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chapter 6INFECTIONS

PN MATERNAL NEWBORN NURSING 71

UNIT 1 ANTEPARTUM NURSING CARE

Section: Complications of Pregnancy

Chapter 6 Infections

Overview

● Maternal infections during pregnancy require prompt identification and treatment.Infections that may affect pregnant clients include HIV, TORCH infections, streptococcusß-hemolytic, Group B, chlamydia, gonorrhea, and Candida albicans.

HIV/AIDS

Overview ● HIV is a retrovirus that attacks and causes destruction of T lymphocytes. It causes

immunosuppression in clients. HIV is transmitted from mothers to the fetus perinatallythrough the placenta and postnatally to newborns through the breast milk.

● Routine laboratory testing in the early prenatal period includes testing for HIV. Earlyidentification and treatment significantly decreases the incidence of perinatal transmission.

● Testing is also recommended in the third trimester for clients who are at an increased risk.

● Use of internal fetal monitors, vacuum extraction, and forceps during labor should beavoided in clients who are HIV positive because of the risk of fetal bleeding.

● Injections and blood testing should not take place until the first bath is given to newbornsof mothers who are HIV positive.

Data Collection

● Risk Factors

◯ IV drug use

◯ Multiple sexual partners

◯ Bisexuality

◯ Maternal history of multiple STIs

◯ Blood transfusion (rare occurrence)

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72 PN MATERNAL NEWBORN NURSING

● Subjective Data

◯ Fatigue

●

Objective Data ◯ Physical assessment findings

■ Diarrhea

■ Weight loss

■ Anemia

◯ Laboratory tests

■ Testing begins with an antibody screening test such as enzyme immunoassay.Confirmation of positive results is confirmed by Western blot testing.

■ Screen clients for STIs such as gonorrhea, Chlamydia, syphilis, andhepatitis B.

■ Obtain frequent viral load levels and CD4 cell counts throughout the pregnancyof mothers who are HIV positive.

Collaborative Care

● Nursing Care

◯ Provide support prior to and after testing.

◯ Use standard precautions.

◯ Administer antiviral combination therapy as prescribed.

● Medications

◯ Retrovir (Zidovudine)

■ Antiretroviral agent

■ Nucleoside reverse transcriptase inhibitor

■ Nursing Considerations

☐ Start administration of retrovir after the first trimester and continue

throughout the pregnancy.

☐ Administer retrovir to newborns following delivery and for 6 weeksfollowing.

● Interdisciplinary care

◯ Request referral for clients to a mental health counselor, legal assistance, and financialresources if indicated.

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● Care After Discharge

◯ Client education

■

Instruct clients not to breastfeed. ■ Discuss safe sexual relations with clients.

● Client Outcomes

◯ The client will remain free from injury during pregnancy.

TORCH INFECTIONS

Overview

● TORCH is an acronym for a group of infections that can negatively affect women who arepregnant. These infections can cross the placenta and have teratogenic affects on the fetus.

Data Collection

● Risk Factors

◯ Toxoplasmosis is caused by consumption of raw or undercooked meat or handling catfeces.

◯ Rubella (German measles) is transmitted by droplet transmission of nasopharyngealsecretions of individuals who are infected. The virus is also present in blood, stool, andurine.

◯ Cytomegalovirus (member of herpes virus family) is transmitted by droplettransmission and is found in semen, cervical and vaginal secretions, breast milk,

placental tissue, urine, feces, and blood. Latent virus may be reactivated and causedisease to the fetus in utero or during passage through the birth canal.

◯ Herpes simplex virus (HSV) is spread by direct contact with oral or genital lesions.Transmission to the fetus is greatest during vaginal birth if the woman has activelesions.

● Subjective Data

◯

Toxoplasmosis symptoms similar to influenza or lymphadenopathy ■ Reports of malaise, muscle aches, (flu-like symptoms)

◯ Rubella

■ Reports of joint and muscle pain

◯ Cytomegalovirus is usually asymptomatic.

◯ Herpes simplex virus

■ Reports of dysuria, malaise, fever, chills and numerous painful genital lesions

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● Objective Data

◯ Physical assessment findings

■

Signs of toxoplasmosis include fever and tender lymph nodes. ■ Signs of rubella include rash, mild lymphedema, fever, and fetal consequences,

which include miscarriage, congenital anomalies, and death.

■ Herpes simplex virus initially presents with macules and papules that progress topurulent vesicles.

View Media Supplement: Herpes Simplex Type 2 (Image)


■ For herpes simplex, obtain cultures from women who have HSV or are at or nearterm.

◯ Diagnostic procedures

■ A TORCH screen is an immunologic survey that is used to identify the existenceof these infections in mothers (to identify fetal risks) or in newborns (detection of

antibodies against infections).

Collaborative Care

● Nursing Care

◯ Monitor fetal well-being.

◯ Educate clients on prevention practices including good hand hygiene and cooking

meat properly. ● Medications

◯ Administer antibiotics as prescribed.

◯ For toxoplasmosis treatment, include sulfonamides or a combination ofpyrimethamine and sulfadiazine (potentially harmful to the fetus, but parasitictreatment essential).

●

Care After Discharge ◯ Client education

■ Instruct pregnant clients with rubella to avoid groups of young children.

■ Encourage clients with low rubella titers to receive immunizations prior to theirnext pregnancy (usually done prior to discharge from the hospital after delivery).Clients need to wait 4 weeks after immunization to become pregnant.

■ Reinforce the need for clients to adhere to the complete prescribed treatment.

■ Provide clients with emotional support.

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● Client Outcomes

◯ Clients will be free of clinical findings indicating viral complications are affecting thepregnancy.

STREPTOCOCCUS BETA-HEMOLYTIC, GROUP B

Overview

● Streptococcus ß-hemolytic, Group B (GBS) is a bacterial infection that can be passed tonewborns during labor and delivery.

Data Collection

● Risk Factors

◯ History of positive culture with previous pregnancy

◯ Risk factors for neonatal GBS

■ Positive culture with pregnancy

■ Prolonged rupture of membranes ■ Preterm delivery

● Objective Data


■ Positive GBS may have maternal and fetal effects including premature ruptureof membranes, preterm labor and delivery, chorioamnionitis, infections of the

urinary tract, and maternal sepsis. ◯ Laboratory tests

■ Vaginal and rectal cultures are performed between 35 to 37 weeks of gestation.

Collaborative Care

● Nursing Care

◯ Administer prophylaxis antibiotics during labor. ● Medications

◯ Penicillin G or ampicillin (Principen) may be prescribed as intermittent IV bolus totreat positive GBS.



■ Instruct clients to monitor for signs of infection and to report to the provider.

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● Client Outcomes

◯ The newborn’s blood culture is negative for GBS with no clinical signs of sepsis.

CHLAMYDIA

Overview

● Chlamydia is a bacterial infection caused by Chlamydia trachomatis. It is the mostcommon STI. The infection is often difficult to diagnose because it is typicallyasymptomatic. According to current guidelines from the Centers for Disease Control andPrevention, all women and adolescents ages 20 to 25 who are sexually active should be

screened for STIs.

Data Collection

● Risk Factors


◯ Unprotected sexual practices

● Subjective Data

◯ Vaginal spotting

◯ Vulvar itching

● Objective Data


■ White, watery vaginal discharge


■ Endocervical culture

Collaborative Care

● Nursing Care

◯ Instruct clients to take the entire prescription as prescribed.

◯ Identify and treat all sexual partners.

◯ Retest clients who are pregnant in 3 weeks after completing the prescribed regimen.

● Medications

◯ Azithromycin (Zithromax), amoxicillin (Amoxil), and erythromycin (Ery-Tab) areprescribed during pregnancy.

■ Broad-spectrum antibiotic

■ Bactericidal action

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■ Nursing Considerations

☐ Administer 0.5% erythromycin ophthalmic ointment to all newbornsfollowing delivery. This antibiotic is both bacteriostatic and bactericidal,

thus it provides prophylaxis against Neisseria gonorrhoeae and Chlamydiatrachomatis.



■ Instruct clients to take all prescription as prescribed.

■ Educate clients about the possibility of decreasing effectiveness of oral

contraceptives. ● Client Outcomes

◯ The client will be free of clinical findings of infection.

GONORRHEA

Overview

● Neisseria gonorrhoeae is the causative agent of gonorrhea. Gonorrhea is a bacterialinfection that is primarily spread by genital-to-genital contact. However, it can also bespread by anal-to-genital contact or oral-to-genital contact. It can also be transmitted to aneonate during delivery. Women are frequently asymptomatic.

Data Collection

● Risk Factors


◯ Unprotected sexual practices

● Subjective Data (Male)

◯ Urethral discharge

◯ Painful urination

◯ Frequency

● Subjective Data (Female)

◯ Lower abdominal pain

◯ Dysmenorrhea

● Objective Data – Male/Female

◯ Physical assessment findings ■ Urethral discharge

■ Yellowish-green vaginal discharge

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■ Reddened vulva and vaginal walls

■ If gonorrhea is left untreated, it can cause pelvic inflammatory disease, heartdisease, and arthritis.


■ Urethral and vaginal cultures

■ Urine culture

Collaborative Care

● Nursing Care

◯ Provide clients education regarding disease transmission.

◯ Instruct clients to take the entire prescription as prescribed.

◯ Identify and treat all sexual partners.

● Medications

◯ Ceftriaxone (Rocephin) IM or azithromycin (Zithromax) PO

■

Given for 7 days ■ Broad-spectrum antibiotic

■ Bactericidal action



■ Instruct clients to finish all prescribed medications.

■ Instruct clients to repeat the culture to assess for medication effectiveness.

■ Educate clients regarding safe-sex practices.

● Client Outcomes


CANDIDA ALBICANS

Overview

● A fungal infection caused by Candida albicans.

Data Collection

● Risk Factors

◯ Diabetes mellitus

◯ Oral contraceptives

◯ Recent antibiotic treatment

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● Subjective Data

◯ Vulvar itching

● Objective Data


■ Thick, creamy white vaginal discharge

■ Vulvar redness

■ White patches on vaginal walls

■ Gray-white patches on the tongue and gums (newborns)


■ Wet prep

◯ Diagnostic procedures

■ Potassium hydroxide (KOH) prep

■ Presence of hyphae and pseudohyphae indicates positive findings

Collaborative Care ● Nursing Care

◯ Medications

■ Over-the-counter treatments, such as clotrimazole (Gyne-Lotrimin) or miconazole(Monistat), are available to treat candidiasis. However, it is important for theprovider to diagnosis candidiasis initially.



■ Administer medication as prescribed.

● Client Outcomes


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APPLICATION EXERCISES

1. A nurse is admitting a client in labor to the obstetrical unit. The client has a positive humanimmunodeficiency virus (HIV) status. Discuss the contraindications for this client.

2. A nurse in an antepartum clinic is providing care for a client. Which of the following clinicalfindings are suggestive of gonorrhea? (Select all that apply.)

Dysmenorrhea

Yellowish-green vaginal discharge

Reddened vulva

Malaise

Lower abdominal pain

3. A nurse is caring for a pregnant client diagnosed with chlamydia. Which of the followingmedications does the nurse anticipate the provider will prescribe? (Select all that apply.)

Ceftriaxone (Rocephin)

Azithromycin (Zithromax)

Amoxicillin (Amoxil)

Metronidazole (Flagyl)

Erythromycin (Ery-Tab)

4. A nurse is caring for a pregnant client diagnosed with human immunodeficiency virus (HIV).Which of the following medications does the nurse anticipate the provider will prescribe?

A. Ceftriaxone (Rocephin)

B. Retrovir (Zidovudine)

C. Metronidazole (Flagyl)

D. Tetracycline (Sumycin)

5. A nurse in an antepartum clinic is reviewing the laboratory reports of several clients. The nurseis aware that which of the following infections have medications that can be prescribed asprophylactic treatment during labor or immediately following delivery? (Select all that apply.)

Gonorrhea

Chlamydia

HIV

Group B Strep

TORCH

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APPLICATION EXERCISES ANSWER KEY

1. A nurse is admitting a client in labor to the obstetrical unit. The client has a positive human

immunodeficiency virus (HIV) status. Discuss the contraindications for this client.

Episiotomy is contraindicated for HIV-positive clients due to the risk of maternal bloodexposure. Additionally, the use of internal fetal monitors, vacuum extraction, and forcepsduring labor should be avoided because of the risk of fetal bleeding.

NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems

2. A nurse in an antepartum clinic is providing care for a client. Which of the following clinicalfindings are suggestive of gonorrhea? (Select all that apply.)

X Dysmenorrhea

X Yellowish-green vaginal discharge

X Reddened vulva

Malaise

X Lower abdominal pain

Symptoms of gonorrhea include reports of dysmenorrhea and lower abdominal pain.Objective findings include yellowish-green vaginal discharge and reddened vulva andvaginal walls. Malaise is not a clinical finding associated with gonorrhea.


3. A nurse is caring for a pregnant client diagnosed with chlamydia. Which of the followingmedications does the nurse anticipate the provider will prescribe? (Select all that apply.)

Ceftriaxone (Rocephin)

X Azithromycin (Zithromax)

X Amoxicillin (Amoxil)

Metronidazole (Flagyl)

X Erythromycin (Ery-Tab)

Azithromycin, amoxicillin, and erythromycin are prescribed during pregnancy to treat

Chlamydia.

NCLEX® Connection: Pharmacological Therapies, Expected Actions/Outcomes

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4. A nurse is caring for a pregnant client diagnosed with human immunodeficiency virus (HIV).Which of the following medications does the nurse anticipate the provider will prescribe?

A. Ceftriaxone (Rocephin)

B. Retrovir (Zidovudine)

C. Metronidazole (Flagyl)

D. Tetracycline (Sumycin)

Retrovir (Zidovudine) is prescribed for the treatment of HIV. Start administration ofretrovir after the first trimester and continue throughout the pregnancy. Additionally, it isprescribed to the neonate following delivery and for 6 weeks. Ceftriaxone (Rocephin) IM isprescribed for the treatment of gonorrhea. Metronidazole (Flagyl) is used in the treatment

of bacterial vaginosis and trichomoniasis. Tetracycline (Sumycin) is used to treat syphilis.


5. A nurse in an antepartum clinic is reviewing the laboratory reports of several clients. The nurseis aware that which of the following infections have medications that can be prescribed asprophylactic treatment during labor or immediately following delivery? (Select all that apply.)

X Gonorrhea

X Chlamydia

X HIV

X Group B Strep

TORCH

Erythromycin is the medication of choice for ophthalmia neonatorum. This antibioticis both bacteriostatic and bactericidal, thus providing prophylaxis against Neisseriagonorrhoeae and Chlamydia trachomatis. It is administrated to the neonate immediately

following delivery. Retrovir (Zidovudine) is prescribed to the client in labor who isHIV positive. It is also administered to the newborn following delivery and for 6 weeksthereafter. Penicillin G or ampicillin may be prescribed to treat positive GBS.


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