UNIT 1 ANTEPARTUM NURSING CARE LABoRAtoRY Tests

PATIENT‑CENTERED CARECLIENT EDUCATION Instruct the client to take all medication as prescribed.Educate the client about the possibility of decreasingeffectiveness of oral contraceptives.Educate the client regarding safe sex practices (e.g.,mutual monogamy and correct, consistent condom use).All states have a reportable diseases list. Chlamydia isa commonly reported condition. It is the responsibilityof the provider to report cases of these diseases to thelocal health department.GonorrheaNeisseria gonorrhoeae is the causative agent of gonorrhea.Gonorrhea is a bacterial infection that is primarily spreadby genital‑to‑genital contact. However, it also can bespread by anal‑to‑genital or oral‑to‑genital contact. Itcan also be transmitted to a newborn during delivery. Women are frequently asymptomatic. If gonorrhea isleft untreated in women, it can lead to PID, which cancause infertility. The CDC recommends yearly screening for all sexuallyactive women younger than 25 years as well as olderwomen who have risk factors (e.g., new or multiplesex partners). All pregnant women at risk should bescreened at the first prenatal visit and rescreened in thethird trimester if at continued high risk.ASSESSMENTRISK FACTORS Multiple sexual partnersUnprotected sexual practicesEXPECTED FINDINGSMale DysuriaUrethral dischargeFemale DysuriaVaginal bleeding between periods and dysmenorrheaPHYSICAL ASSESSMENT FINDINGS Yellowish‑green vaginal dischargeEasily induced endocervical bleedingLABORATORY TESTS 50NURSING CARE Provide client education regarding disease transmission.Identify and treat all sexual partners.Administer erythromycin to all infants followingdelivery. This is the medication of choice for ophthalmianeonatorum. This antibiotic is both bacteriostatic andbactericidal, and thus provides prophylaxis againstNeisseria gonorrhoeae and Chlamydia trachomatis.MEDICATIONSCeftriaxone IM and azithromycin PO: Broad‑spectrumantibiotic; bactericidal actionCLIENT EDUCATION Instruct the client to take all medications as prescribed.Instruct the client to repeat the culture to assess formedication effectiveness.Educate the client about the possibility of decreasingeffectiveness of oral contraceptives.Educate the client regarding safe sex practices (e.g.,mutual monogamy and correct, consistent condom use).All states have a reportable diseases list. Gonorrhea isa commonly reported condition. It is the responsibilityof the provider to report cases of these diseases to thelocal health department.SyphilisSyphilis is an STI caused by the bacterium Treponemapallidum. It can have long‑term complications if notadequately treated. Syphilis has three stages. Primary: Characterized by presence of a chancre Secondary: Characterized by skin rashes, such as arash on the palms of hands and soles of feet Tertiary: Characterized by damage to internal organs Black, Hispanic, and other racial/ethnic minority groupsare disproportionately affected by syphilis in the U.S. It can be transmitted through oral, vaginal, or anal sex,as well as transmitted to an unborn child. Though therate of congenital syphilis has recently decreased, morecases of congenital syphilis are reported in the U.S. thancases of perinatal HIV infection. All pregnant women should be screened at the firstprenatal visit and rescreened in the third trimester if athigh risk (live in areas with high numbers of syphiliscases; not previously tested; or had positive test in thefirst trimester).Urine culture preferred for male clientsEndocervical culture preferred for female clientsCHAPTER 8 InfectionsCONTENT MASTERY SERIES

Human papilloma virusASSESSMENTRISK FACTORS Multiple partnersUnprotected sexual practicesEXPECTED FINDINGSPrimary stage: The client can notice a chancre or sore inthe genital area.Secondary stage: The client can notice skin rashes, suchas a rash on the palmar surface of the hands and the solesof the feet.Tertiary stage: Damage to internal organs can occur forwhich clients can notice the manifestations includingdifficulty coordinating muscle movements and blindness.PHYSICAL ASSESSMENT FINDINGS Primary stage: Provider can observe a chancre in thegenital area.Secondary stage: Provider can observe skin rashes, suchas rough, red or reddish brown spots on the palms ofthe hands and soles of the feet.LABORATORY TESTSSerology tests: Nontreponemal (VDRL and rapidplasma reagin) and treponemal (enzyme immunoassay,immunoassays) Nontreponemal tests are often used for screeningthen treponemal tests to detect antibodies specific forsyphilis to confirm the diagnosis. This sequence of nontreponemal then treponemal testsis considered the standard for testing.PATIENT‑CENTERED CAREMEDICATIONSPenicillin G IM in a single doseCLIENT EDUCATION Instruct the client to abstain from sexual contact untilsores have completely healed.Advise the client that partners need to be testedand treated.Educate the client regarding safe sex practices (e.g.,mutual monogamy and correct, consistent condom use.)All states have a reportable diseases list. Syphilis is acommonly reported condition. It is the responsibilityof the provider to report cases of these diseases to thelocal health department.RN MATERNAL NEWBORN NURSINGHPV is the most common STI. Some types can causegenital warts (also known as Condyloma acuminata)and cancers. It is spread through oral, vaginal, and anal sex(most commonly vaginal or anal routes). When large,widespread, or occluding the birth canal, genital wartscan complicate a vaginal delivery. Therefore, a cesareansection can be recommended. Routine screening for women 21 to 65 years old canprovide early detection. Screening should occur, evenduring pregnancy.ASSESSMENTRISK FACTORS Multiple partnersUnprotected sexual practicesEXPECTED FINDINGSClient reports bumps in the genital area that might notitch or hurt.PHYSICAL ASSESSMENT FINDINGS Small warts or a group of warts in the genital area thatcan have a cauliflower‑like appearanceAbnormal changes to the cervix that can detected by aPap testLABORATORY TESTSPap test with or without HPV co‑testing per AmericanCancer Society and American Congress or Obstetriciansand Gynecologists guidelines. Women 21 to 29 years old should have a Pap test every3 years. Women 30 to 65 years old should have both a Pap testand an HPV test every 5 years (preferred). It is alsoacceptable to have a Pap test alone every 3 years. Women older than 65 years who have had regularscreenings with normal results should not be screenedfor cervical cancer, unless they have cervical precancer,in which they should continue to be screened for20 years after the precancer diagnosis.DIAGNOSTIC PROCEDURES Genital warts are diagnosed by the provider basedon appearance.Based on the Pap test result, colposcopy and biopsy canbe performed to diagnose cervical precancer and cancer.CHAPTER 8 Infections51

PATIENT‑CENTERED CAREPHYSICAL ASSESSMENT FINDINGS MEDICATIONS For genital warts and Condyloma acuminata, optionsinclude a client‑applied cream, such as imiquimod, or aprovider‑administered therapy, such as trichloroaceticacid application.THERAPEUTIC PROCEDURESFor precancerous changes on the cervix, the providercan perform treatments including laser therapy or conebiopsy; for a pregnant woman with an abnormal Papthat requires further follow‑up, further evaluation andtreatment are usually deferred until after birth. Discharge in the vaginal vault, which can be sampledfor microscopyStrawberry spots on the cervix (tiny petechiae)A cervix that bleeds easilyLABORATORY TESTSA sample of the discharge is used for application to pHpaper, and wet mount and whiff test performedDIAGNOSTIC PROCEDURES pH greater than 4.5Wet mount saline prep indicates the presence oftrichomonad(s).Whiff test can be positive or negative.CLIENT EDUCATION Vaccines are recommended to protect against low‑risktypes of HPV that cause genital warts and high‑risktypes of HPV that cause cancer. The vaccine is indicatedfor clients 9 to 26 years of age, though ideally given atage 11 to 12 years.Educate clients regarding safe sex practices (e.g., mutualmonogamy and correct, consistent condom use).TrichomoniasisTrichomoniasis is a STI caused by the protozoan parasiteTrichomonas vaginalis. It can be spread penis‑to‑vagina orvagina‑to‑vagina. If trichomoniasis is left untreated in women, it can leadto PID, which can cause infertility. All women who haveclinical findings should be tested. Pregnant women who have trichomoniasis are morelikely to have preterm delivery and babies with lowbirth weight (less than 5.5 lb).ASSESSMENTRISK FACTORS Multiple partnersUnprotected sexual practicesEXPECTED FINDINGSMale Female 52MEDICATIONSMetronidazole or tinidazole: Orally in a single dose;anti‑infectiveCLIENT EDUCATION Counsel the client to avoid alcohol while taking thismedication due to the disulfiram‑like reaction thatoccurs (severe nausea and vomiting).Instruct the client to take all medication as prescribed.Educate the client about the possibility of decreasingeffectiveness of oral contraceptives.Identify and treat all sexual partners.Educate the client regarding safe sex practices (e.g.,mutual monogamy and correct, consistent condom use).Bacterial vaginosisA bacterial infection most commonly caused byHaemophilus vaginalis or Gardnerella vaginalis. It is the mostcommon vaginal infection in women 15 to 44 years of age.It cannot be related to sexual activity. If BV is left untreated, it can increase a woman’schances of developing PID, which can lead to infertility.All women who have manifestations should be tested. Treatment is especially important for pregnant women.BV is associated with preterm labor and babies with lowbirth weight (less than 5.5 lb).Penile itching or irritationDysuriaPHYSICAL ASSESSMENT FINDINGS: Urethral discharge,which can be swabbed for microscopy PATIENT‑CENTERED CAREYellow‑green, frothy vaginal discharge with foul odorDyspareunia and itchingDysuriaCHAPTER 8 InfectionsASSESSMENTRISK FACTORS New or multiple sex partnersUnprotected sexual practicesAltered pH balance of vagina, such as causedby douchingCONTENT MASTERY SERIES

EXPECTED FINDINGSEXPECTED FINDINGSThin, white or gray discharge with a fish‑like odor,especially after sexVulvar and vaginal pruritusPHYSICAL ASSESSMENT FINDINGS: Discharge in thePHYSICAL ASSESSMENT FINDINGS vaginal vault, which can be sampled for microscopy LABORATORY TESTS Sample of the discharge used for application to pH paperWet mount and whiff test performedDIAGNOSTIC PROCEDURES pH greater than 4.5Wet mount saline prep indicates presence of clue cellsPositive whiff test Thick, creamy, white, cottage cheese‑likevaginal‑dischargeVulvar and vaginal erythema and inflammationWhite patches on vaginal wallsGray‑white patches on the tongue and gums (neonate)LABORATORY TESTS Sample of discharge used for application to pH paperWet mount and whiff test performedDIAGNOSTIC PROCEDURES PATIENT‑CENTERED CARE pH less than 4.5 (normal pH)Wet mount potassium hydroxide prep indicates presenceof yeast buds, hyphae, and pseudohyphae.Negative whiff testMEDICATIONSPATIENT‑CENTERED CAREMetronidazole: Anti‑infectiveCLIENT EDUCATION Counsel the client to avoid alcohol while taking thismedication due to a disulfiram‑like reaction (severenausea and vomiting).Instruct the client to take all medications as prescribed.Educate the client about the possibility of decreasingeffectiveness of oral contraceptives.Treatment is not usually indicated for male partners.Educate the client regarding safe sex practices (e.g.,mutual monogamy and correct, consistent condom use).Instruct the client to avoid tight‑fitting clothing.Instruct the client to wear cotton‑lined underpants.Advise the client to avoid douching.CandidiasisCandidiasis, also known as vulvovaginal candidiasisor yeast infection, is a fungal infection caused byCandida albicans. It is the second most common type of vaginal infectionin the U.S. All women who have symptoms should be tested.MEDICATIONSFluconazole Can be prescribed as a single low doseTopical therapies recommended for use inpregnant‑womenAntifungal agentFungicidal actionOver‑the‑counter treatmentsOTC treatments, such as clotrimazole, are available totreat candidiasis. However, it is important for the providerto diagnose candidiasis initially.CLIENT EDUCATION Instruct the client to avoid tight‑fitting clothing.Instruct the client to wear cotton‑lined underpants.Instruct the client to limit wearing damp clothing.Advise client to avoid douching.Instruct the client to increase dietary intake of yogurtwith active cultures.ASSESSMENTRISK FACTORS PregnancyDiabetes mellitusOral contraceptivesRecent antibiotic treatmentObesityDiet high in refined sugarsRN MATERNAL NEWBORN NURSINGCHAPTER 8 Infections53

Application Exercises1.A nurse is admitting a client who isin labor and has HIV. Which of thefollowing interventions should thenurse identify as contraindicated forthis client? (Select all that apply.)A nurse is caring for a client who hasgonorrhea. Which of the followingmedications should the nurseanticipate the provider will prescribe?A. CeftriaxoneA. EpisiotomyB. FluconazoleB. Oxytocin infusionC. MetronidazoleC. ForcepsD. ZidovudineD. Cesarean birthE. Internal fetal monitoring2.3.4.A nurse in an antepartum clinicis assessing a client who has aTORCH infection. Which of thefollowing findings should the nurseexpect? (Select all that apply.)A nurse is caring for a client whois in labor. The nurse shouldidentify that which of the followinginfections can be treated duringlabor or immediately followingbirth? (Select all that apply.)A. GonorrheaA. Joint painB. ChlamydiaB. MalaiseC. HIVC. RashD. Urinary frequencyD. Group B streptococcusbeta‑hemolyticE. Tender lymph nodesE. TORCH infectionPRACTICE5.A nurse manager is reviewingways to prevent a TORCHinfection during pregnancywith a group of newly licensednurses. Which of the followingstatements by a nurse indicatesunderstanding of the teaching?A. “Obtain an immunizationagainst rubella earlyin pregnancy.”B. “Seek prophylactic treatmentif cytomegalovirus is detectedduring pregnancy.”C. “A woman shouldavoid crowded placesduring pregnancy.”D. “A woman should avoidconsuming undercookedmeat while pregnant.”Active Learning ScenarioA nurse is planning care for a client who is pregnant and positivefor group B streptococcus beta‑hemolytic. Use the ATI ActiveLearning Template: System Disorder to complete this item.LABORATORY TESTS: Describe the test and when it is performed.RISK FACTORS: Describe two maternal risk factors and three fetal risk factors.MEDICATIONS: Describe three clients who shouldreceive intrapartum antibiotic prophylaxis.54CHAPTER 8 InfectionsCONTENT MASTERY SERIES

Application Exercises Key1. A. CORRECT: An episiotomy should be avoided for a client whois HIV‑positive due to the risk of maternal blood exposure.3. A. CORRECT: Ceftriaxone IM or doxycycline orally for7 days is prescribed for the treatment of gonorrhea.B. Oxytocin infusion is not contraindicated for this client.B. Fluconazole is used to treat candidiasis.C. CORRECT: The use of forceps during delivery shouldbe avoided due to the risk of fetal bleeding.C. Metronidazole is used in the treatment ofbacterial vaginosis and trichomoniasis.D. Cesarean birth is not contraindicated for this client.D. Zidovudine is used to treat HIV/AIDS.E. CORRECT: Internal fetal monitoring should beavoided due to the risk of fetal bleeding.NCLEX Connection: Pharmacological and Parenteral Therapies,Medication AdministrationNCLEX Connection: Reduction of Risk Potential, Potential forComplications from Surgical Procedures and Health Alterations4. A. CORRECT: Erythromycin is administered to the infant immediatelyfollowing delivery to prevent Neisseria gonorrhoeae.B. CORRECT: Erythromycin is administered to the infant immediatelyfollowing delivery to prevent Chlamydia trachomatis.2. A. CORRECT: TORCH infections are flu‑likein presentation, such as joint pain.B. CORRECT: TORCH infections are flu‑likein presentation, such as malaise.C. CORRECT: Retrovir is prescribed to aclient in labor who is HIV‑positive.C. CORRECT: TORCH infections can include findings such as a rash.D. CORRECT: Penicillin G or ampicillin may beprescribed to treat positive GBS.D. Urinary frequency is not a clinical findingassociated with a TORCH infection.E. A TORCH infection can be treated duringpregnancy depending upon the infection.E. CORRECT: TORCH infections are flu‑like inpresentation, such as tender lymph nodes.NCLEX Connection: Reduction of Risk Potential, Potential forComplications from Surgical Procedures and Health AlterationsNCLEX Connection: Health Promotion and Maintenance,Ante/Intra/Postpartum and Newborn Care5. A. Immunization against rubella is contraindicated duringpregnancy due to the risk of fetal congenital anomalies.B. There is no treatment for cytomegalovirus.C. A TORCH infection cannot be transmitted by beingin areas where large crowds are present.D. CORRECT: Toxoplasmosis, a TORCH infection, iscontracted by consuming undercooked meat.NCLEX Connection: Reduction of Risk Potential, Potential forComplications from Surgical Procedures and Health AlterationsPRACTICEAnswerUsing the ATI Active Learning Template: System DisorderLABORATORY TESTS: Vaginal and rectal cultures performed at 36 to 37 weeks of gestationRISK FACTORSMaternalHistory of positive culture withprevious pregnancyMaternal age less than 20 yearsAfrican American or Hispanic ethnicityFetalPositive during pregnancyProlonged rupture of membranesPreterm deliveryLow birth weightUse of intrauterine fetal monitoringIntrapartum maternal fever (38 C [100.4 F]) MEDICATIONSClient who has GBS bacteriuriaduring current pregnancyClient who has a GBS‑positivescreen during current pregnancyClient who has unknown GBS status who isdelivering at less than 37 weeks of gestationClient who has maternal feverof 38 C (100.4 F)Client who has rupture ofmembranes for 18 hr or longer NCLEX Connection: Reduction of Risk Potential, Potential for Complications from SurgicalProcedures and Health AlterationsRN MATERNAL NEWBORN NURSINGCHAPTER 8 Infections55

Preterm labor and delivery Chorioamnionitis Infections of the urinary tract Maternal sepsis LABoRAtoRY tests Vaginal and rectal cultures are performed at 35 to 37 weeks of gestation. PATIENT‑CENTERED CARE nURsInG cARe Administer intrapartum antibiotic prophylaxis to the following clients.