FAMILIES EXAM 2

On the arm recoil test on the Ballard Scale the greater the degree of ______ the closer to term? A. flexion B. extension

flexion, the difference between a 3 and 4 is not the degree of flexion but the force of recoil

The eyes of a preterm infant may be _____. They will get a score of -1 if lightly fused and -2 if tightly fused?

fused

The Ballard Scale (modified dubowitz) is used to determine _______ ? It is done at ___ hour of age and again at __ hours?

gestational age (physical/neurological maturity)

Galante's reflex?

hold infant upside down and stroke down along one side of spine. The infant will turn to side that he is touched on.

crawl reflex?

infant will crawl when placed on stomach

Both SGA and LGA have increased risk for?

meconium aspiration and hypoglycemia

At 1 minute after birth the nurse assesses the infant and notes: a heart rate of 80 beats/min, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. The nurse would calculate an Apgar score of: a. 4 b. 5 c. 6 d. 7

b. 5. Each of the five signs the nurse noted would score a 1 on the Apgar scale, for a total of 5.

Dolls eyes reflex?

babies eyes will open when you pull him up into a standing position just like a dolls

In GTPAL A is for Abortion, which is before _____ weeks

before 20 weeks

In GTPAL P is for Preterm, which is _____ weeks or more.

between 20 weeks and 37 weeks

A primipara who is breastfeeding asks: "why am I having so much cramping? I thought this only happened to women who have had babies before."

"Afterpains" (after-birth-pains) are caused by contractions of the uterus in response to oxytocin release that is triggered by nipple stimulation during breastfeeding. Oxytocin receptors on the uterus respond to oxytocin by causing contractions. Afterpains are typically mild in first time moms (primipara's).

Ballard Scores: Lowest score -10, 20 weeks gestation Score of 20, 32 weeks gestation Score of 40, 40 weeks gestation Score of 50, 44 weeks gestation

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NEW

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The popliteal angle is measured by holding the newborns pelvis on the table and the infants thigh against their abdomen. Then lift up the heal and measure the angle formed by the knee joint.

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Why is bladder distention more common in the immediate post part period?

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LOCHIA RUBRA

0-3 days

THE 7 B'S GO IN A CEPHALO-CAUDAL SEQUENCE. WHAT IS THE ORDER?

1) BRAIN 2) BREASTS 3) BELLY 4) BLADDER 5) BOTTOM 6) BLOOD 7) BOWELS 8) EXTREMETIES

LOCHIA ALBA

10 days-3-4 weeks

normal heart rate range is ______ bp

110-160 normal sound is toc-tic

Normal respiratory rate is between _____ and ___?

30 and 60 breaths per minute

The normal axillary temperature range is?

36.5-38 C (97.7-100.4 F)

The T in GTPAL stands for the # of term infants born at ___ weeks or more?

37

In GTPAL T is for Term, which is ______ weeks or more.

37 weeks or more

A pregnant woman is the mother of two children. Her first pregnancy ended in a still birth at 32 weeks of gestation, her second pregnancy with the birth of her daughter at 36 weeks, and her third pregnancy with the birth of her son at 41 weeks. Using the 5-digit system to describe this woman's current obstetric history, the nurse would record ____________________________.

4-1-2-0-2 Gravida (the first number) is 4 since this woman is now pregnant and was pregnant 3 times before. Para (the next 4 numbers) represents the outcomes of the pregnancies and would be described as: 4T: 1 = Term birth at 41 weeks of gestation (son) 4P: 2 = Preterm birth at 32 weeks of gestation (stillbirth) and 36 weeks of gestation (daughter) 4A: 0 = Abortion: none occurred 4L: 2 = Living children: her son and her daughter

LOCHIA SEROSA

4-10 days

A boy was born 1 minute ago. He is crying vigorously with his extremeties well flexed. His body color is pink and the extremities are blue. The heart rate is 138. What is his Apgar score at one minute? Indicate score for each component.

8 Heart rate->100 is 2 Respiratory-Crying vigorously is 2 Muscle tone-well flexed is 1? (active motion is 2 now) Reflex irritability-Cough, sneeze or vigorous cry is 2 Color-Body pink extremities blue is 1 8

A newborn male, estimated to be 39 weeks of gestation, would exhibit: extended posture when at rest. A. testes descended into scrotum. B. abundant lanugo over his entire body. C. ability to move his elbow past his sternum. D. The newborn's good muscle tone will result in a more flexed posture when at rest.

A A full-term male infant will have both testes in his scrotum and rugae on his scrotum. The newborn will exhibit only a moderate amount of lanugo, usually on his shoulders and back. The newborn would have the inability to move his elbow past midline.

Which of the following are parts of the neuromuscular assessment? A. Scarf sign B. Popliteal angle C. laying supine D. Square window E. Arm recoil F. Heal to ear

A,B,C,D,E,F

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is: A. vision. B. hearing. C. smell. D. taste.

A-vision The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.

A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity using the GTPAL system? a. 2-0-0-1-1 b. 2-1-0-1-0 c. 3-1-0-1-0 d. 3-0-1-1-0

c. 3-1-0-1-0 G=Gravida=# pregnancies (pregnant 3 times) P=Parity ("giving birth") explained by TPAL T=# Term infants (1 still birth at 38 wks gestation) P=# Preterm infants (0) A=# Abortions: spontaneous or elective (1 spontaneous abortion at 14 wks gestation) L=# of Living children (0)

For ________ you would place the newborn skin to skin with his mother, for __________ you would delay the bath

conduction, convection

Plantar surface is another physical assessment in the Ballard scale. At term there are ______ over the entire plantar surface?

creases/wrinkles

The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a: A. tonic neck reflex. B. Moro reflex. C. cremasteric reflex. D. Babinski reflex.

B Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the head to the side. These actions show the Moro reflex. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.

When caring for a newborn, the nurse must be alert for signs of cold stress, including: A. decreased activity level. B. increased respiratory rate. C. hyperglycemia. D. shivering.

B Infants experiencing cold stress would have an increased activity level. An increased respiratory rate is a sign of cold stress in the newborn. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: A. begin an IV infusion of Ringer's lactate solution. B. assess the woman's vital signs. C. call the woman's primary health care provider. D. massage the woman's fundus.

D The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from an impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician should be notified after the nurse completes assessment of the woman. The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: A. place her on a bedpan to empty her bladder. B. massage her fundus. C. call the physician. D. administer Methergine, 0.2 mg IM, which has been ordered prn.

B There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.

The priority nursing intervention for a woman who suffered a perineal laceration is to: A. apply a cold compress. B. establish hemostasis. C. administer analgesia. D. administer a stool softener.

B Bleeding should be stopped first. After bleeding has been controlled, the care of the woman with lacerations of the perineum includes analgesia administration, hot or cold applications, and stool softeners. Stool softeners may be used to assist the woman in reestablishing bowel habits without straining and putting stress on the suture lines.

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern since the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by: A. telling the mother not to worry since all breastfed babies have this type of stool. B. explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. C. asking the mother what she ate at her last meal. D. suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.

B This type of stool is the first stool that all newborns, not just breastfed babies, have. At this early age this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. The mother's nutritional intake is not responsible for the appearance of meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

The newborn's nurse should alert the health care provider when which newborn reflex assessment findings are seen? (Select all that apply.) A. Newborn turns head toward stimulus when eliciting rooting reflex. B. Newborn's fingers fan out when palmar reflex checked. C. Newborn forces tongue outward when tongue touched. D. Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited. E. Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect.

B-This is not a normal finding The baby's fingers should curl around the examiner's fingers when eliciting the palmar reflex. When eliciting rooting reflex, the characteristic response is for the baby to turn head toward stimulus and open mouth. Extrusion is elicited by touching tongue, and newborn's tongue is forced outward. The newborn should elicit symmetric abduction and extension of the arms and fingers form a "C" with the Moro reflex. The Babinski reflex is elicited by stroking upward along the lateral aspect on the sole of the feet. The expected response is hyperextension of the toes with dorsiflexion of the big toe.

Describe in order the steps of the maternal physical assessment after a vaginal birth?

BRAIN, BREAST, BELLY, BLADDER, BOTTOM, BLOOD, BOWELS, EXTREMITIES

LGA has increased risk for?

Birth trauma and hyperbilirubinemia

Which postpartum infection is most often contracted by first-time mothers who are breastfeeding? A. Endometritis B. Wound infections C. Mastitis D. Urinary tract infections (UTIs)

C Endometritis is the most common postpartum infection. Incidence is higher after a cesarean birth and not limited to first-time mothers. Wound infections are also a common postpartum complication. Sites of infection include both a cesarean incision and the episiotomy or repaired laceration. The gravidity of the mother and her feeding choice are not factors in the development of a wound infection. Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are first-timers who are breastfeeding. UTIs occur in 2% to 4% of all postpartum women. Risk factors include catheterizations, frequent vaginal examinations, and epidural anesthesia.

Excessive blood loss after childbirth can have several causes; however, the most common is: A. vaginal or vulvar hematomas. B. unrepaired lacerations of the vagina or cervix. C. failure of the uterine muscle to contract firmly. D. retained placental fragments.

C Although vaginal or vulvar hematomas are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although retained placental fragments is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.

Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse would suspect: A. bladder distention. B. uterine atony. C. constipation. D. hematoma formation.

D-Correct Bladder distention would result in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony would result in a boggy fundus. Constipation is unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.

When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: A. massage the fundus. B. administer Methergine, 0.2 mg PO, that has been ordered prn. C. assist the woman to empty her bladder. D. recognize this as an expected finding during the first 24 hours following birth.

C-empty bladder A firm fundus should not be massaged since massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case since it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. This is not a normal finding, and an action is required.

At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as________.

Correct Responses: "9"

Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse suspects: A. bladder distention B. uterine atony C. constipation D. hematoma formation

D Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony results in a boggy fundus. Constipation is unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.

The blink reflex?

Flash light in babies face...he will blink and immediately reopen his eyes

A woman reports 2 pregnancies, one born at 38 weeks and died at 6 months, and another pregnancy that ended in miscarriage at 8 weeks?

G2 P1010

A woman whop has been pregnant twice ending in 2 first semester abortions is G__P___?

G2P0, Gravida 2 Para 0

A woman delivers one living child at 28 weeks, has 2 first trimester pregnancy losses, one loss at 24 weeks and has one adopted child

G4 P0221

A pregnant woman reports 5 previous pregnancies: 1 full term live birth, 1 full term still birth 1 live preterm birth and 2 spontaneous abortions.

G6 P2122

Normal blood pressure?

Greater than 50/30

The Babinki reflex?

elicited by stroking the plantar surface of the foot from heel to toe. Hyperextend toes and dorsiflex great toe while fanning the toes outward.

4 mechanisms of heat loss

evaporation, radiation, convection and conduction

A pregnant woman's last menstrual period began on April 8, 2009, and ended on April 13. Using Nägele's rule, her estimated date of birth would be________.

January 15, 2010. Nägele's rule requires subtracting 3 months and adding 7 days and 1 year if appropriate to the first day of a pregnant woman's last menstrual period. When this rule is used with April 8, 2009, the estimated date of birth is January 15, 2010.

The Ballard score looks at hair. By term there is usually no _______ remaining. In preterm infants there will be more.

Lanugo

There is potential for Rh sensitization if mother is Rh__ and infant is Rh ____?

Mother Rh- with infant Rh+

After a baby is born suction the ________ before the _________? A. Nose B. Mouth

Mouth then nose

What information should you have prior to meeting the client?

Name, age, parity labor and birth history, type of delivery, complications Episiotomy or laceration, repaired or not # of hours or days since delivery V.S. (BP, TPR-Temperature, Pulse, Respiration)

One of the last assessments is EXTREMITIES, which involves looking for Homan's sign. What is Homan's sign?

Pain in calf upon dorsiflexion of the foot

Square window measures the degree of the angle between the palm and forearm at the wrist. The wrist of a ______ infant will resist flexion while that of a _______ infant will allow it to fold flat?

Preterm (resists the square window) term (folds flat)

SGA has increased risk for _______ ?

Respiratory distress syndrome

A baby hears a loud noise and pulls her legs and arms up and her arms shake and go to the midline of the body. What is happening.

This is the startle reflex. It is present at birth and complete response may be seen until 8 weeks. As soon as the amniotic fluid drains from the ears the babies hearing is similar to that of an adult.

The chest of a preterm will have no visible signs of breast formation and no palpable buds? T/F

True

The newborn receives a direct antibody test while the mother receives an indirect antibody test? A. True B. False

True

There is a potential for ABO incompatibility if the mother is type ___ and the infant is A, B or AB?

Type O mother and Type A, B or AB infant

A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity using the GTPAL system? _____.

orrect Responses 3-1-0-1-0 Using the GPTAL system, this woman's gravidity and parity information is calculated as follows: G: Total number of times the woman has been pregnant (she is pregnant for the third time) T: Number of pregnancies carried to term (she has one stillborn) P: Number of pregnancies that resulted in a preterm birth (she has none) A: Abortions or miscarriages before the period of viability (she has had one) L: Number of children born who are currently living (she has no living children)

The Babinki reflex is reversed as a child matures and becomes the opposite reflex called the ____?

plantar reflex-toes curl down

______ has cracked skin over entire body?

post-term

A woman who is pregnant for the first time

primigravida

Diastasis is the separation of the ________ muscle?

rectus abdominus

The physical assessments of the Ballard scale include the skin. A very premature infant will have _____ skin?

red sticky

Moro reflex?

responds to sense of falling. He will fling arms outward and then pull them inward as if grasping something like a tree trunk

During the exam on the male genitalia you should look for _____ at term ?

rugae

With the infant supine reach the arm across the chest. Points are assigned based on where the elbow rests in relation to the midline. This is called the

scarf sign

Increased red bleeding indicates?

subinvolution or PPH

At ____ the pinna of the ear is stiff and resists folding?

term

The first part of the Ballard Scale tests the infant by having them lay, resting in the supine posture. A ______ infant will lay with arms flexed while a _____ infant will lay with arms and legs extended.

term, preterm

What is Vernix caseosa?

vernix is a thick cheesy substance made of sebum and sloughed skin cells. It is present in preterm infants.

What question will you ask each client?

what time she last voided and what time she last changed her pad