO NOT:
Inject insulin
provide food or fluid if unconscious
put hands in mouth
Management
1. Maintain normal FBS, Hba1c(N=6%)
– Glycosylated hemoglobin measures
the amount of glucose attached to
the RBC & reflects average
measurement of the glucose levels
over the past 4-6 wks
– Good test to assess effectiveness of
treatment
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-Hospitalization- if DM is poorly-controlled, with HPN
and infection.
3.
Provide teaching:
-Nature, effects of DM
-Signs & symptoms of hypo/hyperglycemia
-Exercise to regulate glucose levels
-Insulin regulation/self-administration
-Prompt reporting of danger signs and signs of
infection
4.
Promote control of DM
5.
Diet: 1800 to 2,200 cal/day or 35 kcal/kg BW
12%-20& CHON, 40%-45% CHO, 40% from
Polyunsaturated Fats
Use Diabetic food exchange list
Weight gain not > 24 lbs.
6.
Exercise: decreases need for insulin but may cause
hypoglycemia if excessive
-No exercise when glucose levels are low or stomach
is empty
-Don’t administer insulin in extremity used in exercise
-Don’t exercise alone
-always carry diabetic ID
7.Insulin Therapy
-No OHA
-Insulin requirements drops during 1st trimester,
increased in 2nd & 3rd tri(tripled); increased chance of
ketoacidosis
-Regular & NPH(Isophane) insulin; only regular insulin
-IV during labor to prevent ketoacidosis
Humulin (DOC)- least allergenic
Split-dose therapy: regular & intermediate combi; 2/3 daily
dose before breakfast at 2:1 ratio (intermediate to regular);1/3
30 mins before dinner (1:1)
8.Prevention of infection, stress, which leads to hyperglycemia,
which increases the need for insulin
Encourage assessment of fetal well-being: ultrasound,
amniocentesis(L/S ratio), phosphatidyl glycerol( fetal lung
maturity), NST, CST, BPP
Early labor induction or CS in the presence of fetal
distress( 36-37 weeks)
Care During Labor and Delivery
Plan to deliver birth weight 36-40 wks when fetus is mature
enough but not too large to cause CPD
• L/S ratio should be 2.5-3.5:1
• Vaginal delivery is preferred
• Regular insulin on labor day because need for insulin
drops immediately pp and may not need insulin in the
1st 24 hrs pp. Monitor glucose levels.
– Abnormal: >7% of total hemoglobin
2. Clinic visit every 2 wks up to 36 wks
3. Exercise lowers glucose levels
– Ingest protein or complex
Carbohydrates prior to exercise
4. Diet:
– 1800 to 2,200 cal/day or 35 kcal/kg
BW
– 12%-20& CHON, 40%-45% CHO,
40% from PUFAs
– Use Diabetic food exchange list
– Weight gain not > 24 lbs.
5. Instruct on signs of hypoglycemia (dt
excessive insulin, exercise or insufficient
dietary intake):
– Pallor
– Weakness, numbness
– Headache
– Confusion or irritability
– Blurred vision
– Perspiration
– Hunger
– Convulsions, coma
“cold and clammy, need some candy”
Mgt: Give CHO foods like fruit juice, cola, sugar,
candy
6. Self-monitoring of Blood glucose at least TID
– Desired values:
– before meal: 95 mg/d
– 1 hr after meal: <140 mg/d
–
2 hrs after meal <120 mg/dl
7. Fetal Well-being Monitor
– Alphafetoprotein level at 15-17 wks
– Ultrasound at 18-20 weeks and
monthly to rule out deformities,
hydramnios,
– NST starting at 34 wks (if abnormal,
CST, BPP)
– Daily kick counts from wk
28(N=10/hr); report if less
– L/S Ratio starting 34-36 weeks
(N=2.5-3:1)
– Creatinine clearance to monitor
perfusion
Newborn Care
1. Keep warm.
2. Observe respiration since hydramnios inflates
stomach and may interfere with lung
expansion
3. Observe for hypoglycemia (shrill cry, tetany,
tremors), BF or give glucose water
4. Observe for hypocalcemia (tetany, tremors),
give Calcium gluconate
5. Observe for congenital anomalies:
esophageal atresia, NTD
Contraception
1. No IUD- high incidence of PID
2. No COCs- P interferes with insulin and Estrogen raises lipid, cholesterol levels & affect blood coagulation
3. Norplant or progestin only pills(minipills) may be used safely by diabetic women
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CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. A 36-year-old female is currently 18 weeks pregnant. You’re collecting the patient’s health history. She has the
following health history: gravida 5, para 4, BMI 28, hypertension, depression, and family history of Type 2
diabetes. Select below all the risk factors in this scenario that increases this patient’s risk for developing
gestational diabetes?
1. 34-years-old
2. 16 weeks pregnant
3. Gravida 5, para 4
4. BMI 28
5. Hypertension
6. Depression
7. Family history of Type 2 diabetes
A. 1,2,3 and 4
B. 1,3,4 and 5
C. 1,2,3 and 6
D. 1,3,4 and 6
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. A pregnant client is currently diagnosed with Gestational Diabetes at 30 weeks ask you when do most pregnant
women develop gestational diabetes?
A. usually during the 1-3 month of pregnancy
B. usually during the 2-3 month of pregnancy
C. usually during the 1-2 trimester of pregnancy
D. usually during the 2-3 trimester of pregnancy
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. You are having your duty in the out-patient department and you are providing an educational class for
pregnant women about gestational diabetes. You discuss the role of insulin in the body. Select all the CORRECT
statements about the role and function of insulin:
A. “Insulin is a type of cell that provides glucose to the body from the blood.”
B. “Insulin is a hormone secreted by the beta cells of the pancreas.”
C. “Insulin does influences cells by causing them to uptake glucose from the blood.”
D. “Insulin is a protein that helps carry glucose into the cell for energy.”
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. Michelle, a 32-year-old female is diagnosed with gestational diabetes. As the nurse you know that what test
below is used to diagnose a patient with this condition?
A. 1 hour glucose tolerance test
B. 24 hour urine collection
C. Hemoglobin A1C
D. 3 hour glucose tolerance test
ANSWER: ________
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RATIO:___________________________________________________________________________________________
_________________________________________________________________________ ________________________
_________________________________________________________________________________________________
5. Erina, a 25-year-old pregnant female is diagnosed with gestational diabetes at 28 weeks gestation. You ’re
educating Tara Jing about her condition. Which statement by the patient demonstrates they understood your
teaching about gestational diabetes?
A. “Once I deliver the baby, it will go away, and I will not need any further testing.”
B. “It is important I try to get my fasting blood glucose around 70-95 mg/dL and <140 mg/dL 1 hour after meals.”
C. “There are no risks or complications related to gestational diabetes other than hyperglycemia.”
D. “I’m at risk for delivering a baby that is too small for its gestational age due to this condition.”
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. The following are true regarding contraception in Diabetes Mellitus, EXCEPT:
A. Diabetic Women can use Intrauterine Device
B. Clients can use COC type of oral contraceptives
C. Norplant or progestin only pills(minipills) may be used safely by diabetic women
D. Diabetic Women cannot use Intrauterine Device
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7. Glaiza, a 36 weeks pregnant woman and has gestational diabetes. As a part of her prenatal check-up, her
doctor requested to check her blood glucose level. Which of the following lab results is below normal?
A. Blood glucose 55 mg/dL
B. Blood glucose 82 mg/dL
C. Blood glucose 148 mg/dL
D. Blood glucose 325 mg/Dl
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. A client with gestational diabetes and is currently 34 weeks pregnant came to the hospital for her prenatal
check-up. Which assessment findings below should you immediately report to the physician?
129 mg/dL
B. Blood pressure 190/102
C. Proteinuria
D. Linea nigra
ANSWER: ________
RATIO:___________________________________________________________________________________________
_____________________________________________________________________________________________ ____
_________________________________________________________________________________________________
9. Kris a 35 weeks pregnant woman has gestational diabetes and uncontrolled hyperglycemia. Her current blood
glucose is 290 mg/dL. You administer insulin per physician’s order and recheck the blood glucose level per
protocol. It is now 135 mg/dL. Which statement by the patient requires you to notify the physician?
A. “It burns when I urinate.”
B. “My back is hurting.”
C. “I feel tired.”
D. “I feel the baby kick about 10 times an hour.”
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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10. Jenny, a mother with gestational diabetes gave birth to a baby at 37 weeks gestation. As the nurse you know
at birth that the newborn is at risk for? SELECT ALL THAT APPLY
A. Hyperglycemia
B. Hypoglycemia
C. Respiratory distress
D. Jaundice
E. Hyperthermia
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
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LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
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AL STRATEGY: CAT: Student Response Cards
1. Towards the end of the class, you will be asked by your instructor to use index cards or half-sheets of paper to
provide written feedback to the following questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?
2. Your instructor will collect the responses as or pass it before you leave the classroom.
(For next session, review Chapter 22: Nursing Care of Pregnant Family with Special Needs, page 584)
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 3
Materials:
Book, pen, SAS and notebook
LESSON TITLE: CARE OF THE HIGH-RISK
PREGNANT CLIENT (PRE-GESTATIONAL
CONDITIONS-SUBSTANCE ABUSE)
LEARNING OUTCOMES:
Reference:
At the end of the lesson, the student nurse can:
1. Define types and effects of substance abuse to pregnancy,
including preexisting factors that contribute to its development
such as cardiovascular disease.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate knowledge of substance abuse to nursing process
to achieve quality maternal and child health nursing care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
A Woman who is Substance Dependent
(Chapter 22: Nursing Care of Pregnant Family with Special Needs, page 584)
Substance Abuse- inability to meet major role obligations, increase in legal problems or risk-taking behavior, or exposure
to hazardous situations due to an addicting substance.
Substance dependent- if she has withdrawal symptoms after discontinuation of the substance
These substances are usually of low molecular weight & can readily cross the placenta; the fetus has 50% drug
concentration as that of the mother
Common substances abused:
1. cocaine
2. amphetamines
3. marijuana
4. alcohol
5. inhalants
6. opiates
7. phencyclidine
1. Cocaine-most frequently abused drug during
pregnancy,
causes extreme vasoconstriction severely compromising
fetal circulation leading to premature separation of the
placenta resulting to preterm labor or fetal death.
Fetal withdrawal symptoms of COCAINE:
tremulousness,
Cocaine Use
Amphetamines-methamphetamines (speed)
has effects similar to cocaine
Newborn symptoms:
jitteriness,
poor feeding,
growth restriction
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irritability,
muscle rigidity,
learning defects (later on in life),
intracranial hemorrhage
Detected by urinalysis
2. Marijuana or hashish- when smoked causes tachycardia & a sense of well-being.
- Used to counteract nausea in early pregnancy
Effects:
1. loss of short-term memory,
2. reduced milk production
3. incidence or respiratory infection
4. excretion of drug in breast milk
3. Phencyclidine (PCP)-animal tranquilizer frequently used as a street drug
-increases cardiac output & gives a sense of euphoria
-causes hallucinations (flashback episodes)
-tends to leave the maternal circulation & concentrate in fetal cells
4. Narcotic Agonists-used for pain (morphine or
Withdrawal symptoms
meperidine), cough suppression (codeine); is a potent
Nausea and Vomiting
analgesic and provides euphoric effect.
Diarrhea
HEROIN- main opiate used recreationally & is used ID
abdominal pain
(skin-popping), by snorting or IV (shooting)
Hypertension
- Produces immediate but short-lived euphoria followed
Restlessness
Shivering
by sedation
Insomnia
body aches
muscle jerks
Fetal effects:
Small for Gestational Age
increased incidence of fetal distress
meconium aspiration
Management: methadone maintenance program
during pregnancy
5. Inhalants- airplane glue, cooking sprays, computer keyboard cleaner
Refer to sniffing or huffing of aerosol drugs
May lead to severe cardiac and respiratory irregularities
May limit fetal O2 supply
6. Alcohol-causes cognitive challenges and memory deficits
Fetal alcohol Syndrome-is a condition in a child that results from alcohol exposure during the mother's pregnancy.
Fetal alcohol syndrome causes brain damage and growth problems.
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. A newborn has a condition that results from alcohol exposure during the mother's pregnancy that causes
brain damage and growth problems. Which of the following condition does the newborn has?
A. Substance Abuse
B. Fetal Alcohol Syndrome
C. Drug Abuse
D. HIV/AIDS
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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2. An 18-week pregnant client was caught sniffing cooking spray at the Female comfort room You know using
this type of drug may lead to severe cardiac and respiratory irregularities and may limit fetal oxygen supply.
Which of the following does the pregnant client is using?
A. Heroin
B. Marijuana
C. Phencyclidine
D. Inhalants
ANSWER: ________
RATIO:_______________________________________________________________________________________ ____
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. A 24-week pregnant client is using a drug recreationally she use it by “snorting”. What drug does the client is
using?
A. Heroin
B. Marijuana
C. Phencyclidine
D. Inhalants
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. A 12-week pregnant client is smoking a “weed”. You know that this type of substance that when smoked
causes tachycardia & a sense of well-being and is used to counteract nausea in early pregnancy.
A. Heroin
B. Marijuana
C. Phencyclidine
D. Inhalants
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5. A 27-week pregnant client is using an “animal tranquilizer”. You know as a nurse that frequent use or a street
drug that increases cardiac output, gives a sense of euphoria and causes hallucinations. Which of the following
drug is the pregnant woman is using?
A. Heroin
B. Marijuana
C. Phencyclidine
D. Inhalants
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. A 37-week pregnant woman gave birth to a newborn and is experiencing Heroin withdrawal symptoms. The
following are Heroin Withdrawal Symptoms, EXCEPT:
A. Intracranial hemorrhage
B. Restlessness
C. Shivering
D. Insomnia
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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7. A pregnant woman is using cocaine. You know as a nurse that once she will give birth, her child will
experience Cocaine Withdrawal Symptoms. The following are Withdrawal symptoms for Cocaine, EXCEPT:
A. tremulousness
B. irritability
C. muscle rigidity
D. restlessness
E. intracranial hemorrhage
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. You interviewed a pregnant client using a Marijuana to manage her nausea. You know the effect of Marijuana
use in pregnant women and with the fetus. EXCEPT:
A. loss of short-term memory
B. reduced milk production
C. intracranial hemorrhage
D. incidence or respiratory infection
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
9. A pregnant woman asked you what are the effects of Narcotic use with the fetus. You answered the following,
EXCEPT:
A. Small for Gestational Age
B. Increased incidence of fetal distress
C. Meconium aspiration
D. Restlessness
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________ _______
10. A pregnant client asked you what are the effects of Phencyclidine (PCP). You answered the following,
EXCEPT:
A. increases cardiac output
B. gives a sense of euphoria
C. loss of short-term memory
D. causes hallucinations
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
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RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
______________________________________________________________________________ _______________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
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PERIOD 3
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AL STRATEGY: CAT: Student Response Cards
1. The instructor will give you response card and will explain the choices that was included with the card.
2. The Instructor will give a question to the class regarding information just covered in your lesson.
3. Hold up your card with the corresponding answer to the instructor’s question.
(For next session, review Chapter 21: Nursing Care of A Family Experiencing a Sudden Pregnancy ComplicationIsoimmunization, p.558.Chapter 26: Nursing Care of Family with a High Risk Newborn-Illnesses that Occur in
Newborns. P. 704)
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 4
LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT
CLIENT (PRE-GESTATIONAL CONDITIONS- RH
SENSITIZATION AND HIV/AIDS)
Materials:
Book, pen, SAS and notebook
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:
1. Define Rh sensitization in relation to pregnancy,
including pre-existing factors that contribute to its
development.
2. Integrate knowledge of Rh Sensitization in relation to
pregnancy and nursing process to achieve quality
maternal and child health nursing care.
3. Identify the difference HIV/AIDS and its effect to
pregnancy, including preexisting factors that contribute
to its development.
4. Integrate knowledge of HIV/AIDS to nursing process to
achieve quality maternal and child health nursing care.
Reference:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
(Chapter 21: Nursing Care of A Family Experiencing a Sudden Pregnancy Complication-Isoimmunization, p.558.Chapter
26: Nursing Care of Family with a High Risk Newborn-Illnesses that Occur in Newborns. P. 704)
HEMOLYTIC DISEASE OF THE NEWBORN
- is caused by either Rh or ABO incompatibility
*Mother produces antibodies that destroy RBCs of the fetus; hemolysis results in fetal anemia and hyperbilirubinemia



occurs when fetal red blood cells (RBCs) which possess an antigen that the mother lacks
cross the placenta into the maternal circulation, where they stimulate antibody production.
The antibodies return to the fetal circulation and result in RBC destruction.
DIFFERENTIAL DIAGNOSIS of hemolytic anemia in a newborn infant:
 Isoimmunization
 RBC enzyme disorders (e.g., G6PD, pyruvate kinase deficiency)
 Hemoglobin synthesis disorders (e.g., alpha-thalassemias)
 RBC membrane abnormalities (e.g., hereditary spherocytosis, elliptocytosis)
 Hemangiomas (Kasabach Merritt syndrome)
 Acquired conditions, such as sepsis, infections with TORCH or Parvovirus B19 (anemia due to RBC aplasia)
and hemolysis secondary to drugs.
ISOIMMUNIZATION
1. ABO Incompatibility
2. RH INCOMPATIBILITY
Occurs when maternal blood type is O and fetus is
Rh (D) factor is a protein antigen present on the
a. Type A- most common
surface of some people’s RBC (Rh+)
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b. Type B- most serious
c. Type AB- rare
1. The mother has inborn antibodies vs blood type A and B
in her bloodstream. If fetus has type A or B blood and if
maternal and fetal blood mix, maternal antibodies will
perceive the fetal RBC as an antigen and will destroy it
2. Uncommon during pregnancy since antibodies is the
large IgM type & cannot cross placental barrier
3. During delivery when placenta separates from the
decidua, the barrier is broken allowing maternal blood to
enter the fetal bloodstream.
4. Maternal antibodies will then destroy fetal RBCs after
birth
5. Thus, signs of hemolytic disease will manifest several
hours after delivery
CLINICAL PRESENTATION
 generally less severe than with Rh disease.
LABORATORY FINDINGS
 Smear: microspherocytosis
 Mean Corpuscular Volume (MCV) <95, microcytic
for a newborn (normal for adult)
 Direct Coombs test is often weakly +.
MANAGEMENT
A. Preparation prior to delivery should include:
 Blood: type O Rh negative packed RBCs, crossmatched against the mother.
 For severe HDN, have blood in the Resuscitation
Room to correct severe anemia immediately after
birth by partial exchange transfusion (ExTx).
 Anticipate
need
for
later
ExTx
for
hyperbilirubinemia and have additional blood for
these.
 Surfactant, if infant is preterm.
 Catheters (e.g., angiocaths) for immediate
drainage of hydropic fluid.
B. Resuscitation
 Obtain cord blood for bilirubin (total & direct),
albumin, blood type & Rh, Direct Coombs test,
CBC, platelets, reticulocyte count and nucleated
RBCs.
 assisted ventilation with oxygen. If ventilation is
difficult, drain pleural and ascitic fluid; during
paracentesis, take care to avoid puncturing the
enlarged liver and spleen.
 Insert umbilical arterial (UAC) and venous
catheters (UVC) and immediately measure blood
pressures, arterial pH and blood gas tensions,
hematocrit (Hct) and blood sugar.
 Correct metabolic acidosis with alkali, but only if
giving assisted ventilation
 Correct anemia, which is essential for effective
1. Antibodies vs Rh antigen are not naturally-occurring but
are produced when Rh+ blood enters the bloodstream of
an Rh- person.
2. The Rh + gene is a dominant and therefore if either the
mother or the father or both parents are Rh+, the baby will
be Rh+
Rh Sensitization/Rh Isoimmunization- It is the exposure
of Rh- blood to Rh+ blood resulting to production anti-Rh
abs
It can occur through:
 Sensitization from previous pregnancy (Rh- mom
with Rh+ baby)
 Inadequate response to prophylaxis
 Incompatible blood transfusion
-Insignificant amount of antibodies are formed
during pregnancy thus, 1 st baby is not greatly affected.
-Greatest exposure occurs during placental
separation which causes massive production of anti Rh
abs during 1st 72 hrs postpartum
-Rh+ fetuses in future pregnancies will be affected
-Fetal anemia results & to compensate, fetal bone
marrow produces immature RBCs(erythroblasts) causing
Erythroblastosis Fetalis
ERYTHROBLASTOSIS FETALIS
-Fetal anemia may be so profound that it kills the
fetus
-RBC destruction causes massive production &
accumulation of bilirubin as the immature liver is unable to
clear them from the body leading to
HYPERBILIRUBINEMIA & KERNICTERUS
Fetal Complications of Erythroblastosis Fetalis
1. Anemia
2. Splenomegaly & hepatomegaly
3. Hyperbilirubinemia
4. Hydrops fetalis- as organs are not perfused
properly, the heart will eventually decompensate; fluid
builds up resulting to edema
5. Stillbirth
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
resuscitation.
Do not infuse packed RBCs or blood through UAC
because of risk of damage to spinal cord from
emboli.
Complications of Exchange Transfusion (ExTx):
 Hypocalcemia due to Ca++ binding by citrate.
Give Ca-gluconate 100 mg after every 100 mL of blood
exchanged.
 Hypoglycemia particularly after the ExTx, due to
dextrose load from anticoagulant of donor blood
and hyperinsulinism in HDN.
Thrombocytopenia and granulocytopenia due to washout
with the ExTx.
 Hyperkalemia, especially with older units of
blood.
 Hypothermia, associated with inadequate
warming of blood.
Prevention
1. Prenatal Screening
History: past pregnancies, BT, abortion, invasive diagnostic procedures during pregnancy
Blood typing & Rh typing
Coomb’s test (titer >1:16 indicates sensitization); indirect Coomb’s Test (maternal serum), direct Coomb’s Test
(cord blood); if negative, test at 16 to 20 wks and at 26-27 wks
Give RhIg aka anti Rho(D) gamma globulin(RhoGAM) at 28 wks and within 72h after delivery
2. RHOGAM should be given to all Rh- women who:
Have delivered Rh+ babies
Have had untypeable pregnancies such as ectopic pregnancies, stillbirth & abortion
Have received ABO compatible Rh+ blood
Have had invasive dx procedures like amniocentesis or Chorionic Villi Sampling
Management
1. Amniocentesis q 2wks beginning at 26 wks to monitor bilirubin
2. Percutaneous umbilical blood sampling at 18-20 wks if bilirubin levels are high
3. Intrauterine Blood fetal transfusions (IUFT) at 10-day to 2-week intervals until 34-36 wks
HIV/AIDS


HIV infection and AIDS can be caused by placental transfer or direct contact with maternal blood during birth.
HIV is a slowly replicating retrovirus and has at least two main divisions, HIV-1 and HIV-2, followed by a variety of
further subtypes.
 The virus acts by attacking the lymphoreticular system, in particular CD4-bearing helper T lymphocytes.
 The virus enters the cell, substitutes its own RNA and DNA for the cell’s DNA, and begins to replicate, destroying
the lymphocytes in the process as well as their ability to initiate an effective B-lymphocyte response.
(Chapter 42: Nursing Care of A Family with an Immune Disorder, p.1174)
ETIOLOGIC AGENT:
1. retrovirus that targets helper T lymphocytes (T4 cells) that contain the CD4 antigen (which regulates normal immune
response) making the patient susceptible to opportunistic infections
2. Present in infected person’s blood, semen, and other body fluids
Risk factors:
Assessment
1. Multiple sexual partners of the individual or
Early Symptoms:
sexual partner
1. Fatigue
2. Bisexual partner, MSM
2. Anemia
3. IV drug use by the individual or partner
3. Diarrhea
4. Others: BT, tattoo, etc
4. Weight loss
5. Lymphadenopathy
6. Night sweats
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Stages:
1. Initial invasion of virus with mild, flulike symptoms
2. Seroconversion- production of antibodies vs HIV; happens in 6 weeks to 1 year
3. Asymptomatic period for 3 to 11 years
4. Symptomatic period with opportunistic infections & possibly malignancies (CD4 cell count < 200cells/mm3)
5. Toxoplasmosis, tuberculosis
6. Oral & vaginal candidiasis
7. GIT illnesses
8. Kaposi sarcoma
9. P. carinii pneumonia (PCP)- most common opportunistic infection
10. Herpes simplex
11. HIV-associated dementia
KAPOSI SARCOMA-is a cancer that causes patches of
abnormal tissue to grow under the skin, in the lining of
the mouth, nose, and throat, in lymph nodes, or in other
organs. These patches, or lesions, are usually red or
purple.
PCP (Pneumocystis Carinii Pneumonia)- a lifethreatening lung infection that can affect people with
weakened immune systems, such as those infected with
HIV, the virus that causes AIDS.
Assessment
Management
1.
2.
3.
4.
5.
ELISA test- if (+) 2x then
Western Blot Test- confirmatory test
In late infection, CD4+ T cell count <200cells/ul
Presence of opportunistic infections
20-50% of infants born to untreated HIV +
women will contract the virus & develop AIDS in
the 1st year of life
1. Monitor CD4+ T cell counts.
2. Goal: maintain CD4 cell count > 500 cells/ mm3.
3. Antiretroviral therapy: oral Zidovudine during
pregnancy & IV during labor & delivery) plus1 or
more protease inhibitors like ritonavir (Norvir) or
indinavir (Crivixan) in conjunction with a nucleoside
reverse transcriptase inhibitor drug.
4. Neonate is also given zidovudine
5. Breastfeeding is not recommended
6. Educate client on safe sex practices, testing of sex
partners
7. Monitor client for signs of opportunistic infection:
fever, weight loss, fatigue, candidiasis, cough, skin
lesions
8. CS
delivery-performed
before
rupture
of
membranes
9. If vaginal delivery is unavoidable, no episiotomy!
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
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Multiple Choice
1. A 26-week pregnant client was diagnosed with ABO incompatibility. She asked you what her diagnosis means.
Which of the following is incorrect regarding ABO incompatibility?
A. The mother has inborn antibodies vs blood type A and B in her bloodstream.
B. Uncommon during pregnancy since antibodies is the large IgM type & cannot cross placental barrier
C. During delivery when placenta separates from the decidua, the barrier is broken allowing maternal blood to enter the
fetal bloodstream.
D. Antibodies vs Rh antigen are not naturally-occurring but are produced when Rh+ blood enters the bloodstream of an
Rh- person.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. An 18-week pregnant client ask you what is Rh incompatibility. Which of the following is correct regarding Rh
Incompatibility? EXCEPT:
A. Rh (D) factor is a protein antigen present on the surface of some people’s RBC (Rh+)
B. Antibodies vs Rh antigen are not naturally-occurring but are produced when Rh+ blood enters the bloodstream of an
Rh- person.
C. The mother has inborn antibodies vs blood type A and B in her bloodstream.
D. The Rh + gene is a dominant and therefore if either the mother or the father or both parents are Rh+, the baby will be
Rh+
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. Kyra a client who gave birth to a female newborn and was diagnosed as having ABO incompatibility. Which of
the following is incorrect for the laboratory findings of a newborn with ABO incompatibility?
A. Blood Smear result is microspherocytosis
B. <95, microcytic for a newborn
C. Direct Coombs test is often weakly +
D. Direct Coombs test is often weakly –
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. Kyra’s child was ordered to have Exchange Transfusion. She asked you what are the possible complications of
the procedure. The following are complications of Exchange Transfusion, EXCEPT:
A. Hypothermia
B. Hypocalcemia
C. Hyperkalemia
D. Hypoglycemia
E. Hypernatremia
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________ _________________
_________________________________________________________________________________________________
5. A patient was diagnosed with Habitual Abortion due to Rh incompatibility and had a fetal complication of
Erythroblastosis Fetalis. She asked you what will be the complication if she will get pregnant again. The
following are complications of Rh Incompatibility, EXCEPT:
A. Anemia
B. Splenomegaly & hepatomegaly
C. Hyperbilirubinemia
D. Wilms Tumor
E. Hydrops fetalis
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ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. The following are true regarding HIV/AIDS, EXCEPT:
A. HIV infection and AIDS can be caused by placental transfer or direct contact with maternal blood during birth.
B. HIV is a slowly replicating retrovirus and has at least two main divisions, HIV-1 and HIV-2, followed by a variety of
further subtypes.
C. The virus acts by attacking the lymphoreticular system, in particular CD4-bearing helper T lymphocytes.
D. HIV/AIDS is spread through saliva.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7. Reme a pregnant client asked you what are the risk factors for having HIV/AIDS. The following are risk factors
of HIV/AIDS, EXCEPT:
A. Multiple sexual partners of the individual or sexual partner
B. Bisexual partner
C. IV drug use by the individual or partner
D. Deep, open-mouth kissing without mouth sores
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. A patient asked you regarding HIV/AIDS on what is Seroconversion. You know that Seroconversion is:
A. Seroconversion is the production of antibodies versus HIV that happens in 5 weeks to a year.
B. Seroconversion is the production of antibodies versus HIV that happens in 6 weeks to a year.
C. Seroconversion is the production of antibodies versus HIV that happens in 7 weeks to a year.
D. Seroconversion is the production of antibodies versus HIV that happens in 4 weeks to a year.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
9. A pregnant client was admitted with a lung infection that can affect people with weakened immune systems,
such as those infected with HIV, the virus that causes AIDS. Which of the following condition pertains to the
client’s condition?
A. Hospital Acquired Pneumonia
B. Community Acquired Pneumonia
C. Pneumocystis Carinii Pneumonia
D. Fungal Pneumonia
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
10. You were conducting a physical examination to a pregnant client. Upon examining the skin of the patient you
saw red to purplish skin patches and was told that she is taking Zidovudine. You know that the patient is having:
A. Angiosarcoma
B. Fibroblastic Sarcoma
C. Kaposi’s Sarcoma
D. Leiomyosarcoma
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
______________________________________________________________________________ _______________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
1
2
3
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5
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7
17
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PERIOD 1
8
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PERIOD 2
24
PERIOD 3
39
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AL STRATEGY: Minute Paper
1. You will use index cards or half-sheets of paper to provide written feedback to the following questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?
2. Pass the responses to your instructor before you leave.
(For next session, review Chapter 20: Nursing Care of a Family Experiencing Complication From a Preexisting or
Newly Acquired Illness: Hematologic Disorder page 498)
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 5
LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT
CLIENT (PRE-GESTATIONAL CONDITIONS- ANEMIAS OF
PREGNANCY) AND (GESTATIONAL CONDITIONSHYPEREMESIS GRAVIDARUM AND ECTOPIC
PREGNANCY)
Materials:
Book, pen, SAS and notebook
Reference:
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:
1. Define Anemia, Hyperemesis Gravidarum and Ectopic
Pregnancy) its relation to pregnancy, including pre-existing
factors that contribute to its development.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate knowledge of Anemia, Hyperemesis Gravidarum
and Ectopic Pregnancy in relation to pregnancy and nursing
process to achieve quality maternal and child health nursing
care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
(Chapter 20: Nursing Care of a Family Experiencing Complication From a Pre-existing or Newly Acquired Illness:
Hematologic Disorder page 498)
ANEMIAS OF PREGNANCY
(Chapter 20: Nursing Care of a Family Experiencing Complication From a Preexisting or Newly Acquired Illness:
Hematologic Disorder page 498)
ANEMIA- is a condition of too few RBCs, or a lowered ability of the RBCs

Many women lack the sufficient amount of iron needed for the second and third trimesters. When the body
needs more iron than it has available, a woman can become anemic.

Mild anemia is normal during pregnancy due to an increase in blood volume.

More severe anemia can put the baby at higher risk for anemia later in infancy.
Most Common Types during Pregnancy:
• Iron deficiency Anemia
• Vitamin B12 Anemia
• Anemia due to Blood Loss
• Folate Deficiency
Risk Factors
• Poor nutrition
• Excess alcohol consumption
• Illnesses that reduce absorption of nutrients
• Use of anticonvulsant drugs (Tegretol, Lithium,
Carbamazepine, etc.)
• Previous use of oral contraceptives
• G6PD Deficiency
Complications of Anemia
• Premature labor
• Intrauterine growth retardation (IUGR)
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• Dangerous anemia from normal blood loss during labor, requiring transfusions
• Increased susceptibility to maternal infection after childbirth
IRON DEFICIENCY ANEMIA
• Most common type, develops in the 2 nd & 3rd trimester when the Fe requirements increase to compensate for
the expanding blood volume
• Predisposing factors:
– Poor diet & poor nutrition
– Heavy menses
– Successive pregnancies w/in 2 yrs or <6 mos interval
– Unwise reducing programs
– Low socioeconomic status
Signs & Symptoms of IDA
• Easy fatigability
• Sensitivity to cold
• Dizziness
• Brittle, flattened nails
• Changes in Vital Signs: rise in systolic pressure,
tachycardia, tachypnea
Management of Iron Deficiency Anemia
The World Health Organization and most experts
recommend prevention of iron deficiency anemia with
prophylactic iron supplementation in pregnancy.

Pregnancy requires an additional 700–1200 mg of
iron. Of this, 200–300 mg is transferred to the
fetus.

Most of the iron requirements of pregnancy are in
the second half of pregnancy, and they are
approximately 5–6 mg/day.

An average balanced diet will supply only 1–2
mg/day.

Daily supplementation with 300 mg ferrous sulfate
(which contains 60 mg elemental iron) will satisfy
the pregnancy requirement.
Diagnosis
Lab findings:
-low hemoglobin <10 g/100ml
-low hematocrit <37% in the 1st trimester, <35% in the
2nd trimester and <33% in the 3rd trimester
-Serum ferritin < 100 mg/dl
-Serum Fe level < 30 ug/dl
-Hypochromic, microcytic RBCs
Effects of Anemia on Pregnancy
• Decreased resistance to infection
• Associated with prematurity & LBW infants
• Predisposes to heavy bleeding during labor &
delivery
• Associated with PICA
MEGALOBLASTIC ANEMIA
Types:
1. Folic Acid Deficiency/(Pernicious anemia
2. Vit B12 Deficiency/Addison Pernicious Anemia
Folic acid vs. Folate
Folate is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs, citrus
fruit, avocados, and beef liver.
Folic acid is a synthesized version of vitamin B9 that is added to processed foods and the common version used in
supplements.
1. Folic Acid Deficiency Anemia-is necessary for normal formation of RBC and in the prevention of Neural Tube
Defects
– Deficiency leads to formation of large & immature RBCs with shorter lifespan
– develops if diet is mostly meat with little Green leafy vegetables
Effects on Pregnancy:
-abortion
Signs and Symptoms of Folic Acid Deficiency
• Nausea
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-abruptio placenta
-Neural Tube Defect
Most often seen in:
• Multiple pregnancies because of the increased
fetal demand
• Women with secondary hemolytic illness
• Women who are taking Hydantoin
• Poor gastric absorption due to gastric bypass
for morbid obesity
• Vomiting
• Anorexia
MANAGEMENT
 Treatment of patients with pernicious anemia is
undertaken with parenteral therapy because oral
absorption of vitamin B12 is deficient.

Daily injections of 200 μg are given for the first week
followed by weekly injections for 3 weeks and then
once a month thereafter.

Therapy must continue for life to prevent recurrence
of anemia.

Response to therapy is usually manifested by
a brisk production of reticulocytes within the first few
days of therapy.
2. Vit B12 Deficiency/Addison Pernicious Anemia
Vitamin B12 deficiency is extremely uncommon during pregnancy.
Vitamin B12 deficiency (pernicious anemia) is primarily caused by deficiency in oral absorption.
Present in:
 The most common type is that caused by autoimmune atrophic gastritis, which occurs most frequently in
patients of Scandinavian and Northern European ancestry as well as those of Hispanic origins.

Women between 30 and 40 years of age
Rare causes of vitamin B12 deficiency:


Infection by the fish tapeworm (Diphyllobothrium latum)
Chronic conditions such as Crohn’s disease.
Diagnosis
 Patients demonstrating a macrocytic anemia with an abnormally low serum vitamin B12 level.
Management of Vitamin B12 Deficiency is same as Iron Deficiency Anemia
GESTATIONAL CONDITIONS
Please refer to Chapter 13: The Nursing Role in Promoting Nutritional Health During Pregnancy p.299
HYPEREMESIS GRAVIDARUM
-PERNICIOUS or PERSISTENT VOMITING OF PREGNANCY
-extreme nausea and vomiting that is prolonged past week 12 of pregnancy or is so severe (DHN, ketonuria, weight
loss) within the 1 st 12 weeks AOG
-associated with H. pylori
Assessment
Management
-Nausea and Vomiting is so severe that nutrition cannot
1. 24-hour Hospitalization. (I & O, blood chemistries &
be maintained and weight loss is severe
rehydration)
-Elevated Hematocrit due to hemoconcentration
-Reduced Na, K Cl and hypokalemic alkalosis may occur
2. NPO; IVF ( 3L Ringer’s lactated solution+ vitamin B) to
control vomiting
-Polyneuritis due to deficiency in Vitamin B
3. If no vomiting after the 1 st 24h, sips of clear fluid
gradually advanced to a soft, then normal, diet.
-Urine may be (+) for ketones due to breakdown of
protein & fat for cell growth
4. If vomiting returns, TPN or enteral nutrition may be
prescribed
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-Intrauterine Growth Restriction or preterm birth
In history taking ask frequency/quantity of vomiting, how
much she eats in a typical day.
Ectopic Pregnancy
An ectopic pregnancy is one in which implantation occurred outside the uterine cavity. The most common site (in
approximately 95% of such pregnancies) is in the fallopian tube. Of these fallopian tube sites, approximately 80% occur in
the ampullar portion, 12% occur in the isthmus, and 8% are interstitial or fimbrial (Jurkovic, 2012). (Chapter 21: Nursing
Care of a Family Experiencing a Sudden Pregnancy Complication, p.533)
Ectopic Pregnancy
-It is the implantation of a fertilized ovum outside of the
uterus
-Sites: ovary, cervix, peritoneal cavity, fallopian tube
(most common)
Assessment
1. Missed period, usual signs of pregnancy (Nausea and
Vomiting, positive pregnancy test, etc)
2. Spotting, bleeding (dark red or brownish), possible
signs of hypovolemic shock
Etiology
Salpingitis, tumors, adhesions, or scarring, IUD use,
narrowed oviducts
Complication
1. Hemorrhage,
2. Shock,
3. Peritonitis
3. If at the fallopian tube, by 6 to 12 weeks AOG, slowly
increasing or sudden sharp, stabbing pain in LLQ or
RLQ (due to rupture of fallopian tube), followed by
bleeding, abdominal rigidity
4. referred shoulder pain (KEHR’S SIGN) due to blood
in the peritoneum irritating the phrenic nerve
5. CULLEN’S SIGN- ecchymotic blueness around the
umbilicus indicating blood pooling in the peritoneum
6. Dizziness, syncope
7. UTZ confirms extrauterine pregnancy & rupture
Management
 Before rupture, oral administration of METHOTREXATE (folic acid antagonist which destroys fast-growing
cells) followed by LEUCOVORIN; treated until hCG is (-); hysterosalpingogram to assess patency of the tube






After rupture, BT if needed, laparoscopy to ligate bleeding vessels & remove or repair damaged tubes
Assess for bleeding & pain
Monitor VS, start IV with 18-gauge needle
Provide O2 therapy
Administer RhOGAM if Rh (-)
Provide emotional support
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CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. Berta a pregnant patient was diagnosed with Iron Deficiency Anemia. She asked you what are the other types
of Anemia that can be seen in pregnancy. Which of the following are Anemias of Pregnancy, EXCEPT:
A. Vitamin B12 Anemia
B. Anemia due to Blood Loss
C. Folate Deficiency
D. Thalassemia
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. Cilla a student-nurse who takes care of Berta asked you what are the factors that puts the patient at risk of
developing anemia in pregnancy. All but one are risk factors of Anemia, EXCEPT:
A. Poor nutrition
B. Excess alcohol consumption
C. Illnesses that reduce absorption of nutrients
D. Use of anticonvulsant drugs
E. Elevated hematocrit due to hemoconcentration
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________________________________ ____________
3. Cilla a student nurse asked you what is the difference between Folic Acid and Folate. Which of the following
are the correct definition of Folic acid and Folate?
A. Folic Acid is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs, citrus
fruit, avocados, and beef liver while Folate is a synthesized version of vitamin B9 that is added to processed foods and the
common version used in supplements.
B. Folate is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs, citrus fruit,
avocados, and beef liver while Folic acid is a synthesized version of vitamin B9 that is added to processed foods and the
common version used in supplements.
C. Folate is the common form of vitamin B9 present in many synthesized version of vitamin B9 that is added to processed
foods and the common version used in supplements while Folic acid is the common form of vitamin B9 present in many
whole foods, including leafy greens, beans, eggs, citrus fruit, avocados, and beef liver.
D. Folate and Folic Acid is both present in many whole foods, including leafy greens, beans, eggs, citrus fruit, avocados,
and beef liver
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. 4 patients came to the Out Patient Department with Iron Deficiency Anemia EXCEPT:
A. Multiple pregnancies because of the increased fetal demand
B. A woman with secondary hemolytic illness
C. Poor gastric absorption due to gastric bypass for morbid obesity
D. A woman at 36 years of age
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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5. Erina will be having a case presentation regarding the complications of Anemia in pregnancy. The following
are part of Complications of Anemia in Pregnancy, EXCEPT:
A. Premature labor
B. Intrauterine growth retardation (IUGR)
C. Dangerous anemia from normal blood loss during labor, requiring transfusions
D. Poor diet & poor nutrition
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. Belle is diagnosed with Hyperemesis Gravidarum, Which of the following is true regarding Hyperemesis
Gravidarum?
A. Extreme nausea and vomiting that is prolonged past week 12 of pregnancy or is so severe
B. Nausea and Vomiting is so severe that nutrition cannot be maintained and weight loss is severe
C. Urine may be (+) for ketones due to breakdown of protein & fat for cell growth
D. Intrauterine Growth Restriction or preterm birth
E. All of the choices are true
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7. Belle was confined to the hospital due to Hyperemesis Gravidarum, The following are part of management for
Hyperemesis Gravidarum, EXCEPT:
A. 24-hour Hospitalization
B. If no vomiting after the first 24 hours, sips of clear fluid gradually advanced to a soft, then normal, diet.
C. If vomiting returns, TPN or enteral nutrition may be prescribed
D. Provide oxygen therapy
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. Karlie is diagnosed with Ectopic Pregnancy. Your instructor ask you which of the following is the common site
of Ectopic Pregnancy?
A. ovary
B. cervix
C. peritoneal cavity
D. fallopian tube
ANSWER: ________
RATIO:________________________________________________________________________ ___________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
9. Karlie is experiencing sharp shoulder pain. Which of the following conditions is experiencing?
A. Cullen’s Sign
B. Charcot’s Sign
C. Kehr’s Sign
D. Leopold’s Sign
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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10. As you do physical examination on Karlie, you saw that her abdomen has an ecchymotic blueness around the
umbilicus. You know that its:
A. Cullen’s Sign
B. Charcot’s Sign
C. Kehr’s Sign
D. Leopold’s Sign
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
______________________________________________________________________________ _______________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
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LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
1
2
3
4
5
6
7
17
18
19
20
21
22
23
32
33
34
35
36
37
38
PERIOD 1
8
9
PERIOD 2
24
PERIOD 3
39
10
11
12
13
14
15
16
25
26
27
28
29
30
31
40
41
42
43
44
45
46
AL STRATEGY: Minute Paper
1. You will be ask to use index cards or half-sheets of paper to provide written feedback to the following questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?
2. Your instructor will collect or pass your responses before you leave.
3. Respond to students’ feedback during the next class meeting or as soon as possible
(For next session, review Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication Bleeding During Pregnancy page 526 and page. 537.)
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 6
LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT
CLIENT (PRE-GESTATIONAL CONDITIONS- ANEMIAS OF
PREGNANCY) AND (GESTATIONAL CONDITIONSHYPEREMESIS GRAVIDARUM AND ECTOPIC
PREGNANCY)
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:
Materials:
Book, pen, SAS and notebook
Reference:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
1. Define Anemia, Hyperemesis Gravidarum and Ectopic
Pregnancy) its relation to pregnancy, including pre-existing
factors that contribute to its development.
2. Integrate knowledge of Anemia, Hyperemesis Gravidarum
and Ectopic Pregnancy in relation to pregnancy and nursing
process to achieve quality maternal and child health nursing
care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
GESTATIONAL TROPHOBLASTIC DISEASE/HYDATIDIFORM MOLE/MOLAR PREGNANCY (please refer to Chapter
21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication-Bleeding During Pregnancy page 526)
Gestational trophoblastic disease is abnormal proliferation and then degeneration of the trophoblastic villi (Jean-Jacques,
2016). As the cells degenerate, they become filled with fluid and appear as clear fluid-filled, grape-sized vesicles.
The embryo fails to develop beyond a primitive start. Abnormal trophoblast cells must be identified because they are
associated with choriocarcinoma, a rapidly metastasizing malignancy.
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The incidence of gestational trophoblastic disease is approximately 1 in every 1,500 pregnancies.
The condition tends to occur most often in women who have a low-protein intake, in women older than 35 years of age, in
women of Asian heritage, and in blood group A women who marry blood group O men.
2 Types of H Mole
1. Complete Mole-All trophoblastic villi swell & become cystic; embryo dies early
-Chromosomes are normal, 44xy or 44xx but are contributed by only by the father or an empty ovum was fertilized &
the chromosome material from the sperm was duplicated
-May lead to choriocarcinoma
2. Partial Mole-Some of the villi form normally
-Syncytiotrophoblast layer is swollen & misshapen
-It has 69 chromosomes (3 chromosomes instead of 2 for every pair) resulting from 2 sperms fertilizing an ovum
-Rarely leads to choriocarcinoma
Assessment
1. Uterus expands faster than normal
2. No fetal heart sounds
3. hCG test is strongly positive( 1 to 2 million IU) dt
overgrowing trophoblast cells & remains positive after
the 100th day of gestation
4. Marked N/V due to high hCG levels( 1-2 Million
IU/24hrs)
5. Positive pregnancy test
6. Abdominal pain
Diagnosis
1.
Passage of vesicles- 1st sign
2.
TRIAD SIGNS;
-Big uterus
-Vaginal bleeding: brownish, intermittent
-HCG >1 Million IU/24 hrs (NV: 400,000
IU/24hrs)
7. Signs of Pregnancy induced HPN (HPN, proteinuria,
edema) present before week 20 of pregnancy
8. UTZ shows dense growth (snowflake pattern) but no
fetal growth
9. Vaginal bleeding in the 1st trimester, may be brown
like prune juice & may contain grapelike vesicles
10. Very low msAFP levels
11. Expulsion of molar cyst by 16th-18th week
Therapeutic Management
1. Monitor for signs of hemorrhage, PIH, or other
complications such as HELLP Syndrome
2. Suction & curettage to evacuate the mole
3. After extraction, chest xray, pelvic examination,
serum test for ß subunit of hCG
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3.
4.
Ultrasound: no fetal sac, no fetal parts
XRAY: no fetal skeleton
4. hCG is analyzed every 2 weeks until levels are
normal. Afterwards, q 4 weeks for 6 to 12 months
(increase suggests malignancy)
5. Should not get pregnant within 1 year of diagnosis
because signs of pregnancy can mask signs of
choriocarcinoma
6. Chest X-ray to detect early lung metastasis
7. if malignant, methotrexate is the DOC
8. Provide RhOGAM if Rh (-)
9. Address emotional & psychosocial needs.
CERVICAL INSUFFICIENCY (PREMATURE CERVICAL DILATATION/INCOMPETENT CERVIX)
(Please read Chapter 21: Nursing Care of a Family Experiencing A Sudden Pregnancy Complication, page. 537.)
Description & Etiology
-cervix that dilates prematurely and cannot hold a fetus until term
-cause of habitual abortion
-It usually at week 20 when the fetus is still too immature to survive.
-associated with maternal age, congenital structural defects & trauma to the cervix (cone biopsy, repeated D & C)
-The dilatation is usually painless
-1st symptom is usually SHOW, or increased pelvic pressure, which may be followed by rupture of membranes &
discharge of AF
-Uterine contractions begin & after a short labor, the fetus is born
Diagnosis
May be diagnosed by early UTZ before symptoms occur
Management
 Ultrasound to confirm that the fetus is healthy
 weeks 12 to 14, purse-string sutures are placed in the cervix by the vaginal route under regional anesthesia
(CERVICAL CERCLAGE).
 Sutures strengthen the cervix & prevents it from dilating.
 After surgery, bed rest (in slight or modified Trendelenburg position) for a few days to decrease pressure in the
new sutures
 Sutures are then removed at weeks 37 to 38 so that the fetus can be born vaginally.
McDonald’s cerclage- nylon sutures are placed
SHIRODKAR
horizontally & vertically across the
PROCEDURE- sterile
cervix & pulled tight to reduce the
tape is threaded in a
cervical canal to a few millimeters
in purse-string manner
diameter
under the submucous
 Usually temporary
layer of the cervix &
sutured in place to
achieve a closed cervix.
 May be
permanent
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CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. A woman of 16-weeks gestation telephones the nurse because she has passed some “berry-like” blood clots
and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do?
A. “Maintain bedrest, and count the number of perineal pads used.”
B. “Come to the health care facility if uterine contractions begin.”
C. “Continue normal activity, but take the pulse every hour.”
D. “Come to the health facility with any vaginal material passed.”
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. A woman with Hydatidiform Mole develops HELLP Syndrome. During labor, which prescription would the
nurse question?
A. Prepare her epidural anesthesia.
B. Assess her blood pressure every 15 minutes.
C. Assess the urine output every hour.
D. Urge her to lie on her left side during labor.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. A pregnant patient was diagnosed with Hydatidiform Mole. She asked you what does Hydatidiform Mole
means. You answer which of the following?
A. Gestational trophoblastic disease is abnormal proliferation and then degeneration of the trophoblastic villi
B. The cells degenerate, they become filled with fluid and appear as clear fluid-filled, grape-sized vesicles.
C. The embryo fails to develop beyond a primitive start.
D. All of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. A pregnant client is asking you what are the types of Hydatidiform Mole. Which type of Hydatidiform that all
trophoblastic villi swell and become cystic that embryo dies and may early lead to choriocarcinoma?
A. Incomplete Hydatidiform Mole
B. Complete Hydatidiform Mole
C. Partial Hydatidiform Mole
D. Partial Complete Mole
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5. Which type of Hydatidiform Mole that some of the villi form normally and rarely leads to choriocarcinoma?
A. Incomplete Hydatidiform Mole
B. Complete Hydatidiform Mole
C. Partial Hydatidiform Mole
D. Partial Complete Mole
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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6. A pregnant client with a history of premature cervical dilation undergoes cervical cerclage. Which outcomes
indicates that this procedure has been successful?
A. The client delivers a full-term fetus at 39 weeks gestation.
B. The client membranes spontaneously rupture at week 30 of gestation.
C. The client experiences minimal vaginal bleeding throughout the pregnancy.
D. The client has reduced shortness of breath and abdominal pain.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________________________ _________________
7. A pregnant client with a history of premature cervical dilation will undergo cervical cerclage with McDonald ’s
Cerclage procedure. She asked you what is McDonald’s Cerclage. You answered:
A. McDonald’s cerclage is performed by purse-string sutures that are placed in the cervix by the vaginal route under
regional anesthesia. Sutures strengthen the cervix & prevents it from dilating.
B. McDonald’s cerclage is a temporary type of cervical cerclage that are placed horizontally and vertically across the
cervix & pulled tight to reduce the cervical canal to a few millimeters in diameter.
C. McDonald’s cerclage is a permanent type of cervical cerclage that they place a sterile tape is threaded in a purse -string
manner under the submucous layer of the cervix & sutured in place to achieve a closed cervix.
D. McDonald’s cerclage refers to a variety of procedures that use sutures or synthetic tape to reinforce the cervix during
pregnancy in women with a history of a short cervix.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. A pregnant client with a history of premature cervical dilation will undergo cervical cerclage with Shirodkar
Procedure. She asked you what is Shirodkar Procedure. You answered:
A. Shirodkar Procedure is performed by purse-string sutures that are placed in the cervix by the vaginal route under
regional anesthesia. Sutures strengthen the cervix & prevents it from dilating.
B. Shirodkar Procedure is a temporary type of cervical cerclage that are placed horizontally and v ertically across the
cervix & pulled tight to reduce the cervical canal to a few millimeters in diameter.
C. Shirodkar Procedure is a permanent type of cervical cerclage that they place a sterile tape is threaded in a purse -string
manner under the submucous layer of the cervix & sutured in place to achieve a closed cervix.
D. Shirodkar Procedure refers to a variety of procedures that use sutures or synthetic tape to reinforce the cervix during
pregnancy in women with a history of a short cervix.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
9. The following are true regarding Premature Cervical Dilation, EXCEPT:
A. The cervix that dilates prematurely and cannot hold a fetus until term
B. It is one cause of habitual abortion
C. The dilatation is usually painless
D. Uterine contractions begin and after a short labor, the fetus is stillbirth.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
10. The following are management for Premature Cervical Dilation, EXCEPT:
A. Ultrasound is done to confirm that the fetus is healthy
B. At weeks 12 to 14, purse-string sutures are placed in the cervix by the vaginal route under regional anesthesia
C. Sutures are then removed at weeks 37 to 38 so that the fetus can be born vaginally.
D. Chest X-ray is done to detect early lung metastasis
ANSWER: ________
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RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
______________________________________________________________________________ _______________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________
RATIO:_______________________________________________________________________________________
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_____________________________________________________________________
LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
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PERIOD 3
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AL STRATEGY: CAT: Student Response Cards
1. Your instructor will give a set of student response card for each of you and your classmate which is labeled with
answer choices.
2. Your instructor will pose a question to the class regarding information just covered in your lesson.
3. Hold up their card with the corresponding answer to your instructor’s question.
(For next session, review Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication Bleeding During Pregnancy Spontaneous Miscarriage p. 529)
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 7
LESSON TITLE: CARE OF THE HIGH-RISK
PREGNANT CLIENT (GESTATIONAL CONDITIONSSPONTANEOUS MISCARRIAGE)
LEARNING OUTCOMES:
Materials:
Book, pen, SAS and notebook
Reference:
At the end of the lesson, the student nurse can:
1. Define Spontaneous Miscarriage its relation to pregnancy,
including pre-existing factors that contribute to its development.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate knowledge of Spontaneous Miscarriage in relation
to pregnancy and nursing process to achieve quality maternal
and child health nursing care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
SPONTANEOUS MISCARRIAGE.
(Please refer to Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication-Bleeding During
Pregnancy Spontaneous Miscarriage p. 529)
ABORTION- any interruption of a pregnancy before a
Causes of Spontaneous Miscarriage
fetus is viable (> 20 to 24 weeks & weighs at least 500 g)
 Abnormal fetal formation
 Immunologic factors: Rh/ABO incompatibility
 ELECTIVE ABORTION – medical termination of a
 Implantation abnormalities
pregnancy
 Corpus luteum fails to produce enough P to
 MISCARRIAGE- spontaneous interruption of a
maintain the d. basalis (P therapy may be
pregnancy
attempted)
 Early miscarriage occurs before week 16 & late
 Infection (rubella, syphilis, poliomyelitis, CMV,
miscarriage between weeks 16 & 24
toxoplasmosis, UTI)- fetus fails to grow, P & E
decline causing sloughing off of the endometrium
 Trauma
 Incompetent cervix
 Maternal systemic diseases: DM, thyroid
problems, severe anemia
Classifications of Spontaneous Abortions/Miscarriages
1. Threatened Miscarriage
Management:
Symptoms:
 Assess fetal viability via UTZ; FHT
 vaginal bleeding- scant, usually bright red
 Assess amount of bleeding
 Slight cramping or backache
 Monitor VS; assess for impending shock
 No cervical dilatation
 Provide emotional support
 hCG titer at start of bleeding & after 24h (if viable,
hCG doubles)
 Avoid strenuous activity, CBR for 24 to 48 h
 Avoid stress
 coitus is restricted for 2 weeks after bleeding to
avoid bleeding & infection
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2. Imminent or Inevitable Miscarriage
Symptoms:
 + cramping or uterine contractions
 + Vaginal bleeding
 Cervix dilates & membranes rupture
3. Complete Miscarriage
Symptoms:
 the entire products of conception (fetus, placenta,
membranes) are expelled
 Bleeding, cramping & expulsion of conceptus
 Bleeding slows within 2 hours then stops within a
few days after passage of conceptus
 The cervix is closed & the uterus contracts
4. Incomplete Miscarriage
Symptoms:
 Bleeding, cramping & part of the conceptus
(usually the fetus) is expelled but the rest are
retained; cervix is dilated
 danger of hemorrhage because the uterus cannot
contract effectively
5. Missed Miscarriage/ Early Pregnancy Failure
Symptoms:
 the fetus dies in utero but is not expelled & the client
experiences decreasing signs of pregnancy
 Cervix is closed
 Dark brown vaginal discharge
 Pregnancy test (-)
 Fundal height does not increase in size
Management:
 assess bleeding;
 save any tissue fragments passed
 initiate IVT with an 18-gauge needle
 If (-) FHT & UTZ reveals empty uterus or
nonviable fetus, D&E
 after D & E monitor bleeding (saturating > 1
pad/hour is heavy bleeding)
 RhOGAM as necessary
 Provide psychological support
Management:
 Advise the woman to report heavy bleeding.
 No therapy needed since the process of is
complete due to spontaneous expulsion of the
entire products of conception.
Management:
 D & C or suction curettage
Management:
 UTZ to establish fetal death
 D&E
 If > 14 wks AOG, Prostaglandin suppository of
misoprostol (Cytotec) to dilate the cervix, followed
by oxytocin or
 mifepristone
 Miscarriage usually occurs spontaneously within 2
weeks
 If conceptus remains in the uterus > 5 weeks, risk
for DIC and sepsis
6. Recurrent Pregnancy Loss/Habitual Abortion
 Three Spontaneous miscarriage that occurred at the same gestational age
Causes
 Defective spermatozoa or ova
 Poor Thyroid Function
 Septate or Bicornuate Uterus
 Resistance to uterine artery blood flow
 Chorioamnionitis or uterine infection
 Autoimmune disorders such as Lupus Anticoagulant and Anti Phospholipid Antibodies
Complications of Miscarriage
1. Hemorrhage
Management
1. Hemorrhage

complete spontaneous miscarriage Monitor VS
serious or fatal hemorrhage is rare.
 Position flat on bed
 incomplete miscarriage or in a woman
 Blood replacement if necessary
who develops an accompanying
 D&C
coagulation defect (usually DIC)- major
2. Infection
hemorrhage becomes a possibility

Advise women to wipe their perineal area
2. Infection
from front to back after voiding and
fever higher than 100.4°F (38.0°C)

particularly after defecation to prevent the
 abdominal pain or tenderness
spread of bacteria that could cause
 foul-smelling vaginal discharge
infection.
3. Septic Abortion- an abortion complicated by
 Advise the woman not to use tampons
infection
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
occurs in women who have tried to self-abort or
whose pregnancy was aborted illegally using a
nonsterile instrument such as a knitting needle
 fever and crampy abdominal pain; her uterus will
feel tender to palpation.
 Left untreated, such an infection can lead to toxic
shock syndrome, septicemia, kidney failure, and
death
4. Isoimmunization- whenever the placenta is
dislodged some blood from the placental villi may
enter the maternal circulation. If the fetus is Rh (+)
& the woman is Rh (-), the mother may produce
antibodies against Rh (+) blood & would attempt
to destroy RBC of the next infant while it is in
utero.
5. Powerlessness or Anxiety
(stasis of any body fluid increases the risk
of infection).
3. Septic Abortion
 CBC, serum electrolytes and CREA;
blood type and cross-match; and cervical,
vaginal, and urine cultures are obtained
 Combination of penicillin (gram-positive
coverage), gentamicin (gram-negative
aerobic coverage), and clindamycin
(gram-negative anaerobic coverage) is
commonly prescribed to combat the
infection.

D&C or D&E
4. Isoimmunization
 Administer RhOGAM or RhIg to all
women with Rh (-) blood to prevent
buildup of antibodies in case the fetus is
Rh (+)
5. Powerlessness or Anxiety
 assess a partner’s or the extended
family’s feelings as well, or the potential
impact of their grief and possible lack of
support for the woman over the
pregnancy loss can be missed.
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. A 16th week pregnant client had undergone Dilatation and Curettage related to her vaginal bleeding and was
diagnose to have Spontaneous Miscarriage. She asked you what are the possible causes of her Condition. The
following are causes of Spontaneous Miscarriage, EXCEPT:
A. Abnormal fetal formation
B. Immunologic factors: Rh/ABO incompatibility
C. Abruptio Placenta
D. Incompetent cervix
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. A patient who is 17 weeks pregnant is passing pieces of body tissue along with blood clots and dark red blood
from the vagina. What should the nurse direct the patient to do at this time?
A. Begin immediate bed rest.
B. Count the number of perineal pads that are saturated with blood.
C. Continue with the normal daily activity and monitor pulse rate every hour.
D. Seek immediate medical attention and bring the expressed vaginal material.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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3. A 16-week pregnant client was diagnosed to have Threatened Miscarriage. You know that this type of
miscarriage presents which of the following sign and symptoms?
A. Her vaginal bleeding is scant, usually bright red there is slight cramping or backache but there is no cervical dilatation.
B. The entire products of conception (fetus, placenta, membranes) are expelled there is bleeding, cramping & expulsion of
conceptus
C. Bleeding, cramping & part of the conceptus (usually the fetus) is expelled but the rest are retained and her cervix is
dilated
D. The fetus dies in utero but is not expelled & the client experiences decreasing signs of pregnancy.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. An 18-week pregnant client was diagnosed with Incomplete Miscarriage. Which of the following is the best
definition of the patient’s diagnosis?
A. Her vaginal bleeding is scant, usually bright red there is slight cramping or backache but there is no cervical dilatation.
B. The entire products of conception (fetus, placenta, membranes) are expelled there is bleeding, cramping & expulsion of
conceptus
C. Bleeding, cramping & part of the conceptus (usually the fetus) is expelled but the rest are retained and her cervix is
dilated
D. The fetus dies in utero but is not expelled & the client experiences decreasing signs of pregnancy.
ANSWER: ________
RATIO:_____________________________________________________________________ ______________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5. A 20-week pregnant client was diagnosed with Missed Miscarriage/ Early Pregnancy Failure. Which of the
following is the best description for the patient’s diagnosis?
A. Her vaginal bleeding is scant, usually bright red there is slight cramping or backache but there is no cervical dilatation.
B. The entire products of conception (fetus, placenta, membranes) are expelled there is bleeding, cramping & expulsion of
conceptus
C. Bleeding, cramping & part of the conceptus (usually the fetus) is expelled but the rest are retained and her cervix is
dilated
D. The fetus dies in utero but is not expelled & the client experiences decreasing signs of pregnancy.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. A 19-week pregnant client was referred to the hospital and was diagnosed with Complete Miscarriage. Which
of the following is the best description for the patient’s diagnosis?
A. Her vaginal bleeding is scant, usually bright red there is slight cramping or backache but there is no cervical dilatation.
B. The entire products of conception (fetus, placenta, membranes) are expelled there is bleeding, cramping & expulsion of
conceptus
C. Bleeding, cramping & part of the conceptus (usually the fetus) is expelled but the rest are retained and her cervix is
dilated
D. The fetus dies in utero but is not expelled & the client experiences decreasing signs of pregnancy.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7. A 16-week pregnant client was diagnosed to have Threatened Miscarriage. The following are management of
Threatened Miscarriage, EXCEPT:
A. Assess fetal viability via Ultrasound and Fetal Heart Tone
B. Complete bed rest for 24 to 48 hours
C. Coitus is restricted for 2 weeks after bleeding
D. Save any tissue fragments passed
ANSWER: ________
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RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. A patient came to the hospital with fever, abdominal pain and foul-smelling discharge. Which of the following
complications of Miscarriage is the patient experiencing?
A. Septic Abortion
B. Isoimmunization
C. Infection
D. Hemorrhage
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
9. A patient came to the hospital for check-up and she told you that she try to self-abort with a knitting needle.
Which of the following complications of Miscarriage is the patient experiencing?
A. Septic Abortion
B. Isoimmunization
C. Infection
D. Hemorrhage
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
10. A pregnant patient came to the hospital and told you that she is dizzy, pale in appearance and she is having
“heavy bleeding” and soaked 10 maternal pads in a period of 4 hours per day. Which of the complication of
Miscarriage is the patient experiencing?
A. Septic Abortion
B. Isoimmunization
C. Infection
D. Hemorrhage
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
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RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
______________________________________________________________________________ _______________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
1
2
3
4
5
6
7
17
18
19
20
21
22
23
32
33
34
35
36
37
38
PERIOD 1
8
9
PERIOD 2
24
PERIOD 3
39
10
11
12
13
14
15
16
25
26
27
28
29
30
31
40
41
42
43
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46
AL STRATEGY: Minute Paper
1. Your student will ask you to use index cards or half-sheets of paper to provide written feedback to the following
questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?
2. After writing the instructor will collect the responses before you leave.
(For next session, review Chapter 21: Nursing Care of A Family Experiencing a Sudden Pregnancy ComplicationBleeding During Pregnancy p. 537-541)
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 8
LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT
CLIENT (GESTATIONAL CONDITIONS-PLACENTA PREVIA
AND ABRUPTIO PLACENTA)
Materials:
Book, pen, SAS and notebook
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:
1. Define Placenta Previa and Abruptio Placenta in relation to
pregnancy, including pre-existing factors that contribute to its
development.
Reference:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate knowledge of Placenta Previa and Abruptio
Placenta in relation to pregnancy and nursing process to
achieve quality maternal and child health nursing care
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
Causes of Bleeding in the Third Trimester of Pregnancy
(Please refer to Chapter 21: Nursing Care of A Family Experiencing a Sudden Pregnancy Complication-Bleeding During
Pregnancy p. 537-541)
PLACENTA PREVIA
PREMATURE SEPARATION OF THE PLACENTA
It is the low implantation of the placenta in the uterus;
(ABRUPTIO PLACENTA)
as the cervix softens & begins to efface & dilate, placental It is the premature separation of the normally implanted
sinuses are opened causing progressive hemorrhages
placenta after the 20 th week of pregnancy, typically with
severe hemorrhage
Four Degrees of Placenta Previa
Types of Abruptio Placenta:
1. Low-lying Placenta- implantation in the lower
rather than in the upper portion of the uterus
1. MARGINAL ABRUPTION- separates only at the
edges causing vaginal bleeding & a little pain
2. Marginal Implantation- the placenta edge
approaches that of the cervical os.
2. CENTRAL (CONCEALED) ABRUPTION- may not
result in bleeding but increasing uterine irritability
& tenderness
3. Total Placenta Previa-implantation that totally
obstruct the cervical os
3. COMPLETE SEPARATION (100%)- complete
separation from the uterine wall resulting in
profuse bleeding
*The degree to which the placenta covers the internal
cervical os is generally estimated in percentages:
100%, 75%, 30%, and so forth.
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PREMATURE SEPARATION OF THE PLACENTA:
DEGREES OF SPEARATION
GRADE
CRITERIA
0
No symptoms of separation are apparent from
maternal or fetal signs; the diagnosis is made after
birth, when the placenta is examined and a
segment of the placenta shows a recent adherent
clot on the maternal surface.
1
Minimal separation, but enough to cause vaginal
bleeding and changes in the maternal vital signs;
no fetal distress or hemorrhagic shock occurs
2
Moderate separation; there is evidence of fetal
distress; the uterus is tense and painful on
palpation.
3
Extreme separation; without immediate
interventions, maternal hypovolemic shock and
fetal death will result.
Assessment
 Painless
 (+) bright red bleeding
Assessment
 Sharp, stabbing pain
 rigid, board like abdomen
 (+/-) vaginal bleeding
 Abdominal circumference may increase as
bleeding increases; dark red bleeding
 Shock if bleeding is extensive
 DIC may occur as the fibrinogen is used up to stop
the bleeding
Etiology
Etiology













Increased parity
advanced maternal age
past CS births
past D & C
multiple gestation
male fetus (?)
Multiparity,
preeclampsia,
direct trauma,
advanced maternal age,
Drug use or smoking,
uterine anomalies,
short umbilical cord
Diagnosis
Diagnosis




Ultrasonography- 95% accurate, detects site of
implantation
Clinical diagnosis- symptomatic
Ultrasound- detects bleeding
Clotting studies- reveal DIC: small fibrin clots in
the circulation
Hypofibrinogenemia: decrease normal fibrinogen
results in the absence of normal blood coagulation
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Management
to determine if the
patient has
hypovolemic shock











Bed rest in a side-lying position
Assess VS, bleeding (1 cup = 240 ml, 1 Tbsp =
15 ml), pain, shock, contractions, FHR
Monitor hgb, hct, platelet, PT, PTT; do blood
typing & cross-matching
Never perform vaginal or pelvic exam
Vaginal exams are done only in a double setup to allow emergency CS
Begin IVT & prepare for possible BT
Double set-up: room is set up for vaginal delivery
and emergency CS
If labor has begun, bleeding is continuous or fetus
is compromised, birth must be accomplished
If bleeding stops, FHT & maternal VS are of good
quality hospital observation for 48h, sent on bed
rest at home
If labor has begun, bleeding is continuous or fetus
is compromised, birth must be accomplished
If bleeding stops, FHT & maternal VS are of good
quality hospital observation for 48h, sent on bed
rest at home
hemoglobin
hematocrit
Management
 Bed rest, left side-lying position
 IVT (18-gauge needle for fluid replacement)
 O2 therapy
 Monitor: FHR, maternal VS q 5 to 15 mins,
fibrinogen levels, I & O, labor onset, pain, bleeding
 Psychological support
 Prepare for emergency CS or vaginal birth
 Observe for postpartum complications
Complications



Hemorrhagic shock
DIC
Couvelaire uterus- the placenta does not contract
well postpartum
 CVA
 Hypofibrinogenemia
 Renal failure
 Infection
 Prematurity
COUVELAIRE uterus (UTEROPLACENTAL
APOPLEXY)

if the placenta separates first at the center, blood
pools under the placenta & is hidden from view;

blood then may infiltrate uterine muscles forming a
hard, board like uterus with no apparent bleeding
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CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which of the following
statement would best describe the patient’s diagnosis?
A. It is the low implantation of the placenta in the uterus as the cervix softens & begins to efface & dilate, placental
sinuses are opened causing progressive hemorrhages
B. It is the premature separation of the normally implanted placenta after the 20th week of pregnancy, typically with
severe hemorrhage
C. It separates only at the edges causing vaginal bleeding & a little pain
D. The placenta separates first at the center, blood pools under the placenta & is hidden from view
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. A patient came to the Out Patient department to have her check-up but was referred to the Delivery Room due
to dark red vaginal bleeding with sharp stabbing pain on her abdomen and she did not felt any fetal movement
since yesterday and was diagnosed with Abruptio Placenta. What grade of placental abruption does the patient
had?
A. Grade 0 Abruptio Placenta
B. Grade 1 Abruptio Placenta
C. Grade 2 Abruptio Placenta
D. Grade 3 Abruptio Placenta
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. A patient came to the Out Patient department to have her check-up but was referred to the Delivery Room due
to dark red vaginal bleeding, FHT of 116 bpm and upon palpation her uterus hard, tense and painful when
palpated. She was diagnosed with Abruptio Placenta. What grade of placental abruption does the patient had?
A. Grade 0 Abruptio Placenta
B. Grade 1 Abruptio Placenta
C. Grade 2 Abruptio Placenta
D. Grade 3 Abruptio Placenta
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________ ________
4. A patient gave birth to healthy newborn. Upon delivering her placenta you examined a segment of the placenta
shows a recent adherent clot on the maternal surface. What grade of placental abruption does the patient had?
A. Grade 0 Abruptio Placenta
B. Grade 1 Abruptio Placenta
C. Grade 2 Abruptio Placenta
D. Grade 3 Abruptio Placenta
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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5. A patient was diagnosed with Abruptio Placenta with Minimal Separation. With the knowledge you have
regarding Abruptio Placenta, What grade of placental abruption does the patient had?
A. Grade 0 Abruptio Placenta
B. Grade 1 Abruptio Placenta
C. Grade 2 Abruptio Placenta
D. Grade 3 Abruptio Placenta
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. A pregnant woman is admitted to the hospital with a diagnosis of abruptio placenta. Which of the following
statement would best describe the patient’s diagnosis?
A. It is the low implantation of the placenta in the uterus as the cervix softens & begins to efface & dilate, placental
sinuses are opened causing progressive hemorrhages
B. It is the premature separation of the normally implanted placenta after the 20th week of pregnancy, typically with
severe hemorrhage
C. It separates only at the edges causing vaginal bleeding & a little pain
D. The placenta separates first at the center, blood pools under the placenta & is hidden from view
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7. A pregnant woman is admitted to the hospital with a diagnosis of uteroplacental apoplexy. Which of the
following statement would best describe the patient’s diagnosis?
A. It is the low implantation of the placenta in the uterus as the cervix softens & begins to efface & dilate, pla cental
sinuses are opened causing progressive hemorrhages
B. It is the premature separation of the normally implanted placenta after the 20th week of pregnancy, typically with
severe hemorrhage
C. It separates only at the edges causing vaginal bleeding & a little pain
D. The placenta separates first at the center, blood pools under the placenta & is hidden from view
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. A 38-week pregnant woman had an ultrasound and was diagnosed with a type of Placenta Previa that totally
obstruct the cervical os. With this diagnosis it means that the patient has:
A. Placenta Previa
B. Low-lying Placenta
C. Marginal Implantation
D. Total Placenta Previa
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
9. A 37-week pregnant woman had an ultrasound and was diagnosed with a type of Placenta Previa where the
placental edge approaches that of the cervical os. With this diagnosis it means that the patient has:
A. Placenta Previa
B. Low-lying Placenta
C. Marginal Implantation
D. Total Placenta Previa
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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10. A 36-week pregnant woman had an ultrasound and was diagnosed with a type of Placenta Previa that the
implantation in the lower rather than in the upper portion of the uterus. With this diagnosis it means that the
patient has:
A. Placenta Previa
B. Low-lying Placenta
C. Marginal Implantation
D. Total Placenta Previa
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________ ________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
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LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
1
2
3
4
5
6
7
17
18
19
20
21
22
23
32
33
34
35
36
37
38
PERIOD 1
8
9
PERIOD 2
24
PERIOD 3
39
10
11
12
13
14
15
16
25
26
27
28
29
30
31
40
41
42
43
44
45
46
AL STRATEGY: CAT: Student Response Cards
1. You instructor will give you response card with answers on it and will disseminate.
2. Your instructor will ask a question to the class regarding information just covered in your lesson.
3. You and your classmates will hold up their card with the corresponding answer to the question of your instructor.
(For next session, review Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication Premature Rupture of Membranes p.546 and Hypertensive Disorders in Pregnancy p.547)
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NUR 145 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 9
LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT
CLIENT (GESTATIONAL CONDITIONS-PREMATURE
RUPTURE OF MEMBRANES and HYPERTENSIVE
DISORDERS OF PREGNANCY)
Materials:
Book, pen, SAS and notebook
LEARNING OUTCOMES:
Reference:
At the end of the lesson, the student nurse can:
1. Define Premature Rupture of Membranes and Hypertensive
Disorders of Pregnancy its relation to pregnancy, including preexisting factors that contribute to its development.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate knowledge of Premature Rupture of Membranes
and Hypertensive Disorders of Pregnancy in relation to
pregnancy and nursing process to achieve quality maternal and
child health nursing care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
Please refer to Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication-Premature Rupture
of Membranes p. 546
PREMATURE RUPTURE OF MEMBRANES (PROM)
 Loss of amniotic fluid before 37 weeks AOG
Therapeutic Management
 Strongly associated with infections of membranes
 Induction of labor by Oxytocin (for Term
(Chorioamnionitis)
pregnancy, with no labor for 24 hours)
 Preterm labor follows rupture of membranes and
 -to prevent infection
ends the pregnancy
 Preterm babies-immediate delivery
 Associated with vaginal infection (Neisseria
 Administer corticosteroid to hasten lung maturity
Gonorrhea, Group B streptococcus and
 Prophylactic administration of Broad-spectrum
chlamydia)
antibiotics
 Cause: unknown
 Amnioinfusion to reduce pressure on the fetus or
cord to allow a safer transfer
Assessment
 Sudden gush of clear fluid from her vagina with
continued minimal leakage
 Turns nitrazine paper to blue
 Test for ferning
 Amniotic fluid index via ultrasound
 WBC count and C-reactive protein (Increased in
PROM)
 AVOID DOING ROUTINE EXAMINATION TO
MINIMIZE THE RISK FOR INFECTION
Pano malalaman kung urine o amniotic fluid ang
lumabas kay mommy? nitrazine paper o amuyin
Complications
 Uterine and Fetal Infections
 Increased pressure on the umbilical cord from the
loss of amniotic fluid
 Cord Prolapse
 Potter-like Syndrome- distorted facial features
and pulmonary hypoplasia from uterine pressure.
e
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Hypertensive Disorders of Pregnancy
Please refer to Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication -Hypertensive
Disorders of Pregnancy p. 547
Definition
Factors:
 It is a disorder that begins during pregnancy in
 Young primigravida
which vasospasm in both small & large arteries
 women older than 35
occur.
 multiple gestation
 It is associated with signs of hypertension,
 genetic or immunologic factors
proteinuria & edema.
 poor nutrition
 It is unique to pregnancy
 Diabetes Mellitus
 Previously known as TOXEMIA
 Hydatidiform Mole
Classifications
Management
1. GESTATIONAL Hypertension
1. Mild Preeclampsia-can be managed at home
 BP = 140/90 mm Hg or systole elevated 30 mm
 Bed rest (left side-lying)- Na tends to be excreted
Hg or diastole elevated 15 mm Hg above prefaster
pregnancy level; returns to normal after childbirth
 Good nutrition- balanced diet with mod. salt &
 No proteinuria or edema
protein; low Na increases aldosterone secretion
 Provide emotional support
2. MILD PREECLAMPSIA
 BP = 140/90 mm Hg taken on 2 occasions at least
2. Severe Preeclampsia
6 hours apart
 CBR in the hospital
 systolic BP > by 30 mm Hg & diastole > by 15 mm
 Institute seizure precautions:
Hg from pre-pregnancy levels
 private room
 Proteinuria- 1+ or 2+ on a random sample
 dim lighting
 edema in the upper body, weight gain > 2
 minimal handling
lbs/week in the 2nd trimester or 1 lb/week in the
 avoid jarring of bed
3rd trimester
 avoid noise
 raise side rails
3. SEVERE PREECLAMPSIA
Prepare at the bedside:
 BP = 160/110 mm Hg or above on at least 2
 tongue blade
occasions 6 h apart & at bed rest
 O2 tank
 diastole is 30 mm Hg above pre-pregnancy level
 suction machine
 marked proteinuria- 3+ or 4+ in a random sample
 Avoid stress- give clear explanations of
or > 5 g in a 24-hr sample
what is happening & what is planned
 extensive edema- puffiness in the face & hands
 Monitor BP q 4 hours or continuously
*nonpitting edema- cannot be indented
with finger pressure
Laboratory studies:
 oliguria – 400 to 600 ml urine per 24 hours or < 30
 CBC
cc/hour
 platelet count
 headache, blurred vision, epigastric pain,
 hematocrit
dyspnea, N/V
 hemoglobin
 hyperreflexia (+1 hyporeflexia, +2 normal, +3 brisk,
 liver & kidney function tests
+4 hyperreflexia)
 blood typing
 cross-matching
EDEMA GRADING
 1+ pitting edema- can be indented slightly
 Obtain daily weights at the same time each day
 2+ pitting edema- moderate indentation
using the same type of clothing
 3+ pitting edema- deep indentation
 Monitor urine output (I & O)
 4+ pitting edema- indentation so deep it remains
 Monitor fetal well-being
after removal of the finger
 Diet with moderate or high protein & moderate
I sodium
Complete bed rest without bathroom privileges
Can rest undisturbed
O daily - increased hematocrit -> increased fluid leaving the bloodstream for interstitial fluid
Intake and output
Medications:
 hypotensive drug, hydralazine (Apresoline) or
labetalol (Normodyne)
— acts to lower blood pressure by peripheral dilatation

— it does not interfere with placental circulation
Side effects: cause maternal tachycardia
Magnesium sulfate
 cathartic to reduce edema,
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

TONIC-CLONIC seizures
 before a seizure BP rises suddenly,
 temperature rises to 39.4 or 40°C,
 vision blurs,
 headache
 reflexes become hyperactive
STAGES OF A SEIZURE:
1. Aura- a term used to describe symptoms that may
occur before a seizure
2. TONIC STAGE all the muscles contract, her back
arches, arms & legs stiffen, jaw closes abruptly
(may bite her tongue off), respirations halt.
3. CLONIC PHASE- all muscles relax & contract &
relax repeatedly causing extremities to flail wildly;
inhales & exhales regularly & may aspirate her saliva;
-incontinence is possible; lasts up to 1 minute
CNS depressant;
1st given via IV infusion in a loading or bolus
dose over 15 mins (BP lowers immediately
but lasts for only 50 to 60 mins)
 To prevent convulsions, 5 to 6 mg/100 ml
 Always as a piggyback infusion
 urine output must be > 30 ml/hr &
 RR > 12/min,
 serum Mg < 7.5 mEq/L
 MgSO4 toxicity leads to respiratory
depression, arrhythmia, cardiac arrest
*MgSO4 toxicity symptoms: (BURP)
BP low
Urine output low ( < 100 ml in 4 hours)
RR < 12 breaths/min
**Keep CALCIUM GLUCONATE at bedside (antidote to
MgSO4)
Patellar reflexes absent
• Before administering magnesium sulfate,
check respiratory and kapag mababa yung
urine output, wag i-administer
3. Eclampsia
 Maintain patent airway
 Administer O2; assess oxygenation
 Monitor FHT, contractions, vaginal
bleeding (q 15 mins)
 Position on her side to prevent aspiration
 Raise side rails, remove sharp or pointed
objects
 Keep her NPO
 Medications: MgSO4, diazepam
If > 24 weeks AOG, delivery within 12 to 24 hours
preferably vaginal delivery
Postpartum HPN- may occur up to 10 to 14 days after
birth, usually within 48 hours
4. POST-ICTAL STAGE-Semi-comatose for 1 to 4
hours
*fetal prognosis is poor due to hypoxia &
consequent acidosis
Complications:
 cerebral hemorrhage,
 liver rupture,
 coma,
 fetal death
4. ECLAMPSIA
 most severe classification
 cerebral edema is so acute that seizure or coma
occurs
 happens late in pregnancy & up to 48 hours after
birth
HELLP SYNDROME
 variation of PIH named for the symptoms:
Hemolysis, Elevated Liver enzymes, & Low
Platelet count
 occurs in 4% to 12% of patients who have
elevated blood pressure during pregnancy
Laboratory Studies
 RBC hemolysis
 Thrombocytopenia (platelet count <100,000/mm3)
 Elevated liver enzymes (Aspartate Amino
Transferase (AST) and Alanine Amino
Transferase (ALT)) due to hemorrhage and
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


occurs in both primigravida and multigravida
associated with APS (Antiphospholipid
Syndrome)
Cause: UNKNOWN
Assessment
 Proteinuria
 Edema
 Elevated blood pressure
 Nausea
 Epigastric Pain
 General Malaise
 Right Upper Quadrant tenderness from liver
inflammation
necrosis of liver
Normal Values for AST 7-30 IU/L and ALT 9-25 IU/L
Management
 Transfusion of Fresh Frozen Plasma/ Platelet
Concentrate
 Delivery of the baby can be via vaginal or CS
birth.
 Monitor for maternal hemorrhage after delivery
due to poor clotting ability.
 Epidural anesthesia is not possible due to
possible bleeding at the epidural site.
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
1. A pregnant client was admitted to the hospital with a diagnosis of Premature Rupture of Membrane as an initial
diagnosis. All of the following is true regarding PROM, EXCEPT:
A. Sudden gush of clear fluid from her vagina with continued minimal leakage
B. Turns nitrazine paper to red
C. Positive test for ferning
D. Increased WBC count and C-reactive protein
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. A pregnant client came to the hospital with a complaint of sudden pop and burst of fluid. Upon assessment
she is diagnosed with Premature Rupture of Membranes. Which of the following is true regarding PROM?
A. Loss of amniotic fluid before 40 weeks AOG
B. Not associated with infections of membranes (Chorioamnionitis)
C. Preterm labor follows rupture of membranes and ends the pregnancy
D. Not associated with vaginal infection (Neisseria Gonorrhea, Group B streptococcus and chlamydia)
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. A pregnant client was admitted to the hospital with a diagnosis of Premature Rupture of Membrane as an initial
diagnosis. All of the following true regarding the management of PROM, EXCEPT:
A. Preterm babies should delay the delivery for them to fully mature.
B. Administer corticosteroid to hasten lung maturity
C. Prophylactic administration of Broad-spectrum antibiotics
D. Amnioinfusion to reduce pressure on the fetus or cord to allow a safer transfer
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. A woman has been diagnosed as having Premature Rupture of Membranes, Which of the following condition is
the most typical for PROM?
A. Increased perspiration
B. Weight loss
C. Susceptibility to infection
D. Blood pressure elevation
ANSWER: ________
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RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5. The following are associated with vaginal infection that can cause Premature Rupture of Membranes in
pregnant women, EXCEPT:
A. Neisseria Gonorrhea
B. Group B streptococcus
C. Chlamydia Trachomatis
D. Mycobacterium Tuberculosis
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. A pregnant woman came to the hospital with BP of 140/90 mm Hg, urinalysis show no proteinuria and no
edema. Which type of Hypertensive Disorder of Pregnancy does the woman is classified into:
A. Eclampsia
B. Preeclampsia
C. Severe Preeclampsia
D. Gestational Hypertension
E. HELLP Syndrome
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7. A pregnant woman came to the hospital with BP of 210/180 mm Hg and was having a seizure. Which type of
Hypertensive Disorder of Pregnancy does the woman is classified into:
A. Eclampsia
B. Preeclampsia
C. Severe Preeclampsia
D. Gestational Hypertension
E. HELLP Syndrome
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. The following are management for pregnant woman who is diagnosed with Eclampsia who had seizure,
EXCEPT:
A. Complete bed rest at their home
B. Maintain patent airway
C. Position on her side to prevent aspiration
D. Raise side rails, remove sharp or pointed objects
E. Keep her NPO
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
9. You are administering Magnesium Sulfate for patient who is diagnosed with Eclampsia. Which of the following
should be on the bedside?
A. Tongue blade
B. Oxygen tank
C. Calcium Gluconate
D. Suction machine
ANSWER: ________
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RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
10. You are caring for a pregnant patient who is diagnosed with Eclampsia and had a doctor’s order to give
Magnesium Sulfate. Before giving the medication, which of the following is a sign that your patient is having
Magnesium Sulfate Toxicity?
A. Blood pressure of 210/100
B. Urine output is > 100 ml in 4 hours
C. Respiratory rate of 21 breaths/min
D. Patellar reflexes are absent
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
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LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
1
2
3
4
5
6
7
17
18
19
20
21
22
23
32
33
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35
36
37
38
PERIOD 1
8
9
PERIOD 2
24
PERIOD 3
39
10
11
12
13
14
15
16
25
26
27
28
29
30
31
40
41
42
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AL STRATEGY: Minute Paper
1. Your student will ask you to use index cards or half-sheets of paper to provide written feedback to the following
questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?
2. After writing the instructor will collect the responses before you leave.
(For next session, review Chapter 22: Nursing Care of a Family Experiencing a Complication of Labor and Birth
p.597)
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 10
LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT
CLIENT (NURSING CARE OF A FAMILY EXPERIENCING A
COMPLICATION OF LABOR OR BIRTH-PROBLEMS WITH
THE PASSENGER)
Materials:
Book, pen, SAS and notebook
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:
1. Describe the common deviations in the power (i.e., force of
labor), the passage, or the passenger that can cause
complications during labor or birth.
Reference:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate knowledge the common deviations in the power
(i.e., force of labor), the passage, or the passenger that can
cause complications during labor or birth and nursing process to
achieve quality maternal and child health nursing care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
Problems with the Passenger
(Please refer to Chapter 23: Nursing Care of a Family Experiencing a Complication of Labor or Birth-Problems with the
Passenger p.609)
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FHR is
PROLAPSE OF THE UMBILICAL CORD
Definition
Predisposing Factors
 A loop of the umbilical cord slips down in front
 Premature rupture of membranes
of the presenting fetal part
 Fetal presentation other than cephalic
 It may occur any time after the membranes
 Placenta previa
have ruptured if the presenting part is not fitted
 Intrauterine tumors preventing the presenting part
firmly into the cervix
from engaging
 A small fetus
 CPD preventing firm engagement
 Hydramnios
 Multiple gestation
Assessment
 The cord may be felt as the presenting part on an initial vaginal examination during labor
 UTZ evidence (a CS is necessary before rupture of membranes)
 variable deceleration pattern becomes apparent
 The cord may be visible at the vulva
 To r/o prolapse, assess FHR immediately after rupture of membranes
Management
Nursing Consideration
 cord prolapse will lead to cord compression
 Monitor FHR and uterine contractions continuously.
because the presenting part will press against
 Monitor maternal temp every hour
the cord at the pelvic brim
 Placed the bag of fluid in a radian warmer to prevent
 Place the mother’s hips higher than her head:
chilling
knee-chest position
 Trendelenburg position- To cause the fetal
1. Prevention:
head to fall back from the cord
 Always assess FHT after membranes rupture
 Place woman on bed rest after membranes rupture
Nakikita iyon by CTG. CTG — Cardio tocography
irregular —>
Direct Cord
Compression
To detect infection (IMPORTANT)
2. Reduce pressure on the cord by:
 Place in Knee-chest or Trendelenburg position, or
place folded towel under the hips
 Put on sterile gloves and insert 2 fingers into the
vagina, then push presenting part upward
3. If cord is exposed to air, cover with saline-moistened
sterile compress to prevent drying.
 Drying of cord leads to atrophy & constriction of BV

Done in a
straight/
strict or
aseptic
technique
Amnioinfusion-to reduce compression on the
cord with infusion of 5ooml warmed NSS.
-Used for only a short time until the cervix
is fully dilated or a cesarean birth can be
arranged.
-Can also be performed for women with
oligohydramnios
Wina-warm para
hindi mag-chill
yung mother
During procedure, nakaIniiwasan ang variable
deceleration kaya we
need to monitor
lateral recumbent
position. Bawal ang
naka-supine kasi
iniiwasan ang
hypotension
4. Never replace the cord back into the vagina as it may
result in kinking and knotting obstructing blood flow
5. Administer O2 at 10 LPM to improve O2 supply to
fetus
6. Deliver baby ASAP:
 Vaginal delivery if cervix is fully dilated & no fetal
distress
 CS if cervix is not fully dilated & if fetal distress is
present
 Place a gloved hand in the vagina and manually lift
the fetal head off the cord
 Administer O2 at 10 LPM by face mask to the
mother to increase oxygenation to the fetus
 Tocolytic agent may be administered to reduce
uterine activity & pressure on the fetus
 Maintain continuous electronic fetal monitoring
 Prepare for rapid delivery vaginally or by CS
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REMEMBER C-O-R-D! for Emergency Management of
Cord Prolapse
Call for help
Organize delivery
Relieve pressure on the cord
Deliver
Problems with the Passageway
(Please refer to Chapter 23: Nursing Care of a Family Experiencing a Complication of Labor or Birth-Problems with the
Passageway p.617 and Anomalies of the Placenta and Cord p. 619)
ABNORMAL SIZE AND SHAPE OF THE PELVIS
1. INLET CONTRACTION
TRIAL LABOR
 Done when the inlet has a borderline measurement (just
 It is the narrowing of the anteroposterior
adequate) and the fetal lie & position is good
diameter of the pelvis to < 11 cm, or the
 It is allowed to continue as long as descent and dilatations
transverse diameter to 12 cm or less
continue to occur.

Urge her to void every 2 hours
 Usually caused by rickets in early life or
 After rupture of membranes, assess FHR; if head is still
inherited pelvic size
high, increased risk for UC prolapse
 If after a definite period (6-12 hours) adequate progress is
 “what goes in comes out”- a head that
not apparent, CS is done
engages proves it fits into the pelvic brim
& will probably be able to fit through the
midpelvis and outlet

It makes engagement difficult (in primis,
at 36-38 wks; in multis, during labor)

It influences fetal position and
presentation

Primigravidas must have pelvic
measurements done before 24 weeks
2. OUTLET CONTRACTION
 Narrowing of the transverse diameter of
the outlet to < 11 cm (distance between
the ischial tuberosities)
CEPHALOPELVIC DISPROPORTION
 Fetal head is too large to pass through the bony pelvis
 Symptom: fetal head does not descend even if there are
strong contractions
 Risks: prolonged labor, exhaustion, hemorrhage, infection,
fetal hypoxia and distress
 CS is necessary
SHOULDER DYSTOCIA
 Problem occurs at the 2 nd stage of labor, when the fetal
head is born but the shoulders are too broad to enter and
be born through the pelvic outlet
Symptoms:
 prolonged 2nd stage of labor
 arrest of descent,
 when the head appears on the perineum it retracts instead
of protruding with each contraction (TURTLE SIGN)
Maternal risks:
 lacerations,
 postpartum hemorrhage
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Fetal Risks:
 hypoxia,
 fractures to the clavicle,
 injury to neck and head
Management:
 McROBERT’S MANEUVER (as seen below)- ask patient
to flex her thighs sharply on her abdomen to widen the
pelvic outlet and allow the anterior shoulder to be born.
 Suprapubic pressure may be applied to help the shoulder
escape from beneath the symphysis pubis and be born.
ANOMALIES OF THE PLACENTA
Normal placenta:
 weighs 500 g
 15 to 20 cm in diameter,
 1.5 to 3 cm thick,
 weight is about 1/6 of the weight of the fetus
1. PLACENTA SUCCENTURIATA
 It has 1 or more accessory lobes
connected to the main placenta
 The small lobes may be retained in the
uterus leading to hemorrhage and
therefore must be removed
 The placenta appears torn at the edge
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2. PLACENTA CIRCUMVALLATA
 The fetal side of the placenta is
covered to some extent by the chorion
 The placenta is cup-shaped with raised
margins with the whitish opaque chorion
covering the periphery
3. BATTLEDORE PLACENTA
 The cord is inserted marginally rather
than centrally giving the appearance of
a tennis racket
4. VELAMENTOUS INSERTION OF THE
CORD
 The cord, instead of entering the
placenta directly, separates into small
vessels that reach the placenta by
spreading cross a fold of amnion
 Usually found with multiple gestation & is
associated with anomalies
5. VASA PREVIA
 The umbilical vessels of a velamentous
cord insertion cross the cervical os &
deliver before the fetus
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6. PLACENTA ACCRETA
 It is the unusually deep attachment of
the placenta to the uterine
myometrium
 Attempts to remove it will lead to massive
hemorrhage because of the deep
attachment
 Hysterectomy or treatment with
methotrexate to destroy the still-attached
tissue may be necessary
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. You are caring for a pregnant patient who was rushed to the delivery room due to Cord Prolapse. The following
are predisposing factors for this diagnosis, EXCEPT:
A. Premature rupture of membranes
B. Intrauterine tumors preventing the presenting part from engaging
C. A small fetus
D. CPD preventing firm engagement
E. Oligohydramnios
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
2. The following are assessment findings for Cord Prolapse, EXCEPT:
A. The cord may be felt as the presenting part on an initial vaginal examination during labor
B. Ultrasound evidence of prolapse of umbilical cord
C. Late deceleration pattern becomes apparent
D. The cord may be visible at the vulva
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
3. The following are nursing consideration with Cord Prolapse, EXCEPT:
A. If cord is exposed to air, cover with saline-moistened sterile compress to prevent drying.
B. Replace the cord back into the vagina to avoid kinking and knotting obstructing blood flow
C. Administer O2 at 10 LPM by face mask to the mother to increase oxygenation to the fetus
D. Reduce pressure on the cord by placing the pregnant client in Knee-chest or Trendelenburg position
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
4. You are explaining to a patient regarding possible fetal complications with Cephalopelvic Disproportion. The
following are fetal complications of Cephalopelvic Disproportion, EXCEPT
A. Postpartum hemorrhage
B. Hypoxia
C. Fractures to the clavicle
D. Injury to neck and head
ANSWER: ________
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RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
5. Which of the following statement is true regarding Cephalopelvic Disproportion:
A. A loop of the umbilical cord slips down in front of the presenting fetal part
B. Narrowing of the anteroposterior diameter of the pelvis to < 11 cm
C. Narrowing of the transverse diameter of the outlet to < 11 cm
D. Fetal head is too large to pass through the bony pelvis
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
6. It is the narrowing of the anteroposterior diameter of the pelvis to < 11 cm, or the transverse diameter to 12 cm
or less that is usually caused by rickets in early life or inherited pelvic size.
A. Outlet Contraction
B. Inlet Contraction
C. Cervical Contraction
D. Vaginal Contraction
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
7. A type of placental abnormality wherein the placenta has 1 or more accessory lobes connected to the main
placenta that the small lobes may be retained in the uterus leading to hemorrhage and therefore must be
removed:
A. Battledore Placenta
B. Velamentous Insertion of the Cord
C. Placenta Circumvallata
D. Placenta Succenturiata
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
8. A type of placental abnormality wherein the placenta is cup-shaped with raised margins with the whitish
opaque chorion covering the periphery:
A. Battledore Placenta
B. Velamentous Insertion of the Cord
C. Placenta Circumvallata
D. Placenta Succenturiata
ANSWER: ________
RATIO:___________________________________________________________________ ________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________
9. A type of placental abnormality where the cord is inserted marginally rather than centrally giving the
appearance of a tennis racket:
A. Battledore Placenta
B. Velamentous Insertion of the Cord
C. Placenta Circumvallata
D. Placenta Succenturiata
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
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10. A type of placental abnormality wherein the cord, instead of entering the placenta directly, separates into
small vessels that reach the placenta by spreading cross a fold of amnion:
A. Battledore Placenta
B. Velamentous Insertion of the Cord
C. Placenta Circumvallata
D. Placenta Succenturiata
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
______________________________________________________________________________ _______________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
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LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
1
2
3
4
5
6
7
17
18
19
20
21
22
23
32
33
34
35
36
37
38
PERIOD 1
8
9
PERIOD 2
24
PERIOD 3
39
10
11
12
13
14
15
16
25
26
27
28
29
30
31
40
41
42
43
44
45
46
AL STRATEGY: CAT: Student Response Cards
1. You instructor will give you response card with answers on it and will disseminate.
2. Your instructor will ask a question to the class regarding information just covered in your lesson.
3. You and your classmates will hold up their card with the corresponding answer to the question of your instructor.
(For next session, review Chapter 23: Nursing Care of a Family Experiencing a Complication of Labor or BirthComplications with the Power p.598)
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 11
LESSON TITLE: CARE OF A FAMILY EXPERIENCING A
COMPLICATION OF LABOR OR BIRTH-COMPLICATION
WITH THE POWER
LEARNING OUTCOMES:
Materials: Book, pen, SAS and notebook
At the end of the lesson, the student nurse can:
Reference:
1. Describe the common deviations in the power (i.e., force of
labor), the passage, or the passenger that can cause
complications during labor or birth.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate knowledge the common deviations in the power
(i.e., force of labor), the passage, or the passenger that can
cause complications during labor or birth and nursing process to
achieve quality maternal and child health nursing care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
Complication with the Power (The Force of Labor)
(Please refer to Chapter 23: Nursing Care of a Family Experiencing a Complication of Labor or Birth-Complications with
the Power p.598)
DYSTOCIA
— Prolonged, painful
-a difficult labor which can arise from the POWER, the PASSAGEWAY, the PASSENGER, PSYCHE and medical
interventions
-labor that lasts >24 hours
COMMON CAUSES OF DYSFUNCTIONAL LABOR

Inappropriate use of analgesia (excessive or too
early administration)

Pelvic bone contraction that has narrowed the
pelvic diameter so that a fetus cannot pass
(rickets)
— Softening and weakening of bones due to extreme and prolonged Vitamin D
COMPLICATIONS WITH THE POWER (FORCE OF
LABOR)
INERTIA- sluggishness of contractions, now known as
DYSFUNCTIONAL LABOR
PRIMARY (occurring at the onset of labor) or
SECONDARY (occurring later in labor)
deficiency

Poor fetal position (posterior rather than anterior
positions) Ideally, the position of the baby is cephalic or occiput anterior presentation

Extension rather than flexion of the fetal head

Overdistention of the uterus, as with multiple
pregnancy, hydramnios, or an excessively
oversized fetus
Ideally the chin is touching the chest (AKA Flexion)
UTERINE TONES
Uterine Contraction — basic force that moves the
fetus through the birth canal
NORMAL VALUES:
RESTING TONE= 5-15 mm Hg
MILD CONTRACTION= 15-30 mm Hg
MODERATE CONTRACTION= 30-50 mm Hg
STRONG CONTRACTION= 50-75 mm Hg
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
Cervical rigidity (unripe)

Presence of a full rectum or urinary bladder that
impedes fetal descent

Mother becomes exhausted from labor

Primigravida status
INEFFECTIVE UTERINE FORCE
1. HYPOTONIC CONTRACTIONS (SECONDARY
INERTIA) HYPOTONIC UTERINE INERTIA
 The number of contractions is low or
infrequent ( not increasing beyond 2 or 3
in a 10-minute period
 Resting tone of the uterus remains < 10
mm Hg, & strength of contractions does
not rise above 25 mm Hg
 Common in the ACTIVE PHASE
 Increases length of labor & uterus does
not contract effectively postpartally due to
exhaustion, increasing chance for
postpartal hemorrhage
 Cervix is dilated for prolonged periods
increasing risk for infection of mother &
fetus
CAUSES OF HYPOTONIC UTERUS
Kapag hindi nagiincrease yung
strength of
contractions, there
COMPLICATIONS




Maternal/fetal infections- cervix is dilated for a
prolonged time
Postpartum hemorrhage
Fetal distress and death
Maternal exhaustion
will be insufficient for
progress of cervical
effacement and
dilatation
—Dilatation is the
fully opening of the
cervix (10cm)
—Effacement is the
thinning of cervix


administration of analgesia when cervix is not
dilated to 3 or 4 cm,
bowel or bladder distention- prevents descent or
firm engagement,
Nursing
multiple gestation,
Responsibilities
LGA fetus,
• Assess maternal
pulse and BP for
hydramnios,
hypotension
lax uterus due to grand multiparity possible
• Monitor the FHR
—This is when baby’s
head moves down further




for signs of fetal
distress
• Monitor the I and O
for possible water
intoxication-vomiting
or HA
2. HYPERTONIC UTERUS (PRIMARY INERTIA)
 Increase in resting tone to > 15 mm Hg, mostly
seen in the LATENT PHASE
 Muscle fibers do not repolarize or relax after a
contraction, thereby wiping it clean to receive a
new pacemaker stimulus
 More painful because the myometrium becomes
tender from constant lack of relaxation & the
anoxia of uterine cells that results
 Lack of relaxation between contractions may not
allow uterine artery filling leading to fetal anoxia
 **Any woman whose pain is out of proportion to
MANAGEMENT OF HYPOTONIC UTERUS


UTZ to rule out CPD
Walking, if not contraindicated

OXYTOCIN to augment labor by strengthening
contractions & making them effective

Amniotomy to speed up labor
AROM or Amniotomy — artificial rupture of membranes
•breaking the water
usually kapag ni-rupture ang amniotic sac, magpupulsit daw
dapat malayo ka sa irurupture.

st
1 hour postpartum, palpate the uterus and
assess lochia q 15 minutes to ensure that
postpartum contractions are not also hypotonic &
inadequate to halt bleeding
OXYTOCIN FOR HYPOTONIC UTERINE
CONTRACTION
action of oxytocin is to initiate uterine contractions (administered intravenously, incorporated in iv fluid)
example: 10 IU Oxytocin + 1000 mL LR
Do not leave patient alone
Client must be in true labor- at least 3 cm
No obstruction, uterine overdistention, multiple
gestation
 Monitor V/S especially BP (most important
because oxytocin may cause hypo/hypertension
 Assist w/ delivery: after failed trial labor of 6 hours
 After delivery: observe for signs of injury & signs
of poor bonding dt difficult delivery
MANAGEMENT OF HYPERTONIC UTERUS




Rest & pain relief with a drug like morphine sulfate
& sedatives
Provide adequate fluid for hydration

Change linen and client’s gown, darken the room
lights, decrease noise & stimulation

If (+) for deceleration in FHR, abnormally long 1 st
stage of labor, or lack of progress with pushing
(“SECOND STAGE ARREST”), CS may be
necessary
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the quality of her contractions should have both
a uterine & fetal external monitor applied for at
least 15 mins to make sure that the resting phase
of contractions is adequate & that the fetal pattern
is not showing late deceleration.
HYPOTONIC VERSUS HYPERTONIC CONTRACTIONS
CRITERIA
HYPERTONIC
HYPOTONIC
Phase of Labor
Latent
Active
Symptoms
Painful
Painless
Oxytocin
Unfavorable
reaction
Favorable
reaction
Sedation
Helpful
Little value
Medication
3. UNCOORDINATED CONTRACTIONS
 Can occur so closely together that they can
interfere with the blood supply to the placenta.
CONTRACTION RING
 It is a hard band that forms across the uterus at
the junction of the upper and lower uterine
segments and interferes with fetal descent.

BANDL’S RING or PATHOLOGIC
RETRACTION RING (as seen below)- a type of
contraction ring that usually appears at the 2 nd
stage of labor & can be palpated as a horizontal
indentation across the abdomen.

It is a warning sign that severe dysfunctional labor
is occurring as it is formed by excessive retraction
of the upper uterine segment; the myometrium is
much thicker above than below the ring.

It is caused by uncoordinated contractions due to
CPD, manipulation or the use of oxytocin.

The fetus and the undelivered placenta are
gripped by the retraction ring and cannot advance
beyond this point.
Complications
 Uterine rupture
 Neurologic damage to the fetus
Management
 Applying a fetal and uterine external monitor.
 Administration of IV morphine sulfate or inhalation
of amyl nitrate
 Tocolytics to halt the contractions
 Cesarian birth to ensure safety of the fetus and
manual removal of the placenta under general
anesthesia
— given to relax the contraction ring
inhibit labor, slow
down, halt contraction
of the uterus
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DYSFUNCTIONAL LABOR AND ASSOCIATED STAGES OF LABOR
LENGTHS OF PHASES AND STAGES OF NORMAL LABOR IN HOURS
NULLIPARA
MULTIPARA
AVERAGE
UPPER NORMAL
AVERAGE
UPPER NORMAL
First stage: time span from beginning of regular contractions to complete cervical dilatation
Latent Phase: onset
8.6 hr
20.0 hr
5.3 hr
14.0 hr
of labor to 4cm
dilatation
Active Phase: 4cm
4.9 hr; minimum rate
12.0 hr
2.5 hr; minimum rate
6.0 hr
to complete dilatation of dilatation 1.2 cm/hr
of dilatation 1.5 cm/hr
Second Stage: from
1 hr
Under 2 hr without
.5 hr
Under 1 hr without
full dilatation to birth
epidural; under 3 hr
epidural; under 2 hr
with epidural
without epidural
of infant
Placental Stage
30 min
30 min
1. Dysfunction at the First Stage of Labor
2. Dysfunction at the Second Stage of Labor
a. Prolonged Latent Phase
 Contractions becomes ineffective during the first
stage.
 Prolonged latent phase that uterus tends be in
hypertonic state.
Management:
 Providing adequate rest
 Adequate fluid for hydration
 Pain relief (Morphine Sulfate)
 Dark room, decrease noise and stimulation
 Amniotomy
 Oxytocin infusion to assist labor
 Cesarean Delivery
b. Protracted Active Phase
 Usually associated with fetal malposition or
Cephalopelvic Disproportion (CPD) and prolonged
cervical dilation
Management:
 Augmentation of labor with Oxytocin if CPD is not
present
 Cesarean delivery if CPD or fetal malposition
c. Prolonged Deceleration Phase
 deceleration phase is prolonged beyond 3hrs in
nullipara or 1hr in multigravida.
 Most often results from abnormal fetal head
position.
a. Prolonged Descent



Management:
 Ultrasound to rule out sudden faulty contractions,
CPD and poor fetal presentation
 Providing adequate rest
 Adequate fluid for hydration
 Amniotomy
 Induction of labor with Oxytocin infusion
 A semi-fowlers position, squatting and kneeling
may speed descent
b. Arrest of Descent
 no descent has occurred for 2hours in a nullipara
or 1hour in a multipara.
Failure of Descent-occurs when expected descent of the
fetus does not begin or engagement or movement beyond
0 station does not occur.
Cause:

Management:
 Cesarean birth
Rate of descent is less than 1.0cm/hr in a
nullipara or 2.0cm/hr in multipara
Prolonged active phase and prolonged
descent
Contractions are good quality, duration,
effacement and beginning dilation have
occurred then becomes infrequent, poor
quality and dilatation stops.
CPD
d. Secondary Arrest of Dilatation
 no progress in cervical dilatation for longer than 2
hours
Management:
 Cesarean Section
 Induction of labor with Oxytocin infusion if there is
no contraindication to vaginal birth
Management:
 Cesarean birth
PRETERM/PREMATURE LABOR
Definition:
Management
 Lab test to detect presence of fetal fibronectin to
Fetal fibronectin is a protein that is believed to help keep amniotic sac
"glued" to the lining of the uterus
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
labor that occurs before the end of 37 weeks of
gestation
Associated with:
 Dehydration
 Urinary tract infection
 Periodontal disease
 Chorioamnionitis
 Large fetal size
 Strenuous jobs during pregnancy
 Shift work
 Intimate partner violence and trauma
gums are swollen and
red or bleeding
Assessment
 Persistent uterine contractions (4 contractions
every 4 minutes or less)
 Low abdominal cramping with or without diarrhea
 Intermittent sensation of pelvic pressure, urinary
frequency
 Persistent, dull low backache
 Increased vaginal discharge, may be pink-tinged
 Leaking amniotic fluid
 Cervical effacement > 80% & dilatation > 1 cm
Drug





predict impending delivery; if absent, labor will not
occur for at least 14 days
UTZ of cervix to determine shortening
Patient is admitted & placed in complete bed rest
(preferably left side-lying) to relieve pressure of
the fetus on the cervix
IV fluid to maintain hydration which may help stop
contractions (dehydration stimulates PG to
secrete oxytocin)
Vaginal, cervical & urine cultures to rule out
infection
Increase fluid intake since a full bladder inhibits
contractions
TOCOLYTICS- to halt labor
Discharge- once contractions have stopped and
maternal and fetal conditions have stabilized
No MEPERIDINE(DEMEROL)
Terbutaline — prevent and treat bronchospasm and



can be used as a tocolytic agent
— should not be given over 48 to 72 hours —>
serious maternal heart problems
Analyze vaginal
discharge or vaginal
mucous if there is
presence of fetal
Fetal fibronectin is a protein that is believed
to help keep amniotic sac "glued" to the
lining of the uterus
fibronectin
TOCOLYTIC AGENTS TO HALT LABOR
Type/purpose
Major side effects
RITRODRINE
(YUTOPAR)
ß-adrenergic receptor
agonist/tocolysis
TERBUTALINE
(BRETHINE)
ß-adrenergic/tocolysis;
antidote: PROPANOLOL
MAGNESIUM
SULFATE
CNS
Depressant/Tocolysis
BETAMETHASONE
(CELESTONE) OR
DEXAMETHASONE
Corticosteroid/ stimulates
fetal lung maturation by
stimulating surfactant
production
PRECIPITATE LABOR
Nursing concerns
Maternal or fetal tachycardia,
shortness of breath,
pulmonary edema, tremors,
N/V, hyperglycemia,
hypokalemia
SAME AS ABOVE
Assess VS, breath
sounds, FHR,
contractions &
maternal response
Lethargy, heat sensation,
respiratory depression,
depressed reflexes, cardiac
arrest if high serum levels (>
10-12 mg/dl)
Increased risk of infection &
poor wound healing,
hypoglycemia, increased risk
of pulmonary edema when
given with a ß-adrenergic
agent
Assess RR, DTR,
hourly urinary output,
serum Mg levels
SAME AS ABOVE
Must be given 24 to
48 hours before
delivery to be
effective; commonly
used between 24 to
34 weeks AOG
unless fetal lung
maturity can be
documented
Fetal Complications:
Definition:

Fetal hypoxia, anoxia

it is a labor that is completed in < 3 hours

Erb-Duchenne palsy

It occurs when uterine contractions are so strong
that the woman gives birth with only a few, rapidly

Injuries like falling to the floor in unattended
childbirth
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occurring contractions.

Average labor
Causes:
•Primipara — 15 hours
•Multipara — 8 hours
grand multiparity
Large Pelvis
Small Fetus
induction of labor by OXYTOCIN or
AMNIOTOMY
Symptoms:




Management

TOCOLYTICS

In multiparous women with history of a brief past
labor, advise to prepare for appropriately timed
transport starting on her 28 th week of
gestation (BIRTH PLAN)

Never leave client

Monitor FHT q15 min

Provide emotional support: inform client of what is
happening
Rate of cervical dilatation (average)
Nullipara — 1cm/hr
Multipara — 1.2cm/hr


rate of dilatation in the active phase: > 5 cm/hr (1
cm/12 mins) in a nullipara
10 cm/hr (1 cm/6 mins) in a multipara; tocolytics
may be administered
Subdural hemorrhage on the fetus due to sudden
release of pressure on the head, hemorrhage
Maternal Complications:

premature separation of the placenta leading to
hemorrhage,

Assist with the delivery, advising the client to pant
or blow and NOT to push

infection

Never hold the baby back

lacerations on the birth canal


Uterine rupture

Amniotic fluid embolism
Support the perineum with a towel to prevent
lacerations and also subdural hemorrhage
(MODIFIED RITGEN’S MANEUVER) (as seen
below)

Deliver baby in-between contractions

Inspect the perineum for possible lacerations
Erb-Duchene Palsy
—Paralysis of the arm caused by injury to the upper trunk C5-C6 nerves.
in order to protect our sterile gloves kapag natouch yung anus nung mother
kailangan may towel yung non-dominant hand
INVERSION OF UTERUS
Definition:
 turning inside out of the uterus with either birth of
the fetus or the delivery of the placenta
Predisposing Factors
 Pulling or traction on the umbilical cord to remove
Management
 NEVER attempt to replace an inversion since
handling of the uterus will worsen the hemorrhage
 Never attempt to remove the placenta if it is still
kapag niremove it will cause bleeding
attached
 Oxytocic drugs makes the uterus more tense thus,
more difficult to replace
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

the placenta
Vigorous pressure is applied to the fundus while
the uterus is not contracted
The placenta is attached at the fundus and the
passage of the fetus during birth pulls it down
Types of Inversion
1. Complete or Total Inversion
 The uterus is visible outside the vaginal introitus
 Life threatening because of severe hemorrhage &
shock







2. Partial Inversion
 The inverted fundus may lie within the uterine
cavity
 It is not visible but may be palpated
 It hampers or impedes contractions & control of
hemorrhage
Assessment
 Sudden gushing of blood from the vagina
 Signs of blood loss: hypotension, dizziness,
paleness or diaphoresis
 Because bleeding is continuous, exsanguination
could occur within 10 minutes


Start an IV line (use a large-gauge needle to be
used in BT) & open it to achieve optimal flow to
restore fluid volume
Administer O2 by mask
Assess vital signs
Prepare to administer CPR pwede magstop yung heart due to blood loss
General anesthesia, nitroglycerin or a tocolytic is
administered to relax the uterus
Physician or midwife will then replace the
fundus manually
AFTER replacement (BIMANUAL
COMPRESSION/JOHNSON’S
METHOD/MANEUVER) (as seen below) then
administer Oxytocin
midwife or physician ung magbabalik
ng uterus. and also, administer
oxytocin after mabalik. the succeeding
or net pregnancy, cs na
Antibiotic therapy to prevent infection
CS is recommended for succeeding pregnancies
Bimanual Compression/Johnson’s Maneuver
—Begin by wearing sterile gloves
—Grasp the fundus with the palm of your hand
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1.The following are common causes of dysfunctional labor, EXCEPT:
A. Inappropriate use of analgesia
B. Poor fetal position
C. Extension rather than flexion of the fetal head
D. Flexion rather than extension of the fetal head
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. The number of contractions is low or infrequent, common in active phase of labor and it is not increasing
beyond 2 or 3 in a 10-minute period.
A. Hypotonic Contraction
B. Hypertonic Contraction
C. Isotonic Contraction
D. Prolonged Descent
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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3. You are caring for a woman that came to the delivery room whose labor pain is out of proportion to the quality
of her contractions.
A. Hypotonic Contraction
B. Hypertonic Contraction
C. Isotonic Contraction
D. Prolonged Descent
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. It is a hard band that forms across the uterus at the junction of the upper and lower uterine segments and
interferes with fetal descent.
A. Contraction Ring
B. Post-term Ring
C. Hypotonic Ring
D. Hypertonic Ring
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5. A type of dysfunctional labor in first stage of labor that is usually associated with fetal malposition or
Cephalopelvic Disproportion and prolonged cervical dilation.
A. Prolonged Latent Phase
B. Protracted Active Phase
C. Prolonged Deceleration Phase
D. Secondary Arrest of Dilatation
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. All but one is not associated with premature labor.
A. Dehydration
B. Urinary tract infection
C. Periodontal disease
D. Chorioamnionitis
E. Cephalopelvic Disproportion
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________________________________________ ____
7. The following are causes of precipitate labor, EXCEPT:
A. Chorioamnionitis
B. Grand multiparity
C. Large Pelvis
D. Small Fetus
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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8. A woman gave birth in a birthing facility and was brought to the hospital with a globular mass on her vaginal
orifice. You know that this condition is which of the following?
A. Uterine Atony
B. Uteroplacental Apoplexy
C. Uterine Inversion
D. Myoma Uteri
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
9. Most often results from abnormal fetal head position that the deceleration phase is prolonged beyond 3hrs in
nullipara or 1hr in multigravida.
A. Prolonged Latent Phase
B. Protracted Active Phase
C. Prolonged Deceleration Phase
D. Secondary Arrest of Dilatation
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
10. A pregnant client was admitted at 2:00 pm with a cervical dilation of 5cm and was ordered by the Obstetrician
to monitor her progress of labor after 4 hours you checked her cervical dilation is still the same. What type of
dysfunctional labor in first trimester does the client is experiencing?
A. Prolonged Latent Phase
B. Protracted Active Phase
C. Prolonged Deceleration Phase
D. Secondary Arrest of Dilatation
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
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RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
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PERIOD 1
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PERIOD 2
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PERIOD 3
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AL STRATEGY: CAT: Student Response Cards
1. Your instructor will give a set of student response card for each of you and your classmate which is labeled with
answer choices.
2. Your instructor will pose a question to the class regarding information just covered in your lesson.
3. Hold up their card with the corresponding answer to your instructor’s question.
(For next session, review Chapter 10: Nursing Care Related to Psychological and Physiological Changes of
Pregnancy p.203 and Chapter 10: Nursing Care Related to Psychological and Physiological Changes of
Pregnancy p.203)
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 13
LESSON TITLE: CARE OF A FAMILY EXPERIENCING A
POSTPARTUM COMPLICATION-POSTPARTUM
HEMORRHAGE
Materials: Book, pen, SAS and notebook
LEARNING OUTCOMES:
Reference:
At the end of the lesson, the student nurse can:
1. Define postpartum complications at risk for common
deviations from the normal that can occur during the
puerperium, including pre-existing factors that contribute to its
development.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate knowledge postpartum complications at risk for
common deviations from the normal that can occur during the
puerperium and formulating nursing care plan in giving quality
maternal and child health nursing care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
POSTPARTUM HEMORRHAGE
(Please refer to Chapter 25: Nursing Care of a Family Experiencing a Postpartum Complication-Postpartum Hemorrhages
p.649)
EARLY POSTPARTAL HEMORRHAGE
Definition: a blood loss > 500 ml in the 1 st 24 hours after vaginal delivery; greater with CESAREAN SECTION (1000Ml)
4 Main Reasons for Post-Partum Hemorrhage
UTERINE ATONY
TRAUMA/VAGINAL, CERVICAL & PERINEAL LACERATIONS, HEMATOMA, UTERINE INVERSION/RUPTURE)
RETAINED PLACENTAL FRAGMENTS
DEVELOPMENT OF DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
These causes are generally referred to as the 4 T’s of postpartum hemorrhage: TONE, TRAUMA, TISSUE and
THROMBIN.
LATE POSTPARTAL HEMORRHAGE
UTERINE SUBINVOLUTION
UTERINE ATONY
Definition
 Lack of uterine muscle tone or relaxation of the
uterus; hemostasis is due to contraction of the
muscles occluding the open vessels
Predisposing Factors
 large infant,
 multiple gestation,
 hydramnios,
Implementation
 Massage boggy uterus gently but firmly, cupping
uterus between 2 hands & avoiding over massage;
(normal: grapefruit-like)
 Bimanual massage if fundal massage & uterine
stimulants are ineffective
 Administer uterine stimulants: IV Pitocin,
Methergine
 Prostaglandin F2a derivatives may be given IM
 Hysterectomy is a last resort
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



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


precipitous labor,
dysfunctional labor,
retained placental fragments,
anesthesia,
MgSO4,
tocolytics,
low platelet count


Encourage frequent voiding to prevent bladder
distention that contributes to atony; Foley catheter
may be inserted
Blood products & fluids may be administered
Monitor VS, I & O, LOC, fundal tone & placement
& amount of bleeding; elevate legs 15 to 30
degrees
Maintain asepsis

Assessment
 history of labor & delivery
 bleeding every 10 to 15 mins for 1 hour, then q 30
mins for 1 hour until stable
 presence of clots
 Assist to a side-lying position & check pad
underneath frequently for pooling
 Weigh peri-pads to estimate blood loss (1 g of
weight is comparable to 1 ml blood)
 Palpate fundus for firmness, assess for height in
relation to umbilicus and position
 signs of shock
 bladder for fullness or distention
2. VAGINAL, CERVICAL AND PERINEAL LACERATION
VAGINAL, CERVICAL AND PERINEAL LACERATIONS

Most common after operations; a firm uterus with
bright-red blood or a steady stream or trickle of
unclotted blood
Predisposing Factors
Management
 Perineal lacerations are sutured & treated as an
episiotomy repair
 Foley catheter may be inserted
 Diet high in fluid, stool softener for the 1 st week
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primiparous state,
epidural,
precipitous birth,
macrosomia,
forceps delivery,
 episiotomy
3.PERINEAL HEMATOMA



MANAGEMENT
A collection of blood in the subcutaneous layer of
the tissue of the perineum.



CAUSES



after birth
For 3rd or 4th degree laceration, no enema &
suppositories
Avoid infection
Rapid, spontaneous birth
Perineal Varicosities
Injury to the blood vessels in the perineum
Report the presence of hematoma (estimated size
and swelling)
Administer a mild analgesic for pain relief
Apply iced pack to prevent further bleeding
If the hematoma continues to increase in size.

The site of hematoma will be incised and bleeding
vessels should ligated under local anesthesia
ASSESSMENT



Severe pain in the perineal area
Feeling of pressure between the legs
Purplish discoloration with obvious tender
swelling
4. UTERINE INVERSION (discussed on module 13)
UTERINE RUPTURE (p.607)
 Occurs most often in women who have a
previous cesarean scar.
ASSESSMENT

Has 2 distinct swelling on the abdomen:
Retracted uterus
Extrauterine fetus
Contributing Factors







Prolonged Labor
Abnormal presentation
Multiple gestation
Unwise use of oxytocin
Obstructed Labor
Traumatic Maneuvers of forceps or traction

Hemorrhage from the torn uterine arteries floods
into the abdominal cavity and possibly into the
vagina
Signs of hypotensive shock
Rapid, weak pulse
Low BP
Cold and clammy skin
Nasal flaring of the nostrils from air starvation
Fetal heart sounds fade then absent
ASSESSMENT


Sudden severe pain during a strong labor
“Tearing” sensation
MANAGEMENT
TYPES
1. COMPLETE RUPTURE-through the endometrium,
myometrium and peritoneum layers.

2. INCOMPLETE RUPTURE-localized tenderness and a
persistent aching pain over the area of lower uterine
segment.
Uterine contractions immediately stop





Fluid replacement therapy
Use of Oxytocin
Emergency laparotomy for control of bleeding and
birth of the fetus
Advise not to conceive again after the rupture of
uterus unless the rupture occurred in the inactive
lower segment
Cesarean with Hysterectomy or Tubal Ligation
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5. RETAINED PLACENTAL FRAGMENTS

Portion of placenta are left still attached to the
uterus that keeps it from contracting fully and
uterine bleeding occurs
MANAGEMENT



CONTRIBUTING FACTORS



Dilatation and Curettage (D&C)
Methotrexate may be prescribed to destroy the
retained placental fragments.
Continue to observe the color of lochia
Placenta Accreta
Placenta Succenturiata
Placenta Accreta
Previous Cesarean Section


Balloon occlusion and embolization of the
internal iliac arteries to minimize blood loss.
Hysterectomy
ASSESSMENT


Can be detected by ultrasound
Human Chorionic Gonadotropin (hCG) in the
blood
 Abrupt discharge and a large amount of vaginal
bleeding
 Uterus is not fully contracted
5. DISSEMINATED INTRAVASCULAR COAGULATION
(p.541)

An acquired disorder of blood clotting in which
the fibrinogen levels falls to effective limit.

Occurs when there is such an extreme bleeding
and so many platelets and fibrin from the general
circulation rush to the site.





Platelet count (< 100,000/µl)
Low prothrombin
Elevated thrombin time
Decreased Fibrinogen (<150mg/dl
Abnormal D-dimer analysis (specific for fibrin
degradation products)
MANAGEMENT
PREDISPOSING FACTORS






ASSESSMENT
 Stop the underlying cause such as:
Premature separation of placenta
-Premature separation of the placenta and
Hypertension of pregnancy
complication of pregnancy
Amniotic Fluid Embolism
-ending the pregnancy and deliver the placenta
Placental Retention
 Heparin administration IV then SQ
Septic Abortion
 Blood or platelet transfusion
Retention of a dead fetus
 Assess for blood coagulation studies
LATE POSTPARTAL HEMORRHAGE
UTERINE SUBINVOLUTION
MANAGEMENT
Failure of the uterus to return to its normal
prepregnant size and shape after pregnancy

Oral Methergine, 0.2 mg qid to improve uterine
tone & complete involution
It causes bleeding & occurs often within 1 to 2
weeks after childbirth because of retained
placental fragments; blood loss is excessive but
is less risky than immediate postpartal
hemorrhage
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CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1.The following are causes of postpartum hemorrhage, EXCEPT:
A. Uterine Atony
B. Trauma
C. Retained Placental Fragments
D. Chorioamnionitis
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. Lack of uterine muscle tone or relaxation of the uterus; hemostasis is due to contraction of the muscles
occluding the open vessels:
A. Uterine Rupture
B. Uterine Atony
C. Retained Placental Fragments
D. Placenta Accreta
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. The following are predisposing factors of Uterine Atony, EXCEPT:
A. dysfunctional labor
B. retained placental fragments
C. anesthesia
D. forceps delivery
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. A collection of blood in the subcutaneous layer of the tissue of the perineum.
A. Uterine Rupture
B. Vaginal, Cervical and Perineal Lacerations
C. Retained Placental Fragments
D. Perineal Hematoma
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5. Portion of placenta are left still attached to the uterus that keeps it from contracting fully and uterine bleeding
occurs:
A. Uterine Rupture
B. Uterine Atony
C. Retained Placental Fragments
D. Placenta Accreta
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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6. The following are contributing factors for Uterine Inversion/Rupture, EXCEPT:
A. Perineal Varicosities
B. Prolonged Labor
C. Abnormal presentation
D. Multiple gestation
E. Unwise use of oxytocin
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7. Failure of the uterus to return to its normal prepregnant size and shape after pregnancy:
A. Uterine Rupture
B. Uterine Atony
C. Uterine Subinvolution
D. Placenta Accreta
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. A classification of vaginal/perineal laceration wherein the entire perineum, rectal sphincter and some of the
mucous membrane of the rectum is lacerated:
A. First Degree Laceration
B. Second Degree Laceration
C. Third Degree Laceration
D. Fourth Degree Laceration
ANSWER: ________
RATIO:___________________________________________________________________________________________
_____________________________________________________________________________________________ ____
_________________________________________________________________________________________________
9. A classification of vaginal/perineal laceration wherein the vaginal mucous membrane and skin of the
fourchette is lacerated:
A. First Degree Laceration
B. Second Degree Laceration
C. Third Degree Laceration
D. Fourth Degree Laceration
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
10. A classification of vaginal/perineal laceration wherein the entire perineum is lacerated up to the rectal
sphincter:
A. First Degree Laceration
B. Second Degree Laceration
C. Third Degree Laceration
D. Fourth Degree Laceration
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 18
LESSON TITLE: CARE OF A FAMILY WITH A HIGH-RISK
NEWBORN
LEARNING OUTCOMES:
Materials:
Book, pen, SAS and notebook
At the end of the lesson, the student nurse can:
1. Define the common classifications of high-risk newborns and
describe common illnesses that occur in these classifications of
newborn.
Reference:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate the knowledge of the common classifications of
high-risk newborns and describe common illnesses that occur in
these classifications of newborn in formulating nursing care plan
in giving quality maternal and child health nursing care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
ILLNESSES THAT OCCUR IN NEWBORNS
Please refer to Chapter 26: Nursing Care of a Family with a High-Risk Newborn-Illnesses That Occur in Newborns p.696713
RESPIRATORY DISTRESS SYNDROME
 Formerly HYALINE MEMBRANE DISEASE
THERAPEUTIC MANAGEMENT
common in preterms, infants of diabetic moms, CS
Surfactant Replacement
birth, meconium aspiration
 Immediately given after birth, synthetic surfactant
is administered into the ET tube by a syringe or
Pathologic feature:
catheter (lung lavage)
-hyaline-like (fibrous) membrane formed from a
 Position: Tippled to an upright position
exudates of the infant’s blood.
 Adjust ventilator setting to accommodate the
vastly improved lung function.
Cause:
Oxygen
Administration
 lack of surfactant
th

To
maintain correct PO2 and pH levels ff
*Surfactant forms on the 34 week of gestation
surfactant administration.
 Can be administered by:
Pathophysiology
O2 Cannula or Mask
 40 to 70 cm H2O is required for the initial breath
CPAP
but only 15 to 20 cm H2O to maintain quiet
Assisted Ventilation with PEEP
respirations
 If alveoli collapse with each respiration, forceful
COMPLICATION:
inspirations are required to inflate them
Retinopathy of Prematurity
 Areas of hypo inflation begin to occur and ↑
Bronchopulmonary Dysplasia
pulmonary resistance causing blood to shunt
through the foramen ovale and the ductus
Perfusion is the flow of blood or fluid to tissues and organs, and
arteriosus
Additional Therapy
poor perfusion means this flow is insufficient.
 Poor perfusion depresses production of surfactant Nitric Oxide
even more
 It causes pulmonary vasodilation without
 Poor O2 exchange levels leads to tissue hypoxia,
decreasing systemic vascular tone by dilating
releasing lactic acid. This, plus ↑ CO2 causes
pulmonary arterioles.
formation of the hyaline membrane on the alveolar
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

surface leading to severe acidosis
Acidosis causes vasoconstriction, decreased
pulmonary perfusion & further limits surfactant
production
The vicious cycle continues until gas exchange
becomes inadequate to sustain life without
ventilator support
ASSESSMENT
 Difficulty initiating respirations at birth
 Low body temperature
 Nasal flaring
 Sternal & subcostal retractions
 Tachypnea ( > 60 respirations per minute)
 Cyanotic mucous membranes
 Periods of apnea
 Bradycardia
 Pneumothorax
 Expiratory grunting (due to closure of the glottis)
 Fine rales & diminished breath sounds
 Seesaw respirations ( on inspiration, anterior
chest wall retracts & abdomen protrudes, on
expiration, sternum rises)
 Heart failure, evidenced by decreased urine
output & edema of extremities
 Pale gray skin
DIAGNOSIS
 Clinical signs: grunting, cyanosis in room air,
tachypnea, nasal flaring, retractions & shock

Chest x ray: diffuse pattern of radiopaque areas
resembling ground-glass (haziness)

Blood gas reveals respiratory acidosis

* ß-hemolytic streptococcal infection may mimic
RDS. Cultures may be done to rule this out and
antibiotics (penicillin or ampicillin) may be given
while culture reports are pending










EXTRACORPOREAL MEMBRANE OXYGENATION
(ECMO)
 blood is removed by gravity using a venous
catheter in the right atrium of the heart. The
blood circulates to the ECMO machine, where it is
oxygenated & rewarmed. It is then returned to the
aortic arch through a catheter advanced through
the carotid artery
 Currently used in Severe Hypoxemia related to
Meconium Aspiration, RDS, Pneumonia,
Diaphragmatic Hernia
Prevention
 Monitor L/S ratio during pregnancy (Normal is 2:1)
 Avoid premature L &D (tocolytic agents)
 BETAMETHASONE, a is given to the mother at
12 & 24 hours. It is most effective when given
between 24 to 34 weeks of pregnancy. It does
not take effect before 24 to 48hours
 Liquid ventilation- use of perfluorocarbons which
picks up O2 and because they are heavy, help
distend the alveoli; the liquid spreads over the
lung surface, and gas exchange occurs
 Nitric oxide- it caused pulmonary vasodilation
which help increase blood flow to the lungs
 Keep infant warm to prevent acidosis & reduce
metabolic demand
TRANSIENT TACYPNEA OF THE NEWBORN
At birth, RR reaches 80 bpm; after 1 hour, RR slows down to 30 to 60 cpm
In some RR remains high at 80 to 120 cpm
Infant does not appear to be in distress aside from the effort of breathing rapidly
mild retractions but not marked cyanosis
Mild hypoxia and hypercapnia
Feeding may be difficult due to tachypnea
may result from slow absorption of lung fluid, slight decrease in surfactant production limiting alveolar surface
for gas exchange
Common in CS delivered infants
O2 administration may be necessary
Typically fades by 72 hours after birth
SUDDEN INFANT DEATH SYNDROME
SUDDEN INFANT DEATH SYNDROME
CONTRIBUTING FACTORS
 SIDS is a sudden unexplained death in infancy
 Prolonged but unexplained apnea
 CAUSE: Unknown
 Viral respiratory or botulism infection
 Pulmonary edema
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continuous infusion of glucose
check for abdominal distention indicating a
smaller-than-usual colon
AN INFANT WITH FETAL ALCOHOL SYNDROME
 Alcohol crosses the placental barrier in the same
concentration as in the maternal blood stream
 No safe threshold for alcohol so avoid alcohol
during pregnancy

AN INFANT OF A DRUG DEPENDENT MOTHER
 Usually SGA, showing withdrawal symptoms
(neonatal abstinence syndrome)
SYMPTOMS
 irritability
 disturbed sleep pattern
 constant movement possibly leading to abrasions
on the elbows, knees, etc
 tremors
 frequent sneezing
 shrill, high-pitched cry
 possible hyperreflexia & clonus (neuromuscular
irritability)
 convulsions
 tachypnea, possibly so severe it lay lead to
hyperventilation & alkalosis
 vomiting & diarrhea, leading to large fluid losses &
secondary dehydration
Opiate withdrawal: signs begin 24 to 48 hours after birth,
up to 10 days
 -Lasts up to 2 weeks
SYMPTOMS
 pre- & postnatal growth restriction
 CNS involvement (cognitive challenge,
microcephaly, cerebral palsy)
 Short palpebral fissure
 Thin upper lip
 Tremulous
 irritable
 Weak sucking reflex
 Always asleep or always awake
LONGTERM EFFECTS
 Hyperactivity

Growth deficiencies
Heroin –addicted NB’s: signs appear within the 1 st 2
weeks of life
MANAGEMENT
 Swaddling makes them comfortable
 Lessen environmental stimuli
 Maintain F & E balance
 Drugs used for withdrawal: paregoric,
Phenobarbital, methadone, chlorpromazine, &
Diazepam
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed
Multiple Choice
1. Common in preterms, infants of diabetic moms, cesarean birth, meconium aspiration due to hyaline-like
(fibrous) membrane formed from an exudates of the infant’s blood:
A. Transient Tachypnea of the Newborn
B. Sudden Infant Death Syndrome (SIDS)
C. Apnea
D. Hyperbilirubinemia
E. Respiratory Distress Syndrome (RDS)
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
2. A woman gave birth to an infant awhile ago, At birth the respiratory rate reaches 80 bpm; after 1 hour then
slows down to 30 to 60 cpm the infant does not appear to be in distress aside from the effort of breathing rapidly.
Which condition does the infant is experiencing?
A. Transient Tachypnea of the Newborn
B. Sudden Infant Death Syndrome (SIDS)
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C. Apnea
D. Hyperbilirubinemia
E. Respiratory Distress Syndrome (RDS)
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
3. A sudden unexplained death in infancy wherein the cause is still unknown:
A. Transient Tachypnea of the Newborn
B. Sudden Infant Death Syndrome (SIDS)
C. Apnea
D. Hyperbilirubinemia
E. Respiratory Distress Syndrome (RDS)
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
4. It is a pause in respiration longer than 20 seconds with accompanying bradycardia and beginning cyanosis:
A. Transient Tachypnea of the Newborn
B. Sudden Infant Death Syndrome (SIDS)
C. Apnea
D. Hyperbilirubinemia
E. Respiratory Distress Syndrome (RDS)
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
5. An elevated level of bilirubin in the blood resulting from RBC hemolysis:
A. Transient Tachypnea of the Newborn
B. Sudden Infant Death Syndrome (SIDS)
C. Apnea
D. Hyperbilirubinemia
E. Respiratory Distress Syndrome (RDS)
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
6. A condition wherein the bowel develops necrotic patches interfering with digestion & possibly leading to
paralytic ileus:
A. Hemorrhagic Disease of the Newborn
B. Twin to Twin Transfusion
C. Apparent Life-Threatening Event
D. Necrotizing Enterocolitis
E. Periventricular Leukomalacia
ANSWER: ________
RATIO:___________________________________________________________________________________________
___________________________________________________________________________________ ______________
_____________________________________________________________
7.A condition wherein there is an episode where the infant is discovered cyanotic & limp but have survived after
mouth-to-mouth resuscitation:
A. Hemorrhagic Disease of the Newborn
B. Twin to Twin Transfusion
C. Apparent Life-Threatening Event
D. Necrotizing Enterocolitis
E. Periventricular Leukomalacia
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ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
8. It is abnormal formation of the white matter of the brain caused by an ischemic episode that interferes wit h
circulation to a portion of the brain. Phagocytes & macrophages invade the area to clear away necrotic tissue
leaving a hollow space:
A. Hemorrhagic Disease of the Newborn
B. Twin to Twin Transfusion
C. Apparent Life-Threatening Event
D. Necrotizing Enterocolitis
E. Periventricular Leukomalacia
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
9. This condition can happen from lack of Vitamin K essential for formation of prothrombin:
A. Hemorrhagic Disease of the Newborn
B. Twin to Twin Transfusion
C. Apparent Life-Threatening Event
D. Necrotizing Enterocolitis
E. Periventricular Leukomalacia
ANSWER: ________
RATIO:___________________________________________________________________________________________
______________________________________________________________________________ ___________________
_____________________________________________________________
10. This condition occurs in monozygotic twins and if abnormal arteriovenous shunts occur that direct more
blood to 1 twin than the other:
A. Hemorrhagic Disease of the Newborn
B. Twin to Twin Transfusion
C. Apparent Life-Threatening Event
D. Necrotizing Enterocolitis
E. Periventricular Leukomalacia
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 19
LESSON TITLE: CARE OF A FAMILY OF A HIGH-RISK
INFANT-GASTROINTESTINAL DISORDERS
LEARNING OUTCOMES:
Materials:
At the end of the lesson, the student nurse can:
Book, pen, SAS and notebook
1. Define the common classifications of high-risk infants and
describe common illnesses that occur in these classifications of
infants.
Reference:
2. Integrate the knowledge of the common classifications of
high-risk infants and describe common illnesses that occur in
these classifications of infant in formulating nursing care plan in
giving quality maternal and child health nursing care.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
(Please refer to Chapter 45: Nursing Care of a Family When a Child Has a Gastrointestinal Disorder-Intussusception p.
1276, Hirschsprung’s Disease p. 1281, Gastroesophageal Reflux, p.1266, Cleft Lip and Cleft Palate p. 724, Imperforate
Anus p.737, Failure to Thrive p.1567)
INTESTINAL DISORDERS
INTUSSUSCEPTION (p.1276)
HIRSCHPRUNG’S DISEASE (p.1281) Aganglionic megacolon
 It is the invagination (folding inward) of one
 is an absence of ganglionic innervation to the
portion of the intestine into another.
muscle of a section of the bowel- in most
 It generally occurs in the 2 nd half of the first year of
instances, the lower portion of the sigmoid colon
Stools are ribbonlike kasi naiipon siya
life
just above the anus
 If infant < 1 year old, it usually occurs for
 no peristaltic waves in this section to move fecal
idiopathic reasons
material through that segment of the intestine.
 If infant > 1 year old, a “lead point” on the intestine
 chronic constipation or ribbonlike stools
likely cues the invagination
 The portion of the bowel proximal to the
 Lead points: Meckel’s diverticulum, polyp,
obstruction dilates distending the abdomen
hypertrophy of Peyer’s patches (lymphatic tissue
 more often in males than females
of the bowel that increases in size with viral
disease), or bowel tumors
ASSESSMENT
 The point of invagination is usually the juncture of
 is suggested if the infant fails to pass meconium
the distal ileum and proximal colon
by 24 hours of age and have increasing
 It is a surgical emergency; reduction of the
abdominal distention
intussusception must be done promptly by either
 If a gloved finger is inserted into the rectum of a
instillation of solution (or air) or surgery before
child with true constipation, the examining finger
necrosis of the invaginated portion of the bowel
will touch hard, caked stool. With HD, the rectum
occurs
is empty because fecal material cannot pass into
the rectum through the obstructed portion
ASSESSMENT
 Barium enema will show the narrow, nerveless
 The children with intussusception suddenly draw
portion and the proximal distended portion of the
up their legs and cry as if in severe pain; they may
bowel
vomit
Small intestine pumasok sa large intestine
Slight bulge in the small intestine present at birth
Consists of transverse colon,
ascending colon, and cecum
Pwede ang non-surgical management like air
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Peristaltic wave refers to the natural squeezing movements of the intestines to push
food forward.



Usually greenish
color



After the painful peristaltic wave, they are
symptom-free and play happily
In about 15 minutes, the cycle repeats itself
Vomitus contains bile because the obstruction is
below the ampulla of Vater, where the bile
empties into the duodenum
After 12 hours, blood appears in the stool
described as a “CURRANT JELLY” appearance
Abdomen is distended as the bowel above the
intussusception distends
If with necrosis, elevated temperature, peritoneal
irritation (tender abdomen, “guarding” by
tightening their abdominal muscles), leukocytosis,
tachycardia
Diagnosis is suggested by history, confirmed by a
sonogram
Rapid pulse

Increased WBC
THERAPEUTIC MANAGEMENT
 Surgery to straighten the invagination, or
reduction by instillation of a water-soluble
solution, barium enema or air (pneumatic
insufflation).
 If there is no lead point, just the pressure of these
nonsurgical techniques may reduce the
intussusception within 24 hours
 If nonsurgical reduction is accomplished, infants
are kept NPO for a few hours then introduced
gradually to regular feedings
Parang white na powder ang barium
Needs series of xray
DEFINITIVE DIAGNOSIS
 biopsy of the affected segment to show lack of
innervation or by
 anorectal manometry a technique to test the
strength or innervation of the internal rectal
sphincter by inserting a balloon catheter into the
rectum and measuring the pressure exerted
Anastomosis — i-remove nila
against it
yung area na affected, yung area
THERAPEUTIC MANAGEMENT na di affected, pagdidikitin nila
 Repair involves dissection and removal of the
affected section, with anastomosis of the intestine.
 2- stage surgery: a temporary colostomy is
established, followed by bowel repair at 12 to 18
months
 If the anus is deprived of nerve endings, a
permanent colostomy may be established
COLIC (p.804)
 It is a paroxysmal abdominal pain that generally
occurs in infants under 3 months of age and is
marked by loud, intense crying
 An infant cry loudly and pulls the legs against the
abdomen
 The face becomes flushed, fists clench, and
abdomen becomes tense.
 If offered a bottle, will suck vigorously for a few
minutes if starved and stop at another wave of
intense pain
CAUSE
Unclear but may occur in susceptible infants from
 overfeeding,
 swallowing too much air while drinking or
if formula is hard to digest
ASSESSMENT/MANAGEMENT
 Thorough history of infant. Ask parents about
duration and frequency (usually 3hours a day for 3
days a week)
 Ask what happened before the attack, describe
the attack and associated symptoms
 Document number and type of bowel movements
 Family medical history including milk allergy
 Determine feeding pattern, formula, preparation
 Ask if baby is held upright during feeding so air
bubbles can rise
 Ask about burping
 For breastfed baby, ask mother to avoid gassy
foods like cabbage
 Recommend small, frequent feeding, and offering
a pacifier
 Discourage use of hot water bottle to prevent
burns
 Changing formula bottles to those with disposable
bags
 Take infants for car rides, music simulating
heartbeat may help
 Anti-flatulent agents like simethicone may be tried
 Help parents plan relief time from infant to reduce
their stress level
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Colic usually disappears at 3 months of age
because it is easier to digest food and infant
maintains a more upright position during feeding
GASTROESOPHAGEAL REFLUX (ACHALASIA)
GASTROESOPHAGEAL REFLUX (ACHALASIA)
ASSESSMENT
(p.1266)
 Vomiting appears effortless, NOT projectile
 is a neuromuscular disturbance in which the
 Vomiting begins much earlier in life than the
gastroesophageal (cardiac sphincter) and the
vomiting associated with pyloric stenosis
lower portion of the esophagus are lax and thus
 Child may be irritable with periods of apnea
allow easy regurgitation of gastric contents into
 Inserting a probe or catheter through the nose into
the esophagus.
the distal esophagus and determining the pH from
 Starts within 1 week of birth and may be
secretions can show whether gastric secretions
associated with hiatal hernia (diaphragmatic
are entering the esophagus (pH < 7 means acid
hernia)
is present)
 Children with neurologic involvement like cerebral
 Fiberoptic endoscopy or esophagography
palsy are more at risk.
(barium swallow) will show a lax sphincter and the
 Regurgitation starts almost immediately after
reflux of stomach contents into the esophagus,
feeding or when the infant is laid down after a
especially of the infant’s head is tilted down
feeding
 If the reflux is large, the infant does not retain
MANAGEMENT
sufficient calories and will fail to thrive
 Feed with formula thickened with rice cereal (1
tbsp of cereal with 1 oz of formula or breast
COMPLICATIONS
milk) while holding them in an upright position
 dehydration,
and then keeping them upright in an infant chair
 alkalosis ,
for 1 hour after feeding so gravity can help
 aspiration pneumonia and
prevent reflux
 esophageal stricture form the constant reflux
 H2 receptor antagonist such as ranitidine
of HCl into the esophagus
(Zantac) or a Proton pump inhibitor such as
omeprazole (Prilosec) to reduce the possibility of
the stomach acid contents irritating the esophagus
 Metoclopramide (Reglan) to increase lower
esophageal sphincter pressure
 GER is usually self-limiting
CLEFT LIP AND CLEFT PALATE
CLEFT LIP AND CLEFT PALATE (P.724)
POSTOPERATIVE PERIOD
 For both CLEFT LIP & CLEFT PALATE, NPO
postop for 4 hours then small amount of liquids
CLEFT LIP
are introduced (H2O)
 Maxillary and median nasal processes fuse
 No tension must be placed on the suture line to
between weeks 5 and 8 of intrauterine life;
keep sutures from pulling apart & leaving a scar;
 fusion fails ranging from a small notch in the
feed using a specialized feeder
upper lip to total separation of the lip and facial
 Liquids are continued for 1st 3 to 4 days then soft
structure up into the floor of the nose with even
diet until healing is complete
the upper teeth and gingiva absent
 Do not use a spoon to feed the child; for CLEFT
 the nose is flattened because incomplete fusion of
PALATE repair, feed from a CUP
the upper lip allowed it to expand horizontally
 Do not give milk in the 1st fluids because milk
 is prevalent in boys
curds adhere to the suture line.
 is twice as prevalent in the Japanese population
 After feeding, offer clear water to rinse the suture
and rare in African Americans
line & keep it as clean as possible
 occurs as a familial tendency, due to teratogenic
 After CLEFT LIP surgery, the suture line is held in
factors during weeks 5 to 8 (viral infection) or a
close approximation by a LOGAN BAR ( a wire
lack of folic acid
bow taped to both cheeks) or an adhesive
bandage simulating a bar
CLEFT PALATE
 adequate pain relief to prevent crying ( increases
 Palatal process close at weeks 9 to 12 of
tension on the sutures)
intrauterine life
 Try to anticipate the infant’s needs to prevent
 is an opening of the palate, usually on the midline,
crying (feed on demand)
involving anterior hard palate, posterior soft palate
 Rock, carry or hold infant to make infant secure
or both is prevalent in girls
and comfortable
 Bubble well after feeding due to a tendency to

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ASSESSMENT
 Detected by a sonogram while in utero or by
inspection at birth
 can be determined by depressing the NB’s tongue
with a tongue blade
THERAPEUTIC MANAGEMENT
 Fetal surgery
 CLEFT LIP is repaired (CHEILOPLASTY) shortly
after birth or between 2 to 10 weeks after birth to
provide adequate nutrition, experience sucking
& for bonding.
 Revision may be necessary at 4 to 6 years of age
 CLEFT PALATE repair (PALATOPLASTY) is
postponed until 6 to 18 months of age to allow
the anatomic change in the palate contour that
happens during the 1 st year of life
 Provide parents photographs of babies with good
repairs to assure them
PERIOPERATIVE PERIOD
 Breastfeeding a baby with CL is possible because
the bulk of a mother’s breast tends to form a seal
 Support the baby in an upright position & feed
gently using a commercial cleft lip nipple (Breck
feeder, Haberman feeder)
 Use a commercial CP nipple that has an extra
flange of rubber to close the roof of the mouth;
Breck feeder may also be used
USE ESSR
-Enlarge the nipple and Elevate the head
-Stimulate the Suck reflex by rubbing
nipple on lower lip
- Wait for the child to Swallow to prevent
choking
- Allow for a Rest period after each swallow
 Bubble well after feeding because of a tendency
to swallow air
 If cleft extends to the nares, infant will breathe
through the mouth, causing mucous membranes
& lips to become dry. Offer small sips of fluid
between feedings to keep mucous membranes
moist & prevent cracks & fissures that can lead to
infection
 Place infant in arm restraints periodically before
surgery and
 feed with a rubber-tipped Asepto syringe also to
be used in feeding post-op
 If surgery is delayed beyond 6 mos, teach parents
to offer only soft foods; plastic palate guard may
also be used
IMPERFORATE ANUS (p.737)
 It is a stricture of the anus.
 In week 7 in utero, the upper bowel elongates to
pouch and combine with a pouch invaginating
from the perineum and the membrane between
them dissolves.
 If elongation does not occur or the membrane
between them does not dissolve, imperforate
anus occurs





swallow more air than the average infant
Nothing sharp must come in contact with a
recent cleft suture line; avoid toys with sharp
edges, straws, avoid tooth brushing
Keep elbow restraints in place for 4 to 6
weeks. Older children may require jacket
restraints to prevent rolling over on the abdomen
and rubbing the face on the sheets
Provide diversional activities to prevent them
from running their tongue over the sutures
Clean suture lines with sterile water, sterile
saline or 50% H2O2 in sterile water used with a
cotton-tipped applicator after every feeding or
whenever the normal serum that forms on suture
lines accumulate; do not rub!
Encourage parents to interact with their infants;
notice whether the parents look at their baby’s
face while feeding the baby; allow verbalization
Otitis media is a common infection due to changes in the
contour of the Eustachian tube. Teach parents signs of
infection
FAILURE TO THRIVE (REACTIVE ATTACHMENT
DISORDER) (P.1567)
 It is a unique syndrome in which an infant fall
below the 5th percentile for weight & height on
a standard growth chart or is falling in
percentiles on a growth chart
2 Categories:
 ORGANIC TYPE- syndromes that can be
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

It can be minor, needing only a surgical incision of
the membrane or more severe in which sections
of the bowel are far apart with no anus
It is more common in boys than girls
ASSESSMENT
 Inspection reveals no anus;
 A membrane filled with black meconium may also
be seen protruding from the anus
 No “WINK REFLEX” (touching the skin near the
rectum should make it contract) if sensory endings
in the rectum are not intact
 Inability to insert a rubber catheter into the rectum
 No stool passed after the 1 st 24 hours and
abdomen becomes distended
 Xray or sonogram reveals the defect if the infant is
held in a head-down position to allow swallowed
air to rise to the end of the blind pouch of the
bowel
 RECTOVAGINAL FISTULA- meconium passes
through vagina (check urine)
 RECTOPROSTATIC FISTULA- meconium in
urine of males
 ANAL STENOSIS- determined when child is older
with a history of difficult defecation, abdominal
distention, ribbon-like stools
THERAPEUTIC MANAGEMENT
 If the rectum ends close to the perineum and the
anal sphincter is formed, repair involves simple
anastomosis of the separated bowel segments
PREOPERATIVE
 NPO to prevent bowel distention;
 NGT with intermittent suction for decompression
 IVT to maintain F & E
POSTOPERATIVE
 No rectal temperature-taking, enemas,
suppositories or other rectal procedures
 give stool softeners
 Zinc oxide may be applied with hydrocolloid
dressings to prevent skin irritation from frequent
loose stools
 Place a diaper UNDER, not on the infant so bowel
movements can be cleansed ASAP
 Do not place on the abdomen because NBs tend
to pull up their knees causing tension in the
perineal area;
 place infant in a side-lying position, or prone
position with hips elevated or supine with legs
suspended at a 90-degree angle to prevent
pressure on the perianal sutures is best
 NGT for decompression; TPN
 Rectal dilatation (gently inserting a lubricated.
Cot-covered finger into the rectum) to ensure
proper patency and also to correct anal stenosis
 Toilet training will usually be delayed






explained because of organic causes such as
cardiac disease
INORGANIC TYPE- syndromes that occur
because of a disturbance in the parent-child
relationship, resulting in a maternal role
insufficiency (a nonorganic cause)
Sometimes, both physical & emotional factors
play a role in failure to thrive
Nonorganic type can be considered a form of
child abuse- the parent feels little or no
attachment, and may have a history of
frequent moves and little family support.
Some infants are offered sufficient food but the
emotional deprivation they sense may make them
so lethargic they do not eat enough
The child may be irritable, fussy, colicky or a
difficult child
The parent may not be offering enough food (not
aware of hunger cues or does not have enough
concern)
ASSESSMENT
 Weigh child at routine assessments, plot and
compare weight with standard growth curves for id
of Failure to thrive
 Check for motor and social developmental delays
 Take a detailed pregnancy history because
sometimes a breakdown in the development of
parenting begins in the prenatal period
CHARACTERISTICS
 Lethargy with poor muscle tone, loss of
subcutaneous fat or skin breakdown
 Lack of resistance to examiner’s manipulation
 Rocking on all 4’s excessively as if seeking
stimulation (emotionally deprived)
 Reluctance to reach for toys or initiate human
contact or intense eye contact
 Staring hungrily at people who approach them as
if starved for human contact
 Little cuddling or conforming to being held by the
2nd month of life
 Achievement of developmental milestones in the
prone position such as lifting the head and chest
and following an object with the eyes by the3rd or
4th month, but delays in other behaviors such as
sitting erect, pulling ot a standing position,
crawling and walking because the child spends so
much time alone
 Markedly delayed or absent speech because of
lack of interaction
 Diminished or nonexistent crying
 With advanced case, it may be nearing acidosis
due to starvation
MANAGEMENT
 Usually, the child needs to be removed from the
parents’ care for evaluation and therapy
 in the early months must be treated rigorously to
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




prevent permanent neurologic damage or leave a
child cognitively challenged due to protein deficits
and interference with brain metabolism
Infants are placed on a diet appropriate for their
ideal weight
Rapid weight gain on this diet is diagnostic that
their illness was nonorganic FTT
Nurture the child. A member of the staff should be
chosen to be the child’s “parent” during the stay
and not just give routine nursing care, providing
active interaction
Support and encourage the parents to visit and
interact with the child
Ensure evaluation and follow up
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed
Multiple Choice
1. You are caring for a 3-year-old child that was admitted due to abdominal pain. After 12 hours, blood appears in
the stool described as a “CURRANT JELLY” appearance. What condition does the child have?
A. Hirschprung’s Disease
B. Colic
C. Intussusception
D. Achalasia
E. Cleft Lip
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
2. It is the invagination (folding inward) of one portion of the intestine into another:
A. Hirschprung’s Disease
B. Colic
C. Intussusception
D. Achalasia
E. Cleft Lip
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
3. It is an absence of ganglionic innervation to the muscle of a section of the bowel- in most instances, the lower
portion of the sigmoid colon just above the anus:
A. Hirschprung’s Disease
B. Colic
C. Intussusception
D. Achalasia
E. Cleft Lip
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
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4. A parent came to the hospital with their baby. They told you that they offered a bottle when the baby is
starving, their baby will suck vigorously for a few minutes and stop at another wave of intense pain. With this you
know the baby is experiencing:
A. Hirschprung’s Disease
B. Colic
C. Intussusception
D. Achalasia
E. Cleft Lip
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
5. It is a neuromuscular disturbance in which the gastroesophageal (cardiac sphincter) and the lower portion of
the esophagus are lax and thus allow easy regurgitation of gastric contents into the esophagus:
A. Hirschprung’s Disease
B. Colic
C. Intussusception
D. Achalasia
E. Cleft Lip
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
6. It is a unique syndrome in which an infant fall below the 5th percentile for weight & height on a standard
growth chart or is falling in percentiles on a growth chart:
A. Cleft Lip
B. Cleft Palate
C. Imperforate Anus
D. Failure to Thrive
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
7. You are doing a newborn care to a baby born awhile ago, you are checking for the patency of the anus but you
have the inability to insert a rubber catheter into the rectum. What condition does the newborn have:
A. Cleft Lip
B. Cleft Palate
C. Imperforate Anus
D. Failure to Thrive
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
8. It is an opening of the palate, usually on the midline, involving anterior hard palate, posterior soft palate or
both is prevalent in girls:
A. Cleft Lip
B. Cleft Palate
C. Imperforate Anus
D. Failure to Thrive
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
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9. It is a condition wherein the nose is flattened because incomplete fusion of the upper lip allowed it to expand
horizontally and is more prevalent in boys:
A. Cleft Lip
B. Cleft Palate
C. Imperforate Anus
D. Failure to Thrive
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
10. You are reading the chart of newborn, the past shift documented that the newborn has no stool passed after
the 1st 24 hours and abdomen becomes distended. You know that the newborn have:
A. Cleft Lip
B. Cleft Palate
C. Imperforate Anus
D. Failure to Thrive
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
________________________________________________________________________________ _____________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 20
LESSON TITLE: CARE OF A FAMILY OF A HIGH-RISK
INFANT-NERVOUS SYSTEM DISORDERS
LEARNING OUTCOMES:
Materials:
At the end of the lesson, the student nurses can:
Book, pen, SAS and notebook
1. Define the common classifications of high-risk infants and
describe common illnesses that occur in these classifications of
infants.
Reference:
2. Integrate the knowledge of the common classifications of
high-risk infants and describe common illnesses that occur in
these classifications of infant in formulating nursing care plan in
giving quality maternal and child health nursing care.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
Please refer to Diseases Affecting Infants- Nervous System Disorders-Neural Tube Disorders p. 745-746, Chromosomal
Disorders that Results in Physical and Cognitive Developmental Disorders-Down Syndrome p.167, Hydrocephalus p.738,
Bacterial Meningitis p. 1391, Acute Otitis Media p.1428, Chronic Otitis Media p. 1429, Febrile Seizures p. 1395 and
Attention Deficit Hyperactivity Disorder p.1541
NERVOUS SYSTEM DISORDERS- NEURAL TUBE DISORDERS (p.745-746)
SPINA BIFIDA
MANAGEMENT
SPINA BIFIDA OCCULTA
 Spina bifida occulta needs no immediate surgical
 It occurs when the posterior laminae of the
correction
vertebrae fails to fuse. It is common at the level
 Surgery(meningocoele and myelomenigocoele) to
of L5 or S1 but may occur at any point
replace the contents that are replaceable and to
 It is noticeable as a dimpling at the point of poor
close the skin to prevent infection
fusion; abnormal tufts of hair or discolored skin
 Surgery is done as soon as possible after birth
may be present
(within 24 to 48 hours) to prevent infection of the
meninges
SPINA BIFIDA CYSTICA
 The loss of meninges during surgery may limit the
MENINGOCOELE
absorption of CSF causing build up leading to
 If the meninges covering the spinal cord herniates
hydrocephalus
through unformed vertebrae appearing as a
 PREOPERATIVE CARE
protruding mass about the size of an orange; no
 Use sterile gloves and sterile linens when caring
nerves or neural elements
for the infant
 Infant’s head is turned to 1 side for feeding
MYELOMENINGOCOELE
 Protect sac from pressure, irritation, infection,
 The spinal cord and meninges including CSF
rupture (prone with hips abducted, cover sac, no
diaper, meticulous skin care)
and nerves protrude through the vertebrae
 Monitor VS, symptoms of IICP, I & O, increased
 The spinal cord ends at the point of herniation so
head circumference
motor and sensory function end at this point
 Monitor activities of lower extremities; provide
resulting to lower motor neuron damage
ROM exercises
 Flaccidity and lack of sensation of the lower
 Infants may also be positioned on their side with a
extremities
rolled blanket placed behind their upper back
 Loss of bowel and bladder control
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Legs are lax and motionless, urine and stools
continually dribble due to lack of sphincter control
Children usually have accompanying talipes
disorders and DDH
The higher the myelomeningocoele develops the
more likely that hydrocephalus also occurs


ASSESSMENT
 In utero diagnosis by sonogram, fetoscopy,
amniocentesis (increased AFP levels)
 MRI, UTZ, CT SCAN, myelography
 CS to avoid pressure and injury of the spinal cord
 Observe spontaneous movements of the lower
extremities and assess nature and pattern of
voiding and defecation












Latex allergy
Sterile wet compress of saline, antiseptic or
antibiotic gauze over the lesion my be used to
keep the sac moist. Additional fluid may be
poured on the gauze as needed
Neurogenic bladder: frequent, clean, straight
catheterization is preferred
Measure head circumference daily; position the
tape on the same points each time
POSTOPERATIVE CARE
Place on abdomen until skin incision has healed
(about 7 days)
Observe for signs of IICP (VS changes, papillary
changes, increase in head circumference, bulging
fontanelles, irritability or lethargy, projectile
vomiting, high-pitched cry, convulsion, no Moro
reflex, increasing temperature and BP, low PR
and RR)
Meticulous skin care
Provide psychological support: consistent care,
crib mobile, frequent parental visits
Promote elimination: MILK bladder q 4h,
intermittent aseptic catheterization as ordered;
teach parents CREDE’S MANEUVER
Keep tape measure at bedside
CHROMOSOMAL DISORDERS THAT RESULTS IN PHYSICAL AND COGNITIVE DEVELOPMENTAL
DISORDERS-DOWN SYNDROME (p.167)
 Trisomy 21 or 47XX21+ or 47XY21+ is the most
MANAGEMENT
common chromosomal abnormality, seen in 1 in
Provide care of mentally retarded child:
800 births
 Consider DEVELOPMENTAL AGE and not
 Common in pregnancies of women > 35 yo or
chronological age
paternal age >55 yo
 Set REALISTIC GOALS
 Diagnosed by an ultrasound
 Adhere to ROUTINES
 Provide SIMPLE REPETITIVE tasks
ASSESSMENT
 Nose is broad and flat
 The eyelids have an extra fold of tissue at the
inner canthus (EPICANTHAL FOLD)
 Palpebral fissure (opening between the eyelids)
slants laterally upwards
 The iris of the eye may have specks
(BRUSHFIELD’S SPOTS)
 Tongue may protrude from the mouth because the
oral cavity is smaller than normal
 The back of the head is flat, the neck short, and
an extra pad of fat at the base of the neck causes
the skin to be loose it can be lifted up (PUPPY’S
NECK)
 Ears my be low-set
 poor muscle tone (RAG-DOLL APPEARANCE)
 Fingers are short and thick, the little finger is often
curved inward
 Simian crease
 Wide space between the 1st and second toes and
the 1st and 2nd fingers
 Cognitive challenge
 Prone to respiratory tract infections, acute
lymphocytic leukemia
 Congenital heart diseases, atresia or stenosis of
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the duodenum, strabismus and cataracts are
common
HYDROCEPHALUS (p.738)
Definition:
DIAGNOSIS
 CSF is formed in the 1 st & 2nd ventricles of the
 All children < 2yo should have their HC recorded
brain and passes through the aqueduct of Sylvius
and plotted on a growth chart, NB HC must be
and the 4th ventricle to empty into the
measured at birth and before discharge
subarachnoid space of the spinal cord, where it is
 UTZ, CT Scan, MRI
absorbed
 SKULL XRAY shows separating sutures and
 is an excess of CSF in the ventricles of the
thinning of the skull
subarachnoid space
 TRANSILLUMINATION- holding a bright light
 In an infant whose cranial sutures are not firmly
such as a flashlight against the skull with the child
knitted, the excess fluid causes enlargement of
in a darkened room will reveal the skull filled with
the skull
fluid rather than a solid brain
TYPES OF HYDROCEPHALUS
 If it is a non-communicating type, dye inserted into
 COMMUNICATING HYDROCEPHALUS or
a ventricle will not appear in CSF obtained from a
EXTRAVENTRICULAR HYDROCEPHALUSlumbar puncture
CSF can reach the spinal cord
 OBSTRUCTIVE or INTRAVENTRICULAR
MANAGEMENT
HYDROCEPHALUS- there is a block to the
 If due to overproduction of CSF, acetazolamide
passage of CSF
(Diamox), a diuretic promotes excretion
 CONGENITAL –occurs at birth; unknown cause
 Removal of tumor
or due to maternal infection such as
 Destruction of a portion of the choroid plexus
toxoplasmosis or infant meningitis
 Laser surgery to reopen the route or flow or
 ACQUIRED- occurs from an incident later on in
bypassing the obstruction by shunting the fluid to
life
another point of absorption
 Occurrence: 3 to 4 per 1000 live births
SHUNTING
SIGNS AND SYMPTOMS
SHUNTING to bypass obstruction
 Rapid head enlargement (more than 1
1. V-P Shunt: Ventriculo-Peritoneal Shunt
 MOST COMMONLY used in
inch/month)
children
 SUNSET eyes
 Catheter from lateral ventricle, out
 Brow bulges forward (BOSSING)
of the skull & under the skin to
 Separation of sutures
peritoneal cavity
 HEAD LAG: developmental sign
2. V-U Shunt: Ventriculo-Ureteral Shunt
 Shrill(high-pitched) cry
 Requires removal of 1 kidney
 Feeding difficulties
3. V-A shunt: Ventriculo-Atrial Shunt
 Widening & bulging of fontanels
 Distended scalp veins
PREOPERATIVE CARE
 Shiny scalp
1. Measure HC daily
 Opisthotonos
2. assess respiratory status q4 hours
3. Measure I & O
SIGNS OF INCREASED INTRACRANIAL PRESSURE
4. small frequent feedings
 Decreased PR
POST – SHUNTING CARE:
 Decreased RR
1. Proper position-flat on the nonoperative site to
 increased temperature
prevent rapid drainage (subdural hematoma)
 increased blood pressure,
2. Monitor: VS, HC, LOC, I&O, signs of increased
 hyperactive reflexes,
ICP
 strabismus and optic atrophy
3. Pump shunt when ordered to MAINTAIN
PATENCY
4. Maintain nutrition and hydration:
 Small Frequent Feeding
with frequent burping
 Maintain strict I &O; over hydration can
increase ICP
5. Provide parental teaching:
a. Positioning
b. Shunting permanence; need for revision;
need for pumping
Provided to transfer CSF from cerebral
ventricle into the right atrium of the heart
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c. Teach signs and prevention of IICP &
infection
ACUTE OTITIS MEDIA (p.1428)
ACUTE OTITIS MEDIA (p.1428)
CHRONIC OTITIS MEDIA (p.1429)
 It is the inflammation of the middle ear and is
 Middle ear is usually an air-filled cavity, supplied
common after URTI
by the Eustachian tube which opens with
 Common in 6 to 36 months and again at 4 to 6
swallowing, chewing yawning
years
 If the source of air is shut off, the epithelial cells
 males, Alaska, and Native Americans, children
change in function, becoming secretory cells filling
with cleft palate
the middle ear with secretions
 formula-fed infants because they are held in a
 The fluid, over time becomes tenacious or “gluemore slanted position while feeding which allows
like”
milk to enter the Eustachian tube
 Fullness, popping or ringing of ears
 associated with constant pacifier use
 Drop in hearing of 20 to 40 dB due to fluid
 Incidence is highest in the spring and winter
 Usually bilateral, frequent in children 3 to 10 years
months and in homes in which a parent smokes
of age
cigarettes
ASSESSMENT
 It may lead to permanent damage in middle ear
 Muffled hearing and feeling of pressure in the ear
structures leading to hearing impairment
 Examination shows level of fluid behind the
tympanic membrane
ASSESSMENT
 As the fluid becomes thick, it tends to retract the
 Usually after an URTI with increasing temperature
eardrum making the malleus more prominent and
102F (38C) and sharp, constant pain in 1 or both
displaced
ears
 Irritable and pull or tug affected ear; infants may
MANAGEMENT
rub ear against bedclothes
 If intensified by inflammation or allergy, avoidance
 Tympanic membranes appears inflamed or
of allergen, hypo sensitization or pharmacologic
reddened on otoscopic examination and may
management may be necessary
bulge into the external canal
 Aim of therapy is to supply air to the middle ear. If
mild only, antihistamine or nasal decongestant to
MANAGEMENT
shrink the mucous membrane of the ET tube to
 caused by S. Pneumoniae, H. influenzae or S.
achieve air supply
pyogenes but usually resolve spontaneously
 If due to enlarged adenoids, removal of adenoids
therefore antibiotics (ampicillin or amoxicillin) are
may be necessary
no longer prescribed routinely to prevent bacterial
 TYMPANOCENTESIS to remove the fluid
resistance
 TUBAL MYRINGOTOMY- insertion of small
 Analgesics and antipyretics, decongestant nose
plastic tubes (Teflon) through tympanic membrane
drops (3 days only) to open Eustachian tubes and
(tympanostomy) in 1 or both ears in an
allow air to be admitted to the middle ear
ambulatory procedure after local injection of
 Conductive hearing loss may occur during the
lidocaine. Tubes tend to be extruded after 6 to 12
infection and may last for up to 6 months after
months (reinsertion depends on the resolution of
 The child must be routinely screened for hearing
the infection)
during the next 6 months; if it persists check for
 If tubes are in place, H2O must not be allowed to
new infection
enter the ear. Bathe instead of shower (allowed
with use of ear plugs), no swimming (unless with
earplugs
 Check for hearing impairment





BACTERIAL MENINGITIS (p. 1391)
MENINGITIS is an infection of the cerebral
ASSESSMENT
meninges common among children younger than
 In children, 2-3 days of URTI and become
24 months of age, with a peak occurrence in the
increasingly irritable due to headaches
winter.
 Nuchal rigidity- sharp pain on bending the head
Most frequent cause is Streptococcus
forward
pneumoniae or group B Streptococcus
 Seizure or shock is often the 1 st noticeable sign of
In children younger than 2 months, group B
illness
Streptococcus and E. coli are common causes
 (+) Brudzinski sign- forward flexion of the neck
In children with myelomeningocele who develop
causes bilateral hip, knee and ankle flexion,
suggesting meningeal irritation
meningitis, Pseudomonas infection is common.
Hemophilus influenzae is rarely seen as a cause
 (+) Kernig’s sign- the hip and knee are flexed
Refers to condition wherein the neck has stiffness which is caused by bacterial meningitis.
There is tightness in the neck muscles.
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due to routine immunization
hypothermic needle l4-l5 below level of l1&2
Upper part of respiratory tract infection
PATHOPHYSIOLOGY
 Starts with URTI and organisms spread to the
meninges from lymphatic drainage through the
mastoid or sinuses or by direct introduction
through a lumbar puncture or skull fracture
 Once they enter the meningeal space they
multiply rapidly and spread through the CSF
 Organisms invade brain tissue through meningeal
folds that extend down into the brain itself
 The inflammatory response that occurs may lead
to a thick fibrinous exudates that may block CSF
flow leading to hydrocephalus
 Brain abscess can lead to blindness, deafness or
facial paralysis
 Brain tissue edema can put pressure on the
pituitary gland causing increased production of
antidiuretic hormone resulting in the syndrome of
inappropriate antiduretic hormone secretion
(SIADH) causing increased edema because the
body cannot excrete urine




forming a 90-degree angle and as the leg is
extended, pain, resistance and spasm are noted
Opisthotonos- backs become arched, and necks
hyperextended
Cranial nerve paralysis so the child is not able to
follow a light through ful visual fields
open fontanels are tense and bulging
In NB’s, poor sucking, weak cry or lethargy
Decorticate - arms in chest and;
Decerebrate - away from head
DIAGNOSIS
 History, CSF analysis
 CSF: increased WBC, increased protein levels,
lowered glucose level
 Blood culture
 Symptoms of increased ICP
Lumbar puncture: C position bw L3 & L4/ L4 & L5
Spinal needle is used
MANAGEMENT
 Antibiotic therapy after C&S usually through IV or
intrathecal route directly into the CSF to bypass
the blood-brain barrier
 For H. influenzae- ampicillin is the DOC
 Others, cephalosporin for 8 to 10 days
 Corticosteroid like dexamethasone, or osmotic
diuretic (mannitol) may be given to reduce ICP
and prevent hearing loss
 Children with meningitis are placed on respiratory
precautions for 24 hours after the start of antibiotic
therapy
Antibiotics may also be prescribed prophylactically for
the immediate family members or others who have
been in close contact with the child
FEBRILE SEIZURE (p. 1395)
 Seizures associated with high fever (102 to 104F)
PREVENTION
38.9-40C are common in preschool children (5
 Acetaminophen may be given to keep a
months to 5 years) but can occur as early as 3
developing fever below 101F (38.4C)
months or as late as 7 years old
 For a second seizure diazepam may be
 They may occur after an immunization because of
prescribed the next time the child has a high fever
fever
 Seizures show an active tonic-clonic pattern,
lasting for 15 to 20 seconds
 The EEG tracings are usually normal
 There is usually a history of other members with
the same conditions
ATTENTION DEFICIT HYPERACTIVITY DISORDER (p. 1541)
 It is a persistent pattern of inattention and/or
ASSESSMENT
hyperactivity-impulsiveness revealed before the
 Diagnosable at 36 months of age
age of 7.
 Child can’t sit still in school or concentrate for long
 Boys are affected more frequently than girls.
periods
 May be genetic, associated with child neglect,
 Review pregnancy and birth history, ability to
lead poisoning and drug exposure in utero
meet developmental milestones and a typical day
for the child
3 MAJOR BEHAVIOURS
 Assess for activity that is not only excessive but
 INATTENTION
also disorganized, repetitive movements such as
twirling, tapping arm swinging
 IMPULSIVENESS
 Behavior is so variable that they have good and
 HYPERACTIVITY
bad moments
 Inattention may make them unable to complete
 Most have an ALL OR NONE response to stimuli
tasks, become easily distracted, and may not
 Difficulty with concepts such as right or left, before
seem to listen
or after, front or back, yesterday and tomorrow
 Impulsiveness causes them to act before they
because it requires sequencing
think and have difficulty awaiting turns at games
We have respiratory precautions to prevent bacteria and infections
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
Hyperactivity causes shifting from 1 activity to
another, with excessive or exaggerated muscular
activity such as climbing, fidgeting or haphazard
running



Difficulty in speaking fluently spelling and reading
No deficit in intelligence
Difficulty in using a pencil or scissors
MANAGEMENT
 Construction of a stable learning environment free
of distracting stimulation
 Family Support
 Medications:
methylphenidate hydrochloride (Ritalin,
Concerta) to stimulate dopamine receptors to
achieve a more regular nerve transmission.
** Administer the drug early in the day to prevent
insomnia,
**Monitor weight to check for anorexia
 atomoxetine,
 norepinephrine reuptake inhibitors,
 tricyclic antidepressants
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed
Multiple Choice
1. A newborn has a myelomeningocele with the sac intact and has been placed in an incubator. The nurse, when
planning care for the baby, should focus on potential for:
A. Disuse syndrome
B. Infection
C. Fluid volume deficit
D. Decreased cardiac output
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
2. The appropriate nursing interventions for a newborn's myelomeningocele sac prior to surgery include using
sterile technique and:
A. Leaving the sac open to air
B. Applying petrolatum to cover the sac
C. Applying moist saline dressings
D. Applying dry dressings
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
3. Maintaining the proper alignment of the baby with myelomeningocele is important. To maintain proper
alignment of the hips and lower extremities in a baby with a myelomeningocele, the nurse should position the
baby with the:
A. Hips abducted and feet in a neutral position
B. Hips adducted and feet flexed
C. Hips subluxed and feet extended
D. Hips adducted and feet in a natural position
ANSWER: ________
RATIO:_______________________________________________________________________ ____________________
_________________________________________________________________________________________________
_____________________________________________________________
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4. A child is diagnosed due to myelomenigocele and is scheduled for surgery due to myelomeningocele; the
primary reason for surgical repair is which of the following?
A. To prevent hydrocephalus
B. To reduce the risk of infection
C. To correct the neurologic defect
D. To prevent seizure disorders
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
5. A child is diagnosed with increased intracranial pressure (ICP); which of the following if stated by her parents
would indicate a need for Nurse Charlie to reexplain the purpose for elevating the head of the bed at a 10 to 20degree angle?
A. Help alleviate headache
B. Increase intrathoracic pressure
C. Maintain neutral position
D. Reduce intra-abdominal pressure.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
6. A child was brought to the emergency department by her parents before the child loss its consciousness the
parents described what happened with their child that their child had a “sudden uncontrollable jerky
movements”. In diagnosing seizure disorder, which of the following is the most beneficial?
A. Skull radiographs
B. EEG
C. Brain scan
D. Lumbar puncture
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
7. You are discussing health teachings to a parent who has a child with seizure disorder. After explaining to the
parents about their child’s unique psychological needs related to a seizure disorder and possible stressors,
which of the following interests uttered by them would indicate further teaching?
A. Feeling different from peers
B. Poor self-image
C. Cognitive delays
D. Dependency
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
8. A child is diagnosed with a Spina Bifida As a student, you know that Spina bifida is one of the possible neural
tube defects that can occur during early embryological development. Which of the following definitions most
accurately describes meningocele?
A. Complete exposure of spinal cord and meninges
B. Herniation of spinal cord and meninges into a sac
C. Sac formation containing meninges and spinal fluid
D. B and C
E. Spinal cord tumor containing nerve roots
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
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RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
1
2
3
4
5
6
7
17
18
19
20
21
22
23
32
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35
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37
38
PERIOD 1
8
9
PERIOD 2
24
PERIOD 3
39
10
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AL STRATEGY: CAT: 3-2-1
3-2-1
Three things you learned:
1. __________________________________________________
2. __________________________________________________
3. __________________________________________________
Two things that you’d like to learn more about:
1. __________________________________________________
2. __________________________________________________
One question you still have:
1. __________________________________________________
(For next session, review Chapter 30: Nursing Care of a Family with a Toddler p.817)
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 21
LESSON TITLE: CARE OF A FAMILY WITH A HIGH-RISK
TODDLER
LEARNING OUTCOMES:
Materials:
At the end of the lesson, the student nurse can:
Book, pen and notebook, index card/class list,
speaker and LCD projector
1. Define the common classifications of high-risk toddler and
describe common illnesses that occur in these classifications of
toddler.
Reference:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate the knowledge of the common classifications of
high-risk toddler and describe common illnesses that occur in
these classifications of toddler in formulating nursing care plan
in giving quality maternal and child health nursing care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
(Please refer to Chapter 30: Nursing Care of a Family with a Toddler p.817)
COMMON SAFETY MEASURES TO PREVENT ACCIDENTS
1. POISONING









Never present medication as candy.
Buy
medications with childproof caps; put away
DIAGNOSIS
1.Blood lead test:
 >10 mcg/dl(definite concern
immediately after use.
Never take medication in front of a child
Place all medications and poisons in locked
cabinets or overhead shelves where children
 2-10 mcg/dl(for consultation)
2. Bone marrow biopsy
3. CBC
4. Fe level
cannot reach them.
always store food or substances in their original
container
Know the names of house plants and find out if
5. Xray of long bones
they are poisonous
Hang plants or set them up on high surfaces
beyond toddler’s grasp
Be certain that small batteries or magnets are out
of reach
Post telephone numbers of nearest poison control
center by the telephone
Inspect toys to be certain they are free of lead-
MANAGEMENT
 Chelation therapy (for long-term exposure)- EDTA

For high dose in a short period:
 Bowel irrigation using polyethylene glycol
solution(cathartic)
 Gastric lavage
SALICYLATE POISONING
 OTC drug as analgesic, antipyretic, antiinflammatory agent; also used to prevent
based paints

thrombosis
ASA is colorless or white in crystalline, powder or
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LEAD POISONING
Found in:





old houses built before 1978(pre 1960’s)
Makeup
Gasoline
Dust,

toys
tasteless
 Lasts for 12-24 hours
Phase 3
 Dehydration,
 Hypokalemia
COMPLICATIONS
 Behavioral problems




Hearing loss
Decrease in IQ
Stunted growth
Kidney damage



SIGNS AND SYMPTOMS
 Abdominal cramping and pain (1 st sign of
high dosage intake)

Other signs of high dose-intake: vomiting,
staggering walk, muscle weakness, seizures,
coma
Anemia




Irritability
Aggression
Headache
Constipation

PHASES OF SALICYLATE TOXICITY
Phase1
 Hyperventilation due to respiratory alkalosis
 May last for 12 hours
Phase 2
 Paradoxic aciduria in the presence of respiratory
alkalosis due to K & NaHCO3 lost from kidneys
Characteristics:
 odorless &

granular form
Associated with Reye syndrome

of toxicity
Other early signs: vertigo, hyperventilation,
tachycardia & hyperactivity
As toxicity progresses: agitation, delirium,

hallucinations, convulsions, stupor
Hyperthermia indicates severe toxicity

DIAGNOSIS




BEFORE CALLING 911
Identify:
 Age
Progressive met acidosis
Begins 4-6h post-ingestion in a young infant or
24hours in an adolescent & adult
N/V, diaphoresis & tinnitus are the earliest signs
Serum salicylate level test
Toxicity: >40-50mg/dl
Serum electrolytes, BUN, creatinine
urinalysis
MANAGEMENT
 Stabilizing ABC
 Limit absorption




Weight
Condition
Name of product ingested
Date & time of ingestion
 Enhancing elimination
 Supportive care
Acute ingestion:
 Gastric lavage

Amount swallowed
Activated charcoal(w/in 1h of ingestion
Whole bowel irrigation(WBI) with polyethylene
glycol
**NO antidote


2. BURNS
 Buy flame-retardant clothing
 Cook on back burners of stove if possible turn
handles of pots towards back of stove to prevent
3. ASPIRATION
 Examine toys for small parts that can be
aspirated; remove toys that can be dangerous
 Do not feed toddler popcorn, peanuts, etc; urge
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
toddler from reaching up and pulling them down
Use cool mist vaporizer rather than steam


vaporizer or remain in room when vaporizer is
operating so child is not tempted to play with it
Keep screen In front of fireplace or heater.
Monitor toddlers carefully when they are near lit






candles
Do not leave toddlers unsupervised near hot
water faucets.
Check temperature settings for hot water heater

them not to eat while running.
Do not leave a toddler alone with a balloon
4. FALLS
 Keep house windows closed or keep screens in
place.



and turn down thermostat if it is over 125F
Do not leave coffee/tea pots on a table where
child can reach them
Never drink hot beverages when a child is sitting
Place gates at the top and bottom of stairs
Do not allow child to walk or run with sharp
objects in hand or the mouth
Raise crib rails and check to make sure they are
locked before walking away from the crib
on your lap or playing within reach
Do not allow toddlers to blow out matches (teach
that fire is not fun); store matches out of reach.
Keep electrical cords and wires out of reach;
cover electrical outlets with safety plugs.
CHILD ABUSE



PHYSICAL ABUSE- child is beaten or burned
NEGLECT- child is not fed, clothed, supervised
properly or offered medical care or educational
opportunities
PSYCHOLOGICAL/EMOTIONAL ABUSE- a child
is made to feel unintelligent or inadequate
PHYSICAL NEGLECT
 Child may appear

unwashed,
thin
and
malnourished or dressed inappropriately, such as
without mittens, coat or shoes in cold weather
Failing t bring a child for immunization r seek early
medical care for an infection, keeping a child out
of school or allowing a child to go unsupervised
*Abuse places a child at immediate risk for harm and can
also lead to long-term effects
Long term effects:
 they tend to be angry,
 non-compliant,
 hyperactive




PSYCHOLOGICAL ABUSE
 Includes constant


poor self-control
low self-esteem,
withdrawn
undiagnosed medical problems (anemia, otitis
1. Special Parent: Parents Who Abuse
 Most were abused as children
 Some have less self-control than other
parents
or
threatening,
rejecting, isolating or exploiting a child
It is the absence of positive parenting and is
difficult to detect
Evident in parents who use only negative terms to
describe a child
MUNCHAUSEN SYNDROME BY PROXY
 It refers to parents who repeatedly bring a child to
media, lead poisoning, or STI’s
*Abused children tend to grow up as abusive parents
THEORIES OF CHILD ABUSE
belittling


a health care facility and reports symptoms of
illness when, in fact, the child is well
The reporting causes the child to undergo
needless diagnostic procedures or therapeutic
regimens
The parent may deliberately inflict injury on the
child such as giving a laxative to induce diarrhea
or slowly poisoning the child with a prescription
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


Unfamiliar with normal growth and
development of children and have unrealistic
expectations
The parents may be socially isolated with no
support people
Excessive use of alcohol or drugs
drug.
2 CLASSICAL FINDINGS
 1st, the symptoms are not easily detected by
physical examination, only by history;
 2nd, the symptoms are present only when the
2. Special Child: Children Who Are Abused
abuser is providing care and disappear when care
is provided by another person
They may be less intelligent than other children in
the family
The parent has some degree of medical or child care



Unplanned
With birth defect, premature or with illness
preventing bonding
knowledge, tends to stay with the child constantly
SEXUAL ABUSE
 It is any sexual contact between a child an
3. Special Circumstance: Stress
As simple as a blocked toilet, illness in the family,
job loss, financial constraints

SHAKEN BABY SYNDROME
 Caused by repetitive, violent shaking of a small
infant by the arms or shoulders, which causes a
whiplash injury to the neck, edema to the



adult
Molestation- vague term than includes indecent
liberties-such as oral-genital contact, genital
fondling and viewing or masturbation
Incest- sexual activity between family members
Pornography and Prostitution- photographing
or describing sexual acts by any medium involving
children, or distributing such material in person or
by mail or fax or over the internet
brainstem and distinct retinal hemorrhages
RITUAL BASE
 Cult-based, or religiously, spiritually or satanically
motivated
May involve physical, sexual or psychological
abuse with bizarre or ceremonial activities
CEREBRAL PALSY



Definition: a group of nonprogressive disorders of
upper motor neuron impairment that result in motor
dysfunction
Affected children may also have speech or ocular
2. Dyskinetic or Athetoid type
 It involves abnormal involuntary movement
 ATHETOID means “wormlike”
 A child with quadriplegia usually has impaired
difficulties, seizures, cognitive challenges, or
hyperactivity
Muscle spasticity can lead to orthopedic or gait
difficulties
Exact cause: unknown but associated with LBW,
prematurity, or birth injury
PATHOPHYSIOLOGY
 Brain anoxia leads to cell destruction of the motor

speech (PSEUDOBULBULAR PALSY) but may
or may not be cognitively challenged. Swallowing
saliva may be difficult (DROOLS) and has
difficulty swallowing food


tracts

TYPES OF CEREBRAL PALSY
1. Spastic Type

Early in life, the child is limp and flaccid. Later, in
place of voluntary movements, the child makes
slow, writhing motions.
It may involve all 4 extremities, plus the face, neck
and tongue.
The child drools and speech is difficult to
understand
With stress, involuntary movements may become
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
Spasticity is excessive tone on the voluntary
muscles that results in loss of upper motor
neuron
SYMPTOMS
 hypertonic muscles,
 abnormal clonus,
exaggeration of DTR,
abnormal reflexes like (+) Babinski reflex,
continuation of neonatal reflexes like tonic
neck reflex

If they are held in a ventral suspension
position, they arch their backs and extend
their arms and legs abnormally.
They fail to demonstrate a parachute reflex if


4. Mixed Type

With symptoms of both spasticity and athetoid
movements. Ataxic and athetoid movements may
also be present together.
This causes a severe degree of physical
impairment
ASSESSMENT
 History and physical assessment. Note possible
upright (may lead to a subluxated hip).
Tightening of the heel cord usually is so
severe that children walk on their toes, unable
to stretch the heel to touch the ground
anoxia during prenatal life.
 Neurologic assessment, skull radiograph, CT
Scan, MRI
LONG-TERM CARE
Spastic involvement may affect both
extremities on 1 side (HEMIPLEGIA), all 4
extremities (QUADRIPLEGIA) or the lower
extremities (DIPLEGIA or PARAPLEGIA)

The involved arm may be shorter and may
have smaller muscle circumference
Most with hemiplegia have difficulty identifying
objects placed in their involved hand when

the finger-to-nose test or to perform rapid,
repetitive movements (tests of cerebellar function)
or fine coordination movements
lowered suddenly, failing to hold out their
arms as if to break their fall.
Scissors gait because tight adductor thigh
muscles cause their legs to cross when held


with
3. Ataxic Type
 They have an awkward, wide-based gait
 On neurologic examinations, unable to perform




irregular
and jerking (CHOREOID)
disordered muscle tone (DYSKINETIC)
their eyes are closed (ASTEREOGNOSIS)
Upon inspection of the child’s shoes, 1 heel
will be more worn out than the other



Help parents to encourage their children with CP
to reach their fullest potential within the limits of
their disorder
Evaluations at health care visits should note not
only whether the child is achieving goals but also
whether the child and family members find
satisfaction and acceptance in the child’s
achievements

Listen to the parents and encourage verbalization
CHECK FOR UNDERSTANDING (30 minutes)
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You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed
Multiple Choice
1. You are a school nurse and one of the children tells you about the spanking she received from her mother last
night. The girl tells you that her mother got very angry when she "talked-back" to her and this is what usually
happens when she is "bad." You suspect the child has been maltreated, and following organizational policy, you
take her to the administrator. There are no marks on the child and she says she is not in pain?
A. Call ChildLine
B. Make a GPS referral
C. Provide community resource recommendations
D. Call the police
E. Take no action
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
2. You are caring for a child in a pediatric ward, while assessing a parent who abused her child. Which of the
following risk factors would the nurse expect to find in this case?
A. Flexible role functioning between parents
B. History of the parent having been abused as a child
C. Single-parent home situation
D. Presence of parental mental illness
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
3. The following are common safety measure for Poisoning, EXCEPT
A. Buy medications with childproof caps; put away immediately after use.
B. Never take medication in front of a child
C. Do not leave toddlers unsupervised near hot water faucets
D. Place all medications and poisons in locked cabinets or overhead shelves where children cannot reach them.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
4. The following are common safety measure for Burns, EXCEPT:
A. Keep screen in front of fireplace or heater.
B. Monitor toddlers carefully when they are near lit candles
C. Do not leave toddlers unsupervised near hot water faucets.
D. Be certain that small batteries or magnets are out of reach
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
5. Caused by repetitive, violent shaking of a small infant by the arms or shoulders, which causes a whiplash
injury to the neck, edema to the brainstem and distinct retinal hemorrhages:
A. Cerebral Palsy
B. Sexual Abuse
C. Shaken Baby Syndrome
D. Munchausen Syndrome by Proxy
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
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6. It refers to parents who repeatedly bring a child to a health care facility and reports symptoms of illness when,
in fact, the child is well:
A. Cerebral Palsy
B. Sexual Abuse
C. Shaken Baby Syndrome
D. Munchausen Syndrome by Proxy
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
7. Vague term than includes indecent liberties-such as oral-genital contact, genital fondling and viewing or
masturbation:
A. Physical Neglect
B. Molestation
C. Incest
D. Pornography and Prostitution
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
8. A parent failed to bring her child for routine immunization schedule and was reported to you that her child her
sick for a month with cough, colds and fever. You know that this type of abuse is:
A. Physical Neglect
B. Molestation
C. Incest
D. Pornography and Prostitution
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
9. Your caring for an 8-year-old in a pediatric ward told you that she was being photographed by her father-in-law
naked and was asked to change her clothes in front of him for a couple of times with a cellphone camera. You
know that the child is experiencing:
A. Physical Neglect
B. Molestation
C. Incest
D. Pornography and Prostitution
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
10. Act of engaging in sexual intercourse with one's direct family member (siblings, parents, offspring):
A. Physical Neglect
B. Molestation
C. Incest
D. Pornography and Prostitution
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 22
LESSON TITLE: CARE OF A FAMILY WITH A HIGH-RISK
PRESCHOOLER
LEARNING OUTCOMES:
Materials:
At the end of the lesson, the student nurse can:
Book, pen, SAS and notebook
1. Define the common classifications of high-risk preschooler
and describe common illnesses that occur in these
classifications of preschooler.
2. Integrate the knowledge of the common classifications of
high-risk preschooler and describe common illnesses that occur
in these classifications of preschooler in formulating nursing
care plan in giving quality maternal and child health nursing
care.
Reference:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
HEALTH PROBLEMS COMMON IN TODDLERS
(Please refer to Health Problems that are Common in Preschoolers-The Leukemias p. 1512, Nephroblastoma p.1524,
Asthma p.1113, Status Asthmaticus p.1116, Urinary Tract Infection p.1303)
LEUKEMIA (p.1512)
Leukemia is the distorted and uncontrolled proliferation of WBC’s and is the most frequently occurring type of cancer in
children
ACUTE LYMPHOCYTIC(LYMPHOBLASTIC) LEUKEMIA (ALL)
 75% of leukemias
THERAPEUTIC MANAGEMENT
 involves lymphoblasts or immature WBC’s
 Up to 95% will have a first remission but if a child
 With rapid proliferation of lymphoblasts, RBC and
experiences a relapse, chances of long-term
platelet production fall and invasion of body
survival are reduced to 70%
organs by the WBC’s begins
 Induction phase of chemotherapy- complete
 highest incidence is between 2 to 6 years old
remission or absence of leukemia cells
 prognosis in those <1 is not as good as in those
 Sanctuary or consolidation phase- preventing
from 2-6 years old
leukemia cells from invading or growing in the
 more common in boys and in white children,
CNS
children with Down’s syndrome or Fanconi
 3rd, administering delayed intensive therapy
 Maintenance phase-maintaining the original
syndrome
remission
ASSESSMENT
CHEMOTHERAPY IN CHILDREN
 1st symptoms: pallor, w-grade fever, lethargy
 It involves administration via central venous
(symptoms of anemia), petechiae and bleeding
catheter or port to prevent irritation of vessel
from oral mucous membranes and may bruise
walls; also they can be clamped or trapped so the
easily because of low platelet count
child ca be ambulatory between treatments
 As spleen and liver enlarge due to infiltration of
 Drugs:
abnormal cells, abdominal pain, vomiting and
 vincristine,
anorexia occur
 prednisone,
 As abnormal lymphocytes invade the bone
 L-asparaginase,
periosteum, bone and Joint point pain
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







CNS invasion leads to headache or unsteady gait
Physical Exam reveals painless, generalized
swelling of lymph nodes (submaxillary or cervical
LN)
WBC count is markedly elevated but in some,
normal or decreased but composed almost
entirely of immature blast cells
Platelet count and hematocrit are low, but RBC’s
are normochromic and normocytic
Bone marrow aspiration is necessary to ID type of
WBC or type of leukemia (if > 29%blast cells
present, leukemia is the diagnosis)
Bone marrow aspiration is through the iliac crest
because it is less frightening and yields more
marrow
Radiograph of long bones reveals lesions
Lumbar puncture reveals evidence of blast cells in
the CSF
DISEASE CLASSIFICATION AND PROGNOSIS
 B-lymphocyte involvement accounts for 85% of
instances of ALL
 15% to 20% have T-lymphocyte cell involvement
doxorubicin and
methotrexate
*****given over a period of about 1 month
Cell destruction due to chemotherapy results in increased
uric acid levels which may destroy glomeruli and leads to
loss of kidney function. To prevent this, allopurinol is
often administered to reduce UA production
 Hydration also helps UA excretion
 Intrathecal administration of drugs may be
included to bypass the blood-brain barrier


MAINTENANCE AND MONITORING
 Standard maintenance therapy includes a
combination of daily 6-mercaptopurine, weekly
methotrexate, vincristine and prednisone, and
intrathecal methotrexate.
 This is continued for 2 to 3 years
 Leucovorin is usually given after methotrexate to
neutralize its action and protect normal cells from
the effect of the drug
 Blood values must be monitored at least monthly
 Children who are free of the disease for 4 years
are considered cured and their maintenance
therapy can be stopped
COMPLICATIONS

CNS involvement-blindness, hydrocephalus,
recurrent seizures, nuchal rigidity, headache,
irritability

Renal Involvement- from invasion of leukemia
cells; kidneys enlarge and function impaired
Testicular Invasion- leukemic cells in the testes
will not be destroyed by chemotherapy therefore
irradiation is done leading to sterility
ACUTE MYELOID LEUKEMIA
MANAGEMENT
 It involves the over proliferation of granulocytes
 Bone Marrow aspiration and Biopsy; cells are
neutrophils, basophils and eosinophils)
typed to determine prognosis (M1 to M6)
 Accounts for only 20% in childhood leukemias
 1 to 2 months of Cytarabine and anthracycline
 More frequent in late adolescence
(daunorubicin) to achieve full remission
 Granulocytes grow so rapidly they are often
 During maintenance phase, additional
forced out into the bloodstream while still in the
chemotherapeutic agents like cyclophosphamide
blast stage. It results in limited production of RBC
and 6-thioguanine are used usually for 6 to 9
and platelets
months
 Remission is difficult to achieve and is often brief
ASSESSMENT
 Bone Marrow transplantation is recommended
 Same symptoms as ALL.
 Susceptible to infection
WILM’S TUMOR/NEPHROBLASTOMA



Malignant cancer of the kidney; usually
unilateral; encapsulated at the time of
diagnosis
INCIDENCE: most frequent abdominal tumor
and most common type of renal cancer; 1 :
200,000 to 250,000 children; peak – 3 yrs;
increased incidence among siblings 
STAGE
I
II
III
DESCRIPTION
Tumor confined to 1 kidney and
completely removed surgically
Tumor extending beyond the kidney but
completely removed surgically
Regional spread of the disease beyond
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evidence of genetic inheritance
the kidney with residual abdominal
disease postoperatively
Metastases to lung, liver, bone, distant
lymph nodes, or other distant sites
Bilateral disease
ASSESSMENT
IV
 discovered early in life (6 mos to 5 yrs), although it
arises from an embryonic structure present before
V
birth
 Nephroblastomas distort the kidney so that the
TREATMENT
tumor is felt as a firm, nontender abdominal
1. Nephrectomy
mass (sometimes mistaken as hard stool by
2. Chemotherapy
the parents)
3. Radiation therapy
 Fathers often discover the tumor when they toss
4. Thoracotomy
their child in the air and catch him or her by the
abdomen, and feel the mass.
PROGNOSIS: better prognosis if no metastasis and with
 Parents sometimes feel that the tumor grew
younger age of the child; among all childhood cancers,
overnight.
highest survival rates
 It may manifest with hematuria and low-grade
fever
 Hypertension may occur due to excessive rennin
production
 Anemic due to lack of erythropoietin formation by
the diseased kidney
 CT scan reveals the tumor and points of
metastasis
 GFR, BUN tests are done to assess the kidney
before the surgery
 DO NOT palpate the child’s abdomen because
handling appears to aid metastasis
 Place a sign reading “No abdominal palpation”
over the child’s crib
ASTHMA
 Immediate hypersensitivity (Type I) response
HISTORY
 Include history of the attack, and ask parents to
and is the most common chronic illness in children
describe the home environment
 It tends to occur initially before 5 years of age
 The condition may be intermittent, with
PHYSICAL ASSESSMENT
symptom-free periods, or chronic, with continuous
 Auscultate for wheezing
symptoms
 Cyanosis and eosinophilia may be present
 It tends to occur in children with atopy or those
 Pulmonary function studies
hypersensitive to allergens.
 Mast cells release histamine and leukotrienes that THERAPEUTIC MANAGEMENT
3 goals:
result in diffuse obstructive and restrictive airway
 avoidance of allergen by environmental control,
disease because of a triad of inflammation,
 skin testing and
bronchoconstriction and increased mucus
 hypo sensitization to identified allergens, and
production
relief of symptoms by pharmacologic agents
 Most are sensitive to: pollens, molds, house dust,
 Cough suppressants are contraindicated to
cigarette smoke, cold weather, irritating odors like
prevent accumulation and formation of thick
turpentine or smog
mucus plugs
 Increased incidence in cold weather though some
 Inhaled anti-inflammatory corticosteroid such as
may experience the symptoms all year long
fluticasone (Flovent) daily
 Aspirin can be a trigger
 Long-acting bronchodilator at bedtime in addition
to inhaled anti-inflammatory daily corticosteroid
MECHANISM OF THE DISEASE
 For severe and persistent asthma, combination of
 Bronchospasm, inflammation of bronchial mucosa
oral and inhaled corticosteroid daily
and increased bronchial secretions all act to
 Short-acting beta-2 agonist bronchodilator
reduce the airway lumen, leading to respiratory
such as albuterol or terbutaline to use if an attack
distress
should begin
 Bronchial constriction is due to stimulation of
 Cromolyn sodium is a mast cell stabilizer is
parasympathetic nervous system which initiates
given by a nebulizer or metered-dose inhaler to
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
smooth muscle constriction
Inflammation and mucus production occurs
because of mast cell activation to release
leukotrienes, histamine and prostaglandins

prevent bronchoconstriction and prevent
symptoms (not effective once symptoms have
begun)
Leukotriene receptor antagonists such as
montelukast (Kastair, Singulair) for prophylaxis
and chronic treatment of asthma in children over
6yo. Not effective in an attack.
Encourage drinking of fluids during attack to
prevent dehydration but avoid milk ad milk
products because they thicken the mucus
ASSESSMENT
 After exposure to an allergen or trigger, an
episode begins with a dry cough, often at night

and bronchoconstriction begins
 Since bronchiole lumen are larger on inspiration
than on expiration, there is little difficulty in
inhaling. They later on develop difficulty exhaling
due to the narrow lumen and more so as mucus is
produced causing plugging
 This causes the typical dyspnea and wheezing
(sound caused by air forcibly pushed past
obstructed bronchioles) heard primarily upon
expiration
 If the child coughs up mucus, it is usually white
and has the shape of the bronchi from which it
was dislodged.
 Cyanosis, clubbing of fingers (for chronic cases)
 Tripod position to ease breathing
STATUS ASTHMATICUS








It occurs when children fail to respond to medications during an attack
It is an extreme emergency because a child may die of heart failure due to a combination of exhaustion,
atelectasis and acidosis from bronchial plugging
It is managed by Oxygen therapy, continuous nebulizing with beta-2 antagonist, IV corticosteroids and careful
monitoring
URINARY TRACT INFECTION
It occurs more often in females as an ascending
MANAGEMENT
infection from the perineum because the urethra is
 Antibiotic therapy. Make sure to instruct the
shorter in girls
parents to complete the regimen to prevent
Most are caused by gram-negative rods (usually
recurrence
E. coli)
 Increase fluid intake to flush out the organisms
Girls should be taught to wipe from the front to
 Cranberry juice to acidify the urine
back after voiding and defecating to avoid
 Repeat clean-catch sample is obtained after 72
contaminating the urethra
hours of antibiotic therapy to assess effectiveness
Minimize use of feminine hygiene sprays, bubble
of treatment
baths and hot tubs
Encourage voiding after sexual intercourse
SYMPTOMS
 pain on urination,
 frequency,
 burning
 hematuria, l
 low-grade fever,
 mild abdominal pain,
 enuresis
**Urine for culture is obtained by a clean-catch technique
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed
Multiple Choice
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1. It occurs more often in females as an ascending infection from the perineum because the urethra is shorter in
girls:
A. Status Asthmaticus
B. Urinary Tract Infection
C. Asthma
D. Acute Allergic Reaction
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
2. It tends to occur in children with atopy or those hypersensitive to allergens of inflammation,
bronchoconstriction and increased mucus production:
A. Status Asthmaticus
B. Urinary Tract Infection
C. Asthma
D. Acute Allergic Reaction
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
3. It occurs when children fail to respond to medications during an attack with an extreme emergency because a
child may die of heart failure due to a combination of exhaustion, atelectasis and acidosis from bronchial
plugging:
A. Status Asthmaticus
B. Urinary Tract Infection
C. Asthma
D. Acute Allergic Reaction
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
4. Malignant cancer of the kidney; usually unilateral; encapsulated at the time of diagnosis:
A. Acute Myeloid Leukemia
B. Nephroblastoma
C. Acute Lymphocytic Leukemia
D. Asthma
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
5. It involves lymphoblasts or immature WBC’s with rapid proliferation of lymphoblasts, RBC and platelet
production fall and invasion of body organs by the WBC’s begins:
A. Acute Myeloid Leukemia
B. Nephroblastoma
C. Acute Lymphocytic Leukemia
D. Asthma
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
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6. It involves the over proliferation of granulocytes and more frequent in late adolescence.
A. Acute Myeloid Leukemia
B. Nephroblastoma
C. Acute Lymphocytic Leukemia
D. Asthma
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
7. A complication of Acute Lymphocytic Leukemia wherein the leukemic cells in the testes will not be destroyed
by chemotherapy therefore irradiation is done leading to sterility:
A. CNS involvement
B. Renal Involvement
C. Testicular Invasion
D. Wilm’s Tumor
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
8. A complication of Acute Lymphocytic Leukemia wherein blindness, hydrocephalus, recurrent seizures, nuchal
rigidity, headache, irritability:
A. CNS involvement
B. Renal Involvement
C. Testicular Invasion
D. Wilm’s Tumor
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
9. A complication of Acute Lymphocytic Leukemia wherein from invasion of leukemia cells the kidneys enlarge
and function impaired
A. CNS involvement
B. Renal Involvement
C. Testicular Invasion
D. Wilm’s Tumor
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
10. The following are goals in managing asthma, EXCEPT:
A. Avoidance of allergen by environmental control,
B. Skin testing
C. Hypo-sensitization to identified allergens
D. Increase fluid intake to flush out the organisms
E. Relief of symptoms by pharmacologic agents
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 23
LESSON TITLE: CARE OF A FAMILY OF A HIGH-RISK
SCHOOL AGED CHILDREN
LEARNING OUTCOMES:
Materials:
At the end of the lesson, the student nurse can:
Book, pen, SAS and notebook
1. Define the common classifications of high-risk school-aged
children and describe common illnesses that occur in these
classification of school aged children.
Reference:
2. Integrate the knowledge of the common classifications of
high-risk school-aged children and describe common illnesses
that occur in these classifications of school aged children in
formulating nursing care plan in giving quality maternal and child
health nursing care.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
(Please refer to Common Health Problems in School Aged Children-Diabetes Mellitus p.1359, Rheumatic Fever p. 1161,
Juvenile Arthritis p. 1454, Common Parasitic Infection p.1225, Impetigo p.1216.)
COMMON HEALTH PROBLEMS IN SCHOOL AGED CHILDREN
DIABETES MELLITUS
DESCRIPTION
 PLANNING AND IMPLEMENTATION
 malfunction of CARBOHYDRATE, PROTEIN and
 Monitor VS, respiratory status and LOC, hydration
FAT metabolism
status (skin turgor, I&O, mucous membranes),
 Most children have Type I diabetes (formerly
glucose levels (report if >240mg/dl) before each
called insulin-dependent diabetes)
meal and at bedtime
 Type 2 diabetes (formerly called non-insulin IV fluids with electrolytes to regulate acidosis and
dependent diabetes mellitus) may be prevalent in
continuous insulin infusion
overweight adolescents
 Diet low in saturated fat, sufficient calories for
normal G&D; avoid concentrated CHO; refer to
ETIOLOGY AND PATHOPHYSIOLOGY
nutritionists and teach parent about food
exchange lists
 caused by a genetic component, autoimmune
response or environmental influences such as
 3 meals a day and mid-afternoon and bedtime
viruses
snacks
 As blood glucose level exceeds renal threshold of
 Exercise makes the body more sensitive to insulin
and reduces insulin requirement.
160 mg/dl, glucosuria/glycosuria occurs; large
 Glycosylated hemoglobin every 3 months to
amounts of water and electrolytes are lost with
evaluate long-term control the higher the value or
glucose leading to increased urination (polyuria);
level of A1c, the poorer the control. Normal level
polyphagia, fatigue and weight loss may
is from 4% to 7%
accompany other symptoms because of cellular
starvation
 During fat metabolism, the liver produces ketones,
MEDICATION THERAPY
acidic waste products of fat metabolism; ketones
 Type 1 DM: basal-bolus insulin therapy OD
accumulate causing metabolic acidosis or
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ketoacidosis and ketonuria; respiratory system
attempts to rid the body of excess CO2 by
increasing the rate and depth of
breathing( KUSSMAUL’S RESPIRATION); if
acidosis is not corrected, ARF, severe DHN, coma
and subsequent death may occur
Long-term complications:
 retinopathy,
 neuropathy, and
 vascular complications




(Lantos) or BID (Humulin or Ultralente), + bolus of
rapid-acting insulin per meal/snack
Insulin-stored at RT(above freezing and below
86F) & discarded after opening even if
refrigerated).
Most insulins are administered SC; only regular
insulin may by given IV;
insulin pumps are available for kids 2 years old &
below
Glucagon (pancreatic hormone that helps release
stored glucose from the liver) may be given SC or
IM to a hypoglycemic child
if <7yo, 0.5mg
> 7yo receive 1 mg SC.

ASSESSMENT

 FBS>126 mg/dl or >200mg/dl RBS on 2
separate occasions accompanied by
 classic signs of DM: lethargy, confusion, dry
skin, thirst, weakness, abdominal pan, fruity
breath and diminished reflexes; ketonuria and
glycosuria possible
 Polyuria (enuresis in a toilet-trained child),
 polyphagia and
 polydipsia
 with weight loss and fatigue
 Dehydration as indicated by poor skin
turgor(tenting), dry mucous membranes, low
urine output
 Complete physical examination, dietary
history, to rule out other illnesses causing
elevated blood sugar( stress-related illnesses,
steroid use, pancreatitis, liver disease, cystic
fibrosis)
 Diagnosis is based on: 8-hour
FBS(>126mg/dl)
RHEUMATIC FEVER
DESCRIPTION
MINOR CRITERIA
 It is a systemic inflammatory disease that involves
 Chorea involves involuntary movement of limbs;
the heart and joints; CNS and connective tissues
emotional lability and slurred speech; this
may also be involved
symptom has a latent period of 2 months or more
from the GABHS infection; St. Vitus Dance,
 It occurs secondary to infection by Group A betaSydenham’s Chorea
hemolytic streptococcus
 Erythema marginatum is an erythematous,
ETIOLOGY AND PATHOPHYSIOLOGY
macular rash which occurs primarily on the trunk
and proximal limbs, associated with carditis
 2 to 6 weeks after a group A beta-hemolytic
streptococcal infection
 Subcutaneous nodules which are nontender
nodules that develop on the skin over the flexor
 autoimmune reaction vs. group A beta-hemolytic
surfaces of joints and the vertebrae
streptococcal; organisms cannot be cultured from
the lesions
OTHER SIGNS AND SYMPTOMS
 Acute phase lasts 2 to 3 weeks: inflammation of
 Abdominal pain
connective tissues in heart, joints and skin
 Nosebleeds
 Proliferative Phase: ASCHOFF BODIES develop
 Preceding streptococcal infection (scarlet
on heart valves; cardiac valve leaflets scar and
fever, raised ASO titer, positive throat culture)
lead to vascular stenosis and regurgitation
 Episode of RF lasts up to 3 months and is selfDIAGNOSIS
limiting
 2 Major criteria
 Long-term consequence is RHEUMATIC HEART
 Or
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DISEASE, often manifested in valvular damage
ASSESSMENT USING JONES CRITERIA
MAJOR CRITERIA
 Polyarthritis- inflammation of large joints
(knees, elbows, wrists) and arthralgia
 Carditis-most severe symptom (includes
murmurs, pericardial friction rub, ECG
changes, tachycardia)
 Chorea involves involuntary movement of
limbs; emotional lability and slurred speech;
this symptom has a latent period of 2 months
or more from the GABHS infection; St. Vitus
Dance, Sydenham’s Chorea
 Erythema marginatum is an erythematous,
macular rash which occurs primarily on the
trunk and proximal limbs, associated with
carditis
 Subcutaneous nodules which are nontender
nodules that develop on the skin over the
flexor surfaces of joints and the vertebrae



1 Major criterion plus
2 Minor criteria
And evidence of streptococcal infection or rising
ASO titer or Deoxyribonuclease test (DNase test)
PLANNING AND IMPLEMENTATION
 Bed rest with bathroom privileges until ESR
returns to normal
 Use aspirin and prednisone as ordered to
reduce inflammation and provide comfort from
painful joints
 penicillin as ordered in either an oral daily
dose or monthly long-acting injection after
recovery from RHD to reduce risk of
recurrence of strep infection
 erythromycin if allergic to penicillin
 Design nursing activities to promote rest
and encourage diversional activities that do
not stress the heart;
 maintain bedrest with bathroom privileges
JUVENILE ARTHRITIS
DESCRIPTION
 Heat can be applied by the use of warm water
 It primarily involves the joints of the body,
soaks for 20-30 minutes.
although it also affects blood vessels, and other
 Paraffin soaks can be useful for finger and wrist
connective tissues
inflammation
 To be classified as JA, symptoms must begin
 Plan mealtimes for best times of the day when the
before 16 yo and last longer than 3 months.
child is not fatigued and in pain
 The peak incidence is from 1 to 3yo and 8 to 12
 NSAIDS such as ibuprofen or naproxen are the
years old though it can occur in children as young
DOC and are given 1 to 4 times a day for at least
as 6 months old
6 to 8 weeks to control pain and inflammation
 More common in girls
 Give NSAIDS with food to prevent gastric irritation
 low-acting anti-rheumatic drugs (SAARD’s), also
ETIOLOGY AND PATHOPHYSIOLOGY
called disease-modifying-anti-rheumatic
 Unknown cause but may be an autoimmune
process in which the child develops
drugs(DMARD’s) are used if NSAID’s are
antibodies against body cells.
ineffective
 It is revealed by the presence of
 SAARD’s modify the natural progress of the
ANTINUCLEAR ANTIBODIES (ANA)
disease over weeks or months.

Examples of SAARD’s: gold salts, penicillamine,
ASSESSMENT
and hydroxychloroquine
 Persistent fever and rash present before joint
involvement
 Steroids may be added if the disease is severe or
 Assess for ability to do self-care
has not responded to other
 Modify environment to allow increase of overall
 Newer therapy is the use of anticytokines
activity
(Cytokines are protein particles produced by the
 Children with Pauciarthritis must be screened with
immune system that play a role in the destruction
slit-lamp examination every 6 months for UVEITIS
of body joints.)
(inflammation of the iris, ciliary body and choroid
membrane of the eye) which may lead to
blindness
THERAPEUTIC MANAGEMENT
 Balanced program of exercise, rest and
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



medication administration to relieve pain, restore
function, and maintain joint mobility
To preserve muscle and joint function, children
are prescribed a daily program of ROM exercises
to strengthen muscles and put joints through their
full range of motion( swimming and biking)
Encourage them to do self-care as they can.
Avoid excessive activities that place excessive
strain on the joints like running, jumping,
prolonged walking and kicking
Warm bath in the morning to reduce pain and
increase joint movement
Characteristics
No. of joints involved
Joints affected
Gender affected
Body temperature
Other
symptoms
POLYARTICULAR
5 or more
Small joints of fingers & hands,
weight-bearing joints, often
same joint on both sides of the
body
More girls than boys
Low-grade Fever
Stiffness, minimal
joint swelling
leading to limited
motion
Rheumatoid
nodules/bumps on
elbows or other
areas receiving
pressure from
chairs, shoes etc.
+rheumatoid factor
+ANA titer.
PAUCIARTICULAR
4 or less
Large joints- knees, ankles
elbows
SYSTEMIC ONSET
Any number
Any joint
More girls than boys
Low-grade fever
Boys & girls equally
High spiking fever lasting
wks or mos.
Iridocyclitis
(eye
inflammation)
Macular rash on
chest, thighs
Painless joint
swelling with
little redness
Inflammation of
heart and LUNGS
Rheumatoid nodules/bumps
on elbows or other areas
receiving pressure from
chairs, shoes etc.
+ HLA
antigen(possible
in boys)
+ ANA titer
Anemia
+rheumatoid factor
Enlarged lymph
nodes, liver,
spleen.
Rarely +
rheumatoid factor
and ANA titer.
+ANA titer.
Elevated white
blood cell count,
complement and
ESR
Other
symptoms
Stiffness, minimal joint
swelling leading to limited
motion
Elevated white blood cell
count, complement and ESR
Elevated white
blood cell count
INFECTION
Pediculosis
capitis
ORGANISM
Head lice
COMMON PARASITIC INFECTION
SYMPTOMS
TREATMENT
Small, white flecks on
1. Wash hair with shampoo such as LINDANE
hair shaft (nits or eggs
(Kwell)
of lice)
2. Comb nits from hair with fine-toothed comb
Extreme pruritus
3. Wash bedsheets, recently worn clothes
4. Vacuum pillows, , mattresses oR other
personal items
5. Teach children not to exchange combs, hair
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barrettes, or other personal items
Pediculosis
Pubic lice
Same as for head lice
Same as head lice
except on pubic hair
Scabies
Female mite
Black burrow filled with
Caution adolescent that groin infestations might be spread
(Acarus
mite feces 1-2 inches
by physical intimacy
scabiei)
long, usually between
fingers and toes, on
Wash area with lindane (Kwell) lotion or Permethrin
palms, or I axilla or groin (Elimite)
IMPETIGO
Causative agent: Beta-hemolytic Streptococcus, Group
THERAPEUTIC MANAGEMENT
A, Staphylococcus aureus
 Oral penicillin or erythromycin or the application of
mupirocin (Bactroban) ointment for 7 to 10 days
Incubation period: 2 to 5 days
 The lesions will heal quickly if the parent or child
washes the crusts daily with soap and water
Period of Communicability: from outbreak of lesions
 Rare complications: RF or AGN
until lesions are healed
 Follow contact precautions until 24 hours after
initiation of therapy
Mode of Transmission: Direct contact with lesions

Immunity: None
ASSESSMENT
 Superficial infection of the skin that begins as a
single papulovesicular lesion surrounded by
localized erythema
 As more vesicles appear, they become purulent,
ooze, and form honey-colored crusts found
commonly on the face and extremities
 They are often seen as secondary infections to
insect bites or in children with body piercings
 If there are several lesions, children may have
swollen lymph nodes
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed
Multiple Choice/True or False
1. A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides
instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child
to do?
A. Eat twice the amount normally eaten at lunchtime.
B. Take half the amount of prescribed insulin on practice days.
C. Take the prescribed insulin at noontime rather than in the morning.
D. Eat a small box of raisins or drink a cup of orange juice before soccer practice.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
2. The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that
the child has been sick. The mother reports that she checked the child’s urine and it was positive for ketones.
The nurse should instruct the mother to take which action?
A. Hold the next dose of insulin.
B. Come to the clinic immediately.
C. Encourage the child to drink liquids.
D. Administer an additional dose of regular insulin
ANSWER: ________
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RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
3. A pediatrician prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40
mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority
assessment before administering this IV prescription?
A. Obtains a weight
B. Takes the temperature
C. Takes the blood pressure
D. Checks the amount of urine output
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
4. A 7-year-old with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic
ketoacidosis. Which assessment findings should the nurse expect to note?
A. Sweating and tremors
B. Hunger and hypertension
C. Cold, clammy skin and irritability
D. Fruity breath odor and decreasing level of consciousness
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
5. A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that
the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed.
Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?
A. Potassium infusion
B. NPH insulin infusion
C. 5% dextrose infusion
D. Normal saline infusion
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
6. The school nurse has provided an instructional session about impetigo to parents of the children attending the
school. Which statement, if made by a parent, indicates a need for further instruction?
A. “It is extremely contagious.”
B. “It is most common in humid weather.”
C. “Lesions most often are located on the arms and chest.”
D. “It might show up in an area of broken skin, such as an insect bite.”
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
7. The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing
that which laboratory study would assist in confirming the diagnosis?
A. Immunoglobulin
B. Red blood cell count
C. White blood cell count
D. Anti–streptolysin O titer
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
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8. A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the
nurse should ask the parents which question to elicit assessment information specific to the development of
rheumatic fever?
A. “Has the child complained of back pain?”
B. “Has the child complained of headaches?”
C. “Has the child had any nausea or vomiting?”
D. “Did the child have a sore throat or fever within the last 2 months?”
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
9. The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a
painful exacerbation of the disease. The parents ask the nurse if the child can perform range -of-motion exercises
at this time. The nurse should make which response?
A. “Avoid all exercise during painful periods.”
B. “Range-of-motion exercises must be performed every day.”
C. “Have the child perform simple isometric exercises during this time.”
D. “Administer additional pain medication before performing range-of-motion exercises.”
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
10. The clinic nurse is reviewing the health care provider’s prescription for a child who has been diagnosed with
scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the
child’s record?
A. The child is 18 months old.
B. The child is being bottle-fed.
C. A sibling is using lindane for the treatment of scabies.
D. The child has a history of frequent respiratory infections.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
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NUR 145 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 24
LESSON TITLE: CARE OF A FAMILY OF A HIGH-RISK
ADOLESCENT
LEARNING OUTCOMES:
Materials:
At the end of the lesson, the student nurse can:
Book, pen, SAS and notebook
1. Define the common classifications of high-risk adolescent and
describe common illnesses that occur in these classifications of
adolescent.
Reference:
2. Integrate the knowledge of the common classifications of
high-risk adolescent and describe common illnesses that occur
in these classifications of adolescent in formulating nursing care
plan in giving quality maternal and child health nursing care
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
(Please refer to health Problems Common in Adolescents-Scoliosis p. 1450, Bone Tumors (Osteogenic Sarcoma) p.
1521, Accidents p.893, Sexually Transmitted Infections p. 1336, Amenorrhea p.1329, Obesity, Anorexia Nervosa p. 1548,
Substance Abuse p.902, Teen Suicide p.906)
SCOLIOSIS
DESCRIPTION
 Lateral curvature of the spine
 Electrical stimulation for mild to moderate
 FUNCTIONAL, which occurs as a compensatory
curvatures, to cause muscles to contract at
mechanism in children who have unequal leg
regular and frequent intervals, possibly helping to
lengths or poor posture
straighten the spine
 STRUCTURAL scoliosis is a permanent curvature
 If curvature progresses or is > 40 degrees,
of the spine accompanied by damage to the
surgery is warranted for spinal instrumentation;
vertebrae
rods, screws & wires are placed next to the
 Structural scoliosis-most often during rapid growth
curvature; spine is then fused in correct position;
spurt ( 11 to 14 yrs for females, 13 to 16 yrs for
bone from iliac crests may be used to strengthen
males)
fusion
 Post-operative care: ROM exercises, log rolling
ETIOLOGY AND PATHOPHYSIOLOGY
every 2 hours, deep breathing and use if incentive
 70%is idiopathic
spirometry, NPO, NGT, strict I & O, VS &NVS
 There is a familial predisposition for structural
monitoring, BT, pain management, TEDS, and
scoliosis
gradual resumption of activity
 It is common in diseases where there is unequal
muscle balance, such as CP, muscular dystrophy
MILWAUKEE OR OTHER BRACES
and myelomeningocoele
 Worn 23 hours a day, off to shower, bathe, swim
 T-shirt is worn underneath the brace to protect the
ASSESSMENT
skin
 painless and insidious onset
 Exercises (pelvic tilt, lateral strengthening) several
 skirts hang unevenly, or that bra straps are
times a day while in brace
adjusted unevenly
 Slight muscle ache noticed when first wearing the
 unequal shoulder heights, waist angles, scapula
brace
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
prominences, rib prominences, and chest
asymmetry
Screening by school nurse begins in 5 th grade
DISCHARGE TEACHING
 Must not slump on chairs, must not bend or twist
the torso or lift over 10 lbs
 Comply with activity restrictions for 6 to 8 months
PLANNING AND IMPLEMENTATION
 Xray to identify extent of curvature and give
baseline information
 If spinal curve is <15 to 20 degrees, the teen is
monitored every 3 to 6 months; exercises to
improve posture and muscle tone and increase
flexibility of the spine are encouraged
 If curve is >40 degrees, surgery; if >32 degrees,
conservative nonsurgical treatment with bracing
such as a MILWAUKEE brace, made of leather
and plastic and is worn until the growth spurt
stops
BONE TUMORS (OSTEOGENIC SARCOMA)
DESCRIPTION
PLANNING AND IMPLEMENTATION
 It is a tumor that arises from a bone cell, probably
 Treatment may include radical resection or
the osteoblast
amputation
 Most common bone cancer in children
 Selected clients may have prosthetic replacement
 Frequently affects the metaphysis of long bones
 Thoracotomy for lung metastasis
 Chemotherapy may be administered preop and
ETIOLOGY AND PATHOPHYSIOLOGY
postop
 Common in adolescent boys; tumor growth is
 Emotional support of child is important
detected t time of rapid bone growth
 Employ a straightforward approach when
 Frequently affects distal end of femur; also affects
amputation is indicated; allow verbalization
humerus, tibia, pelvis, jaw, and phalanges
 Sterile stump care and special bandaging as
 It is a malignant tumor that frequently
ordered
metastasizes to the lungs
 Elevate stump for 24 hours if prescribed; avoid
 High incidence in children who had retinoblastoma
prolonged elevation
 Maintain body alignment
ASSESSMENT
 Perform ROM exercises to joints above the
 Pain and swelling are the initial symptoms
amputation
 Xrays following traumatic injury may be 1 st
 Assist with early ambulation and temporary
indication of disease
prosthesis use
 CT, or MRI to detect metastasis
 Encourage early interaction with peers
ACCIDENTS
ACCIDENT
HEALTH TEACHING MEASURES
MOTOR
 Use a seatbelt
VEHICLE
 Do not drink alcohol while driving or ride with anyone who has
been drinking
 Wear helmet and long pants when riding a motorcycle
 Accepting dares has no place in safe driving
 Take driving lessons to learn safe driving habits for 2-wheel or 4wheel vehicles
FIREARMS
 Always consider all guns loaded are potentially lethal
 Learn safe gun handling before attempting to clean a gun or hunt
DROWNING
 Learn how to swim; follow safe water rules such as never swim
alone, no diving into a shallow pool, no swimming beyond own
limit
 Never take dares
SPORTS
 Use protective equipment such as hockey mask, football pads,
etc
 Do not attempt in participating beyond physical limits
 Training for sports is necessary
SEXUALLY TRANSMITTED INFECTION
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Symptoms
Common Therapy
Vulvar reddening and pruritus; thick,
white, cheese-like vaginal discharge
Candida
albicans
Thin, irritating, frothy, gray-green
discharge; strong, putrid odor, itching
Gardnerella
vaginalis
Edema and reddening of vulva; milkygray discharge, fishy odor
Foreign Body
Herpesvirus
type II
Vaginal discharge; odor
Painful, pinpoint vesicles on an
erythematous base with watery vaginal
discharge; voiding may be irritating and
painful
Watery, gray-white vaginal discharge,
vulvar itching
Possibly symptomless; profuse yellowgreen vaginal discharge
Rectal pruritus, especially on rising in the
morning
Painless ulcer on vulva or vagina
Nystatin or miconazole (Monistat)
suppositories or fluconazole orally;
bathing with dilute NaHCO3 to
relieve pruritus
Metronidazole (Flagyl) orally;
douching with weak vinegar to
reduce
Pruritus
Metronidazole (Flagyl) or clindamycin
Removal of foreign body
Bathing with dilute NaHCO3,
applying lubricating lotions to lesions
or oral analgesic; topical acyclovir
helps heal lesions
Tetracycline or doxycycline;
erythromycin during pregnancy
Ceftriaxone and doxycycline; oral
amoxicillin
Oral administration of antihelminthic
such as mebendazole(Vermox)
Benzathine penicillin, administered
IM
Chlamydia
trachomatis
Neisseria
gonorrhoeae
Enterobius
vermicularis
Treponema
pallidum
(Syphilis)
Group B
Vaginitis, vulvar itching, edema and
Antibiotic (Amoxicillin)
Streptococcus reddening of vulva
 Hepatitis B and C- spread by semen and blood
 Syphilis- IP of 10-90 days then typical painless lesion (CHANCRE) appears on genitalia,
lips, rectum lasting for 6 weeks then fades; 2-4 weeks after, a generalized, macular, coppercolored rash appears usually on the soles and palms (VDRL serologic test will be +); next
stage is a latency period lasting from years to decades(+ serologic test); final stage involves
major organs casing blindness, paralysis, crippling neurologic deformities, mental
confusion, slurred speech and lack of coordination
 HIV
AMENORRHEA
 Absence of menstrual flow; may be due to
pregnancy, tension, anxiety, fatigue, chronic
illness, extreme dieting and strenuous exercise
 Associated with low ratio of body fat to muscle
which leads to excessive secretion of
PROLACTIN causing a decrease in the secretion
of GnRH by the hypothalamus
 Menstrual cycle usually returns to normal within 3
months after discontinuation of strenuous training
DYSMENORRHEA
 It is painful menstruation caused by the release of
prostaglandins in response to tissue destruction
during the ischemic phase of the menstrual cycle
 Prostaglandins cause the smooth muscles to
contract causing pain in the uterus
 It can be a preliminary symptom of an underlying
illness such as PID, myoma or endometriosis
ASSESSMENT
 1st 2 years of menstruation, dysmenorrhea is rare
because early MC’s are anovulatory
 Categorized as mild (no interference with normal
activities), moderate (some interference), or
severe (interference with majority of daily activities
 Primary if it occurs in the absence of an organic
disease and secondary if it is a result of organic
disease
 Begins with a bloated feeling and light cramping
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


24 hours before menstrual flow
Pain is noticed when the flow beginscolicky(sharp) pain is superimposed on a dull,
nagging pain across the lower abdomen
accompanied by an aching, pulling sensation of
the vulva and inner thighs
Some have mild diarrhea with the abdominal
cramping
Mild breast tenderness, abdominal distention,
N/V, headache and facial flushing
MANAGEMENT
 Analgesics such as aspirin or ibuprofen and
naproxen sodium may be used but most not be
taken on an empty stomach
 Low-dose oral contraceptive to prevent ovulation
 Alternative therapies: imagery, TENS
OBESITY
 Most overweight adolescents have obese parents (environment and inheritance)
 Suicide rate for obese teens is higher than in the non-obese
 Teens generally adhere to a diet closer to 1800 calories a day
 Adolescents who overeat as a reaction to stress need psychological counseling rather than diet counseling
 Obesity causes low self-esteem, body image problems and depression
 Diet and exercise are the main measures
MEASURES TO HELP DECREASE OVEREATING
 Make a detailed log of the amount they eat, the time, and the circumstances and then changing those
circumstances
 Always eat in 1 place instead of while walking or watching TV
 Slow the process of eating by counting mouthfuls and putting the fork down beside the plate between bites, and
being served food on small plates so helpings look larger




ANOREXIA NERVOSA
ASSESSMENT
characterized by refusal to maintain a
 perceive food as revolting or nauseating and
minimally normal body weight because of a
refuse to eat or vomit food after eating
disturbance in perception of the size or
 May use IPECAC for vomiting, laxatives, diuretics,
appearance of the body
intensive exercise to lose weight
Includes 3 separate features: self-induced
 Excessive weight loss, acidosis, dependent
starvation to a significant degree; relentless drive
edema, hypotension, hypothermia, bradycardia,
for thinness, a morbid fear of fatness, or both; and
formation of lanugo
medical signs ad symptoms resulting from
starvation
MANAGEMENT
most often in girls (90%) between 13 and 20 yo
 Oral foods withheld to prevent vomiting; TPN to
It may be manifested as severe weight restriction
supply needed fat, protein and calories
controlled by limiting food intake, excessive
 Establish trust and effective communication
exercise or by BINGE EATING or PURGING
 Antidepressants
SPECIAL CHARACTERISTICS OF A CHILD WITH
ANOREXIA NERVOSA
 BMI < 17.5 or <85% of expected weight
 Intense fear of gaining weight or becoming fat
even though underweight
 Severely distorted body image
 Refusal to acknowledge seriousness of weight
loss
 Amenorrhea




Identification of emotional triggers
Self-monitoring (awareness training)
Education about normal nutritional needs
Gradual weight gain is recommended
SUBSTANCE ABUSE
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DRUGS
Glue


Heroin, morphine,
codeine


Hallucinogens (LSD
PCP, DMT)


Stimulants
(methamphetamine,
cocaine)

Depressants
(barbiturates,
alcohol)

Steroids


SYMPTOMS OF USE
Violence, drunken appearance,
dreamy or blank expression
Glue smears on clothing or fingers;
tubes of glue, paper bags
Stupor, drowsiness, needle marks,
watery eyes, anorexia, bloodstains on
sleeves, runny nose
Needle or syringe, cotton, tourniquet,
burnt bottle caps or spoons, glassine
envelopes
Severe hallucinations, detachment,
incoherent speech, cold hands and
feet, laughing and crying, vomiting
Possession of cube sugar with
discoloration in the center, strong
body odor
Aggressive behavior, giggling,
silliness, rapid speech, confusion,
anorexia, extreme fatigue, black
caries, dry mouth, shakiness,
insomnia. Pills or capsules in varying
colors, absence of nasal hair,
possession of a glass pipe
Drowsiness, stupor, slurred speech,
drunken appearance, vomiting
Pills or capsules in varying colors,
odor of alcohol on breath
Aggressive behavior, increase in
muscle strength and mass
DANGERS
Lung, brain or liver
damage; suffocation or
choking, anemia
Overdose; liver and
other infections
Suicidal tendencies,
unpredictable behavior,
neurologic effects
Overdose,
hallucinations,
psychosis
Death or
unconsciousness from
overdose; addiction,
seizures from
withdrawal
Violent actions, possibly
tumor growth
ASSESSMENT
 Failure to complete assignments in school
 Demonstration of poor reasoning ability
 Decreased school attendance
 Frequent mood swings
 Deteriorating physical appearance
 Recent change in peer group
 Expressed negative perceptions of parents
TEEN SUICIDE
DESCRIPTION
SUICIDE WARNING SIGNS
 It is deliberate self-injury with the intent to end
 Giving away prized possessions
one’s life
 Organ donation questions
 More frequent in males although more attempts
 Sudden, unexplained elevation of mood
are made by females
 Accident proneness, carelessness, and death
 Frequent during spring or fall, reflecting school
wishes
stress and between 3pm and midnight, reflecting
 “This is the last time you will see me.”
depression that increases with the dark
 Decrease in verbal communication
 3rd cause of death in the 15 to 19-year old group
 Withdrawal from peer activities or previouslyenjoyed events
 Some degree of depression is present in
 Previous attempt (80% f completed suicides have
adolescents because they are not only losing their
been preceded by a failed attempt)
parents and also their carefree childhood
 Recent increase in interpersonal conflict with
ASSESSMENT
significant others
 Signs of depression: anorexia, insomnia,
 Running away from home
excessive fatigue, or weight loss
 Recent experience of a friend or a famous person
 In younger adolescents: disobedience, tantrums,
committing suicide
truancy and running away from home
 Inquiring about the hereafter
 Self-destructive behavior, difficulties in school,
 Asking for information (supposedly for a friend)
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THERAPEUTIC MANAGEMENT
 Antipyretics
 adequate hydration
 nasal suctioning
 nasal saline
 avoidance of tobacco exposure
 home monitoring are adequate.
 Hospitalization is warranted for children with severe illness, such as apnea, hypoxia, or dehydration,
which may occur due to difficulty feeding.
 Infection control and hand hygiene is important to reduce the risk of transmission
 Palivizumab, a monoclonal antibody, is recommended as prophylactic injection to prevent RSV during RSV
season.
 Injections are given monthly during RSV season.
ASTHMA
PULMONARY FUNCTION STUDIES
 a chronic inflammatory disorder of the respiratory
 Pulmonary function studies or spirometry can be
track and is the most common chronic illness in
helpful in evaluating children for asthma.
children
 In children with asthma, the vital capacity ( the
air that they are able to exhale) may be low or the
 derived from the Greek word for “panting,” a
description of the child’s distress.
capacity may be normal but because of narrowed
bronchioles as a result of bronchospasm, the
RISK FACTORS
expiratory rate will be abnormally long (more than
10 seconds rather than the normal 2 or 3
 Genetics
seconds).
 environmental exposures

often difficult to perform in young children
 allergens
because
good understanding and effort is needed
 stress
to
effectively
perform.
 pollution, etc.,
MECHANISM OF DISEASE
 primarily affects the small airways.
 The relationship of inflammation to airway
hyperresponsiveness
 airway obstruction contributes to clinical
symptoms.
 This complex interplay of factors presents as
recurrent wheezing, breathlessness, chest
tightness, and coughing
ASSESSMENT
 episode begins with a dry cough
 difficulty exhaling
 dyspnea and wheezing (the sound caused by air
being pushed forcibly past obstructed bronchioles)
HISTORY
 Activity of the child with the time of symptoms
began asthma triggers, and what treatments were
given
 home environment
 pets
 the child’s bedroom
 outdoor play space
 classroom environment
 type of heating in the house, to see whether more
environmental control could reduce allergen
triggers and future occurrences
PEAK EXPIRATORY FLOW RATE MONITORING
 determine the level of severity of their symptoms
at home. Each zone (green, yellow, or red) is
associated with treatment recommendations.
 These may include options for inhaler use and
guidelines for when to call their provider or seek
emergency care.
THERAPEUTIC MANAGEMENT
 history and physical examination and objective
testing to determine asthma severity and control
 education for home self-management
 control of environmental factors that contribute to
symptoms (i.e., allergens)
 Pharmacologic therapy, defined as quick relief
and long acting medications
 The primary goal in asthma management is the
prevention of airway inflammation.
 A child with mild intermittent asthma may be
prescribed an inhaled short-acting β-agonist, such
as albuterol, to take as needed
 children with persistent or severe symptoms will
need an inhaled corticosteroid to take daily in
order to prevent exacerbations
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PHYSICAL ASSESSMENT
 wheezing is evident only by stethoscope
auscultation; in others, it is so loud it can be heard
by simply listening.
 observe for retractions because children have to
use intercostal accessory muscles to achieve full
breaths.
 More comfortable in a sitting position and standing
position rather than lying on bed
 Children who do agree to lie down are either at
the end of an attack and beginning to feel less
threatened by the dyspnea or are so exhausted by
the paroxysms of coughing that they no longer
have the strength to sit upright.
STATUS ASTHMATICUS
THERAPEUTIC MANAGEMENT
 a severe and prolonged asthma attack that is not
responsive to asthma therapy
 Continuous nebulization with an inhaled β2
agonist
 requires hospital evaluation and close
 IV corticosteroids may be necessary to reduce
cardiopulmonary monitoring.
symptoms, along with oral or IV steroids
 A child with status asthmaticus is in ARDS
 smooth muscle relaxers, and others.
 a child in status asthmaticus has failed to respond
to first-line therapy
 In severe attacks, endotracheal intubation and
mechanical ventilation may be necessary to
ASSESSMENT
maintain effective ventilation and perfusion.
 heart rate and respiratory rate are elevated.
 level of alertness and responsiveness may be
altered
 may appear anxious.
 Both oxygen saturation and PO2 are low;
 PCO2 is elevated because the bronchi are so
constricted the child cannot exhale, resulting in
CO2 accumulation. The rising PCO2 rapidly leads
to acidosis.
 In contrast to the loud wheezing initially heard in
an asthma attack.
PNEUMONIA
CHLAMYDIAL PNEUMONIA
 is an infection and inflammation of alveoli.
 Chlamydia trachomatis pneumonia, typically seen
 It often has a bacterial or viral origin and is
in newborns up to 12 weeks of age
categorized as hospital- or community-acquired
 is often contracted from contact with the mother’s
 Pneumocystis carinii pneumonia, seen almost
vagina during birth
exclusively with HIV/AIDS infection.
PNEUMOCOCCAL PNEUMONIA
 generally abrupt and follows an upper respiratory
tract infection.
 In infants, the infection tends to be
bronchopneumonia with poor consolidation.
 In older children, pneumonia often localizes in a
single lobe with full consolidation.
 During the initial 24 to 48 hours of infection,
children may have blood-tinged sputum that
transitions to a thick, purulent sputum.
ASSESSMENT
 high fever
 tachycardia
 chest or abdominal pain
 chills
SYMPTOMS
 nasal congestion
 a sharp cough
 poor weight gain
 These progress to tachypnea
 Wheezing
 rales on auscultation
ASSESSMENT
 elevated levels of IgG and IgM antibodies
 peripheral eosinophilia
 antibodies to C. trachomatis
THERAPEUTIC MANAGEMENT
 Antibiotics are often used for pharmacologic
treatment.
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 27
LESSON TITLE: NURSING CARE OF A FAMILY WHEN A
CHILD HAS A CARDIOVASCULAR DISORDER
Materials:
Book, pen, SAS and notebook
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:
Reference:
1. Define the common types of cardiovascular disorders that
occur in children.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
2. Integrate the knowledge of the common cardiovascular
disorders in children and describe these common illnesses that
occur in these classifications of school aged children in
formulating nursing care plan in giving quality maternal and child
health nursing care.
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
Please refer to Chapter 41: Nursing Care of a Family When a Child Has a Cardiovascular Disorder-Congestive Heart
Failure p. 1134 and Congenital Heart Defects p. 1140
CONGESTIVE HEART FAILURE
 is defined as the inability of the heart to supply
adequate oxygenated blood to meet the metabolic
RIGHT SIDED HEART
LEFT SIDED HEART
demands of the body.
FAILURE
FAILURE
 Heart failure is a cluster of symptoms and physical
 Hepatomegaly
 increased
examination findings that are secondary to an
pulmonary
 increased venous
underlying process.
pressures
pressure noted
 most common causes of CHF in children are
jugular venous
 rales
congenital heart defects that produce an
distention
 tachypnea
excessive workload on the myocardium,
 periorbital edema
 shortness of
cardiomyopathies due to metabolic disorders,
breath
infectious diseases, drugs, Kawasaki disease, and
myocardial dysfunction after heart surgery.
THERAPEUTIC MANAGEMENT
 symptomatically manage the patient
ETIOLOGY
 treat the underlying cause of the heart failure
 inability to meet metabolic demands
 goal is to decrease any fluid overload, enhance
 decreased filling or obstruction of flow,
myocardial contractility, and decrease afterload in
 Either one side or both sides of the heart are
order to ensure adequate perfusion and decrease
unable to pump effectively and will eventually fail
the work of the heart.
if the root problem is not corrected.
 Interventions focus on helping support heart
function and helping parents deal with this crisis
ASSESSMENT
until the child is stabilized and the underlying
 Tachycardia
condition can be treated, if possible.
 tachypnea.
 poor feeding and failure to thrive in infants and
young children
 older children may complain of fatigue, exercise
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intolerance, and breathlessness.
may gain weight from fluid overload
CONGENITAL HEART DEFECTS
ACYANOTIC HEART DISEASE
CYANOTIC HEART DISEASE
the blood shunts left to right, then oxygenated blood from
When venous blood from the right side of the heart mixes
the left side mixes with blood in the right side of the heart
with blood on the left side, this is a “right-to-left” shunt that
and goes back to the lungs again
delivers deoxygenated blood to the body

DEFECTS THAT INCREASES PULMONARY BLOOD FLOW
PATENT DUCTUS ARTERIOSUS (PDA)
TRANSPOSITION OF GREAT VESSELS (TA)
 occurs when the DUCTUS ARTERIOUSUS fails
 the second most common congenital defect and is
to close after several days of life.
described as reversal of the great arteries
 occurs more frequently in children born
 the aorta coming off of the right ventricle and the
prematurely
pulmonary artery arising from the left ventricle
ASSESSMENT
 Produces a systolic murmur early in life and a
continuous murmur as the child ages at the
second intercostal space, left upper sternal
border, or out to the left clavicular area
 If the defect is largely significant that can cause
rales, congestion, increased work of breathing,
difficulty feeding, or failure to thrive
 Confirmed by echocardiogram
MANAGEMENT
 Diuretics (FUROSEMIDE) for the symptoms of the
increased blood flow.
 If the child is experiencing significant
manifestations of the increased pulmonary blood
flow or if left heart dilation is noted from the extra
blood flow returning to the left side of the heart,
the child will be referred for PDA closure.
 indomethacin, a nonsteroidal anti-inflammatory
and prostaglandin inhibitor, can be utilized to
facilitate closure.
ATRIAL SEPTAL DEFECT (ASD)
 Is created when a portion of the atrial septal tissue
does not completely form.
 acyanotic defect that allows blood to flow from the
high-pressure left atrium to the low-pressure right
atrium and continue out to the lungs.
 Has 3 types according to location
 Secundum- is located in the center of the atrial
septum
 Primum- found low in the atrial septum near the
IVC
 Sinus Venosus-allow communication of one or
more of the pulmonary veins with the right atrium.
ASSESSMENT
ASSESSMENT
 Transposition of the great arteries is a cyanotic
defect noted immediately after birth
 tachypneic, and a murmur may not be noted.
 prostaglandin E1 (PGE1) infusion is started
immediately after birth to maintain patency of the
ductus arteriosus and encourage mixing of blood.
Side effects: apnea and hypotension.
 best for the child to remain on room air,
spontaneously breathing
 Echocardiogram will confirm this diagnosis and
will also delineate the coronary artery anatomy
MANAGEMENT
 requires surgical correction within the first 14 days
of life to ensure the most positive outcomes
 Arterial switch or Jatene procedure-dissecting
both the pulmonary artery and aorta above their
respective valves and switching the vessels to the
appropriate location
 before surgery includes ensuring their oxygen
saturation remains normal for this defect, which is
75% to 85%;
 monitoring for signs of increased pulmonary blood
flow; and supporting the family as they wait for
their newborn to undergo heart surgery.
ANOMALOUS PULMONARY VENOUS RETURN AND
TRUNCUS ARTERIOUSUS
 Two rare, uncommon cyanotic defects
ANOMALOUS PULMONARY VENOUS RETURN
(APVR)
 a result of failure of the pulmonary venous
connections to unite with the left atrium in utero.
 they return to another vessel (left innominate,
portal, or coronary sinus vein) or directly to the
right atrium, and the oxygenated pulmonary blood
return drains back into the right side of the heart
 can be seen with one, two, or three of the veins
(partial APVR), or all four veins (total APVR)
draining to the venous side.
MANAGEMENT
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


If the defect is small, it may go undetected or may
cause no clinical concern and require no
intervention
If the defect is large enough- pulmonary
overcirculation, such as rales, congestion, tiring
with activity, or poor weight gain.
Murmurs are not associated with the defect but is
related to the relative increased blood volume
traveling across the pulmonary valve.


Total APVR requires urgent surgical intervention.
Partial PVR, if only one vessel, can be missed
because it may cause no significant clinical
effects.
TRUNCUS ARTERIOUS (TA)
 is characterized by a single arterial vessel that
originates from the heart, overrides the ventricular
septum, and supplies all of the systemic,
coronary, and pulmonary blood flow
 has four classifications, depending on where the
pulmonary arteries arise from the truncal vessel.
 occurs as a result of the great artery failing to
divide in utero into two vessels, the pulmonary
artery and the aorta
MANAGEMENT
 If ASD is less than 5 mm, and is producing no
clinical symptoms, it will not be closed
 With clinically significant defect diuretics will be
attempted first in an effort to allow the defect to
close spontaneously
 5 mm or greater with persistent shunting after an MANAGEMENT
observation period should be referred for closure
 requires urgent surgery
to decrease the incidence of supraventricular
dysrhythmias and prevent pulmonary vascular
disease.
 If the defect is 8 mm or larger with evidence of
increased pulmonary blood flow, the child will be
referred for closure immediately.
 secundum ASD is typically closed in the
catheterization lab with a device that sits in the
defect space
 Sinus venosus and primum defects referred for
surgical closure
 Surgical closure involves a median
sternotomy incision and cardiopulmonary
bypass.
VENTRICULAR SEPTAL DEFECT (VSD)
 the most common defect found in children, either in isolation or combined with other defects.
 occurs when a portion of the ventricular septum does not completely close.
ASSESSMENT
 holosystolic murmur noted at the left lower sternal border
 Symptoms associated with a VSD are similar to those found with a PDA or ASD and are determined by the size
of the defect
MANAGEMENT
 Children with an audible murmur but no symptoms of pulmonary overcirculation and may be very small defects
that will close spontaneously needs no medical management
 If the child exhibits signs of pulmonary overload diuretic such as Furosemide is given
 If closure does not occur, surgical closure can be done
ATRIOVENTRICULAR SEPTAL DEFECT (AVSD)
MANAGEMENT
 comprises several congenital heart defects: a
 Management typically includes medications such
primum ASD, a high VSD, and failure of the
as furosemide, digoxin, and an ACE inhibitor like
tricuspid and mitral valves to develop and attach
captopril or enalapril
correctly
 children may also require concentrated feeds to
 complete AVSD also allows for right-to-left
help maintain weight
shunting, which may lead to desaturation
 Children with Down Syndrome they are typically
referred for surgical correction by 3 months of age
 associated with Trisomy 21
or earlier if the transthoracic echocardiogram
 Children without Down Syndrome are referred for
repair by 5 or 6 months of age or as clinically
necessary.
ASSESSMENT
 Pulmonary artery band, which is a band
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

can present with symptoms of CHF similar to
those seen in other defects that increase
pulmonary blood flow
can present with symptoms of CHF similar to
those seen in other defects that increase
pulmonary blood flow

surgically placed around the pulmonary artery that
constricts it to increase the resistance within the
pulmonary artery
Surgical repair of an AVSD consists of closing
atrial and VSDs and repairing the mitral and
tricuspid valves to make them functional
DIAGNOSIS
 confirmed with echocardiography.
 A cardiac catheterization may be performed
before surgical correction to measure pulmonary
pressures and confirm reactivity with the
administration of oxygen or nitric oxide, both of
which should cause pulmonary pressures to
decrease.
DEFECTS WITH OBSTRUCTION TO SYSTEMIC BLOOD FLOW
COARCTATION OF AORTA
HYPOPLASTIC LEFT HEART SYNDROME (HLHS)
 typically causes a discrete narrowing of the aorta
 a rare disorder, accounting for only 1% to 3% of
congenital heart disease, and is detectable on
 occurs more commonly in males than in females
prenatal ultrasound
ASSESSMENT
 there is poor or no flow to the left ventricle,
typically secondary to mitral or aortic stenosis or
 narrowed area is most frequently distal to the right
atresia.
subclavian artery, so the pressures before that
area increase and refer out these vessels
 ascending aorta is also hypoplastic, and the
coronary arteries are perfused through retrograde
 causes elevated blood pressures to be noted in
flow down the ascending aorta.
the right arm
 A Patent Foramen Ovale (PFO) will occur
 can cause a systolic murmur heard along the left
sternal border and the left midscapular area
 In utero, the circulation is adequate to meet the
needs of the developing fetus. But at birth,
 The narrowing increases the resistance to the left
survival is dependent on a PDA
ventricle and can lead to left ventricular
hypertension and hypertrophy over time
 Infants are typically male, rarely premature, and
have no other associated cardiac anomalies.
 Coarctation noted in infancy is usually more
critical and can produce heart failure within weeks
 has normal right-sided flow out to the lungs.
of birth that require immediate surgical
 These children are at high risk for sudden death
intervention.
due to dysrhythmias, inability to fight infection, or
metabolic imbalance.
 Check radial and femoral pulses concurrently
NORMAL: should be no absence or weakness in
the femoral pulses compared with the radial or
SURGICAL MANAGEMENT
brachial pulse.
NORWOOD PROCEDURE
 systolic pressure reading in the right upper
 This surgery, which includes several
extremity is 10 mmHg higher than that in the lower
components, is done within a few days of birth
extremity
once the child is hemodynamically stable
 Dissection of the main pulmonary artery from
MANAGEMENT
the branch pulmonary arteries, which is then
 Echocardiographic evidence of a significant
attached to the hypoplastic ascending aorta so
gradient across the narrowing, or any signs of left
there is one great vessel taking blood out of the
ventricular hypertrophy due to the increased
heart (right ventricle) to the body and providing
resistance, are indicators for correction either by
blood flow to the coronary arteries.
balloon angioplasty in the cardiac catheterization
 Shunt placement, typically either a BT shunt
lab or by surgical intervention
or a Sano shunt. The BT shunt (as discussed
previously for TOF) directs blood from the right
 CoAo is surgically repaired through a left
thoracotomy incision and with end-to-end
subclavian artery to the branch pulmonary artery,
anastomosis
whereas a Sano shunt is a conduit from the right
ventricle to the branch pulmonary arteries. The
 Future interventions with balloon dilation or stent
purpose of both shunts is to allow for stable blood
placement are typically performed in the
flow to the lungs.
catheterization lab.
 Ligation of the PDA
 Ensuring a widely patent atrial septum
BIDIRECTIONAL GLENN SHUNT
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
This surgery is usually performed at
approximately 4 to 6 months of age or when the
child outgrows their previously placed BT or Sano
shunt.
 The purpose of the shunt is to relieve the volume
load on the single right ventricle, which is
accommodating all of the circulating blood flow
 Ligation of the previously placed BT or Sano
shunt
 Dissection of the SVC at its insertion to the
right atrium and attachment of the SVC
directly to the branch pulmonary artery. This
allows deoxygenated blood returning from the
head and upper body to flow directly but passively
to the lungs to get oxygenated.
FONTAN PROCEDURE
 The final stage is performed when the child
weighs approximately 15 kg or is 3 years old
 the IVC is dissected from the right atrium, and
flow from there is directed through an artificial
conduit directly to the branch pulmonary artery
AORTIC STENOSIS
 Obstruction out the left ventricle can occur below
the aortic valve (subvalvar), at the valve (valvar),
or above the valve (supravalvar)
 most common location for obstruction is valvar
aortic stenosis, which is typically associated with
an abnormal, bicuspid aortic valve
ASSESSMENT
 systolic heart murmur at the right second
intercostal space, but asymptomatic.
 Severe obstruction may experience chest pain
with exercise. Aortic regurgitation is frequently
associated with stenosis

a diastolic murmur may also be noted
 ECG may note left ventricular hypertrophy if the
stenosis has been ongoing
 Echocardiography will determine the exact
location and severity of the narrowing as well as
any impact on ventricular size and function.
CARDIAC TRANSPLANTATION
 is an alternative form of therapy, but the
availability of donor hearts, rejection problems,
and the need for retransplantation
 secondary choice for most infants.
SINGLE VENTRICLE DEFECTS
 A variety of congenital abnormalities such as
mitral atresia, aortic atresia, or pulmonary
atresia with an intact ventricular septum result in
a single-ventricle physiology.
 not possible to address all of these permutations,
but the basic conceptual understanding and
management of single-ventricle defects is grossly
the same.
MANAGEMENT
 Stabilization with a beta-blocker or a calcium
channel blocker may be necessary to reduce or
prevent further ventricular hypertrophy.
 routine echocardiograms and possibly cardiac
catheterizations to best quantify the pressure
gradient across the valve.
 Surgical intervention may be necessary for
recurrent stenosis or ineffective balloon dilation.
CHECK FOR UNDERSTANDING (30 minutes)
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You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed
Multiple Choice
1. A child has been seen by the school nurse for dizziness since the start of the school term. It happens
when standing in line for recess and homeroom. The child now reports that she would rather sit and
watch her friends play hopscotch because she cannot count out loud and jump at the same time. When
the nurse asks her if her chest ever hurts, she says yes. Based on this history, the nurse suspects that
she has:
A. Ventricular septal defect (VSD).
B. Aortic stenosis (AS).
C. Mitral valve prolapse.
D. Tricuspid atresia.
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
2. A heart transplant may be indicated for a child with severe heart failure and:
A. Patent ductus arteriosus (PDA).
B. Ventricular septal defect (VSD).
C. Hypoplastic left heart syndrome.
D. Pulmonic stenosis (PS).
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
3. A newborn is diagnosed with a congenital heart defect (CHD). The test results reveal that the lumen of the
duct between the aorta and pulmonary artery remains open. This defect is known as
_____________________.
A. Patent ductus arteriosus (PDA).
B. Ventricular septal defect (VSD).
C. Hypoplastic left heart syndrome.
D. Pulmonic stenosis (PS).
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
4. A 3-month-old has been diagnosed with a ventricular septal defect (VSD). The flow of blood through the
heart is _____________________.
A. Patent ductus arteriosus (PDA).
B. Ventricular septal defect (VSD).
C. Hypoplastic left heart syndrome.
D. Pulmonic stenosis (PS).
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
5. A child born with Down syndrome should be evaluated for which associated cardiac manifestation?
A. Congenital heart defect (CHD).
B. Systemic hypertension.
C. Hyperlipidemia.
D. Cardiomyopathy.
ANSWER: ________
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RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
6. A child diagnosed with congestive heart failure (CHF) is receiving maintenance doses of digoxin and
furosemide. She is rubbing her eyes when she is looking at the lights in the room, and her HR is 70 beats
per minute. The nurse expects which laboratory finding?
A. Hypokalemia.
B. Hypomagnesemia.
C. Hypocalcemia.
D. Hypophosphatemia.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
7. A nursing action that promotes ideal nutrition in an infant with congestive heart failure (CHF) is:
A. Feeding formula that is supplemented with additional calories.
B. Allowing the infant to nurse at each breast for 20 minutes.
C. Providing large feedings every 5 hours.
D. Using firm nipples with small openings to slow feedings.
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
8. During a well-child checkup for an infant with tetralogy of Fallot (TOF), the child develops severe
respiratory distress and becomes cyanotic. The nurse’s first action should be to:
A. Lay the child flat to promote hemostasis.
B. Lay the child flat with legs elevated to increase blood flow to the heart.
C. Sit the child on the parent’s lap, with legs dangling, to promote venous pooling.
D. Hold the child in knee-chest position to decrease venous blood return.
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
9. During play, a toddler with a history of tetralogy of Fallot (TOF) might assume which position?
A. Sitting.
B. Supine.
C. Squatting.
D. Standing.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
10. For the child with hypoplastic left heart syndrome, which drug may be given to allow the patent ductus
arteriosus (PDA) to remain open until surgery?
A. Furosemide
B. Apresoline
C. Indomethacin
D. Penicillin
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)-Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 29
LESSON TITLE: NURSING CARE OF A FAMILY WHEN A
CHILD HAS A RENAL OR URINARY TRACT DISORDERS
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:
Materials:
1. Define the common renal and urinary disorders that occur in
children and describe these common illnesses that occur in
these children.
Book, pen and notebook, index card/class list,
speaker and LCD projector
2. Integrate the knowledge of common renal and urinary
disorders that occur in children and describe these common
illnesses that occur in these classifications of children in
formulating nursing care plan in giving quality maternal and
child health nursing care.
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
Reference:
LESSON REVIEW/PREVIEW (5 minutes)
To the students: Review of past lessons regarding cardiovascular illnesses that occurs in children.
MAIN LESSON (50 minutes)
Please refer to Chapter 46: Nursing Care of a Family when a Child Has a Renal or Urinary Tract Disorder-Structural
Abnormalities of the Urinary Tract p.1300, Infections of the Urinary System p.1303
STRUCTURAL ABNORMALITIES OF THE URINARY TRACT
PATENT URACHUS
EXSTROPHY OF THE BLADDER
 A narrow tube(urachus) that connects bladder and
 a midline closure defect that occurs during the
umbilicus fails to close during embryonic
10th week of pregnancy. As a result, at birth, the
development.
bladder lies exposed on the anterior abdominal
wall
 Occurs more commonly in males than females.
 same cases on both sexes
ASSESSMENT
ASSESSMENT
 Nitrazine paper test for pH will identify the clear
fluid as urine on the umbilical cord while changing
 detected by fetal ultrasound
the diaper of the newborn.
 pelvic bone defects, particularly a wide pubic
diastasis
 Ultrasound will confirm the patent connection
 Urethral defects in males, such as epispadias—
THERAPEUTIC MANAGEMENT
the opening of the urinary meatus on the dorsal or
 A few patent urachus abnormalities heal
superior surface of the penis—are also common.
spontaneously, but most require surgical
 The skin around the bladder quickly becomes
correction to prevent pathogens from entering the
excoriated because of constant exposure to acid
fistula site and causing persistent bladder
urine.
infection.
 Kidney infection can occur from ascending
 This is done in the immediate neonatal period
organisms from the open bladder.
using only a small sub-umbilical incision
 When children with this disorder begin to walk,
they may demonstrate a “waddling” gait caused
by the wide pubic diastasis.
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HYPOSPADIAS
 a urethral defect in which the urethral opening is
not at the end of the penis but on the ventral
(lower) aspect of the penis
 tends to be familial or may occur from a
multifactorial genetic focus
 The most extreme cases in males result in a
penopubic location of the meatus and complete
incontinence
ASSESSMENT
 to inspect all male newborns at birth for
hypospadias or epispadias as part of a routine
physical examination
 degree of hypospadias may be minimal (on the
glans but inferior in site) or maximal (at the
midshaft or at the penal-scrotal junction)
 Many newborns with hypospadias have an
accompanying short chordee—a fibrous band that
causes the penis to curve downward
THERAPEUTIC MANAGEMENT
 Surgical closure of the bladder and the anterior
abdominal wall, and construction of a urethra
 bladder mucosa should be kept moist and
covered with plastic wrap to prevent the bladder
surface both from drying out and from adhering to
bedclothes or diapers and being injured
 To prevent the skin of the abdomen from
excoriation, consult a wound, ostomy, and
continence nurse for the best approach, which
usually involves a protective topical application
such as A&D Ointment, Karaya Gum, or Maalox.
 Sponge bathe rather than tub bathe the infant to
prevent water from entering the ureters and
becoming a source of infection.
POSTOPERATIVE
 After bladder closure, a suprapubic tube is placed
for urine drainage and will typically remain in
place for 4 to 6 weeks to allow the bladder to drain
continuously and the surgical anastomoses to
heal.
 The infant should be positioned on the back with
the legs raised in traction at 90 degrees is
maintained for 4 to 6 weeks after surgery and is
essential to prevent failure of the closure
 For children who have a successful initial closure,
adequate bladder capacity, pelvic floor function,
and bladder contractility, an alternate continence
procedure, called a bladder neck reconstruction
(BNR), may be an option
 A BNR reconstructs the bladder neck and urethra
and allows the child to void via the urethra and
achieve continence.
THERAPEUTIC MANAGEMENT
 Children with hypospadias should not be
circumcised because, at the time of the repair, the
surgeon may wish to use a portion of the foreskin
for the repair.
 Chordee repair is a surgery to straighten the
penis. It is done for a condition of the penis called
chordee. Chordee causes the penis to be curved,
which is most obvious during an erection. A
chordee repair is done by a specialized doctor
called a pediatric urologist
 Meatotomy—a procedure in which the urethra is
extended to a usual position—to establish better
urinary function
 If the repair will be extensive, all surgery may be
delayed until the child is 3 to 4 years of age
 After surgical repair, a urethral urinary drainage
catheter will be inserted to allow urine output
without putting tension against the urethral
sutures.
 Analgesic such as acetaminophen (Tylenol) and
an anticholinergic medication such as oxybutynin
(Ditropan) may be prescribed for pain relief.

After hypospadias repair, children can be
expected to have usual urinary and reproductive
function unless accompanying anomalies of the
penis are present.
INFECTIONS OF THE URINARY SYSTEM AND RELATED DISORDERS
HYDRONEPHROSIS
 Elevated blood pressure caused by increasing
 enlargement of the pelvis of the kidney with urine
tubular pressure (which activates the renin–
as a result of back-pressure is generally caused
angiotensin system) may be detected on a routine
by obstruction, either of the ureter or of the point
health assessment
where the ureter joins the bladder, as with
 With severe back pressure, the infant will
vesicoureteral reflux.
eventually experience flank or abdominal pain.
 may occur at any age, it occurs most often in the
 An IVP or ultrasound will reveal the enlarged
first 6 months of life and is often diagnosed by
pelvis and the point of obstruction.
ultrasound during intrauterine life
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ASSESSMENT
 usually asymptomatic.
 The infant may have repeated UTIs caused by
urinary stasis (difficult to detect in a young child
except as general irritability or crying on voiding).
 although blood pressure is not taken routinely in
infants.
 Abdominal palpation may reveal an abdominal
mass (the dilated kidney pelvis).
MANAGEMENT
 The treatment is surgical correction of the
obstruction before glomerular or tubular
destruction occurs.
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. Enlargement of the pelvis of the kidney with urine as a result of back-pressure is generally caused by
obstruction, either of the ureter or of the point where the ureter joins the bladder, as with vesicoureteral
reflux.
A. Patent Urachus
B. Hydronephrosis
C. Hypospadias
D. Epispadias
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
2. A urethral defect in which the urethral opening is not at the end of the penis but on the ventral (lower)
aspect of the penis:
A. Patent Urachus
B. Hydronephrosis
C. Hypospadias
D. Epispadias
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
3. A narrow tube that connects bladder and umbilicus fails to close during embryonic development.
A. Patent Urachus
B. Hydronephrosis
C. Hypospadias
D. Epispadias
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
4. You care for a 3-year-old with hypospadias. After a surgical repair, he has a urethral urinary catheter
inserted. You would want to teach his parents that:
A. the catheter insertion site will leave only a minimal scar.
B. back pressure from such drainage may result in nephrotic syndrome.
C. He must be reevaluated at puberty for testicular function.
D. He will always have tenderness on penile erection.
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
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5. A child is administered oxybutynin (Ditropan) following surgical repair of a hypospadias. The purpose of
this drug is to:
A. prevent nausea and vomiting.
B. stimulate kidney function.
C. acidify urine.
D. relieve bladder spasms.
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
6. A procedure in which the urethra is extended to a usual position to establish better urinary function:
A. Chordee Procedure
B. Meatotomy
C. Bladder Neck Reconstruction
D. Vagotomy
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
7. A surgery to straighten the penis. It is done for a condition of the penis:
A. Chordee Procedure
B. Meatotomy
C. Bladder Neck Reconstruction
D. Vagotomy
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
8. An alternate continence procedure that reconstruct bladder capacity, pelvic floor function, and bladder
contractility:
A. Chordee Procedure
B. Meatotomy
C. Bladder Neck Reconstruction
D. Vagotomy
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
9. All of the following are management of Exstrophy of the Bladder, EXCEPT:
A. Surgical closure of the bladder and the anterior abdominal wall, and construction of a urethra
B. Bladder mucosa should be kept moist and covered with plastic wrap to prevent the bladder surface both from
drying out and from adhering to bedclothes
C. Sponge bathe rather than tub bathe the infant to prevent water from entering the ureters and becoming a source
of infection.
D. The treatment is surgical correction of the obstruction before glomerular or tubular destruction occurs.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
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10. The following are postoperative management of Exstrophy of the Bladder, EXCEPT:
A. After surgical repair, a urethral urinary drainage catheter will be inserted to allow urine output without putting
tension against the urethral sutures.
B. After bladder closure, a suprapubic tube is placed for urine drainage and will typically remain in place for 4 to 6
weeks to allow the bladder to drain continuously and the surgical anastomoses to heal.
C. The infant should be positioned on the back with the legs raised in traction at 90 degrees is maintained for 4 to 6
weeks after surgery and is essential to prevent failure of the closure
D. A Bladder Neck Resection reconstructs the bladder neck and urethra and allows the child to void via the urethra
and achieve continence.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________ ________
_____________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
1. RATIO:____________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________
2. ANSWER: ________
2. RATIO:____________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________
3. ANSWER: ________
3. RATIO:____________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________
4. ANSWER: ________
4. RATIO:____________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________
5. ANSWER: ________
5. RATIO:_____________________________________________________________________ _______________
_____________________________________________________________________________________________
________________________________________________________________________
6. ANSWER: ________
6. RATIO:____________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________
7. ANSWER: ________
7. RATIO:____________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________
8. ANSWER: ________
8. RATIO:____________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________
9. ANSWER: ________
9. RATIO:____________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________
10. ANSWER: ________
10. RATIO:____________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________
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STUDENT ACTIVITY SHEET
Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)-Lecture
BS NURSING / SECOND YEAR
Session # 31
LESSON TITLE: NURSING CARE OF A FAMILY
WHEN A CHILD HAS A MALIGNANCY
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:
1. Define the common types of cellular aberrations that
occur in children.
2. Integrate the knowledge of the cellular aberrations in
children and describe these malignancies that occur in
these classifications of children in formulating nursing
care plan in giving quality maternal and child health
nursing care
Materials:
Book, pen and notebook, index card/class list,
speaker and LCD projector
Reference:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
LESSON REVIEW/PREVIEW (5 minutes)
MAIN LESSON (50 minutes)
Please refer to Chapter 53: Nursing Care of a Family When a Child Has a Malignancy- Neoplasia p. 1501, The Leukemias
p.1512 and The Lymphomas p. 1515
NEOPLASIA
The word neoplasm means “new growth,” although it is typically used to refer to a new abnormal growth that does not
respond to normal growth-control mechanisms.
NEOPLASTIC GROWTH
Neoplasms are either benign (growth is limited) or malignant (cancerous or with unlimited growth).
CAUSES OF NEOPLASTIC GROWTH
 UNKNOWN
 almost all childhood cancers have such markers or a genetic trigger or predisposition to cancer.
 Somatic mutation theory postulates that an accumulation of mutations in the cell is what ultimately results in the
transformation to a neoplastic state.
 This theory explains why the growth of neoplastic cells is not reversible (the cells cannot return to a normal
state because they are intrinsically changed at the genomic level) and why neoplasms occur in some people
but not in others (both an intrinsic and an extrinsic factor, or an inherited tendency and an e nvironmental insult,
must be present)
 In other cancers, oncogenic viruses (cancer-causing virus) such as HPV may be directly responsible for tumor
growth. According to this viral theory, oncogenic viruses have the ability to change the structure of DNA or RNA
in cells.
THE LEUKEMIAS
ACUTE LYMPHOCYTIC (LYMPHOBLASTIC)
THERAPEUTIC MANAGEMENT
LEUKEMIA (ALL)
 95% of children with ALL will achieve a first
 accounts for 75% of leukemias and involves
remission. If a child experiences a relapse, the
lymphoblasts (immature lymphocytes).
chances of long-term survival are reduced and
bone marrow transplantation may be required to
 rapid proliferation of so many immature
achieve long-term survival.
lymphocytes, the production of red blood cells
 The drug regimen frequently used to initiate a
(RBCs) and platelets declines.
remission includes vincristine, prednisone or
 The abnormally proliferating cells are so immature
dexamethasone, L-asparaginase, and doxorubicin
that they may be identifiable as an immature
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“blast cell.”
highest incidence of ALL is in children between 2
and 6 years of age
ASSESSMENT
 usually are those associated with decreased RBC
production (anemia) such as pallor, low-grade
fever, and lethargy.
 A low thrombocyte (platelet) count will lead to
petechiae and bleeding from oral mucous
membranes and cause easy bruising on arms and
legs.
 As the spleen and liver begin to enlarge from
infiltration of abnormal cells, abdominal pain,
vomiting, and anorexia occur.
 As abnormal lymphocytes invade the bone
periosteum, the child experiences bone and joint
pain.
 Central nervous system (CNS) invasion leads to
symptoms such as headache or unsteady gait.
 On physical assessment, painless, generalized
swelling of lymph nodes is revealed.
 Laboratory studies reveal an elevated leukocyte
count with cells almost stopped at the blast cell
stage.
 The platelet count and hematocrit value will be
low; RBCs that are present are normocytic and
normochromic (of normal size and color) but few
in number.
 A lumbar puncture may show evidence of blast
cells in the cerebrospinal fluid (CSF).
 A bone marrow aspiration (performed at the iliac
crest) will be prescribed to identify the type of
WBC involved, which documents the type of
leukemia.
ACUTE MYELOID LEUKEMIA (AML)
 involves the overproliferation of granulocytes
(neutrophils, basophils, and eosinophils).
 It is most often seen in adults and accounts for
only about 20% of all childhood leukemias.
 The frequency of the disorder increases in late
adolescence



given over a period of 4 weeks.
Intrathecal administration (injection of
methotrexate into the CSF by lumbar puncture) is
instituted to eradicate this source of leukemic
cells.
Cranial radiation, once used extensively for this
purpose, is rarely used today due to the learning
disorders that may result.
MAINTENANCE AND MONITORING
 Maintenance chemotherapy aims to eliminate
completely any remaining leukemic cells.
 Standard maintenance therapy includes a
combination of daily mercaptopurine, weekly
methotrexate, sporadic vincristine and
prednisone, and intrathecal methotrexate and may
be continued for 2 to 3 years.
COMPLICATIONS
 CNS, renal, and reproductive system disorders.
THERAPEUTIC MANAGEMENT
 The diagnosis is established by bone marrow
aspiration and biopsy.
 chemotherapy to effect remission begins.
Cytarabine (Ara-C), etoposide (VePesid), and
daunorubicin (DaunoXome) make up the drug
regimen commonly used for therapy.
 It may take 1 to 2 months to reach a full
remission.
 Bone marrow transplantation may be attempted
after the initial remission to ensure a sustained
remission
ASSESSMENT
 Children with AML have the same symptoms as
those with ALL.
 Comprehensive history and physical examination
focused on local or systemic infections is
warranted.
THE LYMPHOMAS
HODGKINS DISEASE
NON-HODGKINS LYMPHOMA
 lymphocytes proliferate in the lymph glands, and
 are malignant disorders of the lymphocytes (either
special Reed-Sternberg cells (large,
B or T cells) and occur in a number of forms.
multinucleated cells that are probably
 Metastatic spread to CNS may occur early in the
nonfunctioning monocyte-macrophage cells)
disease, with the common age of occurrence at 5
develop
to 15 years.
 etiology of Hodgkin disease is unknown
ASSESSMENT
 rarely seen in children younger than 7 years of
age, with the incidence increasing greatly during
 involve the lymph glands of the neck and chest
most commonly, although axillary, abdominal, or
adolescence and young adulthood
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
Metastasis is through lymphatic channels.
Untreated, late in the disease process, it spreads
to lung, liver, and bone marrow.
ASSESSMENT
 Usually starts with enlargement of only one
painless, enlarged, rubbery lymph node.
 anorexia, malaise, night sweats, and loss of
weight.
 Fever may be present.
 The sedimentation rate is elevated as well as
other markers of inflammation.
 confirmed by biopsy of the lymph nodes

Bone marrow analysis, liver function tests, chest
and abdominal computed tomography [CT] or MRI
scans, lymphangiography, and abdominal biopsy
are done to classify the clinical stage of the
disorder.
 The chest CT scan may reveal enlarged
mediastinal nodes; the abdominal CT may reveal
enlarged lymph nodes of the abdomen.
 Positron emission tomography–computed
tomography (PET-CT) is typically used to stage
and monitor response to Hodgkin disease
treatment.
THERAPEUTIC MANAGEMENT
 radiation therapy
 combination chemotherapy using the agents
cyclophosphamide, vincristine, procarbazine,
and prednisone



inguinal nodes may be the first involved.
mediastinal lymph glands are swollen, the child
may notice a cough or chest “tightness.”
Children notice abdominal pain; they may have
diarrhea or constipation, and a mass may be
palpable on examination.
To establish diagnosis biopsy of the affected
lymph nodes and bone marrow is performed
THERAPEUTIC MANAGEMENT
 systemic chemotherapy, similar to that used for
ALL
 induction phase-a time during which the child is
put into remission or no tumor can be detected by
clinical examination
 this is followed by a maintenance phase of up to 2
years.
 The common drug regimen used is
cyclophosphamide, doxorubicin (Adriamycin),
vincristine (Oncovin), and prednisone (CHOP
therapy).
 Intrathecal chemotherapy may be included
because of the tendency for non-Hodgkin
lymphoma to invade the CNS.

frequent blood analysis for electrolyte imbalances
will be necessary.
 Anticipate that allopurinol may be added to the
therapy to prevent uric acid accumulation and
blocking of kidney tubules.
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. The client diagnosed with leukemia has central nervous system involvement. Which instructions should
the nurse teach?
A. Sleep with the head of the bed elevated to prevent increased intracranial pressure.
B. Take an analgesic medication for pain only when the pain becomes severe.
C. Explain that radiation therapy to the head may result in permanent hair loss.
D. Discuss end-of-life decisions prior to cognitive deterioration.
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
2. The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The
nurse notes that the platelet count is 20,000/ul. Based on the laboratory result, which intervention will the
nurse document in the plan of care?
A. Monitor closely for signs of infection
B. Monitor the temperature every 4hours
C. Initiate protective isolation precautions
D. Use soft small toothbrush for mouth care
ANSWER: ________
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RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
3. What nursing diagnosis is seen with acute lymphocytic leukemia and thrombocytopenia?
A. potential for injury
B. self-care deficit
C. potential for self-harm
D. alteration in comfort
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
4. Which of the following manifestations would be directly associated with Hodgkin's disease?
A. bone pain
B. generalized edema
C. petechiae and purpura
D. painless, enlarged lymph nodes
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
5. When caring for a client with a diagnosis of thrombocytopenia, the nurse should plan to:
A. Discourage the use of stool softeners
B. Assess temperature readings every six hours
C. Avoid invasive procedures
D. Encourage the use of a hard, brittle toothbrush
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
6. Which statement is correct about the rate of cell growth in relation to chemotherapy?
A. Faster growing cells are less susceptible to chemotherapy.
B. Nondividing cells are more susceptible to chemotherapy.
C. Faster growing cells are more susceptible to chemotherapy.
D. Slower growing cells are more susceptible to chemotherapy.
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
7. An 18-year-old male with Hodgkin’s Lymphoma and engaged. Which of the following diagnoses would be
a priority for this client?
A. Fatigue related to chemotherapy
B. Sexual dysfunction related to radiation therapy
C. Tissue integrity related to prolonged bed rest
D. Anticipatory grieving related to terminal illness
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
8. An 18-year-old female client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease.
Which assessment findings would the nurse expect to note specifically in the client?
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A. Weakness
B. Enlarged lymph nodes
C. Fatigue
D. Weight gain
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
9. A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin's disease. Which of the
following symptoms is typical of Hodgkin's disease?
A. Night sweats and fatigue
B. Weight gain
C. Nausea and vomiting
D. Painful cervical lymph nodes
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
10. You have developed the nursing diagnosis Risk for Impaired Tissue Integrity related to effects of
radiation for a client with Hodgkin's lymphoma who is receiving radiation to the groin area. Which nursing
activity is best delegated to a nursing assistant caring for the client?
A. Apply alcohol-free lotion to the area after cleaning.
B. Explain good skin care to the client and family.
C. Clean the skin over daily with a mild soap.
D. Check the skin for signs of redness or peeling.
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
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Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)-Lecture
STUDENT ACTIVITY SHEET
BS NURSING / SECOND YEAR
Session # 33
LESSON TITLE: NURSING CARE OF A FAMILY WHEN A
CHILD HAS GASTROINTESTINAL DISORDERS
LEARNING OUTCOMES:
Materials:
At the end of the lesson, the student nurse can:
1. Define the common types of disorders in the gastrointestinal
system that occur in children.
2. Integrate the knowledge of the common types of disorders in
the gastrointestinal system that occur in children and describe
these disorders that occur in these classifications of children in
formulating nursing care plan in giving quality maternal and
child health nursing care
Book, pen and notebook, index card/class list,
speaker and LCD projector
Reference:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
USA: Lippincott Williams and Wilkins
LESSON REVIEW/PREVIEW (5 minutes)
MAIN LESSON (50 minutes)
Please refer to Chapter 45: Nursing Care of a Family When a Child Has a Gastrointestinal Problems-Disorders of the
Lower Bowel p.1281 and Disorders Caused by Food, Vitamin and Mineral p. 1287
INTESTINAL DISORDERS
VOLVULUS WITH MALROTATION
SHORT BOWEL/SHORT-GUT SYNDROME
 twisting of the intestine
 Short-bowel or short-gut syndrome is an
absorptive disorder in which there is not sufficient
 The twist leads to obstruction of the passage of
bowel surface area in the small intestine for
feces and to compromise of the blood supply to
proper nutrient absorption.
the loop of intestine involved.
ASSESSMENT
 symptoms occur during the first 6 months of life
intense crying and pain
 pulling up the legs
 abdominal distention
 vomiting from a volvulus is unrelated to feeding.
 The diagnosis is made based on the history and
an abdominal examination, which reveals an
abdominal mass.
 It is confirmed by an ultrasound or lower barium
X-ray
THERAPEUTIC MANAGEMENT
 Surgery is an emergency and should be
performed before necrosis of the intestine occurs
from a lack of blood supply to the involved loop of
bowel
ASSESSMENT
 The condition has several causes, including
surgery for NEC, volvulus, and GI tract trauma,
which resulted in a large portion of the intestine
being removed.
THERAPEUTIC MANAGEMENT
 The treatment includes ensuring adequate
hydration and proper intake of essential vitamins
and minerals.
 Following bowel resection surgery, total parenteral
nutrition, including lipids, may be used initially until
the bowel can tolerate enteral feedings.
 Oral or enteral feedings are then given as
tolerated. If gastrostomy or nasogastric feedings
are used, nonnutritive sucking should be
facilitated to preserve the suck–swallow reflex.
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APPENDICITIS
 Appendicitis (inflammation of the appendix) is the
most common cause of abdominal surgery in
children.
 It occurs most frequently in school-age children
and adolescents, although it can occur in
preschoolers and even in newborns
ASSESSMENT
 appendicitis begins with sharp pain, so they may
dismiss a child’s early symptoms for some time as
simple gastroenteritis.
 Diagnosis is made on a cluster of symptoms:
anorexia, pain or tenderness in the right lower
quadrant, nausea or vomiting, elevation of
temperature, and leukocytosis
 The point of sharpest pain is often one third of the
way between the anterior superior iliac crest and
the umbilicus (McBurney’s point)
 An ultrasound or CT scan will reveal the swollen
appendix.
THERAPEUTIC MANAGEMENT
 surgical removal of the appendix by laparoscopy
before it ruptures
CELIAC DISEASE/MALABSORPTION
SYNDROME/GLUTEN INDUCED
ENTEROPATHY/CELIAC SPRUE
 an immune-mediated abnormal response to
gluten, the protein in wheat, and related proteins
in rye, barley and possibly oats, in a genetically
susceptible individual.
 When children with the disorder ingest gluten,
flattening of the fingerlike projections (villi) of the
small intestine occurs, preventing the absorption
of foods, especially fat, into the body.

If the disease goes undiagnosed, children
develop steatorrhea (bulky, foul-smelling, fatty
stools), failure to thrive, and malnutrition.
 The classic picture of a child with celiac disease—
a thin child with a distended abdomen
RUPTURED APPENDIX
 If a child’s appendix has already ruptured when
the child is seen in the emergency department,
the potential for peritonitis increases greatly.
 Children generally appear severely ill. Their white
blood cell count is apt to be more than
20,000/mm3.
 Position the child in a semi-Fowler’s position, if
possible, so that infected drainage from the
cecum drains downward into the pelvis rather than
upward toward the lungs.
 The child needs an IV fluid line inserted for
hydration.
 Antibiotics will be begun preoperatively or as soon
as the ruptured appendix is confirmed



Serum analysis of antibodies against gluten
(endomysial antibody, tissue transglutaminase is
obtained) and biopsies of the small intestinal
mucosa (done by endoscopy), which are the gold
standards, establish the typical changes in
intestinal villi.
In addition, the child’s response to gluten is
observed by placing the child on a gluten-free
diet.
The child begins to gain weight, steatorrhea
improves, and irritability fades.
THERAPEUTIC MANAGEMENT
 Treatment is to continue the gluten-free diet for
life because there is an associated slightly
increased risk of malignancy in those who are
diagnosed with celiac disease as adults.
ASSESSMENT
 There does not appear to be the same risk in
those diagnosed in childhood, possibly due to
 diagnosis is based on the history; clinical
symptoms such as poor growth, bulky stools,
early introduction of a gluten-free diet.
malnutrition, distended abdomen, and anemia.
 Correction of any vitamin and mineral deficiencies
may be necessary.
DISORDERS CAUSED BY FOOD, VITAMIN AND MINERAL DEFICIENCIES
VITAMIN AND MINERAL DEFICIENCIES
Vitamin
Cause of Deficiency
Signs and Symptoms
Vitamin A
Lack of yellow vegetables in diet
Tender tongue, cracks at corners of
mouth, night blindness
Xerophthalmia (dry and lusterless
conjunctivae)
Keratomalacia (necrosis of the cornea
with perforation, loss of ocular fluid, and
blindness)
Vitamin B1 Most common in children who eat Beriberi (tingling and numbness of
polished rice as dietary staple
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because B1 is contained in hull of
rice
Niacin
Vitamin C
Vitamin D
Common in children who eat corn
as dietary staple because corn is
low in niacin
Lack of fresh fruits in diet
Lack of sunlight
extremities, heart palpitations,
exhaustion)
Diarrhea and vomiting
Aphonia (crying without sound)
Anesthesia of feet
Pellagra (dermatitis, resembles a
sunburn), diarrhea, mental confusion
(dementia)
Scurvy (muscle tenderness, petechiae)
Poor muscle tone, delayed tooth
formation
Rickets (poor bone formation)
Craniotabes (softening of the skull)
Swelling at joints, particularly of wrists and
cartilage of ribs
Bowed legs, tetany (muscle spasms)
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. What tissue of the gastrointestinal tract is affected in Celiac disease?
A. Stomach, causing gastritis
B. Small intestine, causing villous atrophy
C. Large intestine, causing ulceration
D. Rectum, causing fistulation
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
2. You are the nurse taking care of a patient who is receiving ibuprofen for back pain, and the patient
complains of burning epigastric pain after swallowing his ibuprofen pills for the last few days. You
suggest which of the following to the patient?
A. "Try taking the pills without any water."
B. "Try taking the pills with a full glass of water."
C. "Take the pills right before lie down you go to sleep."
D. "Request the pills more frequently."
E. "Try taking the pills while lying down."
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
3. The nurse should administer an as-needed dose of magnesium hydroxide after noting what information
while reviewing a patient's medical record?
A. Abdominal pain and bloating
B. No bowel movement for 3 days
C. A decrease in appetite by 50% over 24 hours
D. Muscle tremors and other signs of hypomagnesemia
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
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4. The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the
patient, the nurse would explain that it acts in what way?
A. Increases bulk in the stool
B. Lubricates the intestinal tract to soften feces
C. Increases fluid retention in the intestinal tract
D. Increases peristalsis by stimulating nerves in the colon wall
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
5. A patient is suspected to be suffering from Celiac Disease. The physician orders an endoscopy. If the
patient has Celiac Disease, what finding will be discovered with the endoscopy?
A. Over exaggerated intestinal villi
B. Ulcerations in the small intestine, specifically the Jejunum
C. Flat intestinal villi
D. Cobble-stone appearance throughout the small intestine
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
6. People with celiac disease often have which other disease?
A. Autoimmune thyroid disease
B. Type 1 diabetes
C. Rheumatoid arthritis
D. All of the above
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
7. After the nurse provides dietary restrictions to the parents of a child with celiac disease, which statement
by the parents indicates effective teaching?
A. “Well follow these instructions until our child’s symptoms disappear.”
B. “Our child must maintain these dietary restrictions until adulthood.”
C. “Our child must maintain these dietary restrictions lifelong.”
D. “We’ll follow these instructions until our child has completely grown and developed.”
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
8. Discharge teaching for a child with celiac disease would include instructions about avoiding which of the
following?
A. Rice
B. Milk
C. Wheat
D. Chicken
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
9. Which of the following would the nurse expect to assess in a child with celiac disease having a celiac
crisis secondary to an upper respiratory infection?
A. Respiratory distress
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B. Lethargy
C. Watery diarrhea
D. Weight gain
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
10. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac
disease. Which of the following foods, if selected by the mother, would indicate her understanding of the
dietary instructions?
A. Ham sandwich on whole-wheat toast
B. Spaghetti and meatballs
C. Hamburger with ketchup
D. Cheese omelet
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
2. ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
3. ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
4. ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
5. ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
6. ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
7. ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
8. ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
9. ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
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