WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 2: MATERNAL AND

CHILD HEALTH NURSING

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 Hegars Sign Goodells Sign Chadwicks Sign Ballottement Braxton Hicks 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 LECITHIN SPHINGOMYELIN (L/S RATIO) Uses amniotic fluid to ascertain fetal lung maturity SHOULD REFRAIN FROM SEXUAL INTERCOURSE AND PHYSICAL ACTIVITY FOR 48 hours. A small amount of spotting is normal for the 1st 24-48 hours. 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 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. Done only before EDC 2 weeks

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

AMNIOCENTESIS Aspiration of amniotic fluid for examination.

X-RAY 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. Done through AMNIOCENTESIS Perform at 35-36 weeks Position: Supine. Place folded towel on the right buttocks. Needle insertion in a 2022 gauge spinal needle, withdrawing amniotic fluid. NORMAL L/S RATIO (lecithin/sphingomyelin) : 2:1 = normal fetal lung maturity ratio

Disadvantages: Risk of Abortion Infection Embryo-fetal/placental damage Spontaneous abortion Premature rupture of the membranes

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

WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 2: MATERNAL AND CHILD HEALTH NURSING
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 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. Warm sitz bathing High fiber diet and increase fluid. Sit on soft pillow Sleep on the side at night. Limit fluid intake during evening Bladder training Back exercise (pelvic rock) Wear low-heeled shoes. Avoid heavy lifting Frequent rest with feet elevated Regular exercise like walking Increase milk intake Elevate legs at least twice a day. Sleep on left side Get regular exercise Sleep as much as needed. Avoid stimulants. Wear well fitted bra Warm compress

Hemorrhoids

TeTox Routine Immunization of Pregnant Women Vaccine TeTox 1 Minimum Interval As early as possible during pregnancy 4 weeks after TeTox 1 Duration of Protection Urinary Frequency

TeTox 2 Minimum required TeTox for pregnant mother TeTox 3

infant will be protected by neonatal tetanus 3 years protection for the mother infant will be protected by neonatal tetanus 5 years protection for the mother infant will be protected by neonatal tetanus 10 years protection for the mother all infant born to that mother will be protected lifetime protection for the mother

Backache

Leg Cramps 6 months after TeTox 2

Pressure of growing fetus, Increase venous pressure Increase blood supply to the kidney/ Pressure of enlarged uterus in the 3rd Tri From exaggerated lumbo-sacral curving during pregnancy. Increase pressure of gravid fetus, low calcium From venous stasis Due to hormonal changes Increase estrogen and progesterone level

Ankle Edema

TeTox 4

1 year after TeTox 3

Fatigue

TeTox 5

1 year after TeTox 4

Breast Tenderness

E. Formula Used In Providing Estimates In Pregnancy D. Discomfort of Pregnancy Changes Nausea and Vomiting Reason Increased HCG Health Teachings Dry crackers 30 min. before arising Small, frequent, low fat meals Avoid anti-emetics. 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 To estimate the EDC Given the Last Menstrual Period (LMP) Date of Quickening Use Nageles Rule Formula First day of LMP 3 months + 7 days Primi: Q + 4 months + 20 days Multi: Q + 5 months + 4 days

Heartburn

Increased progesterone which decrease gastric motility causing esophageal reflux.

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

WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 2: MATERNAL AND CHILD HEALTH NURSING
Fundus Height at Various Week 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 F. Pre-Natal Visit Stages of Labor 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-Fowlers or side-lying position. Monitor for post-test labor onset. Indication: 28 weeks pregnancy high risk mother Contraindicated: Pre Term Labor First Stage Second Stage Third Stage TOTAL Primigravida 12 and hour 80 minutes 10 minute 14 hours Multigravida 7hours and 20 minutes 30 minutes 10 minutes 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 clients 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

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

WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 2: MATERNAL AND CHILD HEALTH NURSING
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 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 Dont 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 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 Pregnant Women Post Partum Women Prep. 100,000 IU 200,000 IU Dose 1 cap 2x a week 1 cap Duration Start from the 4th month of pregnancy until delivery One dose only within 4 weeks after delivery

Iron Supplementation Target Pregnant Women Prep. Coated Tab. contains 60 mg elemental iron with 400 mg folic acid Coated Tab. contains 60 mg elemental iron with 400 mg folic acid Dose / Duration 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 1 tab / day for 3 months or 90 days Remarks

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

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

Lactating Women

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

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

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

WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 2: MATERNAL AND CHILD HEALTH NURSING
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-Ps: 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 (dont 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.

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

WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 2: MATERNAL AND CHILD HEALTH NURSING
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. DIGESTIVE SYSTEM intake 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 Pathologic Jaundice, yellowish discoloration immediately after birth Physiologic Jaundice, yellowish discoloration 2-3 days after birth (normal) Axillary temperature: 96.8 to 99F Newborn cant shiver as an adult does to release heat Cold stress increases o2 consumption may lead to metabolic acidosis and respiratory distress NB develops own antibodies during 1st 3 months but at risk for infection during the first 6 weeks

HEPATIC

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 NBs 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

TEMPERATURE

IMMUNOLOGIC

P. Freuds Theory Freuds Psychoanalytic Theory Psychosexual Development Oral Stage Child explores the world by using mouth, especially the tongue Baby finds pleasure in the mouth Anal Stage Child learns to control urination and defecation (18 months) Toilet training 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 Latent Stage / Latency Period Childs personality development appears to be nonactive or dormant Genital Stage Adolescent develops sexual maturity and learns to establish satisfactory relationships w/ the opposite sex

Infants (birth to 1 year) Toddler (1-3 y/o) Preschooler (3-6y/o)

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) RR = 30-80 breaths /minutes with short periods of apnea (< 15 seconds) Later pattern is 6-10 voidings/ day indicative of sufficient fluid

School-Age (6-12 y/o) Adolescent (13-20 y/o)

RESPIRATORY STATUS RENAL SYSTEM

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

WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 2: MATERNAL AND CHILD HEALTH NURSING
Q. Eriksons Theory Eriksons Theory of Psychosocial Development Trust vs. Mistrust Fear: strangers, anxiety, loud noises, falls, sudden movements in the environment Play: Solitary Learning confidence or learning to love, 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 Initiative vs. Guilt Ability to try new things Bogus playmates/imaginary Fears: dark, being left alone, large animals, ghosts, body mutilation, pain & objects Industry vs. Inferiority Makes things w/ others Strives to achieve success Child learns how to do things well 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 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 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 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. 0-1 Holds head up when prone 2 Holds head & chest up when prone 3 Grasp Stepping Tonic neck Reflexes are fading Turns front to back Has head lag when pulled upright Gross Motor Development Largely reflex Fine Motor Development The eyes is fixated on the person Keeps hands fisted Development of social smile Responds to familiar voice The baby knows how to cry Laughs aloud Babbles and coos Can raise head and chest Reach out to object Roll over Hold blocks at each hand Doubles birth weight Eruption of 1st tooth Sits w/ minimal support Uses palmar grasp dada, mama Sleeps on prone position Uses fingers to hold objects Transfers objects hand to hand Sits alone steadily for an indefinite period Recognizes strangers Peek-a-boo (to test memory) Can hold own bottle Starts to crawl Understands simple gestures From crawling to standing Responds when called by his/her name Walks with assistance Triples birth weight Can say 2 syllable words Can walk w/ help

Infants (birth to 1 year)

Toddler (1-3 y/o)

Preschooler (3-6y/o)

4 5

School-Age (6-12 y/o) Adolescent (13-20 y/o)

Turns both ways Moro reflex fading 6 Reaches out in anticipation of being picked up Sits unsteadily

Young Adult

Sits securely w/o support 8

Creeps or crawls 9 Pulls self to standing 10

Middle Adult

Older Adult

11 12

From crawling to standing Stands alone Some infants take 1st step

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