UNIVERSITY OF CEBU - BANILAD

Gov. M. Cuenco Ave, Cebu City, 6000 Philippines

College of Nursing
Telephone No: (032) 231- 8631

NCM 106 – Pharmacology

Course Outputs / Assessment of Learning for CILO # 1

Written Outputs (Mental Models, Group Activity and Reflection Journal)

CASE STUDY

Instruction: Briefly organize and bring together main ideas. Explain in your own words.
(50 – 100 words for each question)

I. TA (gravida 3, para 0) has a history of spontaneous abortion at 10 weeks gestation and a

preterm delivery and demise of a neonate at 21 weeks gestation. At her 28-week prenatal
visit, she reports increased clear vaginal discharge and feelings of pelvic pressure.
Examination of her cervix reveals 2-cm dilation and a presenting fetal part low in the pelvis.
TA is admitted to the hospital, and uterine activity is documented. Magnesium sulfate therapy
is ordered for treatment of preterm labor. The nurse prepares for IV magnesium sulfate
administration.

A. How will magnesium sulfate therapy be initiated? What intervals and dosages
should be anticipated?

Due to the client's history of spontaneous miscarriage and preterm birth, magnesium sulfate was
prescribed for its tocolytic properties. Magnesium sulfate reduces the uterine contractions by
lowering the intracellular calcium levels in uterine smooth muscle. Magnesium sulfate infusions
are started as a piggyback to a primary IV infusion (40 gm in 1 L) using an IV infusion controller
pump. For starting and increasing the dose of Magnesium sulfate, a baseline activity of the
woman and fetus, as well as serum magnesium levels, are taken into account. For intervals and
dosages of this drug that needs to be anticipated, the loading dosage of magnesium sulfate for its
tocolytic activity is 4 to 6 gm, given over 20 to 30 minutes. The maintenance dose of magnesium
sulfate is 1-4 g/hr. After 24-48 hours or if there are any symptoms of side effects, the infusion is
stopped. To avoid major side effects, total IV intake should not exceed 125 mL/hr.

B. What maternal and fetal side effects will the nurse expect to observe?
Magnesium sulfate is used in pregnancy to prevent seizures due to worsening
preeclampsia, to slow, stop preterm labor, and to prevent injuries to a preterm baby's
brain. However, like any other medication the nurse should expect to observe these
following effects upon TA’s ingestion of medication: Maternal side effects the nurse will
be expected to observe are confusion, decreased reflexes, dizziness, syncope,
arrhythmias, hypotension, flatulence, vomiting, muscle cramps, circulatory collapse,
flushing, dyspnea, hypocalcemia, respiratory depression or paralysis, diaphoresis. Other
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Gov. M. Cuenco Ave, Cebu City, 6000 Philippines
College of Nursing
Telephone No: (032) 231- 8631

side effects include allergic reaction, hypermagnesemia, injection site pain or irritation
(I.M. form), laxative dependence, magnesium toxicity, hypothermia. While fetal side
effects that the nurse will be expected to observe include fetal hypocalcemia, bone
abnormalities, fatal toxic syndrome, poor muscle tone, magnesium toxicity and low
APGAR scores.

C. What should TA be told about the drug effects she will experience?

Magnesium sulfate works as a tocolytic, reducing uterine contractions by lowering intracellular

calcium ions in the smooth muscle of the uterus. TA should be educated about the following drug
effects of the medicine (magnesium sulfate) so that they can anticipate and manage them. The
following mentioned below are the drug effects that TA will experience:

• Muscle weakness

• Hot flushes

• Blurred vision, Diplopia

• Short lived Hypotension

• Shortness of breath

• Headache, Nausea and vomiting

• Dry mouth

• Lethargy, Dizziness

• Local burning sensation at the site of administration

D. How would the nurse respond to TA’s questions about the risks of preterm
delivery?
After 24 hours of magnesium sulfate therapy, uterine contractions have been
reduced to two to three per hour. TA is to be discharged home, and the nurse is preparing
TA’s discharge teaching.

Preterm labor and premature delivery are caused by a number of risk factors,
some of which are "modifiable," To determine if a woman is at high risk for preterm
labor or birth, health care practitioners assess the following factors:

- Women who have delivered preterm before, who are considered to be at high risk
for preterm labor and birth.

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Gov. M. Cuenco Ave, Cebu City, 6000 Philippines
College of Nursing
Telephone No: (032) 231- 8631

- Being pregnant with the use of assisted reproductive technology is associated

with a higher risk of preterm labor and birth.
- Women with certain abnormalities of the reproductive organs are at greater risk
for preterm labor and birth than are women who do not have these abnormalities.
- Age of the mother.
- Medical conditions such as, UTI, STD’s, Placenta previa, hypertension, Diabetes,
and blood clotting problems.
- Certain lifestyle and environmental factors, including: smoking, drinking alcohol,
using illegal drugs, domestic violence, including physical, sexual, or emotional
abuse, and stress.

E. What instructions should the nurse give TA about her activity and diet?

As TA's nurse, I would tell her to do the following: I would tell her that her activities
should be limited and that proper bed rest is suggested to avoid pre-term birth. Prolonged
bed rest, on the other hand, should be considered since it can cause dysphoria, bone
demineralization, weight loss, delayed postpartum recovery, sleeplessness, constipation,
stress, and muscle atrophy. Simultaneously, comfort measures such as comfortable beds
and a warm atmosphere are advised. For frequent bladder emptying, the bed or sofa
should be closer to the bathroom facilities. Boredom-busting activities such as reading,
watching television, and listening to music may aid in stress relief. Taking care of one's
personal hygiene and grooming. Encourage eating small, regular meals with high protein,
carbs, iron supplements, apple, flat drink, crackers, and dry toasts. Avoiding meals with
high fat content, as well as ginger. Finally, stay hydrated but not to the point of
dehydration.

F. TA asks whether the side effects of magnesium sulfate will continue. What is an
appropriate nursing response?

First and foremost, I would explain to TA that the magnesium sulfate side effects will no
longer occur because the majority of the adverse effects of magnesium sulfate are
temporary and disappear once the loading dosage is given. By that period, if ever TA
should be urged to report unacceptable side effects such chest discomfort, changed level
of consciousness, decreased urine output, significant reduction in blood pressure, and
decreased respiratory rate. In such circumstances, a 10% calcium gluconate solution is
given intravenously over 30 minutes to decrease the negative effects of magnesium
sulfate.

G. What signs and symptoms should TA be advised to report?

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Gov. M. Cuenco Ave, Cebu City, 6000 Philippines
College of Nursing
Telephone No: (032) 231- 8631

Any of the above-mentioned negative effects of magnesium sulfate medication should be

reported to the doctor in-charge. If signs and symptoms such as fever or increased pelvic
pressure appear, the client should report them. And if for an hour or longer, uterine
contractions occur every ten minutes; immediate report to the doctor is needed. Bleeding
or drainage from the cervix. Vaginal discharge changes, becoming mucoid, red or brown
in color, and smelling strange. Finally, if you get a sense that your membranes are about
to burst. If you see any of the following signs or symptoms, contact the physician in
charge right away. Because if timely care and treatment are not provided, the baby's and
the mother's lives may be compromised.

II. TA (gravida 3, para 0) is at 42 weeks’ gestation. At her prenatal visit, her health care
provider notes signs and symptoms of pregnancy-induced hypertension and advises TA
about a plan to induce labor after administration of prostaglandin gel. TA asks the
nurse, “Can you help me understand all of this?”
A. What objective tool (scoring system) can be used to predict the extent to which TA’s
cervix is “ripe” and therefore favorable for successful induction? TA’s health care
provider orders dinoprostone gel for use in the cervix.
The scoring system that will be utilized for TA’s condition is Bishop score. Bishop score
is the scoring tool used to identify the percentage of the cervix ripping/effacement. To
elaborate, a bishop score of >= 8 indicates the cervix is 'ripe' and hence posing a great
chance of vaginal delivery. On the other hand, a bishop score of <=6 indicates the cervix
is 'unripe' and hence posing a low chance of vaginal delivery.

B. What will be accomplished with use of the gel?

Prepidil gel or prostaglandin gel is used to soften and dilate the cervix. Prepidil is often
used several hours before pitocin can be administered to induce labor if needed. Prepidil
gel helps in the preparation of the cervix or the womb's lower opening for labor and
delivery. It is for women who are having a normal pregnancy and are nearing or past their
due date and need labor induction.
C. Who will administer the gel?
Prepidil or prostaglandin gel is administered by the attending OBGYNE. This medicine is
used to repair your cervix or lower uterine area for cuts and birth defects. Used by normal
pregnant women. This medicine is used to prepare your cervix or lower uterine area for
contractions and delivery. It is used by women who are normally pregnant and who are
near to their due date. In order to control the product properly, the patient should be on
lithotomy when the cervix is visualized using a speculum. Using a sterile method, inject
the gel through a catheter provided by the cervical canal just below the level of the
internal OS gel applied topically to the vagina. It is used using a syringe, by a health

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Gov. M. Cuenco Ave, Cebu City, 6000 Philippines
College of Nursing
Telephone No: (032) 231- 8631

professional in a hospital or clinic setting. After the dose is given you should lie on the
floor for up to 2 hours as directed by your doctor.

D. How often can the gel be administered?

An accurate vaginal examination is important to determine the percentage of the
effacement and to use the appropriate size endocervical catheter. Following the
procedure, patient is to remain in supine position for about 15-30 minutes to prevent
leakage from the cervical canal. The need to repeat dosing is usually determined by the
attending doctor based on the course of clinical findings. If there is no cervical/uterine
response to the initial dose of prepidil gel, 0.5 mg prostaglandins (dinoprostone) can be
repeatedly administered with a dosing interval of 6 hour.
E. How long after the last dose of gel can the IV oxytocic medication be started to
induce labor?
If the desired prepidil or prostaglandin gel administered is effective, an intravenous
oxytocin can be initiated with 6-12 hours. The prepidil cervix gel takes 6 to 12 hours to
ripen or soften the cervix. The uterus opens and endomyometrium ready to start labor
contractions. Oxytocin can be induced at this point.

F. Why is there a waiting period before starting the oxytocin?

To make sure that the cervix is fully dilated or ripened. When the cervix is fully dilated, it
is the time to administer oxytocin. The cervix gets soft (ripe) and begins to open (dilate)
and thin (efface) as the pregnancy progresses, preparing for labor and delivery. When
labor does not begin spontaneously and a vaginal birth is required quickly, labor may be
triggered artificially (induced). Oxytocin is a hormone that is often utilized in labor and
delivery units across the world. The most common time for oxytocin to be administered
to laboring patients is during the earliest stages of labor. First stage initiation is
considerably more prevalent than second stage initiation among people who get oxytocin.
Oxytocin is a hormone that is used to start labor, intensify uterine contractions, and
reduce postpartum hemorrhage.

G. Further questioning reveals that TA has been ingesting a pregnancy tonic that
includes herbal supplements since 36 weeks’ gestation. List three concerns specific
to pregnancy. It is 16 hours since TA first had the gel applied. Responding to her
call light, the nurse finds TA in the bathroom, upset because she feels nauseated and
is occasionally vomiting a little stomach fluid and complaining that her stool is
watery. “Is something wrong?” TA asks.

The following are the three concerns that is specific to TA’s pregnancy:

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Gov. M. Cuenco Ave, Cebu City, 6000 Philippines
College of Nursing
Telephone No: (032) 231- 8631

A. Many herbal supplements that consumed by pregnant client might pass through the
placenta and affect the well-being of the infant and cause a complication for the fetus.

B. Some herbal supplement has a negative effect on the hormone secretion and that lead to
danger to the fetus as well as the mother.

C. Liver metabolism and renal function change during pregnancy therefore we need to
closely watch when pregnant women take herbal medication since those two organs have
vital organ to deal with detoxification.

Furthermore, because nausea, vomiting, and diarrhea are recognized side effects of the
prostaglandin gel, TA must be reassured that nothing is amiss with her and that the symptoms
are solely due to the medicine she is taking.

H. Analysis of the data about TA’s symptoms supports what conclusion?

The three unfavorable side effects of prostaglandin gel include nausea, vomiting, and
diarrhea, which should be reported to the doctor right immediately. To elaborate the
analysis of TA’s symptoms, prostin E2 (dinoprostone) which is a vaginal suppository is a
hormone-like substance (prostaglandin) that the body makes in preparation for labor used
in a pregnant woman to relax the muscles of the cervix in preparation for inducing labor
at the end of a pregnancy. Overall, nausea, vomiting, diarrhea are the side effects of
prostaglandin gel. Other side effects that might occur may include fever, chills,
abdominal pain, flushing, and dizziness. If any of these effects persist or worsen, one
should alert the doctor or pharmacist promptly.
I. What nursing actions might be taken to support TA?
TA is at 42 weeks gestation and was given prostaglandin gel to help prepare her cervix
for labor and delivery. She is now experiencing diarrhea and vomiting, which are both
side effects of the drug. The appropriate nursing action at this time is to ensure that
patient will not be dehydrated from the current symptoms. It will be helpful to encourage
TA to increase oral fluid as much as possible, and if not tolerated, administer IV fluids as
ordered. Continue monitor vital signs to identify or recognized any further deterioration
or abnormalities in order to initiate timely treatments. It will also be beneficial for the
patient if the nurse will provide emotional support, encourage the patient to remain calm,
to prevent any unwanted consequences. Overall, the nurse has to check vital sign
frequently and do some nonpharmacological therapy like calm down the patient and
giving some oral fluid to rehydrate since she has diarrhea and vomiting.

J. When TA returns to bed and the external fetal monitor is reapplied, what data
should the nurse collect, record, and report to the obstetric provider? It is 24 hours
since TA had the first gel instillation and 6 hours since her last insertion. A vaginal

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Gov. M. Cuenco Ave, Cebu City, 6000 Philippines
College of Nursing
Telephone No: (032) 231- 8631

examination reveals that TA’s cervix is soft, 50% effaced, and 3 cm dilated and that
the presenting part is at 2 station. Contractions are 5 minutes apart and mild, and
the health care provider elects to begin an oxytocin infusion.

Fetal movements, fetal distress, partial placenta previa, borderline cephalopelvic

disproportion, hydramnios, fetal heart rate, cervical effacement, cervix dilation, nature
and duration of contractions, position of fetus/presenting part, and other TA should be
collected, recorded, and reported to the obstetric provider by the nurse. Apart from that,
the vital signs of TA, such as blood pressure, pulse, respirations, and temperature, should
be monitored and reported. This is because the mother's fluid volume has been decreased
owing to vomiting and diarrhea, the placental perfusion has been substantially affected,
causing the fetal heart rate to rise. This must be continuously monitored and IV fluid
administered to compensate for the volume loss. This procedure involves listening to and
recording your baby's heartbeat via your stomach with a gadget (abdomen). A Doppler
ultrasound instrument is one form of monitor. It's commonly used to count the baby's
heart rate during prenatal appointments. During labor, it can also be used to monitor the
fetal heart rate.

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