Question

4. A 28-year-old woman is at 34 weeks' gestation with her second child. At this prenatal visit, her blood pressure is extremely high and there are no audible fetal heart tones. Her obstetrician admits her for an emergency cesarean birth under general anesthetic. The baby boy is stillborn. Immediately after closure of the wound, the client starts to have excessive bleeding and clotting from her vagina and abdominal incision. The client is transferred to ICU and given 8 units of FFP and 6 units of platelets. a. Why does the ICU team need to determine the client's primary problem? b. Twenty-four hours after admission to the ICU, the client dies. Explain why this happened. 5. A 5-year-old boy has petechiae that suddenly appeared over his lower extremities. A 50-year-old female has purpura of the oral mucosa and vaginal bleeding. A 60-year-old man's platelet count is less than 20,000/uL post-cardiopulmonary bypass surgery. a. The nursing supervisor wishes to discuss these cases in rounds. What would be his/her approach? 6. The nurse has been asked to prepare a lecture on the similarities and the differences between hemophilia and von Willebrand disease. a. What should be included? 7. A 31-year-old woman has not received any prenatal care. She is single, is unemployed of low socioeconomic status, and has a seventh grade education. At 40 weeks' gestation, the client gives birth to a 5 pound, 2 oz female neonate, her second child. After birth, the nurse notes that the neonate is very jaundiced, has an enlarged, edematous abdomen, and is having difficulty breathing a. Discuss why the nurse would immediately bring the neonate to the neonatal intensive care unit. b. A student nurse who is assigned to the client and her neonate states, "If she only had cared for herself and the baby while she was pregnant." What elements of health promotion strategies for the client's situation would the nurse include in her explanation to the student?

Answer 1

Answer:4) - This patient seems to be suffering from pre-eclampsia.

The diagnostic criteria for pre-eclampsia are

1. Blood pressure > 140/90 beyond 20 weeks of gestation
2. Proteinuria - urinary protein levels > 300 mg in 24 urine sample or protein:creatinine ratio > 0.3mg/dl or dipstick 1+

a) The ICU team needs to determine the patient's primary condition in order to prevent complications. The most important complication in the mother is eclampsia, HELP syndrome ( Hemolysis, elevated liver enzymes and low platelet count), antepartum hemorrhage.

PIH can cause complications in the fetus as well

1. Stillbirth
2. Intrauterine growth retardation
3. Preterm birth.

b) The client died in this case, due disseminated intravascular coagulation(DIC). This evident from the fact that the patient developed excessive bleeding and this bleed was not responsive to FFP transfusion.

Answer 5)

A 5-year-old boy having petechiae all over his lower extremities is most probably suffering from Henoch-Schonlein purpura.

1. These patients are young (4-7yrs)
2. Have petechiae over the lower extremity. This results from IgA medicated small blood vessel vasculitis
3. Abdominal pain.

The 50-year old lady is suffering from idiopathic thrombocytopenic purpura. This condition is characterized by the presence of

1. Isolated low platelet count (i.e. WBC, RBCs are normal)
2. Mucocutaneous bleeds
3. Menorrhagia in women
4. Absence of hepatosplenomegaly.

The 50-year-old gentleman who has undergone cardiopulmonary bypass must have received heparin during the surgery.

Heparin is known to cause thrombocytopenia. Heparin promotes anti-platelet antibodies ( they are IgG type). These antibodies promote platelet aggregation and microthrombi formation.

The nurse must understand that there are multiple causes of thrombocytopenia. The patient's age, clinical examination features and history of drug exposure must be taken into consideration while narrowing down the diagnosis.

Answer 6

The similarities between hemophilia and von Willebrand disease (vWD)

• Normal prothrombin time
• Increased Activated partial thromboplastin time
• Normal bleeding time
• Normal platelet aggregation

The differences are

• Hemophilia is X-linked whereas vWD is autosomal dominant
• There is a deficiency of factor VIII in hemophiliac whereas there is a deficiency of Von Willebrand factor in the vWD
• Hemophiliac has joint, muscle bleed whereas patients with vWD have bleed in mucosa, skin.

Answer 7

The neonate is most likely suffering from gestational alloimmune liver disease.

In this condition, anti fetal IgG antibodies are transferred from the mother to the fetus. This activates inflammation in fetal liver.

One important factor that differentiates this disease from other causes of neonatal liver failure, is extrahepatic siderosis.

The reason why this child should be transfered to the neonatal ICU, so that iv immunoglobulins and exchange transfusion can be performed in the baby.

Exchange transfusion removes the IgG antibodies and i.v. immunoglobulin slows down the inflammation.

The nurse must inform the mother that,

• There is a high chance her next baby might suffer the same fate
• She should come for a regular antenatal visit in case she becomes pregnant again
• Antenatal transfusion of iv immunoglobulin in the mother helps to reduce fetal deaths.