NCLEX REVIEW- Maternity
A client who had a vaginal birth 1 hour ago has a boggy fundus that is deviated to the left and above the umbilicus. Which intervention should the nurse perform first?
Assist client to use the bedpan to void
A fetus is in an occiput posterior lie. What is the term for this type of labor?
Back labor
Late decelerations
Bad -placental insufficiency LION position changes intravenous fluid- lactate ringer oxygen/stop oxytocin notify the HCP
Types of contraception, examples
Barrier, Hormonal, Intrauterine devices, Natural methods, Surgical
Which recommendation is the American Cancer Society's (ACS) guideline for the early detection of breast cancer?
Beginning at age 40, receive a yearly mammogram
Postterm
Born after completion of 42 weeks gestation At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor.
placenta previa
Bright red vaginal bleeding PAINLESS
A woman seen in the emergency department is diagnosed with primary syphilis. What finding is most likely?
Chancres at the vaginal site
Dinoprostone (Cervidil)
cervical ripening agent in the form of a vaginal insert that is placed in the posterior fornix of the vagina may cause hypotension, nausea/vomiting, diarrhea, and temperature elevation.
medication would be included in the plan of care for a newborn with acute neonatal abstinence syndrome who is not responding to conservative nursing approaches
morphine sulphate
Endometrosis
most common cause of dysmenorrhea
persistent occiput posterior position
most common fetal malposition and occurs when the fetus does not rotate but is born in the occiput posterior position *reports of severe back pain*
eclampsia
most serious form of toxemia during pregnancy
The nurse is caring for a client who has had a right-modified radical mastectomy this morning. Which exercise should the nurse encourage the client to perform this evening?
movement of the fingers and wrists of the right arm
Risk factors for development cancer of the cervix
multiple sex partners, first partner prior to age 20, early childbearing, exposed to HPV, HIV infection, smoker, low socioeconomic status
Which finding is indicative of hypothermia of the preterm neonate?
nasal flaring
Which fetal lie is considered to be unstable?
oblique
The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?
"Circumcision has been delayed to save tissue for surgical repair."
A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be appropriate?
"Do you plan to have any other children?"
The nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client should alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?
"I need to gain only 10 pounds so that my baby will be small like I am."
The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?
"I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."
A perinatal client with a history of heart disease has been instructed on care at home. Which statement made by the client would indicate the need for further teaching?
"It is best to rest on my right side."
The nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which response made by the student indicates an understanding of the function of this hormone?
"It maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus."
The nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client makes which statement?
"My cervix is completely dilated."
The nurse attempts to encourage a new mother to understand and to accept the cesarean section that was necessary to deliver her baby, rather than to focus on the surgical aspect of the procedure. Which nursing statement would provide the best encouragement?
"Tell me about the delivery of your baby."
A client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has placed a strain on the husband-wife relationship. Which statement by the nurse indicates an understanding of the problem?
"You feel you are having difficulty fulfilling your role as a wife."
The nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is in which position?
1 cm above the ischial spines
A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks?
12 to 16
A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior the nurse should suspect the client is how far dilated?
8 to 10 cm
The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount?
500 calories per day
A perinatal client is at risk for toxoplasmosis. Which instruction should the nurse reinforce with the client to prevent exposure to this disease?
Avoid exposure to litter boxes used by cats.
The nurse is collecting data from a prenatal client. The nurse determines that which places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?
A history of intravenous (IV) drug use in the past year
The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated?
A manual pelvic examination
The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding should the nurse expect to note in a healthy breast-feeding mother and newborn?
A mother breast-feeding with the newborn in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow
The nurse is reinforcing instructions to a new breast-feeding mother. Which factor is important to promote an effective and positive learning experience?
A positive nurse-client relationship
The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which?
A softening of the cervix
The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which findings would place the client at risk for preterm labor?
A urinary tract infection
The goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should perform which action?
Administer anticoagulants as prescribed.
The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action?
Ambulate frequently.
A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Which assessment would be part of the plan of care?
Any bleeding, such as in the gums, petechiae, and purpura
The nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?
Ask the client to urinate and empty her bladder.
The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.
Ballottement Chadwick's sign Uterine enlargement Braxton Hicks contractions
The nurse is assisting in caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could do which?
Cause hemorrhage.
A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint which should the nurse do first?
Check for signs of thrombophlebitis.
The nurse is caring for a client in labor. The nurse reviews the health care provider's prescriptions and notes that the client has a prescription for butorphanol tartrate. The nurse understands that the action of this medication is to have which effect?
Decrease pain.
The nurse is assigned to care for a primigravida who is having a precipitate delivery. Which maternal finding does the nurse expect to note?
Decreased periods of uterine relaxation between contractions
The nurse is caring for the nullipara woman in labor. The nurse understands that the health care provider must be contacted if which condition becomes apparent?
Decreased periods of uterine relaxation between contractions
A primigravida's membranes rupture spontaneously. Which action should the nurse take first?
Determine the fetal heart rate.
A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn 2 hours ago. The mother's temperature is 100° F (38° C). What is the initial nursing action?
Encourage oral fluid intake.
The nursing student is preparing to instill a medication into the eyes of a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication for the prophylaxis of ophthalmia neonatorum and gonococcal infection. The student correctly identifies which medication?
Erythromycin
In the prenatal clinic, the nurse is gathering data from a new client for the health history information. Which action is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?
Establish a therapeutic relationship between the nurse and pregnant client.
The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time?
Fear about what is happening
The nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted?
Fetal tachycardia
most important instruction for the mother of a preterm infant for gavage feeding is
Gastric residual present
A pregnant client is positive for the human immunodeficiency virus (HIV). Based on this information, the nurse makes which determination?
HIV antibodies are detected on the enzyme-linked immunosorbent assay (ELISA) test.
The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?
Have the client empty her bladder.
The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, which nursing action would be the most appropriate?
Have the mother place the infant in the bassinet and assist the mother in dressing the baby.
A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which problem does the data best support?
High risk for infection
The nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which action is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia?
Increase the frequency of breast-feeding.
A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following an assessment, tuberculosis is suspected. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum. The nurse reinforces instructions to the client regarding therapeutic management of tuberculosis. Which statement is included in therapeutic management?
Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months.
A pregnant client in the prenatal clinic states that her last menstrual period (LMP) began April 5 and ended April 12. According to Nägele's rule, which would be the estimated date of delivery (EDD)?
January 12
The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2016. Using Nägele's rule, the nurse determines the estimated date of birth is which?
July 27, 2017
A woman with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?
Macrosomia
The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse should include which in the plan of care?
Maintain continuous electronic fetal monitoring.
The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV) positive. The nurse understands that which should be included in the plan of care?
Maintaining standard precautions at all times while caring for the neonate
The maternity nurse prepares the client for which techniques commonly used to relieve shoulder dystocia?
McRoberts' maneuver
The nurse is reviewing the record of a client in the labor room. The nurse midwife noted the following documentation. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?
Minus (-) 1 station
The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?
Notify the physician
A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse should monitor this client for which symptom of this complication?
Oozing from injection sites
The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. The nurse collects data, knowing that in this condition, the viscera are in which location?
Outside of the abdominal cavity but covered with a translucent sac
The nurse is reinforcing instructions to a pregnant client regarding measures that will strengthen the perineal floor muscles. Which should the nurse include in the instructions?
Perform Kegel exercises in 10 repetitions, three times per day.
The nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should take which action?
Place the client in a supine position and place a wedge under the right hip.
After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of which condition?
Placental separation
A new mother is attempting to breast-feed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breast-feeding the newborn?
Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp.
A client has just experienced a precipitate delivery. The nurse observes that the mother is lying quietly in bed and touches the infant only briefly and occasionally. How should the nurse be most therapeutic in this situation?
Provide support to the mother.
Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. Which action is appropriate to deliver the placenta?
Pull gently on the cord as the mother bears down.
A client who consumes alcohol frequently is in the first trimester of pregnancy. Which is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption?
Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structures
The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?
Side-lying
The nurse is collecting data from a client with placenta previa during an office visit. The nurse should check which item as first priority?
Signs of fetal distress
The nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse should document which expected changes?
Slowed pulse rate and elevated blood pressure
The nurse caring for a client who is receiving oxytocin (Pitocin) for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding which is the nurse's priority action?
Stop the oxytocin infusion.
A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation?
The client is required to stay on bed rest.
A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching?
The client is wearing knee-high hose.
The nurse is providing education to the client with gestational diabetes who was recently placed on insulin therapy. Which information should the nurse tell the client about insulin needs during the second and third trimesters of pregnancy?
The insulin needs will increase.
The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate?
The neonate cries incessantly.
The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented finding is unassociated with this disorder?
The passage of bloody mucous stool
In caring for a preterm newborn's skin, which special characteristics should the nurse expect to note?
Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture
A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what?
To regain her breathing pattern
A client in the prenatal clinic presents with a blood pressure reading of 134/90 mm Hg, which is an elevation from last month's reading of 104/66 mm Hg. Which additional sign or symptom suggests to the nurse that the client has mild preeclampsia?
Trace amount of protein
The nurse is working with a woman who has just been diagnosed with gestational diabetes mellitus. The nurse informs the client of which issues that may occur during this pregnancy because of this condition? Select all that apply.
Urinary tract infections Increased chance of cesarean birth Delayed lung maturation in the neonate
The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body area, knowing that venous congestion is commonly noted in which area?
Vulva
The nurse is preparing a client for an emergency cesarean delivery. Which information regarding the client has priority?
When was the last time the client ate or drank?
A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week? Fill in the blank.
week 5
A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which treatment should the nurse consider to be safe for this client?
Laser therapy
A pregnant client asks the prenatal clinic nurse what the fetal period of development means. Which is correct information about the fetal period?
Longest period of fetal development
The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action?
Keep the client in a side-lying position.
The nurse is assigned to care for a client admitted with severe preeclampsia. Which is the priority nursing intervention for this client?
Minimizing the client's exposure to external stimuli
The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse should tell the client that these exercises are for which purpose?
Strengthen the pelvic floor in preparation for delivery.
After a precipitate delivery, the nurse notes that a new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which action first to help the woman process what has happened?
Support the mother no matter what her reaction is to the newborn.
A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?
Tell the client that these are common and they may occur throughout the pregnancy.
Which should be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care?
Tell the dental office staff that she is pregnant.
Signs and symptoms of severe preeclampsia
Pitting edema Blurred vision Severe headache Oliguria .3 g or more in a 24 hour urine specimen 3+ deep tendon reflexes
fibrocystic breast disease have an increased risk of developing
breast cancer
Papanicolaou test would be done to rule out
cervical cancer
The presence of genital warts (condyloma) increases the risk of developing
cervical cancer
HPV vaccine prevents
cervical cancer and genital warts
Only true diagnostics of true labor is
cervical effacement and dilation
Fibroadenoma
mobile, firm well-delineated lumps 1.5 cm in diameter, freely movable, asymptomatic, single tumor near the nipple or in the upper outer quadrant
a fetus' head has sutures that are not fused at the time of birth. This is because the head is
moldable in order to fit through the passageway
The estrogen content in the contraceptive pill
suppresses follicle-stimulating hormone (FSH)
Episiotomy
surgical incision of the perineum to enlarge the vagina and so facilitate delivery during childbirth
fourth stage of labor/recovery stage
1-4 hours after delivery of the placenta time of maternal physiologic adjustment
Once menarche has occurred cycles may take up to
2 years to become regular, ovulatory cycles
The postmenopausal client reveals that it has been several years since her last gynecological examination and states "Oh, I don't need that anymore. I am beyond having children." What should the nurse response be?
"There are situations other than pregnancy that should be checked"
Which signs are most indicative of true labor?
*pain in lower back that moves to lower abdomen *progressive cervical effacement and dilation *regular and rhythmic contractions that increase in frequency *contractions become more intense with walking
Risk factors for breast cancer
- Age - Gender - Personal and Family History - Benign Breast Disease - Genetic mutations of BRAC1 and BRAC2 - Increased tissue density - Early Menarche & Late Menopause - Nullparity - HRT after menopause - Late age when giving birth - Radiation exposure - DES exposure in utero - Alcohol use - Diet
Leopold's Maneuvers steps
- Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? - Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) - Maneuver 3: What is the presenting part? - Maneuver 4: Is the fetal head flexed and engaged in the pelvis?
Military fetal attitude
-associated with a larger diameter, which makes passageway harder
Ovary cancer risk factors
-hx of ovarian cancer among close relatives -hx of breast cancer -hx of never having children
Partial extension fetal attitude
-on vaginal exam, the brow will be felt -also associated with a larger diameter which makes passageway harder
Complete extension fetal attitude
-on vaginal exam, the face will be felt -very difficult to deliver babies vaginally in this position
signs and symptoms of bacterial vaginosis
-white vaginal discharge with a fishy odor -some itching and irritation of vaginal opening -50% are asymptomatic
Latent Phase
0-6cm dilation 0-40% effacement 5 - 10 minutes - contraction frequency 30 - 45 seconds - contraction duration mild to palpation - contraction intensity
signs of true labor
1. Bloody show: mucus and blood 2. Water breaking: amniotic sac rupture 3. True labor contractions- increased frequency, intensity and duration 4. Cervix- dilation and effacement
Cardinal movements of labor
1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External Rotation 7. Expulsion
3 stages of lochia
1. Lochia rubra- deep-red mixture 3- 4 days- small clots are expected 2. Lochia serosa - pink-brown 3 - 10 days 3. Lochia alba- creamy white or light brown 10 - 14 days but can lead to 3 to 6 weeks postpartum in some women
Which questions would help determine if the client is in true labor?
1. do you feel like the contractions are getting stronger? 2. does anything you do make the pain better? 3. do the contractions feel the same when lying down? 4. how frequent are the contractions? 5. where do you feel the contraction pain most?
Spermicide should be inserted into the vagina
10 to 15 minutes prior to the client having intercourse
CD4 T-cell count at or below
200 cells/mm3 (0.2 × 109/l) indicates the development of AIDS
The nurse is concerned that the newborn is hypoglycemic. Which blood glucose level would support the nurse's intervention?
30 mg/dl (1.67 mmol/l)
Active labor
6-10cm dilation 40-100% effacement 2-5 minutes - contraction frequency 45 - 60 seconds - contraction duration moderate to palpation - contraction intensity
neonate can actually see object at
8 to 10 inches (20 to 25 cm) distance
uterine involution process
4-5 weeks post parturition lochia endometrial lining becomes epithelized
Gonorrhea
A bacterial STIs that usually affects mucous membranes Gonococcal infections can be completely eliminated by drug therapy.
The client who is four months pregnant finds a lump in her breast and the biopsy is positive for stage II cancer of the breast. Which treatment would the nurse anticipate the HCP recommending to the client?
A modified radical mastectomy
Biophysical profile
A test that assess five variables; fetal breathing, fetal movement, fetal tone, amniotic fluid volume, and fetal reaction
HELLP syndrome
A variant of gestational hypertension where hematologic conditions coexist with severe preeclampsia and hepatic dysfunction. signs- elevated LDH, AST, ALT, BUN, bilirubin, low platelet, low hematocrit
What intervention should the nurse implement for a client diagnosed with a rectocele?
Administer a stool softener daily Increase fiber intake Increase oral fluid
Syphills
An STI that attacks many parts of the body and is caused by a bacterium called a spirochete.
Six hours after a vaginal delivery, the nurse notes the perineal pad is soaked and there is blood underneath the client's buttocks. Which action does the nurse take first?
Assess the fundus, then massage the fundus if its soft and boggy
Precipitous dilation (dilatation) is cervical dilation that occurs at a rate of
5 cm or more per hour in a primipara or 10 cm or more per hour in a multipara.
Peri-care during postpartum period
Cleaning - squeeze bottle with warm water - wipe front to back - blot perineum dry Pain - Sitz baths - Ice packs - Opioids & NSAIDS - Topical witch hazel - Stool softeners to prevent constipation
A client 6 weeks postpartum, which findings is normal for this client?
Creamy colored discharge with a fleshy odor
The client has undergone a wedge resection for caner of the left breast. Which discharge instruction should the nurse teach?
Don't lift more than five pounds with the left hand until released by the HCP
Clients who have had PID are prone to which complication?
Ectopic pregnancy
Common findings with postpartum blues
Emotional lability, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger
During the third stage of labor and delivery (placental delivery), you do what two things?
Ensure the placenta is intact Check for three vessels - 2 arteries and 1 vein High risk for Infection- if placenta parts are not fully removed Uterine inversion - if pulling on the cord Severe hemorrhaging- decreasing BP and increasing heart rate
complete breech
Fetus is sitting with legs crossed in pelvis.
Client delivered a baby 8 hours ago, the fundus is boggy and softs. Which interventions are most appropriate?
Firmly massage the fundus Encourage the client to void Administer Methergine per order
Signs and symptoms of trichomoniasis
Frothy, malodorous; pruritus; possible vaginal irritation; dysuria green/yellow discharge pH > 4.5
Interventions during the fourth stage of labor
Fundus check first Void or use catheter )in and out) Pitocin/Oxytocin: Intravenously or intramuscularly to control bleeding after childbirth Breastfeeding: stimulate release of natural oxytocin
Pharmacology after placental delivery
Give Pitocin/Oxytocin- to prevent hemorrhage Oxytocin stimulates uterine contractions.
Patients with bacterial vaginosis can become infected with
HIV and other STIs more easily than uninfected women, because of the change in the normal flora of the vaginal area
cause of condylomata
HPV
Early decelerations
Head pressed on. This is ok.
Which specific complication would the nurse assess for in the client with a uterine prolapse recovering from an anterior and posterior repair?
Homans' sign - due to lithotomy position during surgery which can cause DVT
The nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a student to identify the structure where fertilization of an ovum takes place. Which identified by the student indicates an understanding of this process?
In the fallopian tube
Low risk pregnancy requires what dose of iron and folic acid per day
Iron 27 mg per day Folic acid 400 to 800 mcg per day
Most favorable fetal position
LOA
cervical cap
Left in for 6 hours after intercourse and not used during menses because of risk of toxic shock syndrome Spermicidal allergies are contraindications for the cervical cap. Does not protect against sexually transmitted infections. follow-up Papanicolaou test 3 months after beginning to use the cap.
The nurse is assessing a client who delivered a baby 3 days ago. When assessing the lochia, the nurse notes pink discharge with a serosanguinous consistency. This is best described as
Lochia serosa
The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip?
Maternal vital signs
Clomiphene citrate
Medication used to induce ovulation.
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which additional sign would be consistent with fetal alcohol syndrome (FAS)?
Microcephaly and increased respiratory effort
Molding
Overlapping of the soft skull bones
Which drug is used for treating a client with severe postpartum bleeding?
Oxytocin
Common Gynecologic Concerns
Pain or impaired comfort, vaginal discharge, bleeding, urinary elimination problems associated with gynecologic concerns, impact on sexuality
Signs and symptoms of syphilis
Painless ulcers, sores, vaginal discharge, small bump or ulcers. Chancre, fever, rash, stroke, nervous system deterioration. fatigue, itching, rashes on palms and soles, sore throat, swollen lymph nodes, weight loss
Syphillis treatment
Penicillin G
A client who gave birth vaginally with epidural anesthesia reports no urge to urinate 3 hours after birth. The client's fundus is above the umbilicus, but 3 cm to the right. What should the nurse do next?
Perform in and out catheterization
The client diagnosed with cancer of the uterus is scheduled to have radiation brachytherapy. Which precautions should the nurse implement?
Place the client in a private room Wear a dosimeter when entering the room Notify the nuclear medicine technician
A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which intervention should the nurse implement at this point?
Place the infant in an elevated position.
5 P's of Labor
Powers, passenger, passageway, psychology, position
Which hormone decreases just before labor?
Progesterone
If the fetus was found to have its head presenting at the cervix, was facing the right side, and had most of its weight shifted forward, what would the RN document in the EMR?
ROA
The client has been diagnosed with cancer of the breast. Which would be the most appropriate referral for the nurse to make?
Reach to recovery- this is a program specifically for breast cancer
health history with a couple who are experiencing subfertility will include
Sexual history Medication history General Health Surgical history
A woman seen in the emergency department is diagnosed with PID. Before discharge, the nurse should provide the woman with health teaching regarding
Sexually transmitted infections STIs
Effacement
Shortening and thinning of the cervix- measured in percentages 0-100%
During the fourth stage of labor/recovery stage
Skin-to-skin and breastfeeding encouraged. Breastfeeding stimulates maternal oxytocin release, which helps contract the uterus and as well provide nourishment and support the blood sugar for the mother.
To tell of how engaged a fetus is is known as:
Station
Characteristic of postpartum panic disorders
Sudden terror and a sense of impending doom
Omphalocele
The abdominal contents are contained within a thin, transparent sac.
A client frequently finds lumps in her breasts, especially around her menstrual period. Which information should the nurse teach the client regarding breast self-care?
The client should practice breast self-examination monthly. Check breast 7 days after menstruation
Gastroschisis
The exposed intestines appear reddened and swollen and have no sac around them.
frank breech
The fetal legs are flexed at the hips and extend toward the shoulders; this is the most common type of breech presentation. The buttocks present at the cervix
Lightening
The movement of the fetus down into the pelvis late in pregnancy.
Which STIs is characterized by a foul smelling, yellow-green discharge that is often accompanied by vaginal pain and dyspareunia?
Trichomoniasis
True labor vs False labor
True: regular, rhythmic contractions that intensify with ambulation, pain in abdomen sweeping around from back, cervical changes. False: Irregular rhythm, abdominal pain (not in back) that decreases with ambulation
methylergonovine
Used for retained placental fragments Contraindicated in patients with hypertension
flexion attitude
When the chin approaches the chest - it is a good attitude for fetal delivery
A client presents to the emergency department after her water broke. She appears anxious and in pain, bearing down with each contraction. What assessment questions should the nurse ask immediately to prepare for birth and potential newborn resuscitation?
When your water broke, what was the color of the fluid? What is your expected due date (EDD)? How many babies are you expecting? Do you have any active sexually transmitted disease? Recently, have you taken any medications, opioids, or illicit drugs?
Bacterial Vaginosis (BV)
a condition in women in which there is an abnormal overgrowth of certain bacteria in the vagina
Uterine atony would be manifested by
a noncontracted uterus.
If the nurse reports that the fetus is engaged and at station -1, the fetus is:
above the ischial spines
Primary amenorrhea is defined as
absence of menses by age 15, with absence of growth and development of secondary sexual characteristics absence of menses by age 16, with normal development of secondary sexual characteristics
abstinence is the only way to
actually prevent pregnancy and STI contraction
Syphilis (crosses placenta, when?)
after 16weeks
Trichomoniasis
an STD caused by a microscopic protozoan that results in infections of the vagina, urethra, and bladder
Pudendal block
an anesthetic administered to block sensation around the lower vagina and perineum
Fourth stage of labor, early sign of excessive blood loss
an increased pulse rate of 88 to 102 beats per minute
Client reports intense back pain- fetal position is right occiput posterior. Which intervention would help alleviate the back pain during early labor?
applying counterpressure to the sacrum during contractions
The Condylomata acuminata (common genital warts)
are contagious STIs usually on the anus, vulva, penis, thighs, and/or perineum. The lesions usually are moist, soft, red or pink not curable, and are identified by appearance, not culture. Genital herpes is not curable and is identified by the appearance of the lesions or cytologic studies.
Diaphragms
are placed directly in front of the cervical opening.
If a nurse reports that the fetus is engaged and at station 0, the fetus is:
at the level of the ischial spines
progesterone increases
basal body temperature permeability of cervical mucus and endometrial proliferation.
Frequency of contractions is measured from
beginning of one contraction to beginning of the next contraction
Duration of a contraction is measured from
beginning to end of one contraction
second stage of labor
begins with complete cervical dilation and effacement and ends with the delivery of the newborn crowning occurs during this stage pelvic phase- period of fetal descent perineal phase- period of active pushing 10cm dilation 100% effacement 2-3 minutes or less - contraction frequency 60-90 seconds - contraction duration strong to palpation - contraction intensity
If the nurse reports that the fetus is engaged and at station +2, the fetus is:
below the ischial spines
Depo-Provera/Medroxyprogesterone acetate
birth control for 3 months, Progestin Contraceptive, given intramuscularly (injectable), treats dysfunctional uterine bleeding can cause dark patches on the skin- use sunscreen whenever in the sunlight contraindicated in patients with breast cancer and in pregnant women
fertility awareness methods
birth control methods that use the signs of cyclic fertility to prevent or plan conception
Displaced fundus is due to
bladder distension
Cephalohematoma
bleed that does NOT cross suture lines
Hypoglycemia in a neonate is defined as
blood glucose value typically below 35 to 45 mg/dl (1.94 to 2.50 mmol/l).
Hematoma would present as a localized
bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding.
Transient tachypnea of the newborn (TTN) commonly occurs in newborns born via
cesarean birth. The newborn does not experience the compression of the thoracic cavity that occurs with passage through the birth canal, so he or she retains some fluid in the lungs that usually squeezes out as the thoracic area is compressed during a vaginal birth.
syphilis 1
chancre/genital ulcer
Jessica is in the hospital preparing to give birth. She is experiencing severe back pain and irregular contractions. It is determined that her fetus is in ROP lie. Which intervention should the nurse attempt to relieve pain/pressure?
change mothers position to be laying on her left side provide counter pressured. administer IV pain medications
Fibrocystic breast changes
characterized by lumps, pain or tenderness and nipple discharge bilaterally as a result of thickening of the breast
A laboring client reports anxiety, vomiting and the need to have a bowel movement. What is the expected cervical examination finding?
client is at 8 - 10 cm dilated, 100% effaced
Discharge teaching for client recovering from an abdominal hysterectomy
client should report any persistent vaginal bleeding or cramping to the surgeon
Late preterm infants may have more
clinical problems compared with full-term infants
Hepatitis B can be a life-threatening infection that is contracted by
contact with blood as well as sexually
intrauterine device (IUD)
contraceptive device inserted into the uterus that prevents implantation of a fertilized egg it can remain in place for a year or more
Variable decelerations
cord compression
placenta abruptio
dark red vaginal bleed. uterine pain , uterine tenderness, uterine rigidity.
The diagnosis of syphilis is done using
dark-field microscopy or serologic tests.
protracted labor pattern
delayed descent of the fetal head
dystocia
difficult labor and childbirth it is diagnosed after labor has progressed for a time.
caput succedaneum
diffuse edema of the fetal scalp that crosses the suture lines. reabsorbs within 1 to 3 days
What is the proper vaginal exam nomenclature?
dilation/effacement/station
Bloody show
dislodging of thick cervical mucus plug at end of pregnancy, which is a sign of beginning of labor
characteristics of contractions can be determined via an external fetal monitor
duration frequency fetal heart rate
Risk factors for endometriosis
early menarche, nulliparity, prolonged menses, mullerian anomalies, FH in 1st degree relative, autoimmune inflammatory disorders
Chlamydia can cause
ectopic pregnancy
All clients who have had PID need to be informed of the signs and symptoms of
ectopic pregnancy because they are prone to this complication.
Condoms are
effective ways to decrease the potential of pregnancy and limit the spread of STIs
During the early period following a right modified radical mastectomy, which nursing action would be appropriate to include in the client's plan of care?
elevate the right arm on pillows to promote drainage
Tamoxifen is
estrogen-dependent breast tumors in premenopausal women
Causes of primary menorrhea
extreme weight gain or loss congenital abnormalities of the reproductive system stress excessive exercise eating disorders Cushing disease polycystic ovary syndrome hypothyroidism Turner syndrome imperforate hymen chronic illness pregnancy cystic fibrosis congenital heart disease ovarian or adrenal tumors
The fetal heart rate is heard most clearly at the
fetal back
Assessments during second stage of labor
fetal heart rate before, during and after the contractions frequency of contractions duration of contractions uterine tone between contractions
What is considered to be the passenger in labor?
fetus
Normal fundus should be
firm midline level with the umbilicus
sentinel lymph node
first node that receives draining from a body area suspected of having a tumor reduces the need for extensive lymph node dissection for pathologic examination
Most ideal fetal attitude
flexion
Next menses
fourteen days before the next period is expected
Fourth stage of labor, client's perineal pad saturated with blood and blood soaked into the bed linen. Which is the nurse's initial action?
gently massage the uterine fundus
A client in latent labor receiving an oxytocin infusion for labor augmentation is requesting IV pain medication. Which nursing action is appropriate?
give the medication slowly during the peak of the next contraction
long-term hormone replacement therapy increased the risks of
heart attacks, strokes, breast cancer
Assessments for the mother during the fourth stage of labor
infection: temperature over 100.4 after 24 hours of delivery (not good) Hemorrhage- decreasing blood pressure and increasing heart rate (not good)
An infant who is diagnosed with meconium aspiration displays which symptom?
intercostal and substernal retractions respiratory distress
Braxton Hicks contractions
irregular prelabor contractions of the uterus Decrease in intensity with ambulation
Postpartum depression is characterized by a client feeling that life
is rapidly tumbling out of control.
The nurse is educating a group of adolescent women regarding sexually transmitted infections. The nurse knows that learning was achieved when a group member states that the most common sign/symptom of sexually transmitted infections is
lack of signs or symptoms- in women STIs are usually asymptomatic
To diagnose endometriosis is through
laparoscopy
sign of retained placental fragments causing bleeding
large uterus with painless, dark red blood mixed with clots
Which supportive care measure for back labor pain?
lean over a birth ball with knees on the floor
The American Academy of Pediatrics recommends intervening for a blood glucose
less than 40 mg/dl (2.25 mmol/l) in the first 4 hours of life, and less than 45 mg/dl (mmol/l) at ages 4 hours to 24 hours.
Feto-pelvic Relationships
lie attitude. position. presentation.
ovary cancer sites of metastasis
liver, lung, peritoneum
Client gave birth three hours ago, a sudden gush of blood from the vagina while ambulating. Which is the most likely cause of the bleeding?
lochia has pooled in the client's vagina
If the fetus was determined to be breech, which fetal lie is it in?
longitudinal
If the fetus was determined to be vertex, which fetal lie is it in?
longitudinal
carcinoma of the breast
malignant tumor of the breast
Lower back pain/back labor shows that the fetus is mostly in
occiput posterior position OP - oh poop, not good intervention: apply counterpressure to the sacrum during contraction reposition the mother on her hands and knees with birth ball and encourage position changes every 30-60 minutes
footling breech
one or both feet are present first at the cervix
What are the causes of amenorrhea?
ovarian failure congenital absence of the uterus and vagina GnRH deficiency constitutional delay of puberty
Which hormones increases before labor?
oxytocin prostaglandins
Profuse bleeding in a postpartum client, priority intervention is to
palpate the uterus, and massage it if it is boggy
The RN knows that fetal lie can be determined via:
palpation
What is a non-invasive way to determine the intensity of contractions?
palpation
Signs and symptoms of rectocele
pelvic pressure, flatus fecal incontinence, constipation, hemorrhoids
Medication for syphilis
penicillin G IM single dose
The relationship of an assigned area of the presenting part to quadrants of the maternal pelvis is known as:
position
Intervention during second stage of labor
positioning of the mother is priority- high fowlers, lithotomy or side lying Push properly
Though there are 5 P's of labor, which ones are we focusing more on?
powers passageway passenger
Causes of secondary amenorrhea
pregnancy, lactation, menopause, low body weight, malnutrition, anorexia, stress, chronic illness, hypothalamic-pituitary-ovarian dysfunction
Raloxifene is used to
prevent breast cancer, but not for used in post mastectomy
contraceptive for mothers breastfeeding
progesterone only
First stage of labor
progressive dilation of the cervix. -latent - early education and encouragement -active
carboprost
promotes contractions and is used for hemorrhage Contraindicated in patients with history of asthma due to the risk of bronchial spasms.
Rectocele
protrusion of the rectum due to weakness in the wall of the rectum
Brachytherapy
radiation therapy in which the source of radiation is implanted in the tissue to be treated
Nonstress test in pregnancy
reactive (normal) 15
fibrocystic breast changes teaching
reduce caffeine and salt intake and wear support bra
subfertility
reduced level of fertility characterized by unusually long time for conception
Fetal attitude
relationship of fetal head to the rest of its body
Fetal lie
relationship of the long axis of the fetus to the long axis of the mother
Station
relationship of the presenting part to the ischial spines
a postpartum client whose most recent assessment reveals a large, purplish area of edema on the left side of the perineum.
report finding to HCP promptly
Appropriate task to delegates to the unlicensed assistive personnel (UAP)
reposition an unmedicated client who is in active labor onto a birthing ball
Neonates with hypothermia show signs of
respiratory distress - cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting
Sudden gush of liquid or constant leakage of fluid in a pregnant woman?
ruptured membrane
Montgomery's glands (tubercles)
sebaceous
Primary amenorrhea lead to
secondary sexual characteristics
third stage of labor
separation and delivery of placenta usually takes 5-10 minutes but may take up to 30 minutes Placental separation: detaching from uterine wall Placental expulsion: coming outside the vaginal opening
The warning signs to report for a client on Oral Contraceptive Pills are
severe abdominal or chest pain, dyspnea, headache, weakness, numbness, blurred or double vision, speech disturbances, severe leg pain and edema
S/S of back labor include
severe back pain irregular contractions slowly progressing labor
Pelvic infection is most commonly caused by:
sexual transmission
The second stage of labor
significant increase in contractions Ferguson reflex/fetal ejection reflex activated the client experiences a strong urge to bear down
neonate bowel is
sterile
Postpartum psychosis is characterized by clients exhibiting
suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the newborn, are present.
Secondary amenorrhea is
the absence of regular menses for three cycles or irregular menses for 6 months in women who have previously menstruated regularly
The client has has a total abdominal hysterectomy for cancer of the uterus. Which discharge instruction should the nurse teach?
the client should practice pelvic rest until seen by the HCP
A pregnant woman describes to her nurse that she has suddenly felt a "drop" and is now experiencing back discomfort and pressure within her pelvis. What is most likely happening?
the fetus has engaged
The RN knows that "lightening" occurs when:
the fetus has engaged
The biparietal diameter measures
the largest transverse diameter of the fetal skull
Uterine inversion would present with
the uterine fundus at or through the cervix.
McRoberts maneuver for shoulder dystocia
thighs flexed and moved away from the center of the body to open things up
Effacement
thinning of the cervix during labor
Condylomata acuminata
this condition puts the patient at higher risk for HPV
The client diagnosed with uterine cancer is complaining of lower back pain and unilateral leg edema. What is the scientific rational for these signs and symptoms?
this means that the cancer has spread to other areas of the pelvis - due to pain (pain is the last symptoms in cancer)
Pubic lice (crabs)
tiny parasitic insects that infest the genital area of humans the pubic hair should combed with fine tooth comb after shampoo is removed All clothing should be washed in hot water Sexual partner and family members should be treated
Women who use tampons are at risk for
toxic shock syndrome signs of TSS- diffuse rash with fever
If the fetus was determined to have shoulder presentation, which fetal lie are they in?
transverse
suprapubic pressure for shoulder dystocia
two hands, palm down just above symphysis pubis, *never fundal pressure* The provider will place firm pressure on the area just above the pubic bone to unstick the shoulder.
Lacerations typically present with a firm contracted uterus and a steady stream of
unclotted bright red blood.
A soft or boggy uterus indicates
uterine atony, which can result in increase risk for hemorrhage. Intervention is to infuse Oxytocin and massage the fundus
Signs of separation indicate that the placenta is ready to delivery
uterus rises upward umbilical cord lengthens sudden trickle of blood is released from the vaginal uterus changes its shape to globular
Human Papillomavirus (HPV)
viral sexually transmitted disease that causes genital warts and other symptoms
Treatment option for premenstrual syndrome
vitamin and mineral supplements NSAIDs reduction of caffeine intake
Expected during the transition of the first stage of labor
vomiting bloody mucus strong urge to have a bowel movement
When to report to the providers
when large cloths malodorous "foul odor" excessive bleeding: 1 pad in 15 minutes are noted.
In order to maintain perineal integrity, there are many things a provider can do; however, a woman should bear down
when she is ready and gets the sensation to, and the woman should participate in position changes
Dilation
widening, stretching, expanding of the cervix- measured in centimeters 0-10cm
pelvic laparoscopy
will be used to confirm the diagnosis of endometriosis
Signs and symptoms of herpes simplex 2/genital herpes
• Blisters or vesicles on and around the genitals • Painful urination • Watery discharge • Systemic symptoms: fever, headache, tender/swollen lymph nodes • within days, the blisters can evolve into painful, ulcer-like sores * flu-like symptoms
During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily with brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that the goal has been achieved when the client makes which statement?
"I am eating fresh fruits and vegetables for snacks and for dessert each day."
The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormone changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?
It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.
A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response would best support the client?
"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."
A pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. Which nursing response would best support the client?
"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."
A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement?
Massage the breasts before feeding to stimulate let-down.
The nurse is assisting in conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by taking which action?
Massaging the abdomen during contractions using both hands in a circular motion
A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that the primary hormone that stimulates postpartum contractions is which?
Oxytocin
The nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for further teaching regarding possible complications of preeclampsia?
"I should expect that my urine output will decrease."
The nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which statement indicates that the mother needs further teaching?
"I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."
During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. Which is the primary purpose of this action?
Assist in preventing dehydration and hypoxemia.
Which safety measures that should be implemented when working in the newborn nursery? Select all that apply.
Adhere to standard precautions. The parents should be instructed to not release their infant to anyone wearing improper identification. The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room.
The nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action is appropriate?
Encourage oral fluids.
A pregnant client who has gestational diabetes mellitus tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response would best support the client?
"The better control of your blood glucose means less effects; let's review your plan of care."
The nurse is providing emotional support to a client who experienced a spontaneous abortion. The nurse can best assist the client by planning care that focuses on which psychosocial issue?
The feelings of guilt that is often associated with grief
