Care of Mother and Child At-Risk or with

Problems (Acute and Chronic)- Lecture

STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR
Session # 6

LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT Materials:

CLIENT (PRE-GESTATIONAL CONDITIONS- RH
Book, pen, SAS and notebook
SENSITIZATION AND HIV/AIDS)
LEARNING OUTCOMES: References:
At the end of the lesson, the student nurse can: Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
th
Maternal and Child Health Nursing, 8 Edition.
1. Define Rh sensitization in relation to pregnancy, USA: Lippincott Williams and Wilkins
including pre-existing factors that contribute to its
development. Perry, Shannon, Hockenberry, Marilyn J.,
2. Integrate knowledge of Rh Sensitization in relation to Lowdermilk Deitra Leonard and Wilson, David
th
pregnancy and nursing process to achieve quality (2015) Maternal and Child Nursing Care,6
maternal and child health nursing care. Edition. USA: Elsevier
3. Identify the difference HIV/AIDS and its effect to
pregnancy, including preexisting factors that contribute Hockenberry, Marilyn and Wilson, David (2013)
to its development. Wong’s Essential of Pediatric Nursing,9th
4. Integrate knowledge of HIV/AIDS to nursing process to Edition. USA: Elsevier
achieve quality maternal and child health nursing care.

LESSON PREVIEW/REVIEW (5 minutes)

MAIN LESSON (50 minutes)

(Chapter 21: Nursing Care of A Family Experiencing a Sudden Pregnancy Complication-Isoimmunization, p.558.Chapter
26: Nursing Care of Family with a High Risk Newborn-Illnesses that Occur in Newborns. P. 704)

HEMOLYTIC DISEASE

- is caused by either Rh or ABO incompatibility

*Mother produces antibodies that destroy RBCs of the fetus; hemolysis results in fetal anemia and hyperbilirubinemia
1. ABO Incompatibility 2. RH INCOMPATIBILITY
Occurs when maternal blood type is O and fetus is Rh (D) factor is a protein antigen present on the
a. Type A- most common surface of some people’s RBC (Rh+)
b. Type B- most serious
c. Type AB- rare 1. Antibodies vs Rh antigen are not naturally-occurring but
1. The mother has inborn antibodies vs blood type A and B are produced when Rh+ blood enters the bloodstream of
in her bloodstream. If fetus has type A or B blood and if an Rh- person.
maternal and fetal blood mix, maternal antibodies will 2. The Rh + gene is a dominant and therefore if either the
perceive the fetal RBC as an antigen and will destroy it mother or the father or both parents are Rh+, the baby will
2. Uncommon during pregnancy since antibodies is the be Rh+
large IgM type & cannot cross placental barrier
3. During delivery when placenta separates from the Rh Sensitization/Rh Isoimmunization- It is the exposure
decidua, the barrier is broken allowing maternal blood to of Rh- blood to Rh+ blood resulting to production anti-Rh
enter the fetal bloodstream. abs
4. Maternal antibodies will then destroy fetal RBCs after It can occur through:
birth Sensitization from previous pregnancy (Rh- mom
5. Thus, signs of hemolytic disease will manifest several with Rh+ baby)
hours after delivery Inadequate response to prophylaxis
Incompatible blood transfusion

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 1 of 7
 -Insignificant amts of antibodies are formed during
st
pregnancy thus, 1 baby is not greatly affected.
-Greatest exposure occurs during placental
separation which causes massive production of anti Rh
st
abs during 1 72 hrs postpartum
-Rh+ fetuses in future pregnancies will be affected
-Fetal anemia results & to compensate, fetal bone
marrow produces immature RBCs(erythroblasts) causing
ERYTHROBLASTOSIS FETALIS
-Fetal anemia may be so profound that it kills the
fetus
-RBC destruction causes massive production &
accumulation of bilirubin as the immature liver is unable to
clear them from the body leading to
HYPERBILIRUBINEMIA & KERNICTERUS

Fetal Complications of Erythroblastosis Fetalis

1. Anemia
2. Splenomegaly & hepatomegaly
3. Hyperbilirubinemia
4. Hydrops fetalis- as organs are not perfused
properly, the heart will eventually decompensate; fluid
builds up resulting to edema
5. Stillbirth
Prevention
1. Prenatal Screening
History: past pregnancies, BT, abortion, invasive diagnostic procedures during pregnancy
Blood typing & Rh typing
Coomb’s test (titer >1:16 indicates sensitization); indirect CT (maternal serum), direct CT (cord blood); if
negative, test at 16 to 20 wks and at 26-27 wks
Give RhIg aka anti Rho(D) gamma globulin(RhoGAM) at 28 wks and within 72h after delivery

2. RHOGAM should be given to all Rh- women who:

Have delivered Rh+ babies
Have had untypeable pregnancies such as ectopic pregnancies, stillbirth & abortion
Have received ABO compatible Rh+ blood
Have had invasive dx procedures like amniocentesis, CVS
Management
1. Amniocentesis q 2wks beginning at 26 wks to monitor bilirubin
2. Percutaneous umbilical blood sampling at 18-20 wks if bilirubin levels are high
3. Intrauterine Blood fetal transfusions (IUFT) at 10-day to 2-week intervals until 34-36 wks
HIV/AIDS

 HIV infection and AIDS can be caused by placental transfer or direct contact with maternal blood during birth.
 HIV is a slowly replicating retrovirus and has at least two main divisions, HIV-1 and HIV-2, followed by a variety of
further subtypes.
 The virus acts by attacking the lymphoreticular system, in particular CD4-bearing helper T lymphocytes.
 The virus enters the cell, substitutes its own RNA and DNA for the cell’s DNA, and begins to replicate, destroying
the lymphocytes in the process as well as their ability to initiate an effective B-lymphocyte response.
 There is no effective way to destroy the HIV, so it remains in the body for life and can activate if the immune
system becomes depressed.
 When monocytes and macrophages become affected, the person with HIV infection cannot resist usual infections
such as the common cold.
 When the CD4 count falls below 500 cells/mm3 or the viral load rises above 5,000 copies/ml, it is difficult for
infected individuals to resist opportunistic infections such as fungal infections.
 The final result is that both the immune response and the ability to screen and remove malignant cells from the
body are lost (Smith, 2011). (Chapter 42: Nursing Care of A Family with an Immune Disorder, p.1174)

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 2 of 7
ETIOLOGIC AGENT:

1. retrovirus that targets helper T lymphocytes (T4 cells) that contain the CD4 antigen (which regulates normal immune
response) making the patient susceptible to opportunistic infections
2. Present in infected person’s blood, semen, and other body fluids
Risk factors: Assessment
1. Multiple sexual partners of the individual or Early Symptoms:
sexual partner 1. Fatigue
2. Bisexual partner, MSM 2. Anemia
3. IV drug use by the individual or partner 3. Diarrhea
4. Others: BT, tattoo, etc 4. Weight loss
5. Lymphadenopathy
6. Night sweats
Stages:

1. Initial invasion of virus with mild, flulike symptoms

2. Seroconversion- production of antibodies vs HIV; happens in 6 weeks to 1 year
3. Asymptomatic period for 3 to 11 years
4. Symptomatic period with opportunistic infections & possibly malignancies (CD4 cell count < 200cells/mm3)
5. Toxoplasmosis, tuberculosis
6. Oral & vaginal candidiasis
7. GIT illnesses
8. Kaposi sarcoma
9. P. carinii pneumonia (PCP)- most common opportunistic infection
10. Herpes simplex
11. HIV-associated dementia
KAPOSI SARCOMA-is a cancer that causes patches of PCP (Pneumocystis Carinii Pneumonia)- a life-
abnormal tissue to grow under the skin, in the lining of threatening lung infection that can affect people with
the mouth, nose, and throat, in lymph nodes, or in other weakened immune systems, such as those infected with
organs. These patches, or lesions, are usually red or HIV, the virus that causes AIDS.
purple.

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 3 of 7
Assessment Management

1. ELISA test- if (+) 2x then 1. Monitor CD4+ T cell counts.

2. Western Blot Test- confirmatory test 2. Goal: maintain CD4 cell count > 500 cells/ mm3.
3. In late infection, CD4+ T cell count <200cells/ul 3. Antiretroviral therapy: oral ZVD during pregnancy &
4. Presence of opportunistic infections
IV during labor & delivery) plus1 or more protease
5. 20-50% of infants born to untreated HIV +
women will contract the virus & develop AIDS in inhibitors like ritonavir (Norvir) or indinavir (Crivixan)
the 1st year of life in conjunction with a nucleoside reverse
transcriptase inhibitor drug.
4. Neonate is also given zidovudine
5. Breastfeeding is not recommended
6. Educate client on safe sex practices, testing of sex
partners
7. Monitor client for signs of opportunistic infection:
fever, weight loss, fatigue, candidiasis, cough, skin
lesions
8. CS delivery-performed before rupture of
membranes
9. If vaginal delivery is unavoidable, no episiotomy!
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.

Multiple Choice

1. Which of the following is TRUE in Rh incompatibility?

A. The condition can occur if the mother is Rh(+) and the fetus is Rh(-)
B. Every pregnancy of a Rh(-) mother will result to erythroblastosis fetalis
C. On the first pregnancy of the Rh(-) mother, the fetus will not be affected
D. RhoGam is given only during the first pregnancy to prevent incompatibility
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Which of the following conditions can be triggered by Rh incompatibility between mother and fetus?
A. Hyperemesis Gravidarum
B. Hemolytic disease of the newborn
C. Gestational Diabetes
D. Ectopic Pregnancy
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Which of the following maternal/fetal blood types can lead to hemolytic disease of the newborn?
A. Rh negative mother, Rh negative fetus
B. Rh negative mother, Rh positive fetus
C. Rh positive mother, Rh negative fetus
D. Rh positive mother, Rh positive fetus
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 4 of 7
4. What treatment can prevent the development of sensitization to Rh-D antigen in an Rh negative mother
carrying an Rh positive fetus?

A. Short-course immunosuppressant treatment

B. Therapeutic abortion
C. Rho(D) immune globulin
D. Rh-D fetal serum injections
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. You’re educating a group of outpatients about ABO blood typing and compatibility. Which statement is
INCORRECT?
A. A person with B- blood can donate to people with either B- or AB- blood.
B. A person with B- blood can receive blood from donors with O- and B- blood.
C. A person with O- blood can donate to every blood type regardless of the RH factor.
D. A person with AB+ blood can only donate to other people with either AB+ or AB- blood.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Karina, a 26 year old female is 27 weeks pregnant with her second child. The woman is A-. As the nurse you
know that:
A. If the patient was A+ she would need to receive RhoGAM.
B. The patient will need to receive RhoGAM during this visit to prevent hemolytic disease of the newborn.
C. The baby will need to receive RhoGAM after it’s born.
D. Since the mother is A- the baby can be Rh positive, which could lead to an immune attack on the mother’s body.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. The nurse is instructing an unlicensed health care worker on the care of the client with HIV who also has
active genital herpes. Which statement by the health care worker indicates effective teaching of standard
precautions?
A. ''I need to know my HIV status, so I must get tested before caring for any clients."
B. ''Putting on a gown and gloves will cover up the itchy sores on my elbows.''
C. ''Washing my hands and putting on a gown and gloves is what I must do before starting care.''
D. “'I will wash my hands before going into the room, and then put on gown and gloves only for direct contact with
the client's genitals."
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Which statement made to the nurse by a health care worker assigned to care for the client with HIV indicates a
breach of confidentiality and requires further education by the nurse?
A. ''I told the family members they needed to wash their hands when they enter and leave the room.''
B. ''The other health care worker and I were out in the hallway discussing how we were concerned about getting HIV
from our client, so no one could hear us in the client's room.''
C. ''Yes, I understand the reasons why I have to wear gloves when I bathe my client.''
D. ''The client's spouse told me she got HIV from a blood transfusion.''
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 5 of 7
9. A pregnant client will be discharge and her family needs health teaching regarding her AIDS related Dementia.
Which interventions does the Nurse teach to family members to reduce confusion in the client? SELECT ALL
THAT APPLY
A. Report any behavior changes.
B. Use the Glasgow Coma Scale on a daily basis.
C. Change the decorations in the home according to the season.
D. Put the bed close to the window.
E. Write out all instructions and have the client read them over before performing a task.
F. Ask the client when he or she wants to shower or bathe.
G. Mark off the days of the calendar, leaving open the current date.
H. For continuity, the primary caregiver should be the only person reorienting the client.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. The home health nurse is making an initial home visit to the client currently living with family members after
being hospitalized with pneumonia and newly diagnosed with AIDS. Which statement by the nurse best
acknowledges the client's fear of discovery by his family?
A. ''Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?''
B. ''Is there somewhere private in the home we can go and talk?''
C. ''I hope that all of your family members know about your disease and how you need to be protected, since you have
been so sick.''
D. ''It is your duty to protect your family members from getting AIDS.''
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 6 of 7
 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.
PERIOD 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
PERIOD 2
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
PERIOD 3
41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
AL STRATEGY: Minute Paper

1. You will use index cards or half-sheets of paper to provide written feedback to the following questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?
2. Pass the responses to your instructor before you leave.

(For next session, review Chapter 20: Nursing Care of a Family Experiencing Complication From a Preexisting or
Newly Acquired Illness: Hematologic Disorder page 498)

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 7 of 7