July 2012 nle tips mchn

WHAT YOU SHOULD KNOW BEFORE THE PNLE JULY 2012 PNLE PEARLS OF SUCCESS

PART 2: MATERNAL AND CHILD HEALTH NURSING

POSSIBLE TOPICS ON MATERNAL AND CHILD HEALTH NURSING FOR THE UPCOMING JULY 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 July 2012 PNLE

A. Signs of Pregnancy Ø Presumptive Signs

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

Ø Probable Signs

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

Ø Positive Signs

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

B. Maternal and Fetal Diagnostic Test CHORIONIC VILLI SAMPLING Removal of a small piece of Chorionic villi

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

ü Laboratory results are obtained in 1 -‐ 7 days

Disadvantages: • Risk of Abortion • Infection • Embryo-‐fetal/placental

damage • Spontaneous abortion • Premature rupture of the

membranes

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

ü 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.

ü Done 18-‐40 weeks for fetal abnormalities.

ü Best Test for ECTOPIC PREGNANCY

ü Full Bladder ü Use to locate the precise

location of the fetus and its membrane during CVS and amniocentesis

AMNIOCENTESIS Aspiration of amniotic fluid for examination.

ü Possible after the 14th week.

ü The client should be supine during the procedure

ü Afterward, she should be placed on her left side.

ü The patient MUST EMPTY THE BLADDER.

ü Vital signs are assessed every 15 minutes.

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

X-‐RAY ü Done only 2 weeks before EDC

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

ü Test done between 16 and 18 weeks gestation.

ü Normal Value: 10 mg/dl

ü LOW: Chromosomal defects

ü HIGH: Neural tube defects.

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

ü Done through AMNIOCENTESIS

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

right buttocks. ü Needle insertion in a 20-‐

22 gauge spinal needle, withdrawing amniotic fluid.

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

LEOPOLDS MANEUVER

ü Palpate with warm hands. ü Use palms, not fingertips. ü Woman should lie in

supine position with knees flexed slightly.

ü Done with empty bladder. 1st: Presenting Part 2nd: Fetal Back 3rd: Engagement 4th: Descent




C. 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

D. Electronic Monitoring Non-‐Stress Test

Ø Accelerations in heart rate accompany normal fetal movement.

Ø Observation of fetal heart rate related to fetal movement. FHT: Doppler: 8 weeks Fetoscope: 16 weeks / 4 months Stethoscope: 20 weeks / 5months

Ø Teach mother to count 2-3 times daily, 30-60 minutes each time, should feel 5-6 movements per counting time

PREPARATION: v Patient should eat snacks. v 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) Ø Response of the fetus to induced uterine contractions.

PREPARATION: v Woman in semi-Fowler’s or side-lying position. v Monitor for post-test labor onset. v Indication: 28 weeks pregnancy high risk mother v Contraindicated: Pre Term Labor

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

E. 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

F. 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




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

Latent • 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 • 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 • 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

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

H. 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

I. Pregnancy Complications ABORTION

Ø Threatened, the continuation of the pregnancy is in doubt

Ø Inevitable, loss that can be prevented Ø Complete, products of conception are totally expelled Ø Incomplete, some fragments are retained inside the

uterine cavity Ø Missed, retention of the products of conception after

fetal death Ø Habitual, 3 spontaneous abortions occurring

successively




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

milk, breastfeeding is not contraindicated for the mother with diabetes

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

Ø Screen clients between the 24th and 28th weeks of pregnancy

Ø If a pregnant diabetic is in labor, her blood glucose should be monitored hourly.

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

PREGNANCY INDUCED HYPERTENTION (PIH)

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

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

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

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

Ø Monitor VS, I&O and breath sound Ø ECLAMPSIA: to prevent aspiration, turn the

woman on her side to allow secretions to drain from her mouth.

Ø SEVERE PRECLAMPSIA: Lateral recumbent position

Ø DOC: Magnesium Sulfate Ø Magnesium Sulfate Toxicity:

• Decrease urine output • Decrease RR • Absence of reflexes

Ø Antidote: CALCIUM GLUCONATE PLACENTA PREVIA

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

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

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

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

Ø Painless Bleeding Ø #1 Assessment -‐ Monitor maternal vital signs,

FHR, and fetal activity Ø Best Position: Left Lateral

ABRUPTIO PLACENTA

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

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

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

control the hemorrhage and deliver the fetus as soon as possible

J. Care of the Newborn

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

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

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

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

Ø 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

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

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

K. 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

L. Freud’s Theory Freud’s Psychoanalytic Theory

Psychosexual Development Infants

(birth to 1 year)

Oral Stage Ä Child explores the world by using

mouth, especially the tongue Ä Baby finds pleasure in the mouth

Toddler (1-‐3 y/o)

Anal Stage Ä Child learns to control urination and

defecation (18 months) Ä Toilet training

Preschooler (3-‐6y/o)

Phallic Stage Ä The genitals are the pleasure of the

child Ä Oedipus and Electra Complex Ä Masturbation is common during this

phase and may also show exhibitionism

School-‐Age (6-‐12 y/o)

Latent Stage / Latency Period Ä Child’s personality development

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

Genital Stage Ä Adolescent develops sexual maturity

and learns to establish satisfactory relationships w/ the opposite sex

M. Erikson’s Theory Erikson’s Theory of

Psychosocial Development Infants

(birth to 1 year)

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

falls, sudden movements in the environment

Ä Play: Solitary Ä Learning confidence or learning to

love

Toddler (1-‐3 y/o)

Autonmy vs. Shame Ä Psychosocial Theme: “hold on or let

go”

Ä Play: Parallel Ä Child learns to be independent and

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

Preschooler (3-‐6y/o)

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

animals, ghosts, body mutilation, pain & objects

School-‐Age (6-‐12 y/o)

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

Adolescent (13-‐20 y/o)

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

they are going Ä Adjusting to a new body and seeking

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

Young Adult

Intimacy vs. Isolation Ä Person makes commitments to one

another Ä Isolation and self absorption if

unsuccessful Ä Independent from parents, possible

marriage / partnership Ä Major goals to accomplish in career

and family

Middle Adult

Generativity vs. Stagnation Ä Physical Changes: graying hair,

wrinkling skin, pain & muscle aches, menopausal period

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

Ä Become “Pillars of the Community” Older Adult Integrity vs. Despair

Ä Achieves sense of acceptance of own life

Ä Adapts to triumphs & disappointment w/ a certain ego integrity

N. Physical Growth and Development Mo. Yr.

Gross Motor Development

Fine Motor Development

0-1

Ä Largely reflex Ä The eyes is fixated on the person

Ä Keeps hands fisted

2

Ä Holds head up when prone

Ä Development of social smile

Ä Responds to familiar voice

3

Ä Holds head & chest up when prone

Ä The baby knows how to cry

Ä Laughs aloud Ä Babbles and “coos”




4

Ä Grasp Ä Stepping Ä Tonic neck Ä Reflexes are fading

Ä Can raise head and chest

Ä Reach out to object

5

Ä Turns front to back Ä Has head lag when

pulled upright

Ä Roll over Ä Hold blocks at each

hand

6

Ä Turns both ways Ä Moro reflex fading

Ä Doubles birth weight Ä Eruption of 1st tooth Ä Sits w/ minimal support Ä Uses palmar grasp

7

Ä Reaches out in anticipation of being picked up

Ä Sits unsteadily

Ä “dada”, “mama” Ä Sleeps on prone

position Ä Uses fingers to hold

objects Ä Transfers objects hand

to hand

8

Ä Sits securely w/o support

Ä Sits alone steadily for an indefinite period

Ä Recognizes strangers Ä Peek-a-boo (to test

memory)

9

Ä Creeps or crawls

Ä Can hold own bottle Ä Starts to crawl Ä Understands simple

gestures

10

Ä Pulls self to standing Ä From crawling to standing

Ä Responds when called by his/her name

11

Ä From crawling to standing

Ä Walks with assistance

12

Ä Stands alone Ä Some infants take 1st

step

Ä Triples birth weight Ä Can say 2 syllable

words Ä Can walk w/ help

Health & Medicine

July 2012 nle tips mchn