DEC 2012 NLE TIPS MCHN

WHAT YOU SHOULD KNOW BEFORE THE PNLE

DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 2: MATERNAL AND CHILD HEALTH NURSING

POSSIBLE TOPICS ON MATERNAL AND CHILD HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE

A. Pregnancy Ovum: From ovulation to fertilization

Zygote: From fertilization to implantation

Embryo: From implantation to 5-8 weeks.

Fetus:From 5-8 weeks until term

Length of Pregnancy 267-280 days 38-42 weeks (ave.40 weeks) 9 calendar months 10 lunar months 3 trimester

First Trimester: Period of Organogenesis Second Trimester: Most comfortable for mother with continued fetal growth. Third Trimester: Period of rapid fetal growth bec. of rapid deposition of fats iron and calcium B. Signs of Pregnancy Presumptive Signs

Amenorrhea – absence of menses Nausea and Vomiting Increased breast sensitivity and breast changes Increased pigmentation Constipation Frequent urination Quickening Abdominal enlargement

Probable Signs

Uterine enlargement Hegar’s Sign Goodell’s Sign Chadwick’s Sign Ballottement Braxton Hick’s contraction Positive Pregnancy Test

Positive Signs

Fetal Heart Tone X-ray or Ultrasound of fetus Palpable fetal movements

C. Maternal and Fetal Diagnostic Test

CHORIONIC VILLI SAMPLING Removal of a small piece of Chorionic villi

Performed between the 8th – 11th weeks of gestation.

Laboratory results are obtained in 1 - 7 days

Disadvantages: Risk of Abortion Infection Embryo-fetal/placental

damage Spontaneous abortion Premature rupture of the

membranes

SHOULD REFRAIN FROM SEXUAL INTERCOURSE AND PHYSICAL ACTIVITY FOR 48 hours.

A small amount of spotting is normal for the 1st 24-48 hours.

ULTRASOUND Use of sound and returning echo patterns to identify intrabody structures.

Done 18-40 weeks for fetal abnormalities.

Best Test for ECTOPIC PREGNANCY

Full Bladder Use to locate the precise

location of the fetus and its membrane during CVS and amniocentesis

AMNIOCENTESIS Aspiration of amniotic fluid for examination.

Possible after the 14th week.

The client should be supine during the procedure

Afterward, she should be placed on her left side.

The patient MUST EMPTY THE BLADDER.

Vital signs are assessed every 15 minutes.

CALL THE PHYSICIAN FOR THE FF: Chills, fever, leakage of fluid, decrease fetal movement or uterine contractions.

X-RAY Done only 2 weeks

before EDC

ALPHA-FETOPROTEIN SCREENING Maternal serum screens for open neural tube defects.

Test done between 16 and 18 weeks gestation.

Normal Value: 10 mg/dl

LOW: Chromosomal defects

HIGH: Neural tube defects.

LECITHIN - SPHINGOMYELIN –(L/S RATIO) Uses amniotic fluid to ascertain fetal lung maturity

Done through AMNIOCENTESIS

Perform at 35-36 weeks Position: Supine. Place folded towel on the

right buttocks. Needle insertion in a 20-

22 gauge spinal needle, withdrawing amniotic fluid.

NORMAL L/S RATIO (lecithin/sphingomyelin): 2:1 = normal fetal lung maturity ratio




LEOPOLDS MANEUVER

Palpate with warm hands.

Use palms, not fingertips.

Woman should lie in

supine position with knees

flexed slightly.

Done with empty bladder.

1st: Presenting Part 2nd: Fetal Back 3rd: Engagement 4th: Descent

TeTox Routine Immunization of Pregnant Women

Vaccine Minimum Interval

Duration of Protection

TeTox 1 As early as possible during

pregnancy

TeTox 2 Minimum required TeTox for pregnant mother

4 weeks after TeTox 1

infant will be protected by neonatal tetanus

3 years protection for the mother

TeTox 3 6 months after TeTox 2



TeTox 4 1 year after TeTox 3



TeTox 5 1 year after TeTox 4

all infant born to that mother will be protected

lifetime protection for the mother

D. Discomfort of Pregnancy

Changes Reason Health Teachings Nausea and Vomiting

Increased HCG Dry crackers 30 min. before arising

Small, frequent, low fat meals

Avoid anti-emetics. Heartburn

Increased progesterone which decrease gastric motility causing esophageal reflux.

Pats of butter before meals

Avoid fried, fatty foods Sips of milk at frequent

intervals. Small, frequent meals

taken slowly. Bends at the knees, not

at the waist

Constipation Due to displacement of the stomach and intestines; iron supplements

Increased fluids and roughage in the diet.

Regular elimination time.

Increase exercise Avoid enemas, harsh

laxatives and mineral oil.

Hemorrhoids Pressure of growing fetus, Increase venous pressure

Warm sitz bathing High fiber diet and

increase fluid. Sit on soft pillow

Urinary Frequency

Increase blood supply to the kidney/ Pressure of enlarged uterus in the 3rd Tri

Sleep on the side at night.

Limit fluid intake during evening

Bladder training

Backache From exaggerated lumbo-sacral curving during pregnancy.

Back exercise (pelvic rock)

Wear low-heeled shoes. Avoid heavy lifting

Leg Cramps Increase pressure of gravid fetus, low calcium

Frequent rest with feet elevated

Regular exercise like walking

Increase milk intake Ankle Edema From venous

stasis Elevate legs at least

twice a day. Sleep on left side

Fatigue Due to hormonal changes

Get regular exercise Sleep as much as

needed. Avoid stimulants.

Breast Tenderness

Increase estrogen and progesterone level

Wear well fitted bra Warm compress

E. Formula Used In Providing Estimates In Pregnancy To estimate the EDC

Given the Use Formula Last Menstrual Period (LMP)

Nagele’s Rule First day of LMP – 3 months + 7 days

Date of Quickening

Primi: Q + 4 months + 20 days Multi: Q + 5 months + 4 days




Fundus Height at Various Week F. Pre-Natal Visit Schedule of first visit is as soon as the woman missed her

menstrual period and pregnancy is suspected First 32 weeks : once a month 32-36 weeks : twice a month 36-40 weeks : every week G. Electronic Monitoring Non-Stress Test

Accelerations in heart rate accompany normal fetal

movement. Observation of fetal heart rate related to fetal

movement. FHT: Doppler: 8 weeks Fetoscope: 16 weeks / 4 months Stethoscope: 20 weeks / 5months

Teach mother to count 2-3 times daily, 30-60 minutes

each time, should feel 5-6 movements per counting

time PREPARATION:

Patient should eat snacks.

Position: Semi-Fowlers or left lateral positions RESULTS:

1. Reactive (Normal): indicates a fetal fetus Greater than 15 beats per minute- occur with

fetal movement in a 10 or 20 minute period.

2. Non-Reactive (Abnormal): No fetal movement occurs The doctor will order an Oxytocin Test

AFTER the patient has non-reactive test.

Contraction Stress Test (CST) Response of the fetus to induced uterine contractions.

PREPARATION: Woman in semi-Fowler’s or side-lying position.

Monitor for post-test labor onset.

Indication: 28 weeks pregnancy high risk mother

Contraindicated: Pre Term Labor

INTERPRETATION: Early Deceleration: Head Compression Late Deceleration: Utero-placental Insufficiency Variable Deceleration: Cord Compression

H. Signs of Labor

1. Lightening – setting of fetal head into pelvic brim occurs approximately 10-14 days before labor . mother may experience: shooting leg pains from

the increased pressure on the sciatic nerve, increased amounts of vaginal discharge and urinary frequency from pressure on the bladder

2. Increased in Level of Activity 3. Braxton Hicks Contractions 4. Ripening of the cervix 5. Weight Loss 6. Rupture BOW 7. Effacement and Dilation

I. Length of Labor Stages of Labor Primigravida Multigravida

First Stage 12 and ½ hour 7hours and 20 minutes

Second Stage 80 minutes 30 minutes

Third Stage 10 minute 10 minutes

TOTAL 14 hours 8 hours

J. Nursing Care During Labor 1st Stage Onset of true labor pain until complete cervical dilation and effacement

Latent Contractions are mild and short

lasting 20-40 seconds

Cervix dilates from 0-3cm

Monitor frequency, intensity, and patterns of uterine contractions

Monitor fetal status during labor by monitoring fetal heart rate

Assess bloody show (pink or blood streaked mucus), perineal bulging, membrane status

Monitor vital signs Assess client’s ability to cope with

contractions Provide emotional support

Active Dilatation increases from 4 – 7 cm

Contraction lasts 40-60 sec and occur

every 3-5 minutes

Finds assessment techniques between contractions

Assists with frequent position change

Applies counter pressure to sacrococcygeal area

Encourages and praises Keeps woman aware of progress Check bladder and encourages

voiding




Transitional Contractions reached their peak of

intensity occurring every 2-3 minutes

with duration of 60-90sec

Maximum dilatation 8-10cm

Complete cervical effacement

Woman experiences intense discomfort accompanied by nausea and vomiting

Woman may also experience a feeling of loss of control, anxiety, panic or irritability

2nd Stage From complete dilation and effacement to delivery of the fetus

Prep client for delivery Immediate assessment of the

newborn 6 Cardinal Movements of the Mechanism of labor

1. Descent

2. Flexion

3. Internal Rotation

4. Extension

5. External Rotation

6. Expulsion

3rd Stage From delivery of the fetus to delivery of the placenta

Assess umbilical cord for 3 vessels (2 arteries, 1 vein)

Assess placenta for intactness The fundus should be midline at or

2 cm. below the umbilicus Don’t hurry the expulsion of the

placenta, just watch for the signs of placental separation:

Lengthening of the cord

Sudden gush of blood

Change of shape of the uterus

Palpate the uterus to determine degree of contraction. If relaxed, massage gently and apply ice cap

Inspect for lacerations The fundus should descend

approximately 1-2 cm every 24 hours

4th Stage The period of immediate recovery and observation after delivery of the placenta

Promote parent-infant bonding Assess maternal vital signs, fundal

height, lochia and bladder distention

Degrees of Perineal Lacerations: 1. First Degree – skin and superficial to muscle 2. Second Degree – muscles of the perineum 3. Third Degree – continues to anal sphincter 4. Fourth Degree – involves the anterior anal wall

K. Micronutrient Supplementation Vitamin A Supplementation

Target Prep. Dose Duration Pregnant Women

100,000 IU

1 cap 2x a week

Start from the 4th month of pregnancy until delivery

Post Partum Women

200,000 IU

1 cap One dose only within 4 weeks after delivery

Iron Supplementation Target Prep. Dose / Duration Remarks Pregnant Women

Coated Tab. contains 60 mg elemental iron with 400 mg folic acid

1 tab/day for 6 months or 180 days during pregnancy period OR 2 tab/day if prenatal consultation are done during the 2nd/3rd trimester

A dose of 800 mcg folic acid is still safe to pregnant woman

Lactating Women

Coated Tab. contains 60 mg elemental iron with 400 mg folic acid

1 tab / day for 3 months or 90 days

L. Pregnancy Complications ABORTION

Threatened, the continuation of the pregnancy is in

doubt

Inevitable, loss that can be prevented Complete, products of conception are totally expelled

Incomplete, some fragments are retained inside the

uterine cavity

Missed, retention of the products of conception after

fetal death

Habitual, 3 spontaneous abortions occurring

successively

ECTOPIC PREGNANCY

A pregnancy that occurs in another than uterine site, with implantation usually occurring in fallopian tubes

Knife-like abdominal pain Profound shock if rupture occurs

Symptoms of Shock: decreased BP Increased RR, Fast but thready pulse

Surgery: Salpingostomy




INCOMPETENT CERVIX Painless premature dilatation of the cervix (usually in

the 16th to 20th week) #1 Sign: Rupture of membranes and discharge of

amniotic fluid Best Position: Side lying position Pre-op: Encourage patient to maintain bed rest Post-op: Check for excessive vaginal discharge and

severe pain. Bed rest in trendelenburg position Administer tocolytic medications as ordered

Eg; Ritodrine Hydrochloride (Yutopar) Surgery: Cervical Cerclage

Shirodkar-Barter Technique ( internal os) permanent suture: subsequent delivery by C/S.

Mc Donald Procedure ( external os)-suture removed at term with vaginal delivery

CARDIAC DISEASE

Class I: no limitation of activities. No symptoms of cardiac insufficiency.

Class II: slight limitation of activity, Asymptomatic at rest. Ordinary activities causes fatigue, palpitations and dyspnea

Class II: marked limitation of activities, comfortable at rest, less than ordinary activities causes discomforts

Class IV: unable to perform any physical activity without discomfort. May have the symptoms during rest.

GESTATIONAL DIABETES Diabetes during pregnancy. 3-P’s: Polyuria, Polydipsia and Polyphagia Because insulin does not pass into the breast

milk, breastfeeding is not contraindicated for the mother with diabetes

Maternal Complications: PIH, Placental disorders, stillbirth, macrosomia, neural tube defects.

Screen clients between the 24th and 28th weeks of

pregnancy

If a pregnant diabetic is in labor, her blood glucose

should be monitored hourly.

Treatment: Insulin therapy (don’t use Oral hypoglycemics, they are Teratogenic)

PREGNANCY INDUCED HYPERTENTION (PIH)

Blood pressure over 140/90, or increase of 30 mm systolic, 15 mm diastolic over pre-pregnancy level

Pre Eclampsia: HPN, Protenuria , Edema (face&hand)

Eclampsia: HPN, Protenuria, Edema plus Fever and Epigastric pain.

During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia.

Monitor VS, I&O and breath sound

ECLAMPSIA: to prevent aspiration, turn the woman on her side to allow secretions to drain from her mouth.

SEVERE PRECLAMPSIA: Lateral recumbent position

DOC: Magnesium Sulfate Magnesium Sulfate Toxicity:

Decrease urine output Decrease RR Absence of reflexes

Antidote: CALCIUM GLUCONATE PLACENTA PREVIA

Improperly implanted placenta in the lower uterine segment near or over the internal cervical os

Total: the internal os is entirely covered by the placenta when cervix is fully dilated

Marginal: only an edge of the placenta extends to the internal os

Low-lying placenta: implanted in the lower uterine segment but does not reach the os

Painless Bleeding #1 Assessment - Monitor maternal vital signs,

FHR, and fetal activity Best Position: Left Lateral

ABRUPTIO PLACENTA

Premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered.

Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking and alcohol or cocaine abuse.

Painful vaginal bleeding Board-like rigidity of abdomen The goal of management in abruption placentae is to

control the hemorrhage and deliver the fetus as soon as possible

M. Post Partum LOCHIAL CHANGES Lochia Rubra

• Dark red discharge occurring in the first 2-3 days. • Characteristic human odor.

Lochia Serosa

• Pinkish to brownish discharge occurring 3-10 days after delivery.

• Has a strong odor. Lochia Alba

• Almost colorless to creamy yellowish discharge occurring from 10 days to 3 weeks after delivery.

• Has no odor.




UTERINE INVOLUTION Process of involution takes 4-6 weeks to complete. Weight decreases from 2 lbs to 2 oz. Fundus steadily descends into true pelvis; Fundal height

decreases about 1 fingerbreadth (1 cm)/day; by 10-14 days postpartum, cannot be palpated abdominally.

NOTE: Deviation of the fundus to the right or left and location of the fundus above the umbilical are signs that the bladder is distended N. Care of the Newborn

Suction the mouth first before the nose Delay initial bath until temp. has stabilized for at

least 6 hours. APGAR scoring is taken twice: initially @ 1 minute,

and then @ 5 minutes after birth Give prophylactic eye treatment (credes ointment)

against gonorrheal conjunctivitis or ophthalmia neonatorum within the first hour after delivery.

Prevent hemorrhage , give 0.5mg (preterm) to 1 mg (full term) Vit. K or Aquamephyton is injected IM in the NB’s vastus lateralis (lateral anterior thigh)muscle

The cord is clamped and cut approximately within 30 seconds after birth when cord pulsation stop

The cord stump usually dries and fall within 7 to 10 days

O. Newborn Assessment CIRCULATORY STATUS

DUCTUS ARTERIOSUS constrict with establishment of respiratory function, remains open cause PDA (patent ductus arteriosus)

FORAMEN OVALE closes functionally as respirations established, remains open cause ASD (atrial septal defect)

RESPIRATORY STATUS

RR = 30-80 breaths /minutes with short periods of apnea (< 15 seconds)

RENAL SYSTEM Later pattern is 6-10 voidings/ day – indicative of sufficient fluid

intake DIGESTIVE SYSTEM

IMMATURE CARDIAC SPHINCTER – may allow reflux of food, burped, REGURGITATE-placed NB right side after feeding

FIRST STOOL is MECONIUM - Black, tarry residue from

lower intestine - Usually passed within 12-24

hours after birth TRANSITIONAL STOOLS thin,

brownish green in color After 3 days MILK STOOLS:

a. MILK STOOLS for BF infant – loose and golden yellow

b. MILK STOOLS for FORMULATED FED- formed and pale yellow

HEPATIC Pathologic Jaundice, yellowish discoloration immediately after birth

Physiologic Jaundice, yellowish discoloration 2-3 days after birth (normal)

TEMPERATURE Axillary temperature: 96.8 to 99F Newborn can’t shiver as an adult

does to release heat Cold stress increases o2

consumption – may lead to metabolic acidosis and respiratory distress

IMMUNOLOGIC NB develops own antibodies during 1st 3 months but at risk for infection during the first 6 weeks

P. Freud’s Theory Freud’s Psychoanalytic Theory

Psychosexual Development Infants

(birth to 1 year)

Oral Stage Child explores the world by using

mouth, especially the tongue Baby finds pleasure in the mouth

Toddler (1-3 y/o)

Anal Stage Child learns to control urination and

defecation (18 months) Toilet training

Preschooler (3-6y/o)

Phallic Stage The genitals are the pleasure of the

child Oedipus and Electra Complex Masturbation is common during this

phase and may also show exhibitionism

School-Age (6-12 y/o)

Latent Stage / Latency Period Child’s personality development

appears to be nonactive or dormant Adolescent (13-20 y/o)

Genital Stage Adolescent develops sexual maturity

and learns to establish satisfactory relationships w/ the opposite sex




Q. Erikson’s Theory Erikson’s Theory of

Psychosocial Development Infants

(birth to 1 year)

Trust vs. Mistrust Fear: strangers, anxiety, loud noises,

falls, sudden movements in the environment

Play: Solitary Learning confidence or learning to

love, Toddler

(1-3 y/o) Autonmy vs. Shame Psychosocial Theme: “hold on or let

go” Play: Parallel Child learns to be independent and

make decisions for self Favorite word: “I”, “no”

Preschooler (3-6y/o)

Initiative vs. Guilt Ability to try new things Bogus playmates/imaginary Fears: dark, being left alone, large

animals, ghosts, body mutilation, pain & objects

School-Age (6-12 y/o)

Industry vs. Inferiority Makes things w/ others Strives to achieve success Child learns how to do things well

Adolescent (13-20 y/o)

Identity vs. Role Confusion Determines own sense of self Development of who, what & where

they are going Adjusting to a new body and seeking

emancipation from parents, choosing a vocation & determining a value system

Young Adult

Intimacy vs. Isolation Person makes commitments to one

another Isolation and self absorption if

unsuccessful Independent from parents, possible

marriage / partnership Major goals to accomplish in career

and family

Middle Adult

Generativity vs. Stagnation Physical Changes: graying hair,

wrinkling skin, pain & muscle aches, menopausal period

Mature adult is concerned w/ establishing & guiding the new generation or else feels personal impoverishment

Become “Pillars of the Community”

Older Adult Integrity vs. Despair Achieves sense of acceptance of own

life Adapts to triumphs & disappointment

w/ a certain ego integrity

R Physical Growth and Development Mo. Yr.

Gross Motor Development

Fine Motor Development

0-1

Largely reflex The eyes is fixated on the person

Keeps hands fisted

2

Holds head up when prone

Development of social smile

Responds to familiar voice

3

Holds head & chest up when prone

The baby knows how to cry

Laughs aloud Babbles and “coos”

4

Grasp Stepping Tonic neck Reflexes are fading

Can raise head and chest

Reach out to object

5

Turns front to back Has head lag when

pulled upright

Roll over Hold blocks at each

hand

6

Turns both ways Moro reflex fading

Doubles birth weight Eruption of 1st tooth Sits w/ minimal

support Uses palmar grasp

7

Reaches out in anticipation of being picked up

Sits unsteadily

“dada”, “mama” Sleeps on prone

position Uses fingers to hold

objects Transfers objects

hand to hand

8

Sits securely w/o support

Sits alone steadily for an indefinite period

Recognizes strangers Peek-a-boo (to test

memory)

9

Creeps or crawls

Can hold own bottle Starts to crawl Understands simple

gestures

10

Pulls self to standing

From crawling to standing

Responds when called by his/her name

11

From crawling to standing

Walks with assistance

12 Stands alone Some infants take

1st step

Triples birth weight Can say 2 syllable

words Can walk w/ help

Documents

DEC 2012 NLE TIPS MCHN