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153 Cards in this Set
- Front
- Back
Define labor dystocia
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long, difficult, or abnormal labor; not following "textbook"
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What factors are associated with labor dystocia?
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the 5 p's: passageway, passenger, position, powers , position, psychological
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Example where passenger is cause of labor dystocia
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fetal anomalies, malpresentation, CPD, suboptimal fetal position
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Example where the passageway is the cause of labor dystocia
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pelvic structure, soft tissue dystocia
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Example where maternal position is cause of labor dystocia
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supine
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Example where psychological factors contribute to labor dystocia
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anxiety and fear
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Define "cleansing breath"
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breath taken before bearing down to push in order to increase O2
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Example where powers are cause of labor dystocia
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ineffective uterine cx's
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Some common problems associated with labor dystocia
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pelvic structure, fetal causes, maternal position, psychological response, inadequate pain management/coping, inadequate uterine cx's
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Risk factors that affect the "powers" associated with labor
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body build, uterine abnormalities, malpresentations, cephalic-pelvic disproportion (CPD), overstimulation with pitocin, maternal fatigue, dehydration, fear, inappropriate timing of analgesics
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Explain body build as a risk of labor dystocia
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overweight by 30# or out of shape or short in stature
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What is a hypertonic uterus
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over-active tone, uterus is contracting too much
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What pattern is observed with a hypertonic uterus
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cx's are not coordinated with phase of labor
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What phase of labor do we typically diagnose hypertonic uterus? Why?
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latent phase when mom should be coping well but is not
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Tx for hypertonic uterus
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therapeutic rest
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What is therapeutic rest
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pain management, hot shower, rest
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Which is the more common disorder r/t uterine tone?
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hypotonic uterus
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Define hypotonic uterus
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decreased uterine tone
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What is the problem with a hypotonic uterus
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cx's are weak and ineffective; they aren't doing anything
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What phase of labor is a uterus most commonly diagnosed as hypotonic
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active phase
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Upon palpation, if you are able to make an indent in the uterus during the active phase of labor, what does this suggest?
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mild uterine tone, hypotonic uterus
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Tx for hypotonic uterus
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augment labor
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What do you need to r/o before augmentation of labor
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CPD
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ROM and pitocin are used to do what, r/t labor dystocia?
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induce or augment labor
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What fetal presentation is considered an emergency
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shoulder
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Pelvic dystocia
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contractures of pelvic diameter
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Soft tissue dystocia
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anatomic abnormality, full bladder or rectum,cervical edema
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Can a fetus with breech presentation be delivered vaginally?
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yes
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What is a major risk with malpresentation
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cord prolapse
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What is the major problem with malpresentation and fetal tasks?
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affects fetal ability to participate in cardinal movements and navigating through the birth canal
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Examples of malpresentation
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breech (complete, incomplete), face, shoulder
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Complete Breech - lie, presenting part, reference point, attitude
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vertical, breech, sacrum and feet, flexion
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Percentage of births with breech malpresentation
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3-4%
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Examples of breech presentation
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incomplete breech - frank, single foot; complete breech
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Frank breech - lie, presenting part, reference point, attitude
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vertical, incomplete breech, sacrum w/out feet, flexion except knees extended
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Single foot breech - lie, presenting part, reference point, attitude
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vertical, incomplete breech, sacrum, flexion except extension on one leg at hip and knee
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What is external cephalic version (ECV)?
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way of repositioning fetus in breeched position
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What gestational age is ECV performed? Why?
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36-37 wks; can induce delivery
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What are the risks associated with ECV?
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nuchal cord, fetal death, fetal distress, ROM, placental abruption, maternal/fetal
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What factors does Friedman's Classification look at to monitor progress
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cervical dilation, fetal descent, and parity
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Define precipitous labor
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<3hrs from onset of true labor
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What doesn't happen during precipitous labor that leads to increased risk of complications?
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not enough time to maneuver
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What is one cause of precipitous labor
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maternal cocaine use
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Examples of complications associated with precipitous labor
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subdural hematoma, lacerations, uterine rupture, amniotic fluid embolism, pph
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If spontaneous active labor isn't progressing as expected, what methodology is often used?
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reasonable period of time, typically 4-6h, is allowed to determine safety
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What might interrupt this reasonable period of time?
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suspected complications
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What is meant by "trial of labor"
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if labor isn't progressing as expected, we allow 4-6hrs to pass to determine the safety of the delivery
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During a "trial of labor" what factors are assessed to determine safety of the delivery
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maternal pelvis is questionable size/shape, vaginal birth after c/s, abnormal presentation
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Define induction of labor (IOL)
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initiate cx's before spontaneous onset w/ pitocin or amniotomy
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What methods are used to induce/augment labor
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pitocin, amniotomy
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What determines how successful IOL is?
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how favorable the cervix is
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Define "favorable cervix"
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how ripe the cervix is; how soft it is for stretching
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Vaginal births are associated with what kind of cervix
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favorable cervix
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Define "Bishop Scoring"
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method of evaluating how favorable/inducible the cervix is
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The higher the Bishop Score/ the lower the Bishop score
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the more inducible the cervix is; to more likely induction will be unsuccessful and result w/ a c/s
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What measurement is used to determine how inducible the cervix is?
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Bishop Scoring
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Describe the changes the cervix experiences as it becomes more favorable
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firm to soft, posterior to anterior
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What Bishop Score is considered appropriate for a nullparous woman? Multiparous woman?
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>9, >5
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If it is deemed necessary to induce labor but the cervix has a low Bishop Score, what intervention is necessary?
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administer chemical agents to ripen the cervix
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High success rate of induction, lower doses of pitocin, and quicker progression are associated with what?
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ripe cervix
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What chemical agents are administered to ripen the cervix
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prostaglandins, misoprostal
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Describe the dosage of pitocin associated with IOL
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1 milliunit q15-20m until adequate contractions are achieved
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What assessment is also necessary to perform with careful administration of pitocin to augment labor?
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monitor FHR q15m/ between cx's
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Indications for IOL
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suspected fetal jeopardy, PROM, post term, chorioamnionitis, maternal medical problems, pregnancy induced HTN, FD
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Why might you want to induce labor with FD?
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don't want to put mom at risk, helps with grieving process
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Fetal distress, failed induction, uterine rupture, water intoxication and hyper-stimulation are all considered what?
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risks of IOL
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What defines hyper-stimulation with pitocin
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very frequent and intense cx's with non-reassuring FHR
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What is the uterine resting tone associated with hyper-stimulation with pitocin? Its significance?
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20mmhg; the uterus is not resting and vulnerable to rupture
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The resting time between contractions is radically decreased with hyper stimulation with pitocin. Why is this a concern?
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decrease O2 perfusion as mom bears down during contractions
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If a pt is experiencing hyper-stimulation with pitocin what nursing invention is most important
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turn off the pit
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Why is turning off the pit the most important nursing intervention during hyper-stimulation w/ pitocin
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it is the cause
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Nursing management for hyper-stimulation w/ pitocin
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turn of the pit, increase IV fluid, O2 via face mask, notify provider
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Why do we want to increase IV fluid and administer O2 after turning off the pit during hypser-stimulation with pitocin
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increase perfusion to fetus
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What methods are used to augment labor
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pitocin, amniotomy
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What is the difference between IOL and Augmentation of labor?
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spontaneous labor has already started but cx's have decreased with augmentation whereas induction of labor initiates the onset of spontaneous labor
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What are the following signs associated with: pelvic pressure, low-dull back ache, menstrual-like cramping, change or increase in vaginal discharge, intestinal cramping (w/ or w/out diarrhea), and cx's < q10m
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labor; pre-labor if <37wks
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Generally speaking, what is the cause of PTL
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unknown, multifactorial
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What is a major culprit of PTL
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infection
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Why is infection a major culprit of PTL
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fetus knows it is better to be out than in
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What infections are associated with PTL
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bacterial vaginosis, chlamydia, gonorrhea, UTI/pyelonephritis
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What is the #1 infectious cause of PTL
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BV
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BV increases risk of PTL by what percentage
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50%
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infection, long-distance traveling, "on feet," stress (acute or chronic), poor nutrition, underweight, late or no prenatal care, lower SES or education, elicit drug use, and pre-exisiting or pregnancy complications are all associate with what?
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risks of PTL
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How is PTL diagnosed
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documented uterine cx's, 80% effacement, dilation >1cm, <37wks
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Biomedical markers, transvaginal u/s and home uterine activity monitoring are used to diagnose what?
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PTL/PTB
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What biomedical markers are tested with diagnosing PTL
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salivary estriol, fetal fibronectin
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Where is salivary estriol found
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in mouth
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Where is fetal fibronectin found
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in vaginal canal
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What predictive values do salivary estriol and fetal fibronectin have
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high negative-predictive value, low positive-predictive value
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Biomedical markers are best to determine who will/ who will not experience PTL
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who will not
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When do levels of salivary estriol increase
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Prior to PTL
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What is the accuracy of a swab positive for salivary estriol?
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7-25%
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What is the accuracy of a swab negative for salivary estriol
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98%
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A swab positive for salivary estriol is considered a ___________ ____________ predictor
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poor-positive
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When do levels of fetal fibronectin (FFN) normally appear during pregnancy?
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early and late
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What gestational age should we be concerned about if FFN is found positive in the canal?
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24-34wks
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What is the accuracy of positive FFN as an indicator of PTL
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25-40%
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What is the accuracy of negative FFN?
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95%
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What is the importance of negative findings of FFN and salivary estriol?
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you are not at risk for PTL
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What two steps are taken during the clinical management of PTL
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tocolytic therapy and glucosteroids
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What purpose does tocolytic therapy serve? Glucosteroids?
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suppress uterine activity; promote development of lungs
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General concern with tocolytic agents r/t ADE
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CNS depressants
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Therapeutic effect of Ritodrine and Terbutaline
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relax smooth muscle
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Magnesium sulfate
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CNS depressant
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Indomethacin
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prostaglandin inhibitor
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Nifedipine
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calcium channel blocker
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tachycardia, dysrhythmias, tremors/m. weakness, headache, N/V, hyperglycemia, pulmonary edema, mycoardial ischemia, hypotension, jitteriness and apprehension are all examples of what?
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side effects of terbutaline
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Examples of tocalytic agents
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ritodrine, terbutaline, magnesium sulfate, indomethacin, nifedipine
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SE od MgSO4
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CNS depressant = decreased RR, absent or decreased DTRs, m. weakness, decreased urine output
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What score would be appropriate for decreased DTRs
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< 2+
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How many cc's or urine is considered normal every hour? every 24hrs?
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30cc's/hr, 500cc's/24hrs
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After administering MgSO4 you notice the pt is very sleepy. What light bulb should go off?
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change in LOC
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Once noting a change in LOC or decreased RR of a pt taking MgSO4, what are some appropriate interventions
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turn off the MgSO4, sternal chest rub, open main line to flush, administer O2, antedote
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What is the antedote for MgSO4
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calcium gluconate
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MgSO4 has to be monitored very carefully. What are its therapeutic levels?
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4-7, 4-8
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Examples of nursing care necessary with administration of tocolytic agents
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asess VS regularly, notify provider if HR>120, monitor urine output q1h, monitor ketonuria, assess for s&s's of pulmonary edema, limit fluid intake to 2500-3000cc's/day, position on l. lateral, provide pyschosocial support
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S&S's of pulmonary edema
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SOB, breath sounds are rhonchi or crackles
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What purpose does the left lateral position serve
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increased perfusion
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Best place to listen for lung sounds
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base of lungs, posteriorly
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Why do we limit fluid intake with administration of tocolytic agents
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decrease risk of pulmonary edema
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What type of agents are Betamethasone and Dexamethasone?
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glucosteroids
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What purpose do Betamethasone and Dexamethasone serve
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accelerate fetal lung maturity
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General management considerations concerning tocolytic therapy
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do not administer if it is best for the baby to come out
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What dilation determines birth as inevitable
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4cm
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Early ROM
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PROM, PPROM
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PROM
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early rupture of membranes at least 1h before onset of labor at any gestational age
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PPROM
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preterm pre-mature rupture of membranes <37wks GA
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Percentage of PTLs that experience PPROM
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25%
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What is the goal of PPROM management
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preventing PTL and maternal/fetal complications
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What is expectant management? When do we use it?
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observe and see what happens after PPROM
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What testing is performed after PPROM? How often?
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Biweekly BPP - U/S, NST and amniotic fluid measurements
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What information does amniotic fluid measurements tell us? What is considered normal?
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if amniotic fluid is decreasing; there is daily turnover of amniotic fluid, there shouldn't be too much or too little
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Criteria for home care r/t PPROM and time
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> 72hr
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Criteria for home care r/t PPROM and cervical dilation
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< 3cm
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Criteria for home care r/t PPROM and sxs's
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no sxs's of infection or PTL
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Criteria for home care r/t PPROM and fetal presentation
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no breech or transverse presentation
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What self-assessments must be performed by the pt caring for herself at home after PPROM
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T q4h (when awake), sxs's of infection, assess for uterine cx's, daily fetal movement counting
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Activity modifications r/t PPROM and home care
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modified bed rest, NPV, no baths, proper hygiene, antibiotics as prescribed
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Complications of PPROM and PTL
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infection, PTB, cord prolapse
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Why is cord prolapse an associated complication of PPROM and PTL
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if the baby is preterm, the head is smaller, leaving room for the cord to fall down alongside
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Define chorioamnionitis
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intraamnion infection with maternal-fetal risks
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sxs's of chorioamnionitis
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fetal tachycardia, elevated maternal temp, uterine tenderness, decreased cx's
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What is the standard of care regarding chorioamnionitis and tocolytic therapy
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tocolytic therapy is contraindicated
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Risks associated with premature newborns
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maintaining body temp, organ function, respiratory disorder syndrome (RDS)
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What is L/S ratio?
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Lecithin/sphingomyelin ratio
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What assessment is the L/S ratio used for?
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to check fetal lung maturity
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What values of the L/S ratio suggest a newborn is at risk for RDS
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< 2, < 3 (if diabetic)
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Some terms used to describe different patterns of hours of labor
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precipitous, multipara, nullipara, protracted active, secondary arrest, prolonged latent
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protracted active labor
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rate of dilation during active phase is below normal
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secondary arrest r/t hours of labor
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dilation stops > 2h during active phase
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prolonged latent phase r/t hours of labor
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nullipara > 20h, multipara > 14h
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Based on Friedman's labor curve, how long should it take for a multiparous woman to FD
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7-8h
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Based on Friedman's Labor Curve, how long should it take for a nulliparous woman to FD
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13-14h
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