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46 Cards in this Set
- Front
- Back
1st Trimester Psychosocial Responses
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Ambivalence; financial worries; career concern
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2nd Trimester Psychosocial Responses
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Quickening; pregnancy becomes real; pregnant woman accepts pregnancy; ambivalence wanes
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3rd Trimester Psychosocial Responses
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Introverted and self absorbed; begins to ignore partner
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Throughout Pregnancy Psychosocial Responses
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Mood swings; ultrasensitive; strained relationship
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Gravida and Parity
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Gravida - # of times a woman has been pregnant
Para - # of births past 20 weeks |
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TPAL
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Term, Preterm, Abortion, Living
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HESI Hint
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Look for signs of maternal-fetal bonding during pregnancy (talking to baby, nicknames, massaging)
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HESI Hint
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Abuse begins during pregnancy; assess for abuse in private, away from partner
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Nagele Rule
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Count back 3 months from LMP and add 7 days
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V/S During Pregnancy
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BP - average 90-140/60-90
HR - 60-90 RR - 16-24 T - 97-100 |
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Office Visits During Pregnancy
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Every month until 28 weeks; every 2 weeks 28-36 weeks; every week after 36 weeks
(for low risk clients) |
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Labs to check in prenatal visit
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HIV, Hep B, CMV, Toxoplasmosis, Rubella, Syphillis, TB, Rh and blood type, Urinalysis
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Rubella
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>1:10 = immunity
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Foods Rich in Iron
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fish, red meat, green leafy vegetables, cereals, yellow vegetables, citrus fruits, egg yolks, dried fruits
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Weight Gain During Pregnancy
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3.5-5lb during 1st tri; 0.9lb thereafter; total should be 25-35 lbs
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Urine - Albumin & Glucose
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Albumin - no more than trace amount (r/t preeclampsia)
Glucose - no more than +1 (r/t gestational diabetes) |
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Fundal Height
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12-13 wks - fundus rises out of symphysis; 20 wks - at umbilicus; 24 wks - fundal height is measured in cm with the number of cm = to # wks gestation
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Fetal Heart Rate
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10-12 weeks detectable using doppler; 15-20 weeks detectable using fetoscope; 110-160 bpm is normal range
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HESI Hint
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Fetal well being is detected by fetal tone, FHR, UCs, fundal height, fetal movement; changes in FHR are first and more important indicator of compromised blood flow
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HESI Hint
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Teach clients to report immediately: visual changes, swelling of face, fingers, sacrum, severe HA, persistent vomiting, infection, fluid discharge, change in fetal movement
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Nutrition Interventions
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Iron 30+mg/day; folic acid 800-1000mcg/day; increase vit A, C, and calcium
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HESI Hint
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Only healthcare provider can prescribe prenatal vitamins but it is the RN's responsibility to teach about proper diet and taking vitamins
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HESI Hint
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It is recommended that pregnant women consume 1 qt/day of milk or yogurt to ensure adequate calcium (dec. leg cramps)
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Position recommended for optimal perfusion to uterus, placenta, fetus
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Knee-Chest Position
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Maternal Risk Factors
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Age <17 or >34; high parity; HTN; anemia; multiple gestation; Rh incompatibility; Hx of dystocia Malnutrition; Infection; Medical disease during pregnancy; abuse
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HESI Hint
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In some states, screening for neural tube defects by AFP or amniotic fluid AFP levels is mandated by state law; this test is highly associated with false positives and false negatives
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Ultrasound
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High frequency sound waves are beamed into the abdomen; echoes are returned to a machine that records the fetus' location and size; bladder must be full
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Ultrasound in 1st trimester
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Used for # of fetuses, presence of cardiac movement and rhythm, uterine abnormalities, gestational age
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Ultrasound in 2nd/3rd Trimester
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fetal viability, gestational age, amniotic fluid vol, placental location and maturity, uterine abnormalities, results of amniocentesis
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BPP
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5 variables assessed: FHR, Fetal tone, fetal breathing movements, body movements, amniotic fluid volume; score can go up to 10 = good
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HESI Hint
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Gestational age is best determined by an early sonogram rather than a later one
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Chorionic Villi Sampling
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Removes small piece of villi between 8-12 wks to test for genetic dx; informed consent
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Amniocentesis
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Removal of amniotic fluid sample from uterus between 14-16 weeks; used for genetic dx, fetal maturity, fetal well-being; meconium in fluid may indicate stress
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L/S Ration
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Should be 2:1, indicates fetal lung maturity which is best predictor of extrauterine survival
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Nursing Care during amniocentesis
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Obtain Mom V/S and FHR, supine position, scrub with Betadine, emotional support, assist to void after
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HESI Hint
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When an amniocentesis is done in early pregnancy, bladder must be full. In late pregnancy bladder must be empty
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Contractions
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Duration, Frequency, Intensity (30mmHg is weak, 70mmHg is strong)
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What is the most important indicator of health of the fetal CNS?
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FHR
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Accelerations of FHR
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caused by sympathetic response, occur in response to movement, indicative of a reactive/healthy fetus
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Early Decels
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Due to head compression, HR decels at beginning of contraction and returns to baseline at end
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Variability
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Absent or minimal; Short term is absent, long term is minimal; Causes - hypoxia, acidosis, maternal drug ingestion, fetal sleep
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Bradycardia
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Baseline is below 110 bpm for 10 min; causes - LATE manifestation of hypoxia, maternal hypotension, med induced, fetal heart block, cord compression
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Tachycardia
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baseline is about 160 bpm; causes: early sign of hypoxia, fetal anemia, dehydration, maternal infection, maternal hyperthyroid disease, med induced
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Variable Decels
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Caused by cord compression
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Variable Decels Nursing Interventions
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Change mom position, stimulate fetus, d/c Oxytocin, Administer O2, perform vaginal exam, report to MD
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Late Decels
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Indicative of uteroplacental insufficiency
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