Care of Mother and Child At-Risk or with

Problems (Acute and Chronic)- Lecture

STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR
Session # 5

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

CLIENT (PRE-GESTATIONAL CONDITIONS- ANEMIAS OF
Book, pen, SAS and notebook
PREGNANCY) AND (GESTATIONAL CONDITIONS-
HYPEREMESIS GRAVIDARUM AND ECTOPIC
PREGNANCY)
Reference:
LEARNING OUTCOMES:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
At the end of the lesson, the student nurse can:
Maternal and Child Health Nursing, 8th Edition.
1. Define Anemia, Hyperemesis Gravidarum and Ectopic USA: Lippincott Williams and Wilkins
Pregnancy) its relation to pregnancy, including pre-existing
factors that contribute to its development.

2. Integrate knowledge of Anemia, Hyperemesis Gravidarum

and Ectopic Pregnancy in relation to pregnancy and nursing
process to achieve quality maternal and child health nursing
care.

LESSON PREVIEW/REVIEW (5 minutes)

MAIN LESSON (50 minutes)

(Chapter 20: Nursing Care of a Family Experiencing Complication From a Pre-existing or Newly Acquired Illness:
Hematologic Disorder page 498)
ANEMIAS OF PREGNANCY
(Chapter 20: Nursing Care of a Family Experiencing Complication From a Preexisting or Newly Acquired Illness:
Hematologic Disorder page 498) - significant in achieving optimal oxygenation of our diff. body cells and organs.
-when demand exceeds the supply, the person can be anemic.
-not common or seldom in 1st world countries.
ANEMIA- is a condition of too few RBCs, or a lowered ability of the RBCs

 Many women lack the sufficient amount of iron needed for the second and third trimesters. When the body
needs more iron than it has available, a woman canText
become anemic.

 Mild anemia is normal during pregnancy due to an increase in blood volume.

 More severe anemia can put the baby at higher risk for anemia later in infancy.

Most Common Types during Pregnancy: Risk Factors

• Iron deficiency Anemia • Poor nutrition
• Vitamin B12 Anemia • Excess alcohol consumption
• Anemia due to Blood Loss • Illnesses that reduce absorption of nutrients GI problems
• Folate Deficiency • Use of anticonvulsant drugs (Tegretol, Lithium,
Carbamazepine, etc.)
• Previous use of oral contraceptives
• G6PD Deficiency Enzyme that’ll help in production of RBC’s
Complications of Anemia
• Premature labor
• Intrauterine growth retardation (IUGR)

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 • Dangerous anemia from normal blood loss during labor, requiring transfusions
• Increased susceptibility to maternal infection after childbirth
IRON DEFICIENCY ANEMIA
• Most common type, develops in the 2 nd & 3rd trimester when the Fe requirements increase to compensate for
the expanding blood volume
• Predisposing factors: Normal hemoglobin
– Poor diet & poor nutrition 11.5-15 g/dl
– Heavy menses Normal hematocrit is
– Successive pregnancies w/in 2 yrs or <6 mos interval 35.5-48%
– Unwise reducing programs
– Low socioeconomic status

Signs & Symptoms of IDA Diagnosis

• Easy fatigability Lab findings:
• Sensitivity to cold -low hemoglobin <10 g/100ml
• Dizziness -low hematocrit <37% in the 1st trimester, <35% in the
• Brittle, flattened nails 2nd trimester and <33% in the 3rd trimester
• Changes in Vital Signs: rise in systolic pressure, -Serum ferritin < 100 mg/dl
tachycardia, tachypnea -Serum Fe level < 30 ug/dl
-Hypochromic, microcytic RBCs
Management of Iron Deficiency Anemia Effects of Anemia on Pregnancy
The World Health Organization and most experts • Decreased resistance to infection
recommend prevention of iron deficiency anemia with • Associated with prematurity & LBW infants
prophylactic iron supplementation in pregnancy. • Predisposes to heavy bleeding during labor &
delivery
 Pregnancy requires an additional 700–1200 mg of • Associated with PICA -eating disorder where person
iron. Of this, 200–300 mg is transferred to the eats non-edible foods usually
fetus. -refers to the color of the blood caused by nutritional
-means the blood lacks redness deficiencies like anemia
 Most of the iron requirements of pregnancy are in Iron is best absorbed
the second half of pregnancy, and they are in an acidic medium.
approximately 5–6 mg/day. Take iron supplements
with orange juice or
vitamin c supplement
 An average balanced diet will supply only 1–2
mg/day. RBC size smaller than normal ranges

 Daily supplementation with 300 mg ferrous sulfate

(which contains 60 mg elemental iron) will satisfy
the pregnancy requirement. Side effects: constipation and gastric irritation

MEGALOBLASTIC ANEMIA
Types:
1. Folic Acid Deficiency/(Pernicious anemia
2. Vit B12 Deficiency/Addison Pernicious Anemia

Folic acid vs. Folate

Folate is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs, citrus
fruit, avocados, and beef liver.

Folic acid is a synthesized version of vitamin B9 that is added to processed foods and the common version used in
supplements.

1. Folic Acid Deficiency Anemia-is necessary for normal formation of RBC and in the prevention of Neural Tube
Defects
– Deficiency leads to formation of large & immature RBCs with shorter lifespan
– develops if diet is mostly meat with little Green leafy vegetables

Effects on Pregnancy: Signs and Symptoms of Folic Acid Deficiency

-abortion • Nausea

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 -abruptio placenta • Vomiting
-Neural Tube Defect • Anorexia
Most often seen in: MANAGEMENT
• Multiple pregnancies because of the increased  Treatment of patients with pernicious anemia is
fetal demand undertaken with parenteral therapy because oral
• Women with secondary hemolytic illness absorption of vitamin B12 is deficient.
• Women who are taking Hydantoin
• Poor gastric absorption due to gastric bypass  Daily injections of 200 μg are given for the first week
for morbid obesity followed by weekly injections for 3 weeks and then
once a month thereafter.

 Therapy must continue for life to prevent recurrence

of anemia.

 Response to therapy is usually manifested by

a brisk production of reticulocytes within the first few
days of therapy.
2. Vit B12 Deficiency/Addison Pernicious Anemia
Vitamin B12 deficiency is extremely uncommon during pregnancy.

Vitamin B12 deficiency (pernicious anemia) is primarily caused by deficiency in oral absorption.

Present in:
 The most common type is that caused by autoimmune atrophic gastritis, which occurs most frequently in
patients of Scandinavian and Northern European ancestry as well as those of Hispanic origins.

 Women between 30 and 40 years of age

Rare causes of vitamin B12 deficiency:

 Infection by the fish tapeworm (Diphyllobothrium latum)

 Chronic conditions such as Crohn’s disease.

Diagnosis
 Patients demonstrating a macrocytic anemia with an abnormally low serum vitamin B12 level.

Management of Vitamin B12 Deficiency is same as Iron Deficiency Anemia

GESTATIONAL CONDITIONS
Please refer to Chapter 13: The Nursing Role in Promoting Nutritional Health During Pregnancy p.299
HYPEREMESIS GRAVIDARUM
-PERNICIOUS or PERSISTENT VOMITING OF PREGNANCY
-extreme nausea and vomiting that is prolonged past week 12 of pregnancy or is so severe (DHN, ketonuria, weight
loss) within the 1 st 12 weeks AOG
-associated with H. pylori
Assessment Management
-Nausea and Vomiting is so severe that nutrition cannot 1. 24-hour Hospitalization. (I & O, blood chemistries &
be maintained and weight loss is severe rehydration)

-Elevated Hematocrit due to hemoconcentration 2. NPO; IVF ( 3L Ringer’s lactated solution+ vitamin B) to
control vomiting
-Reduced Na, K Cl and hypokalemic alkalosis may occur
3. If no vomiting after the 1 st 24h, sips of clear fluid
-Polyneuritis due to deficiency in Vitamin B gradually advanced to a soft, then normal, diet.

-Urine may be (+) for ketones due to breakdown of 4. If vomiting returns, TPN or enteral nutrition may be
protein & fat for cell growth prescribed

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-Intrauterine Growth Restriction or preterm birth
In history taking ask frequency/quantity of vomiting, how
much she eats in a typical day.
Ectopic Pregnancy
An ectopic pregnancy is one in which implantation occurred outside the uterine cavity. The most common site (in
approximately 95% of such pregnancies) is in the fallopian tube. Of these fallopian tube sites, approximately 80% occur in
the ampullar portion, 12% occur in the isthmus, and 8% are interstitial or fimbrial (Jurkovic, 2012). (Chapter 21: Nursing
Care of a Family Experiencing a Sudden Pregnancy Complication, p.533)

Ectopic Pregnancy Etiology

-It is the implantation of a fertilized ovum outside of the Salpingitis, tumors, adhesions, or scarring, IUD use,
uterus narrowed oviducts
-Sites: ovary, cervix, peritoneal cavity, fallopian tube
(most common)
Assessment Complication
1. Missed period, usual signs of pregnancy (Nausea and
Vomiting, positive pregnancy test, etc) 1. Hemorrhage,
2. Shock,
2. Spotting, bleeding (dark red or brownish), possible 3. Peritonitis
signs of hypovolemic shock
DIAGNOSTIC TEST
3. If at the fallopian tube, by 6 to 12 weeks AOG, slowly -MRI
increasing or sudden sharp, stabbing pain in LLQ or -ULTRASOUND
RLQ (due to rupture of fallopian tube), followed by
bleeding, abdominal rigidity

4. referred shoulder pain (KEHR’S SIGN) due to blood

in the peritoneum irritating the phrenic nerve

5. CULLEN’S SIGN- ecchymotic blueness around the

umbilicus indicating blood pooling in the peritoneum

6. Dizziness, syncope

7. UTZ confirms extrauterine pregnancy & rupture

Management
 Before rupture, oral administration of METHOTREXATE (folic acid antagonist which destroys fast-growing
cells) followed by LEUCOVORIN; treated until hCG is (-); hysterosalpingogram to assess patency of the tube

 After rupture, BT if needed, laparoscopy to ligate bleeding vessels & remove or repair damaged tubes
 Assess for bleeding & pain
 Monitor VS, start IV with 18-gauge needle
 Provide O2 therapy
 Administer RhOGAM if Rh (-)
 Provide emotional support

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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. Berta a pregnant patient was diagnosed with Iron Deficiency Anemia. She asked you what are the other types
of Anemia that can be seen in pregnancy. Which of the following are Anemias of Pregnancy, EXCEPT:
A. Vitamin B12 Anemia
B. Anemia due to Blood Loss
C. Folate Deficiency
D. Thalassemia
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. Cilla a student-nurse who takes care of Berta asked you what are the factors that puts the patient at risk of
developing anemia in pregnancy. All but one are risk factors of Anemia, EXCEPT:
A. Poor nutrition
B. Excess alcohol consumption
C. Illnesses that reduce absorption of nutrients
D. Use of anticonvulsant drugs
E. Elevated hematocrit due to hemoconcentration
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________________________________ ____________

3. Cilla a student nurse asked you what is the difference between Folic Acid and Folate. Which of the following
are the correct definition of Folic acid and Folate?
A. Folic Acid is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs, citrus
fruit, avocados, and beef liver while Folate is a synthesized version of vitamin B9 that is added to processed foods and the
common version used in supplements.
B. Folate is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs, citrus fruit,
avocados, and beef liver while Folic acid is a synthesized version of vitamin B9 that is added to processed foods and the
common version used in supplements.
C. Folate is the common form of vitamin B9 present in many synthesized version of vitamin B9 that is added to processed
foods and the common version used in supplements while Folic acid is the common form of vitamin B9 present in many
whole foods, including leafy greens, beans, eggs, citrus fruit, avocados, and beef liver.
D. Folate and Folic Acid is both present in many whole foods, including leafy greens, beans, eggs, citrus fruit, avocados,
and beef liver
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. 4 patients came to the Out Patient Department with Iron Deficiency Anemia EXCEPT:
A. Multiple pregnancies because of the increased fetal demand
B. A woman with secondary hemolytic illness
C. Poor gastric absorption due to gastric bypass for morbid obesity
D. A woman at 36 years of age
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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5. Erina will be having a case presentation regarding the complications of Anemia in pregnancy. The following
are part of Complications of Anemia in Pregnancy, EXCEPT:
A. Premature labor
B. Intrauterine growth retardation (IUGR)
C. Dangerous anemia from normal blood loss during labor, requiring transfusions
D. Poor diet & poor nutrition
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. Belle is diagnosed with Hyperemesis Gravidarum, Which of the following is true regarding Hyperemesis
Gravidarum?
A. Extreme nausea and vomiting that is prolonged past week 12 of pregnancy or is so severe
B. Nausea and Vomiting is so severe that nutrition cannot be maintained and weight loss is severe
C. Urine may be (+) for ketones due to breakdown of protein & fat for cell growth
D. Intrauterine Growth Restriction or preterm birth
E. All of the choices are true
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. Belle was confined to the hospital due to Hyperemesis Gravidarum, The following are part of management for
Hyperemesis Gravidarum, EXCEPT:
A. 24-hour Hospitalization
B. If no vomiting after the first 24 hours, sips of clear fluid gradually advanced to a soft, then normal, diet.
C. If vomiting returns, TPN or enteral nutrition may be prescribed
D. Provide oxygen therapy
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Karlie is diagnosed with Ectopic Pregnancy. Your instructor ask you which of the following is the common site
of Ectopic Pregnancy?
A. ovary
B. cervix
C. peritoneal cavity
D. fallopian tube
ANSWER: ________
RATIO:________________________________________________________________________ ___________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Karlie is experiencing sharp shoulder pain. Which of the following conditions is experiencing?
A. Cullen’s Sign
B. Charcot’s Sign
C. Kehr’s Sign
D. Leopold’s Sign
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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10. As you do physical examination on Karlie, you saw that her abdomen has an ecchymotic blueness around the
umbilicus. You know that its:
A. Cullen’s Sign
B. Charcot’s Sign
C. Kehr’s Sign
D. Leopold’s Sign
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: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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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
PERIOD 2
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
PERIOD 3
32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

AL STRATEGY: Minute Paper

1. You will be ask to 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. Your instructor will collect or pass your responses before you leave.
3. Respond to students’ feedback during the next class meeting or as soon as possible

(For next session, review Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication -
Bleeding During Pregnancy page 526 and page. 537.)

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