Kaplan Maternity-Gynecology 3 of 3

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Nutritional needs of lactation vs. nutritional needs of pregnancy
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The lactating women needs more CALORIES but the same amount of calcium, protein and fluids are needed.
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Example two week old full term neonate – normal findings
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– regained initial weight loss within 14 days – 1 to 3 BM/day – 6 to 8 wet diapers indicated the baby is well hydrated – breastfed 8x /day
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Oxytocin
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– used to stimulate an active labor pattern – naturally occuring hormone released by POSTERIOR PITUITARY – synthetic form is used to stimulate or augment UC during labor. Therp Class – oxytocic – synthetic hormone Action – acts on uterine myofibrils to contract
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Oxytocin Nursing Care
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Nursing care – admin with infusion pump – closely monitor mom and fetus If contractions occur < 2 min. apart, last longer than 60-90 seconds, or sig change in FHR – STOP INFUSION and turn client to left side
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Oxytocin Indications
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– to induce / augment labor – in pts with PIH, prolonged gestation, maternal diabetes. Rh sensitization, PROM or PPROM, incomplete or inevitable abortion – to control bleeding and enhance UC AFTER the placenta is delivered – rare cases in nonstress contraction test (>31 weeks) if nipple stimulation fails to produce contractions
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Oxytocin Nursing Implications / Care
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Admin IV with infusion pump – starting primary IV line – insert tubing of admin set through infusion pump set drip rate to prescribed dosage and infusion rate – infusion rate: 0.5 to 1.0 ml/minute – labor starting dose: 10 units of oxytocin in 100 mL isotonic solution – maximum dose: 20-40 mU Admin Oxytocin by piggyback method in IV line – always given in piggyback, so if hyperstimulation occurs, the drug can be stopped immed. and IV fluid can continue – also if necessary, drug can be restarted easily to achieve goal
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Oxytocin Nursing Implications / Care continued
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Using external electronic fetal monitoring methods – monitor for FHR decelerations or fetal distress and stop infusion immed. if these occur Be prepared to monitor UC as drug acts immed -regulate infusion rate to achieve contractions that mimic labor Increase oxytocin dose as ordered – DONT increase more than 1-2 mU/min once every 16 to 60 min. Before each increase – assess contraction – maternal VS – fetal HR/rhythm – verify uterine relaxation btw/ contractions by external or internal fetal monitor Monitor maternal HR – if HTN occurs, stop infusion and notify doctor Assist with comfort measure – repositioning pt on her side prn Review infusion rate to prevent uterine hyperstimulation – if hyperstim occurs, D/C oxytocin and admin O2 – increase uterine blood flow by changing the pts position and increasing infusion rate of primary IV line – resume oxytocin infusion, per policy after hyperstim is resolved Monitor I&O, water for signs of water intox (HA/vomitting) – limit IV fluids to 150 mL/hr prepare pt for birth
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Oxytocin Expected Outcomes
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– contractions begin and follow pattern of natural labor – pt suffers NO adverse effects from drug – fetus suffers NO distress – Fetus is delivered successfully
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Oxytocin Action
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– increases UC by increasing circulation of free intracellular calcium – oxytocin receptors increase during preg, esp in 3rd trimester and in LATENT phase of labor due to influence of estrogen, progesterone, prostaglandin – with increased # of receptors, amt of oxytocin needed for labor DECREASES – continuous infusion of oxytocin raises circualting blood level slowly over 20-30 min – half life is only 1-5 min. so stopping infusion results in RAPID DECREASE in effect
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Oxytocin Adverse Effects
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– N/V (water intox) – cardiac arrhythmias – uterine hypertonicity – titanic contractions – uterine rupture (excessive dosages) – severe water intox – fetal BRADYCARDIA
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If a woman’s membranes rupture, what is the nurses FIRST action?
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– observe for prolapsed cord or menconium stained fluid these are signs of potentially life threatening complications to the fetus that may require emergency delivery
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Patient is in labor and appears peaceful and there is an increase in bloody show, what stage of labor is she in?
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2nd stage – a short period of peace and an increase in bloody show occur immed. BEFORE the baby is born and at the beginning of 2nd stage of labor
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Stages of Labor
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1st stage – 1 to 10 cm dilitation 2nd Stage – peaceful time, bloody show 3rd Stage – delivery of placenta 4th Stage – 1st 2 hours of delivery
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Stage 1 of labor
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begins with onset of regular contractions and ENDS when cervix is completely effaced and dilated
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Stage 2 of labor
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from complete dilatation of cervix to the birth of the infant
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Stage 3 of labor
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from birth of infant to delivery of placenta
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Stage 4 of labor
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from 1-4 hours post birth
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How to recognize the onset of labor
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– may feel a gush of water at the beginning of labor – may have blood tinged vag discharge – regular UC that become stronger – FM remains UNCHANGED during true labor
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Gush of water at the beginning of labor indicated what?
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– ruptured membranes – labor usually begins within 24 hours of SROM
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Bloody show is a sing of what?
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preceding labor
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Other signs of preceding labor include
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– lightening – urinary frequency – backache – surge of energy – stronger Braxton Hicks contractions
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Regular uterine contractions that become stronger indicates what?
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– true labor discomfort radiates from back to the abdomen contractions dont decrease with rest cervix progressively effaces and dilates
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cheesy white vaginal discharge indicates what?
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candidiasis other Sx – vaginal pruritus Tx with anti fungal prep
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During labor induction with oxytocin, contractions are observed at 2 min intervals and last > 90 seconds, what should the nurse do?
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stop the infusion! its extrem important to continually assess contractions for pt receiving oxytocin drip if contractions occur too freq, (intervals of 90 secs), they may endanger mom and fetus nurse should STOP infusion, and notify doctor
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Patient is in labor and with regular contractions and her cervix is 9cm dilated, what stage of labor is she in?
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1st stage from the beginning of labor until the cervix is completely dilated = 1ST STAGE subdivided into Latent Phase (0-3cm) Active Phase (4-7cm) Transition Phase (8-10cm)
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Second Stage
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from complete dilitation to the birth of the baby Phase 1 = 0 to +2 station Phase 2 = +2 to +4 station Phase 3 = +4 to birth
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Third stage
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delivery of placenta, slight gush of blood and lengthening of umbilical cord
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Fourth Stage
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– 2 hours following birth of baby
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Normal amount and character of lochia
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– bright red and less than a heavy menstrual period
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12 hours after deliver the fundus should be
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1 cm above the umbilicus within 12 hours of birth > 12 hours, the fundus should descend 1-2 cm /day
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Heredity can be a factor for LGA infants, true or false?
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true
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Macrosomia of insulin dependent diabetic mothers is caused by what
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poor maternal control infant has round face, chubby body, flushed complexion
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What are macrosomia infants at risk for?
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hypoglycemia hypocalcemia hyperbilirubinemia
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Gravida
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total number of pregnancies regardless of duration includes – present pregnancy a pregnant woman
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Parity
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number of past pregnancies that have gone beyond the period of viability (capability of fetus to survive outside of the uterus) after 20 weeks gestation or > 500 grams regardless of # of fetuses or whether the infant was born dead or alive
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Gravid
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the state of being pregnant
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Para
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a woman who has carried 1 or more viable offspring to 20 weeks or more
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Gravida/Parity
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– the # of pregnancies a woman had, including the current pregnancy = gravida – the # of children a woman has borne at 20 weeks or later = para – ex. a woman who’s preg for the 2nd time and who has 1 child = gravida 2, para 1
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Primigravida
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woman who is pregnant for the 1st time
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Multigravida
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a woman who has previously been pregnant
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Nulligravida
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woman has never been and is not pregnant
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Primpipara
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a woman who has borne 1 child in past 20 weeks
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Multipara
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a woman who has borne 2 or more children in the past 20 weeks
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GTAL and GTPALM provide more detailed info about a womans preg Hx
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G = gravida remains the same T = number of full term infants P = number of preterm infants A = number of abortions L = number of living children M= number of multiple pregs
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RDS
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altered resp state d/t surfactant deficiency in lungs labored resp after several min. or hours of normal respirations initially cyanosis, grunting, nasal flare, retractions, tachypnea
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Cold stress
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– mottled skin and metabolic/resp acidosis – excessive loss of heat that results in increased resp and nonshivering thermogenesis – metabolic acidosis occurs – place in heated environment
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Perinatal Asphysxia
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occurs in utero chronic hypoxia occurs in fetus that is – SGA – maternal Hx of heavy cig smoking Prepare for aggressive ventilatory assistance keep airway open
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Hypovolemia
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low blood volume
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Cold Stress
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excessive heat loss in newborns in order to maintain core temp, infant uses metabolic processes to generate heat Indications include – increased resp – mottling of skin / cyanosis – abnormal blood gases (metabolic acidosis)
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Nursing Care for Cold Stress
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– place infant in heated environ immed after birth – maintain neutral environment – monitor temp – fabric insulated cap for head
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Gonorrhea can may you unable to have children, true or false?
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TRUE – bc it causes pelvic inflamm disease which is one of the most common causes of sterility
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How is Gonorrhea treated?
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with antibiotics
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Gonorrhea can cause
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– preterm labor – premature ROM – PP endometriosis May cause the following the infant: – sepsis – conjunctivitis – preterm birth
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How to care for the newborns umbilical cord
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– clean the cord and skin around it with water – contact doctor if there’s white or yellow discharge from cord DO NOT – bathe baby in tub (until it falls off) – cover the cord with diaper (fold diaper below umbilicus to maintain dry area) – will on cord when it becomes loose (allow it to fall off) – apply petroleum jelly to base of cord
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Newborn Cord Care
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– umbilical cord surrounding the skin need be kept clean, dry and open to air until it falls off (usually 7-14 days after delivery) – cord is left clamped (to prevent oozing of blood) until it dries, usually 24 hours post delivery – clean cord with WATER – no bath tubs allowed – diapers folded below base to facilitate drying – report redness, edema, purulent drainage which may indicate infection Once cord falls off, remaining stump needs another 3-5 days of care
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Newborn Cord Care expected outcomes
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– shriveled and blackened umbilical cord falls of in 7-10 days and the umbilicus heals completely
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Newborn Cord Care Implementation
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– assess area freq for blood / signs of infection – follow facility policy on cleansing and applying any appropriate agent at every diaper change – ensure edge of diaper is BELOW the cord area to prevent irritation and promote drying – remove cord clamp ONLY AFTER CORD IS FULLY DRY
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Newborn Cord Care – Patient Teaching
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– apply alcohol or recommended solution to cord site at each diaper change – monitor for bleeding, redness, drainage, or foul odor – dont give infant a tub bath until cord has fallen off or healed – fold diapers below stump – observe color change from yellow to brown to black – allow cord to fall off on its own
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Newborn Cord Care Unexpected Outcomes and Associated Interventions
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Hemorrhage – ensure cord is clamped securely until after thrombosis obliterates the umbilical vessels Infection – keep cord stump dry and clean and dont use creams, lotions, oils near cord Ulcerous area remaining 1 week after the cord falls off – may require cautery with silver nitrate to speed healing
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FHR during labor is 59bpm, what should the nurse do?
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turn the mom onto her left side admin oxygen by nasal cannula start IV
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Bradycardia in fetus indicates what
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– fetal distress persistent bradycardia may indicate – cord compression / separation of placenta
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When is a woman most likely to become pregnant?
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10-14 days after the onset of her menstrual period this is the time of ovulation (around 14th day) if pt has intercourse 2-3 days before this time or 2-3 days after this time, its possible that she will become pregnant, since the sperm lives for about 48 hours.
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Secretory phase occurs when
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between the day of ovulation and about 3 days prior to next menstrual period large amounts of progesterone are produced
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Implantation of fertilized ovum occurs when
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7-10 days after ovulation
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Ovulation
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periodic ripening and rupture of mature graafian follicle and discharge of ovum occurs approx 14 days prior to next menstrual period
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Fertilization occurs when?
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approx 24 hours after ovulation usually in outer third of fallopian tube
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Ovulation
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rupture of mature follicle, which releases an ovum – occurs at about 14 days BEFORE menstruation – low levels of estrogen and progesterone stimulate secretion of gonatotropin releasing hormone which stimulates the secretion of LSH which spurs the development of follicle LH surges, leading to ovulation within 48 hours
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gonadotropin releasing hormone
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this hormone stimulates the anterior pituitary to secrete FSH and LH goes to the anterior pituitary gland and makes it release FSH and LH, prolactin responsible for sex maturation
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Follicle stimulating hormone
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WOMEN: initiates growth of ovarian follicles each month and stimulates ovulation; MEN: stimulates sperm production
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Lutenizing Hormone
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stimulates the formation of corpus luteum, estrogen and progesterone in females and testosterone in males
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Sex intercourse within 72 hours of ovulation aids in what?
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conception
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Ovulation Assessment
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– menstrual history, to determine regularity and length of cycle – evaluation of hormone levels (serum progesterone, FHS, LH, prolactin – Progesterone test to confirm ovulation – Eval of thyroid hormones to determine thyroid functioning and pituitary glands Hypothyroid condition can interfere with – pituitary feedback cycle and disrupt secretion by pituitary of FSHand LH Cervical mucus assessment – at ovulation peak, mucus is thin, watery, transparent and stretches when pulled Measurement of women’s BBT – temp rises with ovulation
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Painless vaginal bleeding indicates what? for example at 29 weeks gestation
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placenta previa
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placenta previa
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placenta thats abnormally implanted in the lower uterine segment pt will be Tx with – bedrest – no vag exams – IVs to restore blood volume – monitor FWB
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Severe abdominla cramps and PAINFUL bleeding indicates what?
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abruptio placenata – premature separation of a normally implanted placenta
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Placenta Previa
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– implanted near or over the cervical opening Indications – PAINLESS bright red vaginal bleeding accompanied by soft uterus usually in 3rd trimester btw 29-30 weeks Caused by – scarring of uterus from preg – tumor
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PLacenta Previa Tx
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– bedrest – US to locate placenta – no vag/rectal exams before fetal viability – amniocentesis for lung maturity – daily Hgb and Hct – 2 U of cross matched blood avail
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Diabetes S/S
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– fatigue/weakness – irritability – polyuria – polydipsia – polyphagia – nocturia – blurred vision – slowly healing lesions – numbness of hands and feet – weight loss – dry skin
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Type 1 DM TX
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-strict diet to meet nutrient needs, control bg levels, recduce acidosis – injected insulin, implantable insulin pumps, inhaled insulin
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Type 2 DM
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– meal planning to control blood glucose levels – weight loss to decrease insulin resistance – reg exercise to lower bg, increase insulin effectiveness, reduce cardiovasc risk – injected insulin
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Gestational Diabetes Tx
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– diet modification – blood glucose monitoring – insulin if necessary (oral antidiabetic agents arent used in women)
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Diabetes Nursing Care
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– monitor pts blood glucose freq during insulin infusion – plan pts usual insulin regimen after any crisis – monitor pts electrolyte levels closely and admin K+ replacement if needed – design meal plan – monitor insulin complications (hypo/hyper glycemia) – check for history for conditions such as pregnancy, breastfeeding stress or illness, which can increase insulin requirements – check pts urine for ketones, esp if he is ketosis prone with type 1 dm – show pt how to check their own glucose – monitor A1C
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Gestational Diabetes
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– insulin resistance results from SECRETION OF PLACENTAL HORMONES – in most instances, blood glucose levels return to normal after delivery, but these women are at risk for Type 2 DM later in life
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The baby’s anterior fontanelle should close after how long?
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about a year and a half 18 months – diamond shaped, 3×2 cm – junction of saggital, coronal and frontal sutures
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Posterior Fontanelle
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triangular n shape jx of sutures of the 2 parietal bones and 1 occiptal bone closes 6-8 weeks post delivery
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when is the most critical time for fetal development?
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the first 3 months
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1st 2 weeks of pregnancy
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preembryonic stage lasts from conception to 14 days initial development of embryonic membranes and establishment of primary germ layers occur
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The first 3 months of pregnancy
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– 1st trimester aka first 3 months – all major systems of the fetus are developed – exposure of mother to noxious environmental agents can interfere with proper development of fetus
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The 4th-6th months of pregnancy
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the systems are all developed at this time
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The last month of preg
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fetus increases in weight at 36 weeks, able to adjust to extrauterine life
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Fetal Development at 4 weeks
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– fetal heart begins to beat
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Fetal Development at 8 weeks
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– all body organs are formed
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Fetal Development at 8-12 weeks
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fetal heart rate can be heard by doppler device
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Fetal Development at 16 weeks
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baby’s sex can be seen fetus looks like a baby
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Fetal Development at 20 weeks
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– heartbeat heard with fetoscope – mom feels movement – baby develops regular schedule of sleeping, sucking, kicking – vernix/lanugo present
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Fetal Development at 24 weeks
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– increased activity, weighs 1lb 10oz – resp movement begins
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Fetal Development at 28 weeks
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– eyes open and close – can breathe at this time – surfactant needed for the baby to breath at birth is formed – 2/3 final size
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Fetal Development at 32 weeks
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– has fingernails, toenails, subcut fat formed
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Fetal Development at 38-40 weeks
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fills uterus
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Fetal Development begins with conception and continues until birth, its typically divided into 3 periods:
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1. Pre-embryonic Period (fertilization to week2) 2. Embryonic Period (weeks 3-7) 3. Fetal Period (week 8 – birth)
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Pre-embryonic Period
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fertilization to week 2 – fertilized ovum advances through the fallopian tube toward the uterus and undergoes miotic division, becoming a ZYGOTE – zygote reaches the uterus about day 3 after fertilization Called a blastocyst when it reaches the uterus, – trophoblast layer develops into fetal membranes and the placenta – inner cell mass then forms the embryo By the end of the 1st week of fertilization, the blastocyst attaches to the ENDOMETRIUM – During the next week, the invading blastocyst sinks below the endometrium’s surface – the penetration site seals, restoring the continuity of the endometrial surface
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Embryonic Period
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weeks 3-7 – blasotcyst becomes an embryo
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Embryonic Period – ectoderm develops into the
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Epidermis Nervous system Pituitary gland Tooth enamel Salivary gland Optic lens Lining of the lower portion of anal canal Hair
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Embryonic Period – Mesoderm develops into
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– connective tissue and supporting tissue – the blood and vasc system – musculature – teeth – mesothelial lining of pleural, and peritoneal cavities – kidneys / ureters
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Embryonic Period – Endoderm develops into
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– epithelial lining of pharynx and trachea – auditory canal – ailmentary canal – liver – pancreas – bladder and urethra – prostate
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Embryonic Period – at the end of the month
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the head, trunk and tiny buds that will become arms, legs = are discernible CV system has begin to function umbilical cord is visible in its primitive form
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Embryonic Period – during the 2nd month,
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it grows to 1 and 1 gram head and facial features develop arms / legs take shape external genitalia are present CV function is complete umbilical cord has a definite form
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Fetal Period
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week 8-birth – during the 3rd month, the fetus is 3 and 1 ounce – teeth and bones begin to appear – kidneys start to function – fetus opens mouth – grasps with fully developed hands – preps for breathing by inhaling and exhaling gender is distinguishable by THE END OF THE 3RD MONTH
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Growth and development of fetus follows what type of pattern?
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cephalocaudal (head to toe) proximal to distal pattern
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Implantation occurs where?
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the upper uterus
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Embryo develops into a fetus, which grows and develops at a predictable rate
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– heart beats regularly by week 5 – resembles a human being at the end of week 8 – weight quadruples during the 4th month – FM detected by mother during the 4th month – Fetal heart sounds can be detected by stethoscope during 5th month – muscles are well developed by week 20 – lungs begin to produce surfactant during the 6th month – fetus reaches 15 inches in length during the 7th month – increased CNS control over body fx occurs during the 8th month – fetus is considered full term at 38 weeks – fetus fills uterus during 9th month
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Adequate amounts of amniotic fluid
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– maintain a consistent body temp – protects fetus from trauma – promotes symmetric growth and development – protects from umbilical cord compression – allow for FM to enhance MS development
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The placenta
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– forms the trophoblasts – attaches to the uterus & provides the following functions: – acts as a transfer organ btw mom and fetus – produces hormones necessary for a normal preg (hCG, hPL, estrogen, progesterone, relaxin) – protects fetus from mom’s immune system – removes waste products from fetus – triggers mom’s body to provide more food to placenta – produces hormones that mature fetal organs in prep for birth
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The umbilical cord is formed from amnion and is made of how many veins / arteries?
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1 large vein 2 small arteries surrounded by Whartons jelly to protect the blood vessels from compression – acts as a lifeline from fetus to mom – approx 22 inches long and 1 in wide at term
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Oligohydraminos
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< 500 mL of amniotic fluid associated with – utero-placental insufficiency – fetal renal abnorms
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Hydraminos
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> 2,000 mL of amniotic fluid at term Associated with – maternal diabetes – neural tube defects – chromosomal deviations – malformations of CNS/GI that prevent fetus from swallowing amniotic fluid
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Teratogens, infections, radiation, nutrient deficiencies
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are the most dangerous during embryonic period bc of rapid growth, and forming of organs / structures
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Chromosomal abnorms
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– numeric or structural abnroms Downs, fragile X syndrome
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Autosomal Dominant inherited disorders
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– abnormal gene pair causes disease even if the matching pair from the other parent is normal – familial hypercholesterolemia – breast and ovarian cancer r/t BRCA genes –
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Autosomal Recessive inherited disorders
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– both gene pairs are mutated, causing disease sickle cell, cystic fibrosis
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mom addicted to narcotics gives birth to day, when is the most likely time to observe symptoms of narcotic withdrawal?
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within 24-72 hours after birth infant wil be jittery, hyperactive, high pitch cry, diaphoresis, tachypnea
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if mom is taking methadone, infant demonstrates signs of withdrawal when
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about 7 days after birth
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Toxoplasmosis
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protozoan infection caused by eating infected undercooked meat or after handling infected kitty litter infection can cross placenta and infect the fetus preg woman shouldnt clean cat liter box, if she must, wear latex gloves and wash hands after

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