NCLEX-RN: Maternal–Newborn Nursing: Pregnancy-Induced Hypertension

Pregnancy-Induced Hypertension

Preeclampsia

Definition: An acute, hypertensive disease that is peculiar to pregnancy, but most likely to develop in women who are less than age 19 or greater than age 40, have a family history of obesity or preexisting conditions: connective tissue disease (systemic lupus erythematosus, rheumatoid arthritis [RA]), or vascular disease (HTN, renal). Pregnancy-induced hypertension (PIH) occurs in 7% to 10% of all pregnancies.

Assessment

A. Assess period in pregnancy that condition appears: usually after 20 weeks’ gestation.

B. Evaluate for major symptoms: hypertension, proteinuria, and edema (may appear separately or together). Two of these three symptoms are usually needed for diagnosis.

C. Assess for mild preeclampsia.

1. Elevation of blood pressure 30/15 mm Hg on two occasions, 6 hours apart, or > 140/90.
2. Generalized edema—colloid osmotic pressure lowered.
3. Proteinuria: 0.3 g/L, 24-hour specimen.
4. Weight gain: more than 1360 g/wk in second trimester and 450 g/wk in third trimester.
5. Cardiac output lower than normal.
6. Hematocrit (Hct) values elevated; platelet count lowered.

D. Assess for severe preeclampsia.

1. Blood pressure 160/110 or above, or systolic 50 mm Hg above normal.
2. Massive edema: excessive weight gain.
3. Proteinuria: 5 g or more in 24 hours.
4. Oliguria: 400 mL or less in 24 hours.
5. Visual disturbances.
6. Headache.
7. Vasospasms.
8. Hemoconcentration.
9. Epigastric pain (usually a late sign).
10. Central nervous system (CNS) irritability (hyperreflexia).

Implementation

A. Maintain client on bed rest (left lateral recumbent usually best) and plan care to promote rest.

B. Monitor magnesium sulfate (given to prevent eclamptic convulsions).

1. Monitor for toxic dose: hypotonia, loss of deep tendon reflexes, respiratory failure.
2. Check serum levels of MgSO4: 4–7 mEq/dL.

C. Monitor fetal heart rate and observe for signs of labor.

D. Carefully monitor vital signs and lab values (CBC, biochemical profile).

E. Record intake and output; examine urine for proteinuria, 24-hour urine for total protein and creatinine clearance, and adequate volume.

F. Immediately report increases in signs and symptoms.

G. Check weight at the same time each day.

H. Examine retina daily for arteriole changes or edema.

I. Limit visitors in severe cases.

J. Maintain seizure precautions.

K. Final resolution is delivery of the fetus.

L. Prepare client for surgery if indicated.

Maternal–Newborn Nursing: Gestational Hypertension Home Management

A. Allowed home management when following criteria present.

1. Blood pressure (BP) < 150/100 mm Hg. Able to monitor own BP.

Maternal–Newborn Nursing

2. Proteinuria less than 500 mg/24 hrs. Able to monitor protein and weight daily.
3. Normal fetal growth.
4. No signs of complicating factors (vaginal bleeding).
5. Mother understands her condition and is able to recognize and report signs and symptoms if condition deteriorates.
6. Mother is able to count fetal movements and knows when to call doctor.
B. Mother may or may not be on complete bed rest, but is encouraged to rest frequently.

C. Antihypertensive therapy.

1. Medications—therapeutic goal is to maintain diastolic blood pressure between 90 and 100 mm Hg (maximum).

a. Apresoline (hydralazine) used for acute hypertension.
b. Trandate (labetalol) HCl PO should be avoided in women with asthma or chronic hypertensive disease (CHD).

2. Herbs and supplements.

a. Herbs: burdock, dandelion, hawthorn.
b. Nutrients: CoQ10, magnesium sulfate (MgSO4.)

Maternal–Newborn Nursing: Eclampsia

Definition: A more severe form of hypertensive disease, characterized by convulsions and even coma.

Assessment

A. Observe for severe edema.

B. Assess for headache.

C. Check for visual disturbances, blurring, or even blindness caused by edema of the retina.

D. Determine if severe epigastric pain is present.

E. Assess for blood pressure elevation to 160/110 mm Hg or above on two occasions, 6 hours apart.

F. Check urine output and for urine that contains red blood cells, varied casts, and protein (3+ or greater with two random samples).

G. Observe convulsions, both tonic and clonic.

H. Assess for signs of labor. (Labor may begin and fetus may be born prematurely or die.)

I. Assess vital signs: temperature and respiratory status.

J. Observe reflex irritability (deep tendon reflexes [DTR], clonus).

K. Assess level of consciousness.

L. Determine fetal heart rate and uterine contractibility.

M. Assess for necessity of doing emergency cesarean section.

N. Have emergency medications at bedside—magnesium sulfate and calcium gluconate (antidote for magnesium sulfate toxicity).

Implementation

A. Educate client about classifications and effects of pregnancy before conception.

B. Educate client about special needs and danger signals during pregnancy and postpartum.

C. Care for client during labor.

1. Check vital signs every 15 minutes or more often as needed.
2. Keep client in bed, preferably lying on one side or in semirecumbent position.
3. Assess lung fields every 1–4 hours.
4. Administer oxygen as necessary.
5. Provide calm atmosphere and emotional support to alleviate fears.
6. Administer pain medications as ordered to reduce discomfort during labor.
7. Be alert for signs of impending heart failure.
8. Monitor fetal heart tones.

D. Provide careful observation during postpartum period.

E. Counsel client during postpartum to have help at home and planned rest periods.

Maternal–Newborn Nursing: Diabetes Mellitus

Focus Topic: Maternal–Newborn Nursing

Definition: A chronic metabolic disease caused by the inability to metabolize glucose properly.

Characteristics

A. Estimated 4–14% of pregnancies seen in large metropolitan areas will have some degree of diabetes.

B. In 3–6% of pregnant women, there is a tendency to develop gestational diabetes as a result of placental hormones, variations in insulin level, and an increase in free cortisol.

1. Abnormalities disappear after pregnancy.
2. Symptoms of hyperglycemia are mild, but may be risky for fetus.
3. Diet is cornerstone of intervention, but insulin therapy is instituted when diet doesn’t control condition.

Maternal–Newborn Nursing

C. Maternal glucose crosses placenta, but insulin does not. Maternal hyperglycemia leads to fetal hyperglycemia, which leads to fetal hyperinsulinemia.

D. Pregnant women should be screened for glucose levels: Normal fluctuation is between 60 mg/dL and 120 mg/dL (24–28 weeks).

E. A 3-hour glucose tolerance test will confirm diabetes when two or more values are above normal.

F. Sepsis, eclampsia, and hemorrhage, the most common causes of maternal death, are more common in the pregnant diabetic.

Maternal–Newborn Nursing: Implications of Diabetes in Pregnancy

Focus Topic: Maternal–Newborn Nursing

A. Diabetes is more difficult to control.

B. There is a tendency for client to develop acidosis.

C. Client is prone to infection.

D. PIH, hemorrhage, and polyhydramnios are more likely to develop.

E. Gestational diabetes may develop into full-blown diabetes.

F. Insulin requirements are increased.

G. Premature delivery is more frequent.

H. Infant may be overweight but have functions related to gestational age rather than size.

I. Infant is subject to hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, and congenital anomalies (incidence 5–10%).

J. Stillborn and neonatal mortality rates are high, but may be reduced by proper management and strict control of diabetes.

Assessment

A. All pregnant women should be screened for glucose intolerance between 24 and 28 weeks of pregnancy.

1. Observe for signs of hypoglycemia.
2. Observe for signs of hyperglycemia.

B. Major signs and symptoms.

1. Weight loss.
2. Excessive hunger or thirst with excess fluid intake.
3. Polyuria—excess urination.
4. Recurrent monilial infections.
5. Maternal hypertension.
6. Weakness, fatigue, drowsiness.

C. Assess for signs of preeclampsia.

1. Hypertension.
2. Proteinuria.
3. Edema.

D. Check for signs of infection—recurrent and difficult to resolve.

1. Increased temperature.
2. Erythematous areas.
3. Respiratory problems.
4. Urinary problems.

Maternal–Newborn Nursing

E. Check for signs of premature labor.

F. Assess for signs of polyhydramnios.

1. Respiratory distress.
2. Fluid stasis in legs.

G. Assess insulin needs.

H. Assess fetal status.

Implementation

A. Educate client on the effects of diabetes on her and the fetus during pregnancy and the reasons for adhering to therapy protocol.

1. Bimonthly visits for 6 months; weekly visits thereafter.
2. Maintenance of blood glucose levels according to gestational week.
3. Frequent home monitoring of blood glucose.
4. Weight control.
5. Dietary control to increase calorie intake with adequate insulin therapy so glucose will go into the cells. Usually provided with three small meals and three snacks.

a. Daily calories of 2000–2500 Kcal. (Severe calorie restriction may lead to ketosis.)
b. Protein: 15–20%, 0.8 g/kg unless renal disease is present.
c. Carbohydrate: 40–50%, primarily complex carbohydrates, consistent throughout day.
d. Fat: less than 20–30% total calories.
e. Fiber: 28 g/day to control glycemia and constipation—also satisfies appetite.

6. Exogenous insulin if diet cannot control blood sugar levels. Oral hypoglycemics contraindicated; may cause fetal hypoglycemia and abnormalities.

7. Insulin administration.

a. Human insulin used for more rapid onset and shorter duration of action. Triggers fewer antibodies.
b. Multiple injections are preferred; mixture of intermediate and regular insulin twice daily.
c. Pregnant women already using insulin should not change insulin brands.
d. Methods of administration—see insulin administration in Endocrine section of Medical–Surgical chapter (Chapter 8).

B. Provide care if client is hospitalized.

1. Maintain insulin on regular schedule. Insulin may change daily.
2. Test blood for glucose level as ordered.
3. Provide adequate diabetic diet as prescribed by physician.
4. Monitor fetal heart rate.
5. Check vital signs, especially blood pressure qid and prn.
6. Weigh daily at the same time.
7. Keep accurate records of I&O.
8. Provide diversion for client.
9. Provide support and explanations to help allay fears and reduce anxiety.

C. In addition, provide following care to client in
labor.

1. Monitor fetal status continuously for signs of distress. If noted, prepare client for immediate cesarean section.
2. Carefully regulate insulin and provide IV glucose as labor depletes glycogen.

D. Provide postpartum care.

1. Observe client closely for insulin reaction: precipitous drop in insulin requirements usual; hypoglycemic shock may occur.

a. May require no insulin for first 24 hours.
b. Reregulate insulin needs following first day according to blood sugar testing.
c. Diet and exercise must also be reexamined.

2. Observe for early signs of infection.
3. Observe for postpartum hemorrhage.

 

Maternal–Newborn Nursing: Chronic Hypertension in Pregnancy

Focus Topic: Maternal–Newborn Nursing

Definition: Hypertensive vascular disease is characteristic of hypertension that is already present. It may be aggravated by the pregnancy, or clinical symptoms may first manifest with pregnancy.

Assessment

A. Observe for hypertension: evident before the 20th week; blood pressure is 140/90 at rest.

Maternal–Newborn Nursing

B. Check for presence of headache; client may otherwise feel weak.

C. Evaluate edema (however, proteinuria usually not present).

D. Assess for signs of superimposed preeclampsia.

E. Check for fetal heart rate.

Implementation

A. Maintain bed rest and create an environment conducive to rest.

B. Accurately record vital signs, check urine for protein, and check weight daily.

C. Monitor fetal heart tones.

D. Keep careful record of I&O.

E. Provide adequate diet and fluids.

F. Report any unusual symptoms.

G. Observe for signs of heart failure.

H. Maintain on antihypertensive drugs.

I. Provide supportive atmosphere.

Maternal–Newborn Nursing: Anemia

Focus Topic: Maternal–Newborn Nursing

Definition: A deficiency in the blood, usually referring to a decrease in the numbers of erythrocytes to a reduction in hemoglobin. Hemoglobin less than 12 g/dL in nonpregnant women and less than 10 g/dL in pregnant women (lower values in pregnancy due to hemodilution).

Assessment

A. Evaluate iron deficiency status. This is cause of anemia in 90% of the cases.

B. Observe for client who looks pale, tires easily, and is lethargic.

C. Assess for headache or dizziness.

D. Assess for shortness of breath.

E. Hemoglobin levels 10 g/dL or below, or hematocrit below 37%.

Implementation

A. Medical treatment of supplemental iron (ferrous gluconate, 300 mg/day or ferrous sulfate, 150 mg/day) is given, or in severe cases, Imferon (iron dextran) as a parenteral medication is given.

1. Educate client about the need to take supplements.
2. Iron absorption is reduced (40% to 50%) when taken with meals; however, when taken after meals, it minimizes gastric upset.
3. The client may enhance absorption of iron by taking with a food rich in vitamin C.
4. Client may choose to take oral liquid iron supplement through a straw to protect teeth.

B. Let client know that stools will become dark from iron absorption.

C. Instruct client to use frequent oral hygiene measures to guard against iron deposit on teeth and gums.

D. Administer Imferon intramuscular (IM) as directed.

E. Encourage client to eat foods high in iron (organ meats, blackstrap molasses, egg yolk, seeds, nuts, green leafy vegetables, dried fruits, fish).

Maternal–Newborn Nursing: Urinary Tract Infection

Focus Topic: Maternal–Newborn Nursing

Definition: Bacteria enter the urinary tract by way of the urethra, causing infection.

Characteristics

A. Usually occurs after the fourth month or in early postpartum; affects 10% of maternity clients.

B. Causes.

1. Pressure on ureters and bladder.
2. Hormonal effects on tone of ureters and bladder.
3. Displacement of bladder.
4. History of urinary infections, vaginitis.

C. Kidneys as well as ureters may be involved.

Assessment

A. Observe for frequent micturition.

B. Check for paroxysms—pain in kidney or “flank pain.”

C. Assess for fever and chills.

D. Evaluate catheterized urine specimen to determine if it contains bacteria and pus.

E. Check for burning on urination.

F. Check for signs of premature labor.

Implementation

A. Maintain client on bed rest.

B. Encourage fluid intake by providing client with a variety of fluids.

C. High-risk women: young nonwhites with multiple sex partners and women not using barrier contraceptives.

D. Chlamydia is not a reportable disease in 50% of states.

E. Statistics:

1. Twenty percent of men and 40–50% of women with gonorrhea also are infected with chlamydia.
2. Twenty-five to fifty percent of PID is caused by chlamydia.
3. Each year 155,000 infants born to mothers with chlamydia are at risk for pneumonia (5–15%) and ophthalmia neonatorum (conjunctivitis, 15–25%).
4. Each year $1 billion spent on infection.

F. Chlamydiae are bacteria microorganisms, but have characteristics of both viruses and bacteria.

G. Sensitive to antibiotics (Zithromax [azithromycin] or Oracea [doxycycline]). Treat newborn eyes with 0.5% Ilotycin (erythromycin) ointment at birth.

H. Spread through sexual contact. Incubation period 5–10 days or longer (28 days—gonorrhea is only 2–10 days).

I. Tests for chlamydia include Chlamydiazyme— enzyme immunoassay test; Microtak—direct fluorescent antibody test; and BD ProbeTec— amplified DNP assay.

Assessment

A. Observe for a discharge—vaginal or urethral.

B. Assess for burning.

C. Check for lower abdominal pain or testicular pain.

D. Assess for bleeding or pain with coitus.

E. Assess for rectal pain or discharge.

F. Assess for painful, frequent urination.

G. Thirty-three percent of women report no symptoms.

Implementation

A. Administer antibiotics as ordered.

1. Zithromax 1 g × one dose.
2. Ilotycin 500 mg 4×/day × 7 days for pregnant woman.
3. Amoxil (amoxicillin) 500 mg 3×/day × 7 days.
4. Bicillin does not cure chlamydia.

B. Educate men and women about transmission, symptoms, and prevention.

1. Frequent examinations if people are not monogamous.
2. If symptoms/signs occur, seek help immediately— teach importance of taking medication as prescribed.
3. Suggest that sexually active people use barrier methods of contraception.
4. Avoidance of sex until completion of treatment.

C. Provide accurate information about disease, health care, and prevention.

Maternal–Newborn Nursing: Syphilis

Focus Topic: Maternal–Newborn Nursing

Definition: A chronic infectious disease caused by Treponema pallidum.

Characteristics

A. Transmission is by intimate physical contact with syphilitic lesions, which are usually found on the skin or the mucous membranes of the mouth and the genitals.

1. Since 2000, incidence of early-stage syphilis has increased 29%.
2. Increase is largely among gay men (CDC, 2014).

B. Incubation period is 10 to 90 days following exposure.

C. Primary stage (nonreactive VDRL).

1. Most infectious stage.
2. Appearance of chancres, ulcerative lesions.
3. Usually painless, produced by spirochetes at the point of entry into the body.

D. Secondary stage (reactive VDRL).

1. Maculopapular rash appears about 3 weeks to 3 months after the primary stage and may occur anywhere on the skin and the mucous membranes, especially face, palms of hands, and soles of feet.
2. Highly infectious.
3. Generalized lymphadenopathy.

E. Tertiary stage.

1. The spirochetes enter the internal organs and cause permanent damage.
2. Symptoms may occur 10 to 30 years following the occurrence of an untreated primary lesion.
3. Invasion of the central nervous system.

a. Meningitis.
b. Locomotor ataxia: foot slapping and broad-based gait.
c. General paresis.
d. Progressive mental deterioration leading to psychosis.

4. Cardiovascular: Most common site of damage is at the aortic valve and the aorta itself.

F. Characteristics relating to pregnancy.

1. May cause abortion or premature labor.
2. Infection is passed to the fetus after the fourth month of pregnancy as congenital syphilis.

Assessment

A. Evaluate serum test for syphilis (STS) on first prenatal visit.

B. May repeat just before fourth month, as disease may be acquired after initial visit.

Implementation

A. Educate women to recognize signs of syphilis.

B. Educate women to seek immediate treatment if known exposure occurs.

C. Educate women as to the need for simultaneous treatment of partner because reinfection may occur.

D. Monitor treatment: during pregnancy, 2.4 million units of procaine penicillin G with 2% aluminum monostearate, IM, normally in divided doses.

E. Report all cases of syphilis to health authorities for treatment of contacts.

Maternal–Newborn Nursing: Gonorrhea

Focus Topic: Maternal–Newborn Nursing

Definition: An infection caused by Neisseria gonorrhoeae, which causes inflammation of the mucous membrane of the genitourinary tract.

Characteristics

A. Transmission is almost completely by sexual intercourse.

B. Incidence is of epidemic proportions in the United States.

C. Signs and symptoms.

1. Male.

a. Painful urination.
b. Pelvic pain and fever.
c. Epididymitis with pain, tenderness, and swelling.
d. Mucoid or mucopurulent discharge.

2. Female (usually asymptomatic).

a. Vaginal discharge—greenish-yellow.
b. Urinary frequency and pain.

D. Complications.

1. Female: pelvic inflammatory disease (PID) with abdominal pain, fever, nausea, and vomiting.
2. Male: postgonococcal urethritis and spread of infection to posterior urethra, prostate, and seminal vesicles.
3. PID can lead to sterility.
4. A secondary infection can develop in any organ.

E. Infection may be transmitted to baby’s eyes during delivery, causing blindness.

Assessment

A. Obtain culture for gonorrhea (usually done on first prenatal visit).

B. Repeat later as infection may occur during pregnancy.

Implementation

A. Educate women to recognize signs of gonorrhea and to seek immediate treatment.

B. Administer prophylactic broad-spectrum antibiotic (Suprax [cefixime] 400 mg × 1 dose or Rocephin [ceftriaxone] 125 mg IM × 1 dose).

C. Monitor treatment: same as for syphilis.

D. Important to treat sexual partner, as client may become reinfected.

Maternal–Newborn Nursing: Herpes Simplex Virus

Focus Topic: Maternal–Newborn Nursing

Definition: Herpes infection caused by the herpes simplex virus (HSV). Forty-five million people in the United States have been diagnosed.

Characteristics

A. HSV types 1 and 2 both present risk to infant.

B. Type 2 most common as genital herpes.

1. Involves external genitalia, vagina, and cervix.
2. Development and draining of painful vesicles.

C. Virus may be lethal to fetus if inoculated duringvaginal delivery (50% of HSV-infected infants die). Delivery usually by cesarean section.

D. Zovirax (acyclovir) is started at 36 weeks’ gestation and continues until delivery.

Assessment

A. Evaluate for presence of painful, draining vesicles on external genitals, vagina, and cervix.

B. Check for increased temperature and vital signs.

Implementation

A. Educate client about dangers to fetus.

B. Encourage client to report symptoms.

C. Explain to client the possibility of a cesarean section should an outbreak occur around the time of delivery.

1. Policy regarding time limit of outbreak in relation to time of delivery varies, but usual policy is an outbreak within 2 weeks.
2. Conservative physicians now advocate cesarean section if condition is present regardless of outbreak.

D. Maintain precautions during vaginal examinations of client.

E. Maintain isolation precautions during hospitalization if disease is active.

F. Postpartum.

1. Encourage careful hand washing by client.
2. Avoid direct contact with lesions.
3. Breastfeeding is not contraindicated unless lesions are on breast.

Maternal–Newborn Nursing: Human Papillomavirus—Genital Warts

Focus Topic: Maternal–Newborn Nursing

Definition: A sexually transmitted infection caused by the human papillomavirus (HPV).

Characteristics

A. The virus affects cervix, urethra, penis, scrotum, and anus.

B. Warts appear 1 or 2 months after exposure, transmitted through intimate sexual contact.

Assessment

A. Assess for small to large wartlike growths on genitals (no symptoms other than lesions).

B. Assess for cervical cell changes—HPV associated with up to 90% of cervical malignancies.

Implementation

A. There is no cure for HPV—treatment is cryotherapy, liquid nitrogen, or electrocautery to remove lesions.

B. Key is prevention—similar to any other STD: limit sexual contacts and use condoms.

C. Suggest Pap test every year (cancer risk).

D. A vaccine (Gardasil) was introduced in 2007 that is effective against several strains of this virus that cause 70% of all cervical cancers.

Maternal–Newborn Nursing: Human Immunodeficiency Virus

Focus Topic: Maternal–Newborn Nursing

Definition: A retrovirus that may develop into acquired immune deficiency syndrome (AIDS). Contracted through exchange of body fluids, it has a long latency period before progressing to AIDS.

Characteristics

A. History of belonging to high-risk group (drug user, prostitution).

B. Pregnancy associated with slight reduction of helper T cells—may increase possibility of opportunistic infections.

C. HIV transmitted to 20–25% of exposed infants— risk increases with low T-cell count.

Assessment

A. Assess for symptoms of seropositivity (mononucleosis-like symptoms) or AIDS-related complex (ARC) (pre-AIDS condition).

B. Check for severely compromised immune system (indicates presence of AIDS).

C. Take careful history of risk behaviors.

D. Assess for signs of STDs and cytomegalovirus (CMV).

Implementation

A. Complete posttest counseling if client tests HIV-positive.

B. Counsel importance of continued medical care during pregnancy.

C. Maintain body fluid precautions for cell contact with client and teach client precautions.

D. Assess signs and symptoms of illness and serum tests.

E. See Newborn with AIDS, page 598.

Associated Complications of Pregnancy

Focus Topic: Maternal–Newborn Nursing

Pregnancy in Adolescents

Characteristics

A. Crisis of pregnancy compounds the crises of adolescence—physical, social, emotional, and developmental.

B. More than 1 million teenagers become pregnant every year, and 85% of these pregnancies are unintended.

1. Trend of teenage pregnancy is going down with more birth control options available.
2. Education about protection from pregnancy as well as STDs is important.

C. Client may be unwed and have no financial resources.

D. Problems associated with teen pregnancy.

1. Physical development may not be complete.
2. High incidence of PIH, preterm labor, small for gestational age (SGA) infants, anemia, infections, cephalopelvic disproportion (CPD).
3. Diet may be inadequate.

Assessment

A. Assess nutritional status of client.

B. Evaluate any signs of emotional problems, conflicts, or crisis.

C. Evaluate financial status.

D. Assess for signs of premature labor and preeclampsia.

E. Assess knowledge of pregnancy and infant care.

Implementation

A. Encourage early antepartum care.

B. Provide health instruction on pregnancy, nutrition, hygiene, childbirth preparation, and infant care.

C. Observe frequently for complications.

D. Provide emotional support and counseling.

Maternal–Newborn Nursing: Disseminated Intravascular Coagulation

Focus Topic: Maternal–Newborn Nursing

Definition: A condition in the mother’s body that results in an exaggerated clotting process.

Characteristics

A. Possible complication of abruptio placenta, missed abortion, fetal death, amniotic fluid embolism.

B. May result in uncontrolled bleeding.

1. Thromboplastin from placental tissue and clots enters the bloodstream through open vessels at the placental site and initiates an exaggeration of the normal clotting process.

2. As more thromboplastin is introduced into circulation, more fibrinogen and clotting factors are used up.

3. In addition, the fibrinolytic process that disintegrates fibrin is initiated, resulting in fibrin degradation products, which in turn further interfere with the clotting process.

Assessment

A. Observe for uncontrolled bleeding.

B. Assess for signs of shock: tachycardia, hypotension, decreased urinary output, restlessness, anxiety.

C. Be alert for symptoms in women with predisposing factors such as fetal death, abruptio placenta, PIH.

D. Observe for prolonged and uncontrolled bleeding (e.g., skin and mucous membranes, IV sites).

Implementation

A. Provide emotional support to client and family.

B. Assist with medical management and administration of medications.

1. Heparin solution may prevent clot formation and increase available fibrinogen, coagulation factors, and platelets.
2. Fresh-frozen plasma, cryoprecipitate, and/or platelets may be ordered.

C. Monitor IV therapy as ordered.

D. Administer oxygen at 2–3 L/min.

Maternal–Newborn Nursing: Intrauterine Fetal Death

Focus Topic: Maternal–Newborn Nursing

Assessment

A. Cessation of fetal movement.

B. Absence of fetal heart rate.

C. Failure of uterine growth.

D. Low urinary estriol.

E. Check for negative pregnancy test—may remain positive for a few weeks due to elevated human chorionic gonadotropin.

F. Assess client’s external support system (family, friends, priest, etc.).

G. Assess for complications such as disseminated intravascular disease (DIC) from prolonged retention of the dead fetus.

Implementation

A. Provide emotional support to parents—may feel unfulfilled, incomplete, and depressed.

B. Do not listen for fetal heart rate or do Leopold’s maneuvers.

C. Observe for hemorrhage.

D. Observe for psychological disturbances.

E. Prepare emotionally for delivery process and birth of baby.

F. Parents may go through mourning process— encourage them to express feelings; may be angry at staff.

G. Parents may want to see fetus; allow them to do so should they desire.

H. Guide parents in planning future pregnancies.

Maternal–Newborn Nursing: Pseudocyesis/Pseudopregnancies

Focus Topic: Maternal–Newborn Nursing

Definition: A condition that occurs when all the signs of pregnancy develop without the presence of an embryo.

Assessment

A. Observe for amenorrhea, breast changes, and secretion of colostrum.

B. Check for enlargement of abdomen.

C. Ask for reports of quickening.

D. Assess presence of fetal heart rate or visible fetus on sonogram.

Implementation

A. Offer client continued emotional support.

B. Allow client to express her feelings regarding pseudopregnancy.

C. Refer client for continued psychological assistance.

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