Maternity and Pediatric Nursing

Maternity and Pediatric Nursing
Chapter 20
Nursing Management of the Pregnancy at
Risk: Selected Health Conditions and
Vulnerable Populations
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
KEY TERMS
acquired immunodeficiency syndrome (AIDS)
Adolescence
anemia
fetal alcohol spectrum disorder (FASD)
gestational diabetes mellitus
glycosylated hemoglobin(HbA1C) level

human immunodefciency virus (HIV)
impaired fasting glucose
impaired glucose tolerance
KEY TERMS
neonatal abstinence syndrome
perinatal drug abuse
Pica
Pre-gestational diabetes
teratogen
type 1 diabetes
type 2 diabetes
Diabetes Mellitus
Typical classification
Type 1
Type 2
Impaired fasting glucose and impaired glucose
tolerance
Gestational diabetes
Classification during pregnancy
Pregestational diabetes
Gestational
Diabetes Mellitus (contd)

Pathophysiology and pregnancy
Fetal demands
Role of placental hormones
Changes in insulin resistance
Effects on mother
Effects on fetus (see Table 20-1)

Therapeutic management
Preconception counseling
Blood glucose level control (HbA1C <7%)
Glycemic control
Nutritional management
Hypoglycemic agents
Close maternal and fetal surveillance
Management during labor and birth

Assessment
Health history; physical examination; risk factors
Screening at first prenatal visit; additional
screening at 24 to 28 weeks for women
considered at risk
Maternal surveillance: urine for protein, ketones,
nitrates, and leukocyte esterase; evaluation of
renal function/trimester; eye exam in 1st
trimester; HbA1c q 4-6 weeks
Fetal surveillance: ultrasound; alpha-fetoprotein
levels; biophysical profile; nonstress testing;
amniocentesis

Nursing management (see Nursing Care Plan 20-1)
Optimal glucose control
Blood glucose levels; medication therapy
Nutritional therapy
Measures during labor and birth; postpartum
Prevention of complications
Client education and counseling (see Teaching
Guidelines 20-1)
Question
Is the following statement True or False?
A woman who develops diabetes during pregnancy is
said to have type 2 diabetes.
Answer
False.
A woman who develops diabetes during pregnancy is
said to have gestational diabetes.
Congenital and Acquired Heart Disease

Congenital usually due to structural defects at birth
(see Table 20-2)
Acquired primarily rheumatic in origin
Functional classification system
Class I: asymptomatic; no limitation of physical
activity
Class II: symptomatic (dyspnea, chest pain) with
increased activity
Class III: symptomatic (fatigue, palpitation) with
normal activity
Class IV: symptomatic at rest or with any physical
activity
Congenital and Acquired Heart Disease

(contd)
Pathophysiology
Hemodynamic changes overstressing womans
cardiovascular system
Risk assessment, prenatal counseling, increased
frequency of prenatal visits
Nursing assessment
Vital signs, heart sounds, weight, fetal activity,
lifestyle
Signs and symptoms of cardiac decompensation
Congenital and Acquired Cardiac Disease

(contd)
Nursing Management
Stabilization of hemodynamic status
Risk reduction measures: education, counseling,
support
Cardiac medications if prescribed
Energy conservation; nutrition
Fetal activity monitoring
Signs and symptoms of cardiac decompensation
Monitoring during labor
Question
Is the following statement True or False?
A woman with class II heart disease would have
symptoms with increased activity.
Answer
True.
A woman with class II heart disease would be
symptomatic when she increases her physical
activity.
Chronic Hypertension
Hypertension before pregnancy or before 20th week
of gestation or persistence >12 weeks postpartum
Therapeutic management: preconception counseling,
lifestyle changes, antihypertensive agents for severe
hypertension; fetal movement monitoring; serial
ultrasounds
Nursing assessment
Nursing management: lifestyle changes (DASH diet);
frequent antepartal visits; monitoring for abruptio
placentae, preeclampsia; daily rest periods; home
BP monitoring; close monitoring during labor and
birth and postpartum follow-up
Asthma
Pathophysiology
Effect of normal physiologic changes of
pregnancy on respiratory system
Drug therapy (budesonide, albuterol, salmeterol)
Nursing assessment
Asthma triggers; lung auscultation
Nursing management
Client education (see Teaching Guidelines 20-2)
Oxygen saturation monitoring during labor
Infections
Cytomegalovirus
Rubella
Herpes simplex virus
Hepatitis B virus
Varicella zoster virus
Parvovirus B19
Group B streptococcus
Toxoplasmosis (see Table 20-3)
TORCH Infections
T=Toxoplasmosis
O Other(syphilis)
R-Rubella
C-Cytomegalovirus
H-Herpes
TORCH
All of the TORCH infections can affect people of any age or sex.
However, the term TORCH is only used when it applies to pregnant
women and their unborn or newborn children. As a group, the TORCH
infections represent a common cause of birth defects. They can also
cause stillbirth, the delivery of a dead baby.
The infection usually causes few, if any, symptoms in the pregnant
woman. On the other hand, babies risk serious birth defects if they
catch one of these infections during pregnancy or delivery. Babies are
usually most severely affected when the mother gets the infection in
the first trimester, or first three months of pregnancy. This is the time
of pregnancy when the baby's organs are first starting to form.
Vulnerable Populations
Adolescents
Pregnant woman over age 35
Women who are positive for the human
immunodeficiency virus (HIV)
Women who abuse substances
Pregnant Adolescent
Nursing assessment
Vision of self in future
Realistic role models; emotional support
Level of child development education
Financial and resource management; work and
educational experience
Anger and conflict resolution skills
Knowledge of health and nutrition for self and child
Challenges of parenting role
Community resources
Pregnant Adolescent (contd)

Nursing management
Support
Future planning (return to school; career or job
counseling); options for pregnancy
Frequent evaluation of physical and emotional wellbeing
Stress management; self-care
Education (see Box 20-4)
Woman Over Age 35

Nursing assessment
Preconception counseling; lifestyle changes;
beginning pregnancy in optimal state of health
Laboratory and diagnostic testing for baseline;
amniocentesis; quadruple blood test screen
Nursing management
Promotion of healthy pregnancy; education;
early and regular prenatal care; dietary
teaching; continued surveillance
Review
Which of the following would the nurse include when
teaching a pregnant woman about the pathophysiologic
mechanisms associated with gestational diabetes?
A. Pregnancy fosters the development of carbohydrate
cravings.
B. There is progressive resistance to the effects of
insulin.
C. Hypoinsulinemia develops early in the rst trimester.
D. Glucose levels decrease to accommodate fetal growth.
Review
The correct response is B:
caused levels of the hormone hPL (insulin antagonist)
progressively rise throughout pregnancy, and additional insulin
is needed to overcome its resistance. Having a carbohydrate
craving is not associated with gestational diabetes.
Hyperinsulinemia in the fetus develops in response to the
mothers high blood glucose levels. Glucose levels are diverted
across the placenta for fetal use, and thus maternal levels are
reduced in the first trimester. This lower glucose level doesnt
last throughout the gestation, just the first trimester. For the
remaining two trimesters, the maternal glucose levels are high
because of the insulin resistance by hPL.
Review
When providing prenatal education to a pregnantwoman with
asthma, which of the following would beimportant for the
nurse to do?
a. Explain that she should avoid steroids during her pregnancy.
b. Demonstrate how to assess her blood glucose levels.
c. Teach correct administration of subcutaneous
bronchodilators.
d.Ensure she seeks treatment for any acute exacerbation.
Review
The correct response is D:
a pregnant woman with asthma who is having an acute
exacerbation will be poorly oxygenated, and thus perfusion to
the placenta is compromised. Immediate treatment is needed
for her well-being as well as that of the fetus. Corticosteroids
are used as a first-line drug therapy for asthma treatment and
management because of their anti-inflammatory properties.
Having asthma has no influence on the womans glucose
levels, unless she also has diabetes. Bronchodilators usually
are inhaled, not given subcutaneously, so instruction about this
route of administration would not be necessary.
Review
Which of the following conditions would most likely cause
a pregnant woman with type 1 diabetes the greatest
difculty during her pregnancy?
a. Placenta previa
b. Hyperemesis gravidarum
c. Abruptio placentae
d. Rh incompatibility
Review
The correct response is B:
The highest percentage of HIV transmission results from
sexual activity, followed by intravenous drug use.
Transmission can occur despite a low viral load in the
blood of the infected person. Pregnant women who take
antiretroviral therapy during their gestation significantly
reduce the chances of transmitting HIV to their newborn.
The use of standard precautions will minimize the risk of
transmission of HIV to health care workers. A very small
percentage of nurses contract HIV through needlesticks if
using appropriate precautions.
The End!! Questions??

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Maternity and Pediatric Nursing

gestational diabetes mellitus

glycosylated hemoglobin(HbA1C) level

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Diabetes Mellitus (contd)

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Diabetes Mellitus (contd)

Diabetes Mellitus (contd)

Diabetes Mellitus (contd)

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Congenital and Acquired Heart Disease

Congenital and Acquired Heart Disease

Congenital and Acquired Cardiac Disease

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pregnant Adolescent (contd)

Woman Over Age 35

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

The End!! Questions??

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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