By B. Holloway, et al.
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Nursing Health Assessment: A Critical Thinking, Case Study Approach. A. Davis, p. ) ■ Count FHR between, during, and immediately following a contraction ■ Note both rate and rhythm of FHR ■ Frequency of auscultation based on: ■ Phase/stage of labor ■ Hospital protocol 54 03Holloway (F)-03 12/28/05 12:25 PM 55 ■ Risk status ■ Labor interventions ■ Physician orders Stage/Phase of Labor Stage Stage Stage Stage Frequency of FHR Monitoring 1: Latent phase 1: Active phase 1: Transition 2 Every Every Every Every 30–60 minutes 15–30 minutes 5–15 minutes 5–15 minutes Continuous Fetal Monitoring Monitored with external or internal fetal monitoring External Fetal Monitoring (EFM) ■ ■ ■ ■ ■ Encourage patient to void before applying EFM Test internal circuitry of EFM Place ultrasound transducer over fetal back Place toco transducer over uterine fundus Monitor for 20–30 minutes on admission Ultrasound transducer Toco transducer (FHR) (uterine contractions) External fetal monitor INTRAPARTUM Page 55 03Holloway (F)-03 12/28/05 12:25 PM Page 56 INTRAPARTUM Internal Fetal Monitoring ■ Indicated when EFM not providing adequate FHR or contraction tracing ■ May be implemented only after amniotic sac is ruptured ■ FHR measured by spiral electrode attached to presenting part ■ Uterine tone measured by intrauterine pressure catheter (IUPC) ■ Resting tone of uterus averages 5–15 mmHG ■ Contraction tone of uterus averages 50–85 mmHG Scalp electrode Catheter Internal fetal monitor Evaluating the Baseline Fetal Heart Rate ■ ■ ■ ■ ■ Normal baseline FHR is 110–160 BPM Evaluated between contractions over 10 minutes Documented as a range Does not include accelerations or decelerations Influences on the fetal heart rate ■ Central nervous system Fetal sleep ↓ variability of FHR Fetal movement ↑ variability of FHR ■ Autonomic nervous system Sympathetic branch (↑ FHR) Parasympathtic branch (↓ FHR) ■ Baroreceptors respond to ↓ blood pressure with subsequent ↓ FHR ■ Chemorecptors sense ↓ oxygen and ↑ FHR 56 57 Normal fetal heart rate.
S. Food and Drug Administration Nutrition ■ ■ ■ ■ ■ ■ Inquire about dietary practices Gather 24-hour diet recall Suggest an addition of 300 healthy calories per day Encourage daily prenatal vitamin with 400 g folic acid Suggest 6–8 glasses of water daily Encourage to follow food pyramid in daily choices ANTEPARTUM KEY These symbols show fats and added sugars in foods Fat (naturally occurring and added) Sugars (added) Dairy group 2-3 servings Vegetable group 3-5 servings Bread, cereal, pasta and grain group 6-11 servings Fats,oils and sweets Use sparingly Protein group 2-3 servings Fruit group 3-5 servings Food Pyramid.
Nursing Health Assessment: A Critical Thinking, Case Study Approach. A. ) ■ ■ ■ ■ ■ Record presence of fetal movement Assess for presence of edema/deep tendon reflexes Record symptoms since last visit Discuss procedure for diagnostic testing Provide patient education appropriate for gestational age 36 02Holloway (F)-02 12/28/05 12:24 PM Page 37 37 Diagnostic Tests 1-hour glucose screen Performed at 24–28 weeks Clinical Application Detection of gestational diabetes Nursing Considerations Administer 50 g glucose load Patient should not eat, drink, or smoke during the test Serum sample drawn in 1 hour EXPECTED RESULT р 140 mg/dL Group B vaginal culture Performed between 35–37 weeks Clinical Application Positive culture treated with antibiotics in labor to prevent newborn transmission Explain test to patient Collect vaginal/rectal specimen EXPECTED RESULT Negative Fetal fibronectin (fFN) Performed between 22 and 35 weeks in women at high risk for preterm labor Clinical Application Negative predictive value for preterm labor NO intercourse 24 hours prior to exam Cervical/posterior fornix specimen Antibody screen Performed at 28 weeks in Rh negative women Administer Rh (D antigen) immune globulin at 28 weeks to prevent antibody formation if Rh negative and antibody screen negative EXPECTED RESULT Negative Clinical Application Detects presence of positive antibodies in serum of Rh negative women ANTEPARTUM EXPECTED RESULT Negative 02Holloway (F)-02 12/28/05 12:24 PM ANTEPARTUM Education in the Second and Third Trimester ■ Teach patient to count fetal movement and report change in fetal movement pattern to primary health-care provider immediately (See bulleted information under “Teach patient to count fetal movements” on page 50) ■ Discuss fetal growth and development ■ Demonstrate palpating for contractions ■ Discuss symptoms of preterm labor ■ Lower backache ■ Increased vaginal discharge ■ Bloody show ■ Leaking amniotic fluid ■ Contractions ■ Pelvic pressure ■ Differentiate between true and false labor True Labor Cervix dilates Contractions increase in intensity and frequency Leaking amniotic fluid, bloody show False Labor Cervix unchanged Contractions irregular and decrease with change of position/activity No evidence of change in vaginal discharge ■ ■ ■ ■ ■ Encourage childbirth preparation class Discuss options for pain control in labor Cesarean preparation class, if indicated Epidural anesthesia class, if indicated Explore preparing for the newborn ■ Breastfeeding ■ Circumcision ■ Choosing a pediatrician ■ Car seat safety ■ Discuss the discomforts associated with late pregnancy and teach reportable symptoms (in red) 38 Page 38 02Holloway (F)-02 12/28/05 12:24 PM Page 39 39 Discomfort Changes in pigmentation Linea nigra (pigmented line from umbilicus to pubic bone) Chloasma (deeper facial pigment) Striae (stretch marks) Round ligament pain (occasional, sharp lower abdominal pain) Braxton-Hicks contractions (false labor contractions) Ankle edema Varicose veins Faintness Patient Education Related to hormone changes in pregnancy; fade after pregnancy Moisturizers decrease itching, but will not prevent striae Report body rashes Related to round ligament stretching as uterus grows Change positions slowly Encourage good body mechanics Report abdominal cramping, constant pain, or bleeding Instruct patient how to palpate contractions Labor should occur after 38 weeks gestation Teach patient to differentiate between true and false labor Report signs of preterm labor Related to decreased venous return due to pressure of the gravid uterus Rest in lateral recumbent position Elevate legs when sitting Continue with 6–8 glasses water daily Report generalized edema Caused by increased venous stasis related to pressure from the gravid uterus Wear pregnancy support hose Avoid lengthy standing Change positions frequently Report pain, redness, localized heat to legs Related to hemodynamic changes Avoid sudden position change Avoid long periods without eating Avoid lying supine Report loss of consciousness (Continued text on following page) ANTEPARTUM 02Holloway (F)-02 12/28/05 12:24 PM Page 40 ANTEPARTUM Discomfort Patient Education Heartburn Related to increased pressure on abdominal organs and sphincter relaxation Encourage small, frequent meals Avoid spicy foods Sit up after meals Report persistent symptoms Backache Related to shift in posture due to gravid uterus Encourage low-heeled shoes Avoid standing for long periods Teach pelvic tilt exercises Report constant or rhythmic backache Shortness of breath Related to upward diaphragmatic pressure exerted by the gravid uterus Allow more time for strenuous activities Eat small, frequent meals Lightening will lessen symptoms Report dyspnea with rest Insomnia Related to fetal movement, nocturia Teach relaxation techniques Encourage side-lying with pillow support Warm milk/shower before sleep Leg cramps Related to uterine pressure on the pelvic nerves or calcium imbalance Review daily calcium intake Teach signs of deep vein thrombosis Report pain, redness, localized heat Constipation Hemorrhoids Related to decreased gastric motility; iron supplement may worsen constipation Increase dietary fiber and water intake Encourage exercise Discourage enemas and laxatives Report painful or bleeding hemorrhoids 40 02Holloway (F)-02 12/28/05 12:24 PM Page 41 41 Pregnancy Complications Vaginal Bleeding (before 20 weeks’ gestation) May be related to spontaneous abortion, ectopic pregnancy, or gestational trophoblastic disease Spontaneous Abortion Loss of pregnancy before viability ■ Clinical Findings ■ Vaginal spotting (may pass clots) ■ Abdominal cramping ■ Cervical changes ■ Fetal heartbeat may be present or absent Ectopic Pregnancy Products of conception implant outside the uterus ■ Clinical Findings ■ Vaginal spotting ■ hCG lower than expected for dates ■ Lower abdominal pain ■ Ultrasound findings: absence of intrauterine gestational sac ■ If rupture occurs: • Positive Cullen’s sign (periumbilical bluish hue) • Shoulder pain • Signs of shock Gestational Trophoblastic Disease Abnormal proliferation of trophoblastic cells without viable fetus ■ Clinical Findings ■ Vaginal spotting (dark brown) ■ Fundal height greater than expected for dates ■ hCG greater than expected for dates ■ Excessive nausea and vomiting ■ Absence of fetal heart tones ■ Ultrasound findings: Snowflake-like clusters, absence of fetus ANTEPARTUM 02Holloway (F)-02 12/28/05 12:24 PM Page 42 ANTEPARTUM ■ Nursing Care (vaginal bleeding/early pregnancy) ■ Monitor amount of bleeding ■ Assess vital signs ■ Observe for signs of shock ■ Auscultate for fetal heart tones (FHTs) ■ Collect passed tissue/clots ■ Monitor patient comfort ■ Check blood type and Rh factor ■ Administer Rh(D) immunoglobulin if indicated ■ Initiate IV fluids as ordered ■ Report lab/ultrasound findings ■ Attend to patient’s emotional needs Vaginal Bleeding (after 20 weeks’ gestation) May be related to placenta previa or abruptio placentae Placenta Previa Low-lying position of placenta in the uterus that partially or completely covers the cervical os ■ Clinical Findings ■ Painless bright red vaginal bleeding ■ Bleeding may be reported after intercourse ■ Uterine tone soft upon palpation ■ Interventions dependent on amount of bleeding and labor status ■ If partial placenta previa is noted in early gestation, repeat ultrasound later in pregnancy (may demonstrate absence of previa as uterus grows) ■ If labor active and os is covered, cesarean birth necessary ■ If bleeding controlled and labor absent, conservative management • Patient Teaching (Conservative Management) – No tampon use – No sexual intercourse – Monitor and report bleeding – Patient instructed to report placenta placement when admitted to hospital – Cesarean preparation class – Count fetal movements 42 02Holloway (F)-02 12/28/05 12:24 PM 43 Internal os Blood External os A Membranes Internal os Blood External os B Membranes Internal os Blood External os C Placenta previa.