NR327 ATI CMS/Final Exam Review
A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include?
"A Doppler device can detect your baby's heart rate at 12 weeks."
A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make?
"A progestin-only pill or injection is available for use while you are breastfeeding."
A nurse is teaching a client who is postpartum and breastfeeding. Which of the following statements should the nurse include?
"A reduction in sexual interest could indicate postpartum depression."
A nurse in a prenatal clinic is caring for a client who is within the recommended guideline for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse offer?
"A weight gain of about 25 to 35 lb is good."
A nurse in a prenatal clinic is caring for a client who is within the recommended guideline for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse make?
"A weight gain of about 25 to 35 pounds is good."
A nurse is discussing epidural anesthesia with a client who is receiving oxytocin to induce labor. Which of the following statements should the nurse make?
"An epidural given too early can prolong labor."
A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide?
"Call me so I can check your baby's latch the next time you breastfeed."
A nurse is teaching a parent of a newborn how to care for the newborn's umbilical cord stump. Which of the following instructions should the nurse include?
"Cover the cord with the edge of the diaper"
A nurse is providing discharge instructions to the parent of a newborn. Which of the following statements should the nurse include?
"Crib slats should be less than 2.25 inches apart."
A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching?
"Do not become pregnant for at least 1 year"
A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following client statements indicates a need for further instruction?
"I can conceive anytime I want after 10 days." -Client who receives a rubella immunization should not conceive for at least 1 month after receiving the rubella immunization to prevent injury to the fetus.
A nurse is caring for a client who is in labor. The client asks the nurse, "Why are you pressing on my abdomen?" Which of the following responses should the nurse make?
"I can determine the position of your baby."
A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching?
"I may notice increased cramping when I am feeding my baby"
A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements by the client requires clarification?
"I need to have a full bladder at the time of the procedure."
A nurse is evaluating a client who has just received instructions about breastfeeding. Which of the following statements should the nurse identify as an indication that the client understands how to prevent mastitis?
"I should avoid waiting too long between feedings."
A nurse is providing nutritional teaching for a pregnant client who had a prepregnancy body mass index (BMI) of 38. Which of the following statements by the client demonstrate an understanding of the teaching about her recommended weight gain during pregnancy?
"I should plan to gain 5 to 9.1 kg during my pregnancy."
A nurse is teaching a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching?
"I should press the button on the handheld marker when my baby moves."
A nurse is providing teaching about home care to the parent of a newborn. Which of the following statements indicates an understanding of the teaching?
"I should remove the bumper pad and stuffed toys from my baby's crib."
A nurse is providing postpartum discharge teaching about proper storage of breast milk for a client who is breastfeeding. Which of the following client statements indicates an understanding of the teaching?
"I will discard any unused breastmilk that is left in the bottle."
A nurse is teaching a client who is in labor about the use of nitrous oxide analgesia for pain control. Which of the following statements by the client indicates an understanding of the teaching?
"I will feel the effects of the nitrous oxide almost immediately."
A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching?
"I will place my baby no his back when putting him to sleep."
A client who is at 8 weeks of gestation tells the nurse that she isn't sure she is happy about being pregnant. Which of the following is an appropriate response by the nurse to the client's statement?
"It is normal to have these feelings during the first few months of pregnancy."
A provider tells a client at 12 weeks gestation who practices Hinduism that she needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make?
"Let's discuss other foods that are also high in protein that you could substitute for meat"
A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information?
"My baby has a higher risk of developing jaundice."
A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching?
"My baby may sometimes feed every hour for several hours in a row."
A nurse is caring for a client at 34 weeks gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the patient is the priority?
"My heart feels as if it is racing."
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following statements should the nurse include?
"Notify your provider if you notice cracking on your nipples." -risk of infection
A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include?
"Place fresh cabbage leaves on your breasts"
A nurse is caring for an adolescent who is in the second trimester of pregnancy. The client states, "I've gotten used to the idea of this pregnancy. It will be fun to have a little baby around the house." Which of the following is the appropriate response by the nurse?
"Tell me how you think your life will be after the baby is born."
A nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make?
"The bleeding is minimal until I discontinue your IV medication."
A nurse is caring for a client who is at 20 weeks gestation. The client asks the nurse what the baby looks like at this point. Which of the following answers by the nurse provides an accurate response?
"The fetus resembles a human."
A nurse is teaching a client who is at 8 weeks gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following pieces of information should the nurse include?
"The fibroid can increase the risk of postpartum hemorrhage."
A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is common during pregnancy. Which of the following responses should the nurse make?
"The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common."
A nurse is caring for a newborn who has a prescription for phototherapy. The mother asks why the newborn needs to lay under a special light. Which of the following responses should the nurse make?
"The light will help lower your baby's bilirubin level."
A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements?
"The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract."
A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make?
"These feelings are common for expectant fathers in early pregnancy."
A nurse is preparing to administer meperidine hydrochloride to a client who is in labor. Which of the following statements should the nurse make to the client?
"This medication can make you sleepy."
A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding?
"This will resolve in 3 to 6 weeks without treatment" -Cephalohematoma
A nurse is caring for a client who asks, "How will I know if I'm having true or false labor contractions?" Which of the following responses should the nurse make?
"True contractions will begin irregularly and then become regular in timing."
A nurse is providing education about continuous heparin therapy for a client who is 18 hours postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching?
"Use a soft toothbrush to brush your teeth gently." -An adverse effect of heparin therapy is an increased risk of bleeding. The client should use a soft toothbrush to prevent trauma and bleeding.
A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp monitor. Which of the following responses should the nurse make?
"We need to observe your baby more closely"
A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse provide to the client about the treatment plan?
"You and your partner need to take the medication and use a condom during intercourse until cultures are negative."
A nurse is providing education to a client who is at 34 weeks of gestation about a non-stress test (NST). Which of the following pieces of information should the nurse include?
"You might have to drink orange juice during the test."
A nurse is teaching a client who is pregnant about toxoplasmosis. Which of the following instructions should the nurse include?
"You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis."
A nurse is teaching a client who is at 12 weeks gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching?
"You should continue to take zidovudine throughout the pregnancy."
A nurse is providing teaching for a client who is pregnant and has type 1 diabetes mellitus. Which of the following statements should the nurse include in the teaching?
"You should expect to decrease your insulin dosage immediately after you deliver your baby."
A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching?
"You will have a cesarean birth prior to the onset of labor."
A nurse is providing discharge teaching to the parent of a newborn. Which of the following statements should the nurse include in the teaching?
"Your baby should be rear-facing in a car seat until 2 years of age."
A nurse is providing teaching to a client who has come to the family-planning clinic requesting an intrauterine device (IUD). Which of the following pieces of information should the nurse provide the client? A. "If you lose weight, you will need to have your IUD refitted." B. "An IUD provides protection from certain sexually transmitted infections." C. "Your risk for ectopic pregnancy increases with an IUD." D. "You shouldn't use an IUD if you want to have children later." Check Answer Question Feedback Show Explanation
"Your risk for ectopic pregnancy increases with an IUD."
Fetal Tachycardia
**Maternal: •Fever/infection •Dehydration •Hypoxia •Hypovolemia •Anemia •Hyperthyroidism •Drugs -Could occur with fetal hypoxia, acidosis, or cardiac disorders
Signs that a baby is post-term (42 weeks)
- Dry skin with creases on palms/soles - Dry, cracked leathery skin - No lanugo or vernix - Overgrown nails - stained yellow-green from meconium - Large size - Hair on head Scope of the problem: - Oligohydramnios/cord compression, placental insufficiency - Large size, meconium/aspiration Assess for injury and hypoglycemia
Preeclampsia Signs and Symptoms
- Oliguria (=abnormally small amounts of urine) - Invasive (intra-arterial) blood pressure (IBP) - Proteinuria - Hyperreflexes/HYPERreflexia - Neuro S/S - vision changes (blurred vision and seeing spots) - Sudden weight gain (gaining more than 5 pounds in a week) - Headache - Stomach pain - Feeling nauseous/throwing up - Face and hands swollen because they are losing protein so fluid will not stay in the vascular space - Clonus -> SEIZURES (Clonus = neurological condition that creates involuntary muscle contractions)
Immunizations/Vaccinations
-Administer TDAP at about 28 weeks and influenza vaccine -Give MMR postpartum if rubella titer non-immune (<1:8) during pregnancy
Postpartum Assessment
-BUBBLEHER -Vitals, fundus, lochia, Q15 min for 1st hour -Nl bradycardia, shivering, Temp up to 100. BP NORMAL •Increased cardiac output, Diaphoresis, Diuresis •SIGNS OF INFECTION? TEMP >100.4 2 days. PHYSICAL SIGNS? -WBC NOT RELIABLE. -NORMAL ELEVATED WBC (up to 25,000) •Clotting factors elevated- Assess for DVT! -No BM okay for 2-3 days •Involution! Fundus at level of umbilicus, 1 cm lower each day LOCHIA: DOCUMENT.. •Initially lochia RUBRA = red, clots up to 3 cm (days 1-3) -Blood, fragments of decidua •Then, lochia SEROSA = pink/brown (days 4-10) -Blood, mucus, and invading leukocytes •Lochia ALBA = yellow/clear (day 10-14, may last 6 weeks!) - Rule out infection or onset of menses -Largely mucus; leukocyte count high •Monitor for syncope with 1st ambulation. Anticipate lochia flow. •Report: heavy bleeding/clots, RED/ARM LUMP ON BREAST (*MASTITIS), painful urination, calf tenderness •Should void in 4 hours. Suspect RETENTION if freq void <150mL, palpate for suprapubic mass, deviated uterus. Void every 2-3 hours. 150 mL or more •Cardiac output -Increased after delivery; begins to decrease in 1 hour; to normal in 6-12 weeks •Monitor episiotomy site for lacerations or [assess perineum for-] REEDA (redness, edema, ecchymosis, discharge, approximation)
Fourth Stage of Labor - Maternal Homeostatic Stabilization Stage
-Begins after delivery of placenta and continue for 1-4 hours after delivery. -Recovery period
The following IS required prior to hormonal IUD insertion:
-Consent form completion -Cervical cultures -Pregnancy test
Nausea Interventions
-Crackers before getting out of bed or dry toast "carbs" -Ginger* -Small meals, limit liquids with meals -Avoid fatty, greasy, foul odors
Supine Hypotension/Vena Cava Syndrome
-Dizziness -Lightheadedness -Pale, clammy skin Positions: -Left lateral side-lying position -Semi-Fowler's position -If supine, place a wedge under one hip to alleviate pressure to the vena cava.
Measuring fundal height
-Empty bladder -Supine position -Head slightly elevated on pillow, knees in flexed position, or both -Note distance from symphysis pubis to top of fundus
Newborn HIV Exposure
-Exposed transplacental, during vaginal birth, breast milk -Antiretroviral prophylaxis to mom, Retrovir/Zidovudine during labor & newborn- 6 wk course of ZDV -Usually deliver C-section. Prevent SROM. Bathe quickly -Bactrim to decrease risk opp. Infection -May take 18 months for newborn testing
Prior to an amniotomy, what should be performed? Select all of the following:
-FHR assessment -Cervix check
Stillbirth
-Give as much time with newborn -Allow parents to bathe and dress newborn
Siblings
-Give doll to child for practice -Give gift from newborn -Give age appropriate tasks
Fetal Bradycardia
-Head compression -Cord compression -With maternal pushing -?Meconium aspiration -Could occur with fetal hypoxia, acidosis, or cardiac disorders
Newborn Screenings
-Hearing screen -Congenital heart screen -PKU (Phenylketonuria) •How to collect a heel stick sample •Best in 48-72 hours (after feeding established)...autosomal recessive (both parents) -Hypothyroidism- High TSH Low T4 -Galactosemia -Diabetic screen: mother or large or small baby→ glucose screenings (should be above 40) -TCB (transcutaneous bilirubin) press on forehead and then will give you a reading of what the bilirubin will be. If too high then follow up with an actual serum bilirubin test
Nutrition
-Hemoglobin >11 -Hematocrit >33% (can be 32% in early 3rd trimester) -2-3 L fluid a day -71 g protein -3-4 servings of dairy for calcium (seafood, leafy greens, legumes, dried fruit, tofu, and broccoli) -Moderate sodium intake -300 extra daily calories in pregnancy -500 extra daily calories during lactation
Newborn Herpes Exposure
-Hopefully C-section delivery if active outbreak -Most often transmitted during birth -Show signs 2-4 weeks after birth, may cause death -Standard/Contact precautions -Samples from mouth, nasopharynx, conjunctivae, rectum, skin lesions, urine, stool, blood, CSF. -Tx: Acyclovir -May give mother acyclovir at end of pregnancy
Postpartum Care/Peri-Care
-Ice pack at least first 12 hr -Cleanse front to back after each pad change -Warm squirt bottle -Hand hygiene -Sit C-Section Considerations: -Pooling with ambulation. -Risk: Blood clots/DVT. -PPH>1000 mL -"Walk" fingers over abdomen to assess fundus
Gestational Diabetes Mellitus (GDM)
-Keep blood glucose 70-110 -Nutrition Education: Low glucose, good complex carbs and fiber. May teach carb counting
Smoking effects on baby
-Low birth weight -IUGR (intrauterine growth restriction)
The nurse is assessing a postpartum patient, the fundus is soft and spongy. What are the priority actions?
-Massage the fundus -Assess vaginal bleeding/clots
Signs of Pregnancy
-Presumptive: Expect breast tenderness, morning sickness -Probable: Preg test (Hcg) -POSITIVE: BABY! Found by HCP... ultrasound, fetal heart tones
Amniocentesis
-Report cramping and signs of infection following the procedure. -Encourage client to drink extra fluids and rest during the 24 hrs following an amniocentesis. -Client's bladder should be empty to avoid an inadvertent puncture during the procedure. -Amniotic fluid is tested to identify fetal genetic defects.
Pitocin (oxytocin)
-Stimulates uterine smooth muscle; Induce labor, control postpartum bleeding. -Cervical ripening-Before Pitocin, place intravaginally-cervadil or a prostaglandin-risk for uterine tachysystole •Risk uterine tetany or rupture, fetal hypoxia -Hypersystole or tetanic contractions = More than 5 contractions in 10 min or lasting more than 2 min each or no full minute breaks, >90 sec duration****TURN DOWN INFUSION -S/E: seizure, hypotension, increased uterine motility, painful contractions, decreased uterine blood flow, hyponatremia. ↑BP -If complications, RN/Dr may: -TURN DOWN/OFF PITOCIN (Stop Pitocin for contractions lasting >90 sec, contractions <2 mins apart, and w/ fetal pattern of late decels.) -POSITION PATIENT SIDE LYING -O2 FACEMASK •Monitor for: -Maternal: BP and pulse changes, & hypertonicity of uterus -Fetal: FHR and rhythm •Urine output should be >100 mL Q4 hr (antidiuretic)-water intoxication risk with Pitocin •REASONS FOR induction by Pitocin: -POST-TERM- induction (>42 weeks) risk macrosomia/shoulder dystocia, oligohydramnios, cord compression, meconium aspiration -Preeclampsia, Diabetes/macrosomia •May do Bishop Score...8 is good.
Postpartum Emotional Adaptation
-Taking in phase—lasts about 24 hours •**Moms need for food and sleep •More passive, allows others to make decisions •**Wants to talk about her birth experience -Taking hold phase—lasts several days •More independent, self care •Focus on infant now •Welcomes education -Letting go phase •Accepts her family structure has changed •Accepts "real" infant •Connects with partner, returns to work
Down Syndrome (Trisomy 21)
-Triple screen- Low MSAFP levels -Trisomal (chromosomal abnormality) -Increased risk with increased parental age (against medical advice-AMA) -Confirm with AMNIOCENTESIS
VEAL CHOP
-Variable decelerations = Cord compression •Think prolapse •Turn trendelenberg or knee-chest, check for cord, contact provider -Early decelerations = Head compression/Contractions •Think contractions •Monitor -Accelerations - these are Ok! -Late decelerations = Poor placental perfusion/Uteroplacental insufficiency •LIONS: L - lateral position I - increase IV fluids O - oxygen nonrebreather mask 8-10L N - notify provider S - stop/slow Pitocin (oxytocin)
A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5 kg. The amount available is morphine oral solution 0.4 mg/mL. How many mL should the nurse administer? (Fill in the blank with the numeric value only, round the answer to the nearest hundredth, and use a leading zero if applicable. Do not use a trailing zero.)
0.25
A nurse is providing teaching about calcium intake to a client who is breastfeeding. Which of the following is the recommended daily calcium intake for a client who is breastfeeding?
1,000 mg
Put the tests in order from earliest to latest.
1. Blood type 2. MSAFP 3. Glucose challenge test/Glucose tolerance test (GCT/GTT)-diabetes testing 4. Group B Streptococcus Test (GBS) sample for culture
Normal fetal heart rate/tone (FHR)
110-160 bpm
Fundal Height
12-13 weeks: Starts to rise above symphysis pubis-Can take FHT by doppler (Fundal height matches week gestation in centimeters = 16-38 weeks, within 3 cm) 16 weeks: Halfway between symphysis pubis and umbilicus 20 weeks: at umbilicus 24 weeks: measured in cm, with the number of cm above the symphysis equal to the number of weeks of gestation 36 weeks: Xiphoid process After 36 weeks: "Lightening" fetus dropping into the pelvis and decrease in fundal height seen
A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider?
3+ deep tendon reflexes -3+ or greater can indicate preeclampsia
A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority?
480 mL urine output in 24 hr -Minimum urine output is 30 mL/hr -720 mL in 24 hr would be normal
Uterine Souffle
= A soft blowing sound auscultated over the uterus. It corresponds to the maternal pulse.
Kegel Exercises
= Alternate tightening and relaxation of pubococcygeal muscles •Promote during pregnancy and postpartum •Client is taught how to perform Kegel exercises to reduce stress incontinence (leakage of urine with coughing and sneezing). •For back pain, do pelvic tilt exercises/arching back like a cat •Regain pelvic floor muscle control by performing Kegel exercises. The same muscles are used when starting and stopping the flow of urine. Have the client relax and contract the pelvic floor muscles 10 times 8 times a day.
Versus Caput Succedaneum
= Bilateral scalp swelling (edema) after birth as a result of pressure against cervix during labor. -"Crosses suture lines". -Feels soft and spongy -Present at birth; disappears in 12-48 hrs or 3-4 days. -"Vacuum" risk
Bladder Exstrophy
= Birth defect in which bladder develops outside of fetus. -Keep bladder moist and clean -Cover it with dressing-Tegaderm, a clear adhesive dressing, or plastic cling food wrap like Glad brand "Press'n Seal."
Autosomal recessive disorders
= Both parents; 25% chance -Tay Sachs -Cystic fibrosis -PKU (Phenylketonuria) requires a mandated newborn screen (blood test given 24-72 hrs after birth)
Cephalohematoma
= Collection of blood beneath skull bone and periosteum (covering on skull bone). -Unilateral -Does NOT cross suture lines -May appear several hours after birth (24-48 hrs) -Resolve 3-6 wks or 2-3 months -Increased risk for hyperbilirubinemia (jaundice) -"Forceps" risk
Preeclampsia
= Complication of pregnancy including HTN, edema, and proteinuria •Gestational HTN = Pregnancy BP >30+ sys, >15 dias, >140/90.. -Severe HTN >160/110... HTN occurs after 20 weeks •Monitor BP, ultrasound, may order 24 hour urine, daily weight •S/S: -*Vision changes, +3/+4 clonus DTR's (such as patellar reflex) -Swelling- generalized/upper body. DEPENDENT -Headache -Change in fetal movement/HR -Oliguria -A variant of severe preelampsia- HELLP syndrome involving liver: Hemolyisis (low hgb/hct), Elevated liver enzymes (AST/ALT), Low platelets (<100,000)-abdominal/epigastric pain •Tx: Bedrest, limit sodium, may need to deliver (INDUCE). Delivery is TX. May give magnesium sulfate to prevent eclampsia, (CNS depressant) •Postpartum monitor: BP/DTR/urine output
Which fetal position is preferred for a vaginal delivery?
= LOA (Left Occiput Anterior) - Think "leave of absence" = Preferred fetal position for vaginal delivery
Oligohydramnios
= Less than 50% amniotic fluid) Associated with poor placental blood flow, preterm membrane rupture, failure of kidney dev, and blocked urinary excretion.
Postpartum Hemorrhage (PPH)
= Loss of more than 500 mL or 1000 mL of blood within first 24 hours following childbirth. •CHECK TO SEE IF UTERUS CONTRACTED. ASSESS 1st, THEN MASSAGE..CALL THE DR •Fundal massage technique: -Support with 1 hand, massage with other. -Knees slightly flexed, head on pillow. •Sx: abnormal VS, tachycardia, hypotension -Uterus isn't contracting (boggy, flaccid, atony) -More than 1 pad soaked within 15 minutes (1st hour PP). A pad soaked in 2 hours is heavy •Causes: atony, lacerations, hematoma, retained placenta, full bladder; many other risks .. Long labor, abruption, infection RISKS: -Hypovolemic shock= hypotension, tachycardia, cool/clammy -Hypovolemia in PPH -Oliguria - sign of PPH -Skin pale/cool -Trickle of blood flow -Uterine atony -Lacerations: •Cervix, vagina, perineum •Bleeding continues despite firm contracted fundus •Risks from operative birth, precipitous birth, •*Concern with a large baby delivered spontaneously- check peri •1st-4th degree •Usually sutured after birth •Do not give rectal supp or enemas •REEDA •Risk for infection -Hematoma: •Collection of blood within tissue •Vulvar most common •Painful, pressure- pelvic/deep •Risks from forceps, episiotomy, primigravida, C-section scar may rupture •PALPATE bladder for distension which can promote uterine atony/PPH -Should void at least 150 mL in 4 hrs -May need catheter if distended bladder and unable to urinate on own •TX: -Pitocin to help uterus contract after placenta delivered, for uterine atony -Methergine a 2nd option, (risk htn) -Prostaglandin F2/Carboprost (Hemabate) -IV fluids -Blood transfusion -O2 -Keep pt warm, supine, catheter; Anticipate possible surgery
Late decelerations
= NOT a normal finding
Early decelerations
= Normal finding
Nonstress test (NST)
= Observing FHR response to fetal movement; Noninvasive -NST evaluates the effect of fetal movement on fetal heart activity. •Norm FHR: 110-160 •Want: FHR accel. 15 beats, last 15 sec, 2x/20 min •Good=Reactive=healthy •2 sensors to mom's abdomen •Void before procedure •Mom may record fetal movement - Push button •May need to stimulate fetus, drink orange juice -Reactive (reassuring) -Nonreactive (nonreassuring); May need contraction stress test (CST) or biophysical profile (BPP) •Tip: Doppler FHR 10-12 wks, 15-20 wks fetoscope •BPP (NST & ultrasound) common after abdominal trauma. Priority to check mom's vitals then FHR. Risk for abruption. •NST common if reports decreased fetal movement (after doing kick counts). May do BPP to include ultrasound.
Myelomeningocele (severe form of spina bifida)
= Severe form of spina bifida; Hernia of the spinal cord and meninges -Cover the sac with a sterile dressing moistened; dressings may be covered with plastic protective covering.
Funic Souffle
= Soft, whistling sound heard over the umbilical cord and corresponds to the fetal heart rate.
Magnesium Sulfate
= Stops preterm labor (tocolytic) OR prevents seizures associated with gest. HTN/preeclampsia •CNS Depressant: -Concern for toxicity (Calcium gluconate= antidote) -Decreased respirations (!<12) and reflexes +1, 0 -----FIRST ACTION: STOP THE INFUSION -Monitor for decreased urine output (<30mL/hr) and pulmonary edema -Labs: therapeutic= 5-8mg/dl •IV MATH!
A 38 year old woman who is a smoker should avoid estrogen-containing contraceptives. True or False?
= TRUE - Also avoid vaginal ring and patch options b/c they are hormonal
A community health nurse is planning care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first?
A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy
Kleihauer-Betke test
A Kleihauer-Betke test is used to verify that fetal blood is present during a percutaneous umbilical blood sampling procedure.
Which client should the nurse closely monitor for severe afterpains?
A multigravida who is breastfeeding.
A nurse is caring for four newborns. Which of the newborns is at greatest risk for hypoglycemia?
A newborn who is large for gestational age
Lecithin/sphingomyelin (L/S) ratio
A test of L/S ratio is done as part of an amniocentesis to determine fetal lung maturity.
A nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (Select all that apply.)
A. Massage the fundus C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30° -Urinary catheter helps to monitor urinary output and perfusion to the kidney
Leopold's Maneuvers
A. Palpate fundus for fetal body part (legs) B. Palpate sides of uterus for fetal back C. Palpate for the fetal presenting part at the inlet D. Assess the attitude of baby's head **Fundal massages: 2 hands, with gloves, check lochia, empty bladder ** Deviated fundus = Empty bladder/void -Left occiput anterior (LOA) position most common -Back pain associated with posterior positions
Alpha-fetoprotein (AFP)
AFP is a test to assess for fetal neural tube defects or chromosome disorders.
A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect?
Abundant lanugo
A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester?
Accepting the pregnancy
A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication for the use of this medication?
Active genital herpes
A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication to the use of this medication?
Active genital herpes
A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure?
Administer immune globulin to the client to prevent fetal isoimmunization
A nurse is reviewing recent laboratory values during a prenatal visit for a client who is pregnant. The nurse notes a hemoglobin level of 10 g/dL. Which of the following actions should the nurse take?
Advise the client to start iron and vitamin C supplementation
A nurse is discussing epidural anesthesia with a client who is receiving oxytocin for induction of labor. Which of the following statements should the nurse make?
An epidural given too early can prolong labor
Indirect Coombs' test
An indirect Coombs' test detects Rh antibodies in the mother's blood.
APGAR Scale
Appearance (skin color) Pulse Grimace (reflex ability) Activity (muscle tone) Respiration -Good score 7-10 -Most common is 9; Acrocyanosis (blue extremities) -APGAR at 1 & 5 min to assess (4-6= moderate resuscitation, 0-3= severe resuscitation). -HR should be >100 -Never delay resuscitation for APGAR
A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take?
Apply cold ice packs to the client's perineum
While caring for a client who is in active labor, a nurse notes late decelerations on the fetal monitor. Which of the following actions should the nurse take?
Apply oxygen at 10 L/min via nonrebreather face mask
A nurse is caring for a client whose last menstrual period (LMP) began on July 8. Using Naegele's rule, what is the client's estimated date of birth (EDB)?
April 15
A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test?
Ask the client to drink a glass of orange juice
A nurse is assessing a client on the first postpartum day. Findings include the following: fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take?
Ask the client when she last voided
A nurse is assessing a client on the first postpartum day. Findings include fundus firm and 1 fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3 C, and pulse rate 52/min. Which of the following actions should the nurse take?
Ask the patient when she last voided -A deviated, firm fundus indicates a full bladder
A woman is 1 hour postpartum with an epidural block and wishes to get up to go to the bathroom. What action by the nurse is most appropriate?
Assess sensation in the lower extremities.
A nurse is assisting with an amniotomy for a client who is in active labor. Which of the following actions should the nurse take?
Assess the fetal heart rate before and after the procedure
A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform?
Assess the newborn's blood glucose level
A nurse is caring for a client who is at 38 weeks gestation and in the active phase of the first stage of labor. The nurse notes 2 late decelerations of the fetal heart rate during the last 5 contractions. Which of the following actions should the nurse take?
Assist the client to a lateral position
A nurse is caring for a client who reports intestinal gas pain following a cesarean section. Which of the following actions should the nurse take?
Assist the client to ambulate in the hallway -this stimulates peristalsis in order to promote the expulsion of gas
Which nursing action is most appropriate for the laboring woman whose membranes have ruptured?
Assist the woman in emptying her bladder every 2 hours
A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Immune Globulin?
At 28 weeks of gestation
Immunizations/Vaccinations to AVOID
Avoid the "ellas"-varicella and rubella (MMR) b/c they're live vaccines
A nurse is preparing to obtain a newborn's temperature. Which of the following methods should the nurse use?
Axillary
What is the most common treatment for gonorrhea?
Azithromycin/Ceftriaxone - Gonorrhea = Risk for preterm labor, pelvic inflammatory disease, and newborn eye problems
A nurse is assessing a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect?
Barrel-shaped chest
A term infant is failing to breathe with initial stimulation, heart rate 80 bpm. Priority action:
Begin positive pressure ventilation (PPV) - Heart rate less than 100 = Start positive pressure ventilation (PPV) - Heart rate less than 60 = Start chest compressions
Third Stage of Labor - Placental Stage
Begins immediately after fetus is born and ends when placenta is delivered. -Delivery of placenta
Second Stage of Labor - Stage of Expulsion
Begins with complete cervical dilation (10 cm) and ends with delivery of fetus -1 hr primigravida, 15 min multipara -Bloody show, bulging, see presenting part -Risk for hyperventilation
First Stage of Labor - Stage of Cervical Dilation
Begins with regular contractions and end with complete dilation & effacement. o Latent Phase: 0-3 cm dilated -Mildly anxious, talkative o Active Phase: 4-7 cm dilated -Mod-severe ctx -Effacement starting -Anxious, discomfort -Food limited to ice chips -Pain med/epidural o Transition Phase: 8-10 cm dilated -Fully effaced -Ctx Q 1.5 min, last 60-90 sec -Irritable, nausea, hiccups, changes in behaviors, urge to push - wait until 10 cm
A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which of the following medications should the nurse plan to administer?
Betamethasone
A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider?
Bilirubin -Erythroblastosis fetalis risk
A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended action of the medication in relation to the central nervous system (CNS)?
Block effects of narcotics on the CNS -Naloxone prevents CNS and resp depression in the newborn following delivery.
A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended action of the medication in relation to the central nervous system (CNS)?
Block the effects of narcotics on the CNS
The physician orders methylergonovine. Before administering this drug, the nurse should assess the client's:
Blood pressure - Methylergonovine = Firms the fundus and controls severe bleeding from the uterus after childbirth. - It's a uterotonic agent for postpartum hemorrhage
A nurse is providing teaching to the parents of a newborn about bottle-feeding. Which of the following instructions should the nurse include in the teaching?
Boil water for powdered formula for 1-2 min
A nurse is reviewing the plan of care before assuming the care of a newborn who is prescribed a hepatitis B vaccine, vitamin K, and an antiretroviral regimen. The plan of care indicates the newborn's mother is HIV-positive and plans to breastfeed. Which of the following findings should the nurse address with the newborn's interdisciplinary team?
Breastfeeding
A nurse is caring for a woman who is going to have an epidural block. The physician orders that an IV be started. Which of the following solutions would be appropriate for the nurse to choose? (Select all that apply.)
C. Lactated Ringer's (LR) solution D. Normal saline (NS)
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer?
Calcium gluconate
Which assessment finding should the nursery nurse report to the pediatric healthcare provider?
Central cyanosis when crying -Infant with respiratory distress
Chadwick's sign
Cervix/vagina purplish blue
The nurse suspects cord prolapse/variable decelerations. What is the immediate nursing action?
Change patient position to side lying or Trendelenburg - Trendelenburg position = Body is laid supine on the back on a 15-30 degree incline with the feet elevated above the head; Increasing blood flow to brain
A nurse is caring for a client who is in labor. The client speaks a different language than the nurse and is grimacing. Which of the following actions should the nurse take while waiting for an interpreter?
Change the client's position
A nurse is caring for a client who is at 33 weeks of gestation and reports dark red vaginal bleeding and contractions that do not stop. Which of the following actions should the nurse take first?
Check fetal heart tones
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of the following actions should the nurse include in the plan of care?
Check the cervix prior to analgesic administration. -Must know how many cm cervix is dilated before administering analgesic. If administered too close to the time of delivery, the analgesic could cause respiratory depression in the newborn.
A nurse is instructing a client who has been prescribed oral contraceptives about danger signs. The nurse evaluates that the client understands the teaching regarding side effects when she states the need to report
Chest pain or shortness of breath -may indicate pulmonary embolus or myocardial infarction
Newborn Circumcision Care
Circumcision Care: -Yellow crust normal -Loose diaper -Monitor for infection -Apply vaseline to site post Gomco clamp; Hypospadias- Wait [Hypospadias=birth defect in boys where opening of urethra is not located at tip of penis] -Ensure can urinate. Monitor bleeding. -Plastibell Ring- NO topical application; Leave ring in place until falls off around 10 days.
Contraindication for contraction stress test (CST)
Classic C-section previously
Breast Care
Colostrum starts at 16/20 wks Breast Engorgement: -If breast feeding: •Nurse frequently/good latch •Bra •Warm shower/compresses before feeds •Ice packs in between - Bottle feeding: •Cold •Tight, supportive bra or binder •Cabbage •NO stimulation Mastitis: -Cracks, fissures, red/tender -Nipple care: •Warm water •Air dry •Baby position •10 min feed each breast -Still feed Q 2-3 hrs. NOT if purulent/some antibiotic (bad=sulfa). But still need to expel milk. PO antibiotic. •Rooming In: Keep baby with mother who has HIV but do NOT breastfeed •HIV is a contraindication to breastfeeding. •Can still feed with hepatitis.
Biophysical Profile (BPP)
Combination of NST and ultrasound to evaluate fetal status based on 5 variables: 1. fetal heart rate (NST) 2. fetal breathing movements 3. gross body movements 4. fetal muscle tone 5. amniotic fluid volume (AFV) - long term marker - AFI 10-17 Scoring technique: -Each area scored 0-2 pts -Score of 10 = Perfect; Score of 0 = Worst score -Total score of 8 to 10 is normal unless oligohydramnios (less than 50% amniotic fluid) is present -BPP recommended after trauma
For the morning after pill, levonorgestrel, which should be included in the education?
Commonly causes nausea and heavier bleeding
A nurse is teaching a client who is at 10 weeks gestation about self-care management for common discomforts during pregnancy. Which of the following instructions should the nurse include?
Consume frequent snacks to decrease episodes of nausea
A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 sec. Which of the following actions should the nurse take?
Continue routine monitoring
An induction patient is experiencing contractions lasting 60 seconds, 3 min apart, with an interval of 1 min, 60 mmHg
Continue to monitor
A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take?
Continue to routinely monitor the newborn -Newborn is exhibiting a normal respiratory rate and rhythm
A nurse is caring for a client who is in the first stage of labor. Which of the following findings should the nurse identify as a cause for concern?
Contractions lasting 100 seconds -Contractions during the first stage of labor range from 45 to 80 seconds. They should not exceed 90 seconds.
Contraction Frequency and Length
Contractions should be every 2 to 3 minutes, lasting 60 to 90 seconds.
A nurse receives a report for a client who is in labor and is experiencing contractions that are 4 min apart. Which of the following patterns should the nurse expect on the fetal monitor tracing?
Contractions that last for 60 sec each with a 3 min rest between contractions
A nurse receives report on a client who is in labor and is experiencing contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?
Contractions that last for 60 seconds each with a 3 min rest between contractions
Which long-term method may be recommended to someone cautioned against using hormonal birth control? Which of the following is also an option to be used as emergency contraception?
Copper IUD
A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend?
Copper intrauterine device -Thrombophlebitis is a contraindication for hormonal contraceptive methods
Newborn Cord Care
Cord Care: -Clean/dry -No tub bath -Fold diaper -Monitor for moist, red, odor, discharge. -Cord should be clamped until discharge (24 hr)
What is the most common cause of a variable deceleration?
Cord prolapse/compression
A nurse is caring for a client who is in active labor and whose birth plan requests only nonpharmacological pain relief strategies. Which of the following strategies should the nurse offer as a form of cutaneous stimulation?
Counter-pressure
A nurse is providing teaching about the selection of commercial formula to the guardian of a newborn. Which of the following pieces of information should the nurse include?
Cow's milk-based formula is recommended for healthy newborns
A nurse is caring for a client at 35 weeks gestation who has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status?
Daily weight
Which does NOT indicate possible development of HELLP syndrome in a pregnant patient?
Decreased AST/ALT ^NOT a finding of HELLP HELLP = Severe form of preeclampsia HELLP: -Hemolysis (low hgb/hct) -Elevated Liver enzymes (AST/ALT) -Low Platelet count/Thrombocytopenia (<100,000)-abdominal/epigastric pain NOTE: -Normal Hgb is 12.0 to 15.5 g/dL -Normal Hct is 35.5% to 44.9% HELLP syndrome indications: - Low Platelets/Thrombocytopenia (Platelets 80,000 cells/mm3) - Increased liver enzymes (AST/ALT) - Low hematocrit and increased bilirubin (Hematocrit 30% and increased bilirubin) - Abdominal pain or epigastric pain (Right upper quadrant pain)
A nurse administers betamethasone to a client who is at 33 weeks of gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication?
Decreased blood glucose
A nurse is monitoring a newborn for indications of septic shock. Which of the following findings should the nurse expect if the newborn develops this complication?
Decreased blood pressure
Medroxyprogesterone injection top concern:
Decreased bone mineral density
Which of the following is a concern for the woman laboring with a pudendal block?
Delayed 2nd stage of labor
Caring for a newborn with Neonatal Abstinence Syndrome (NAS). Which nursing action is NOT appropriate for this situation?
Do not allow the mother to participate in the infants' care Actions to take: - Administer morphine or methadone per order - Maintain baby in a flexed position and swaddled - Low stimuli, low sound - Cluster care (scheduling routine) -nutrition -hydration -promote bonding -close contact -wrapped snugly -skin care - Social work decides if parents can be involved or not
A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching?
Do not become pregnant for at least 1 yr -Hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar pregnancies.
A nurse is monitoring a patient postpartum. She notes that the fundus is contracted and midline at umbilicus.
Document findings - Fundus is NOT deviated...It is contracted and midline, so document these normal findings. - If fundus is deviated, then assist mother to void.
A 14-week gestational client, who weighed 125 pounds before pregnancy, comes into the health clinic for a prenatal appointment. The client's weight today is 129 pounds. What action should the nurse implement?
Document the finding in the medical record. -Gain 2.2-4.4 lb in 1st trimester, 1 lb each wk from 2nd trimester on -Total of 25-35 lbs for normal bmi 18-24
A nurse is caring for a client in labor and observes a pattern of early decelerations on the fetal monitor. Which of the following actions should the nurse take?
Document the findings and continue to monitor -Early decels are a normal finding
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider?
Double vision
What FHR finding is a deceleration which begins at the start of a ctx and returns to baseline by the end of the ctx?
Early deceleration
A primigravida who is at 34-weeks gestation complains she is experiencing heartburn. What recommendation should the nurse make?
Eat five small meals daily
A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide the client?
Eat some crackers before rising from bed in the morning
A patient tells the nurse that she hasn't had a period in a month with a small amount blood, pain in the right abdomen. We suspect...
Ectopic pregnancy -Ectopic pregnancy = Pregnancy in which the fertilized egg implants outside the uterus (in a fallopian tube).
A nurse is reviewing the laboratory report for a client with suspected HELLP syndrome. Which of the following findings should the nurse report to the provider as an indication of this disorder?
Elevated liver enzymes -AST/ALT
A postpartum nurse is caring for a client who reports abdominal cramping. Which of the following actions should the nurse take?
Encourage client to interact with the newborn -Helps as a distraction and decreases discomfort of uterine contractions
A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching?
Encourage non-nutritive sucking for pain relief
What is the priority care measure during an eclamptic seizure?
Ensure the airway is open and monitor oxygen saturation
A nurse is providing teaching about breastfeeding to a client who is 4 hours postpartum. Which of the following pieces of information should the nurse include?
Ensure the newborn's mouth covers the nipple and areola
A nurse is planning care for a requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care?
Ensure the newborns eyes are closed before applying the eye shield
A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1-2 hr of delivery?
Erythromycin ophthalmic ointment
A nurse is caring for a client who is in labor. Which of the following methods will determine the frequency of the client's contractions?
Evaluating the time from the beginning of a contraction to the beginning of the next contraction
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect?
Exaggerated reflexes
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect?
Exaggerated reflexes - ^indicate CNS irritability
A nurse is assessing the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress?
Expiratory grunting
A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate?
Extended extremities
Prolonged deceleration
FHR <100-110 for greater than 2 mins -Change patient position to side-lying or Trendelenburg
The nurse assists with continual fetal monitoring and pushing efforts during the 3rd stage of labor. True or False?
False - Baby is born at end of 2nd stage of labor!
We know that magnesium sulfate is effective in preeclampsia if the blood pressure stays less than 160/110?
False - Magnesium sulfate is an anticonvulsant. It reduces seizure risks in women with preeclampsia.
A nurse is teaching a client with pre-eclampsia who is scheduled to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching?
Feeling of warmth
Alcohol effects on baby
Fetal alcohol syndrome(FAS) (-microcephaly [small head] -growth retardation -short palpebral fissures -maxillary hypoplasia -flat nasal bridge -strabismus) -Mental retardation -Hyperactivity -Developmental delay
A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect?
Fetal gastrointestinal anomaly
The nurse should assess which first on a patient with placenta previa?
Fetal heart rate (FHR)
A nurse is providing care to a client who is in labor and experienced a spontaneous rupture of membranes. Which of the following findings requires intervention by the nurse?
Fetal heart rate decreased by 15/min
A nurse is reviewing the provider's admission orders for a client who is at 37 weeks of gestation and is HIV positive. Which of the following orders should the nurse clarify with the provider?
Fetal scalp electrode
A nurse is visiting a postpartum client on day 5. We will suspect endometritis if which finding is noted?
Fever that began day 3 postpartum - You would NOT choose elevated WBCs because fever is a more indicative finding. - Endometritis = uterine infection (inflammation of inner lining of uterus) with foul discharge and abdominal pain. - Fever greater than 100.4 F
Trimesters
First: weeks 1-13 Second: weeks 14-26 Third: weeks 27-40
A nurse in labor and delivery is teaching a newly licensed nurse about performing the McRoberts maneuver to relieve shoulder dystocia. Which of the following pieces of information should the nurse include?
Flex the client's legs apart and raise her knees to her abdomen
Quickening
Fluttering movements of the fetus that can be felt by the mother by 16-20 weeks
A nurse is caring for a newborn who was born to a client with a narcotic use disorder. Which of the following nursing actions is a contraindication for the care of the newborn?
Frequent stimulation
A serum bilirubin is ordered. Where will the nurse obtain the sample from?
From the heel -Heel stick procedure
Which client is at the highest risk for developing gestational hypertension?
G1P0 age 44 with diabetes mellitus Risk: - Advanced maternal age - Already has diabetes - Preeclampsia also hits 1st time pregnancies
A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider?
Generalized petechiae -This could be associated with an infection or clotting-factor deficiency
A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, which of the following actions should the nurse take next?
Give oxygen at 10 L/min via face mask
Rho(D) immune globulin
Given to clients who are Rh negative following an amniocentesis b/c of potential of fetal RBCs entering the maternal circulation. -Rh negative mom and positive baby -Also given after trauma, abortions -Get consent signed -Considered a blood product, so screen for Jehovah's Witnesses-may also refuse transfusion PP -COOMBs test.
A nurse is planning care for a client who is at 35 weeks of gestation. Which of the following lab tests should the nurse obtain?
Group B streptococcus Beta-hemolytic (GBS) -Obtain GBS at 35-37 wks of gestation
A nurse is planning care for a client who is at 35 weeks gestation. Which of the following laboratory tests should the nurse obtain?
Group B streptococcus ß-hemolytic
A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider?
Grunting with expiration
HELLP Syndrome (additional info)
HELLP = Severe form of preeclampsia HELLP: -Hemolysis (low hgb/hct) -Elevated Liver enzymes (AST/ALT) -Low Platelet count (<100,000)-abdominal/epigastric pain NOTE: -Normal Hgb is 12.0 to 15.5 g/dL -Normal Hct is 35.5% to 44.9%
HELLP Syndrome
HELLP = severe form of preeclampsia HELLP: -Hemolysis -Elevated Liver enzymes -Low Platelet count
The nurse is reviewing self-care information with a pregestational client with type 1 diabetes mellitus. What information should the RN reinforce with the client?
HYPOglycemic episodes are more likely to occur during the first trimester. -HYPERglycemia common in 2nd and 3rd trimester as insulin resistance increases. Glucose tolerance test (GTT) at 28 wks!
What is the priority assessment when caring for a woman on terbutaline?
Heart rate - Terbutaline = Tocolytic, preterm labor; Prevents and slows contractions of the uterus & helps with SOB, asthma, etc. - Tachycardia risk for mom and baby
Cytomegalovirus (CMV)
Herpes-type virus that usually causes disease when the immune system is compromised Manifestations include: -microcephaly (baby's head is much smaller than expected) -impaired hearing -jaundice -seizures
A nurse is caring for a client who is in labor and has an epidural for pain relief. Which of the following is a complication from the epidural block?
Hypotension
What is an immediate concern after placement of an epidural?
Hypotension
A nurse is discussing diaphragm use with a client. Which of the following statements by client indicates an understanding of the teaching?
I should replace my diaphragm every 2 years
A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of the medication?
IV narcotics administered to the mother during labor
A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication?
IV narcotics administered to the mother during labor
A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take?
Increase the rate of the primary IV infusion
A nurse is preparing to help with a vacuum-assisted birth. Which of the following actions should the nurse plan to take?
Inform the client that caput succedaneum resolves in a few days
A nurse at a prenatal clinic is assessing an adult client who had genital cutting performed as a child as part of her cultural practices. The nurse notes the client's clitoris and labia minora were removed, and she has scarring in the vaginal area. Which of the following actions should the nurse take?
Inform the client that giving birth vaginally might not be possible.
A nurse in an antepartum clinic answers a phone call from a client who is at 37 weeks of gestation and reports, "I became very dizzy while lying in bed this morning, but the feeling went away when I turned on my side." Which of the following actions should the nurse take?
Instruct the client about vena cava syndrome and measures to prevent it
A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take?
Instruct the client to apply cold compresses
A nurse is teaching a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn?
Intracranial hemorrhage -Vitamin K is necessary for blood clotting
Pudendal Block
Intravaginal admin; local anesthetic. Late 2nd or 3rd stage. Helps with episiotomy/forceps/vacuum Safer but decreased pushing ability
For the implantable arm progestin, what should be included in the teaching?
Irregular and unpredictable menstruation is common.
The nurse provides diet instructions to a client with iron deficiency anemia. Which is recommended?
Kidney beans
A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis to assess fetal lung maturity. Which of the following is a test for fetal lung maturity?
Lecithin/sphingomyelin (L/S) ratio
A nurse is assessing a newborn for congenital hip dysplasia. Which of the following findings should the nurse expect?
Limited abduction of a hip
Labs to watch when experiencing preterm labor on magnesium sulfate
Magnesium sulfate toxicity is indicated by respiratory depression. Magnesium sulfate is a CNS Depressant: - Concern for toxicity (Calcium gluconate= antidote) - Decreased respirations (!<12) and decreased deep tendon reflexes +1, 0 -----FIRST ACTION: STOP THE INFUSION Monitor for: - Decreased urine output (<30mL/hr) • Urinary output SHOULD be greater than or equal to 30 mL/hour - Pulmonary edema - Patellar reflexes are present - Vitals - SpO2 - Decreased respirations (!<12) - Decreased deep tendon reflexes +1, 0 - LOC - FHR - Maternal uterine activity (contractions) Labs: therapeutic= 5-8mg/dL
A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first?
Massage the fundus
A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify which of the following findings as a complication of the infusion?
Maternal hypotension
A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2019. Based on Nägele's rule, what is the estimated date of delivery?
May 9, 2020 -Minus 3 months, add 7 days to first day of last menstrual period, consider year
A nurse is caring for a client who desires an intrauterine device for contraception. Which of the following findings is a contraindication for the use of this device?
Menorrhagia -menorrhagia = menstrual bleeding lasting for longer than 7 days. -IUD is contraindicated in women who have menorrhagia, severe dysmenorrhea, or history of ectopic pregnancy.
A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions?
Methylergonovine
With the basal body temperature method, which is true regarding temp monitoring?
Monitor first thing in the morning
Preterm labor on magnesium sulfate
Monitor for: - Decreased urine output (<30mL/hr) - Pulmonary edema - Vital signs - SpO2 - Deep tendon reflexes (DTRs) - LOC - FHR - Maternal uterine activity. Labs: therapeutic= 5-8mg/dL
A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification?
Monitor the client's weight weekly -we want daily weights
A woman in labor has just received an epidural block. The most important nursing intervention is to:
Monitor the maternal blood pressure for possible hypotension. Intravenous fluids are increased for a woman receiving an epidural, to prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal tachycardia secondary to hypotension.
When discussing natural family planning, what are the core components?
Monitoring cervical mucous and oral temperature
What should the patient be told about spermicide use?
Must reapply after each act of intercourse -It only stays for 1 hour
A nurse is assessing a newborn. Which of the following findings suggests the newborn is post-mature?
Nails extending over fingers
A nurse is assessing a newborn. Which of the following findings should the nurse immediately report to the provider?
Nasal flaring -Nasal flaring, grunting, and respiratory muscular retractions signal serious breathing problems that should be reported to the provider.
Amniocentesis
Needle puncture of amniotic sac to withdraw amniotic fluid for analysis to identify genetic defects. •At 14-16 wks -Diagnostic for genetic defects (Downs, neural tube defect) •Later in preg- lung maturity L/S ratio (want >2:1); Monitor vitals and FHR: prior, during •Before: Informed consent, bladder EMPTY, abdomen exposed, lidocaine, ultrasound-- Position supine- wedge, hands across chest •**After: Monitor for Preterm labor: 30 min contractions, leaking, decreased movement -Slight pressure, but keep breathing •Amniocentesis Risk: abortion/fetal loss, fetal injury, infection -Report cramping and signs of infection •?Need for Rhogam •Rest for 24 hours, drink plenty of fluids
A nurse is assessing a client who is at 30 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse identify as an indication that the client needs a biophysical profile?
Nonreactive non-stress test
A nurse is caring for a client who is at 36 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse identify as the priority?
Nonreactive nonstress test
A nurse is assessing a postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and located 1 cm below the umbilicus. Which of the following actions should the nurse take?
Notify the provider
A nurse is using Naegele's rule to determine the estimated date of birth (EDB) for a client whose first day of her last menstrual period was February 2, 2018. The nurse should identify which of the following as the client's EDB?
November 9, 2018
A nurse at a prenatal clinic is assessing an adolescent who is pregnant and is visiting the clinic for the first time. Which of the following factors is the nurse's priority to evaluate?
Nutritional status
Nursing interventions to prepare a client for an epidural block
Observe for HYPOTENSION and urinary retention/bladder distension: - Administer IV fluids for hypotension. - Palpate the suprapubic area for a full bladder every 2 hours. • A full bladder can delay birth and can cause hemorrhage after birth. • A full bladder necessitates catheterization if the woman cannot feel the urge to void. - Cannot give until at least 4 cm dilated. - Record fetal heart rate (FHR). - Assess pain score Effects: - HYPOTENSION - Monitor BP! • Sit upright; Lactated Ringer's bolus before administrations - Bladder distension - Prolonged 2nd stage of labor (risk cesarean section) - Risk later for headache Monitor maternal blood pressure for possible hypotension: - Increase IV fluids • Lactated Ringer's (LR) bolus before administrations • Normal saline (NS) - Observe for fetal bradycardia - Monitor signs of maternal tachycardia secondary to hypotension - Place woman in lateral position; sit upright - Administer oxygen To prevent risk for injury: - Assess leg movement and sensation before ambulating. - Observe for signs of impending birth. -Assess leg strength before ambulating - Change positions regularly - Observe for signs that birth may be near: • Increase in bloody show, perineal bulging, and/or crowning. CONTRAINDICATED for client with: - Abnormal clotting/coagulation abnormalities (Women with severe preeclampsia may have this) - Infection in the area of injection or a systemic infection - Hypovolemia (inadequate blood volume) Low platelet counts may reduce safety of epidural block Observe for any change in facial expression as ice is applied: - Muscle flinching or pushing away. Gentle palpation over surgical site can also give an impression of: - Comfort if epidural is effective, or - Pain if epidural is not effective. Refrain from eating or drinking 4 hours prior appt
Contraction Stress Test (CST)
Observing FHR response to stress of uterine contractions that may induce recurrent episodes of fetal hypoxia; Minimally invasive •"Oxytocin challenge test" •See if initiation of contractions causes decreased O2 to baby, or late decels •Consider who would NOT be a good candidate for this procedure •Nipple stimulation v. oxytocin admin •10-20 minutes: Ultrasound and Toco sensors •A negative result (reassuring) is 3 contractions in 10 mins, but no Late or Variable decels. -Positive CST result (nonreassuring) - May require Biophysical profile (BPP) •May be performed after a nonreassuring/nonreactive NST
A nurse is assessing a newborn who is 12 hr old and notes mild jaundice of face and trunk. Which of the following actions should the nurse take?
Obtain stat prescription for a bilirubin level
A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take?
Offer client hydrotherapy
A nurse is assessing a postpartum client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. The nurse should plan to administer which of the following medications?
Oxytocin
Which of the following is NOT a priority test for the preterm labor patient?
PT/INR (Prothrombin Time and International Normalized Ratio) Priorities for preterm labor patient: - Fetal fibronectin and Fern test - Ultrasound and vaginal cultures - CBC/CRP (Complete blood count/C-reactive protein)
A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect?
Painless, bright red bleeding
A nurse in a labor and delivery unit is preparing to teach a newly licensed nurse about intermittent auscultation of the fetal heart rate. Which of the following interventions should the nurse include?
Palpate and count the maternal radial pulse while listening to the fetal heart rate
A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?
Patellar reflex 4+
A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy?
Pelvic inflammatory disease (PID)
For a woman who was determined to be Group B Strep positive, what nursing intervention is anticipated?
Penicillin IV during labor
A nurse is caring for a client who is receiving oxytocin for induction of labor. Which of the following actions should the nurse take?
Perform continuous fetal heart rate monitoring
A nurse is reviewing the medical record of a client at 33 weeks gestation who has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider?
Perform vaginal examination
A nurse is discussing the expected changes related to pregnancy with a client who is at 8 weeks gestation. Which of the following findings should the client to report to the provider during the first trimester?
Persistent vomiting
A nurse is initiating phototherapy for a newborn who has hyperbilirubinemia. Which of the following actions should the nurse take?
Place an opaque mask over the newborn's eyes
A nurse is assisting with the care of a client who is in labor. The nurse observes late decelerations on the fetal monitor. Which of the following actions should the nurse take?
Place the client in a left lateral position
A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take?
Place the unwrapped newborn on the mother's bare chest.
Placenta Previa
Placenta previa occurs when a baby's placenta partially or totally covers the mom's cervix •PAINLESS bright red bleeding •Greater risk in 3rd trimester as preparing for labor, uterus thinning •Ultrasound •Bleeding-Considered an emergency for FHR/O2, and mom risk hemorrhage/shock •Monitor for signs of shock. FHR may be normal •May try to extend pregnancy for fetal lung maturity, so bed rest •Side lying position. Monitor blood loss. Possible oliguria as a result of decreased blood flow/loss of blood •REPORT ANY CONTRACTIONS •C-section if cervix is completely covered •Do NOT continue abdominal or vaginal exams/manipulation •Vaginal placental abruption leads to painful bleeding.
A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider?
Platelet count 135,000/mm^3 -This result is an indication of thrombocytopenia. -A low platelet count is a manifestation of preeclampsia or HELLP syndrome and requires further evaluation.
A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development?
Position the naked newborn on the parent's bare chest
Chorionic Villus Sampling (CVS)
Prenatal diagnostic technique that involves taking a sample of tissue from the chorion of placenta. CVS determines chromosomal or genetic disorders in the fetus Earlier at 10-13 weeks but considered higher risk than amniocentesis for spontaneous abortion or fetal deformity. Some spotting/cramping a few hours expected. Report leaking of fluid, signs of infection. Could be transcervical or transabdominal procedure
A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform?
Prepare equipment needed for newborn resuscitation
A nurse is caring for a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the following actions should the nurse take?
Prepare the client for an emergency cesarean delivery
Folic acid & Folate
Prevents neural tube defects -400 mcg preconception -600 mcg while pregnant
The FHR has dropped from baseline to 100 and has remained there for 3 minutes. What is being described?
Prolonged deceleration
A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take?
Promote active movement in and out of bed
A client experiencing preterm labor at 29 weeks' gestation has been admitted to the hospital. The client has an order to receive betamethasone. The nurse explains to the client that the medication will do which of the following?
Promote maturation of the fetal lungs
Dinoprostone
Promotes softening and dilation of the cervix
A nurse is assessing a client who is in the first stage of labor and has preeclampsia. Which of the following findings should the nurse expect?
Proteinuria
A nurse is providing care for a pregnant adolescent who is at 12 weeks gestation and verbalizes a fear of gaining weight during pregnancy. Which of the following actions should the nurse take?
Provide examples of how eating well will help maintain a healthy weight during pregnancy.
A nurse is providing education for the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to perform?
Provide kangaroo care for the infant
A nonstress test (NST) is being performed. There are 3 FHR accelerations in the past 12 minutes, 30 beats above baseline, 20 sec in length
Reactive
Neonatal Infant Pain Scale (NIPS)
Recommended for children less than 1 year old A score greater than 3 indicates PAIN. Facial Expression: 0 - Relaxed muscles (Restful face, neutral expression) 1 - Grimace (Tight facial muscles; furrowed brow, chin, jaw) Cry: 0 - No Cry (Quiet, not crying) 1 - Whimper (Mild moaning, intermittent) 2 - Vigorous Cry (Loud scream; rising, shrill, continuous) [Note: Silent cry may be scored if baby is intubated as evidenced by obvious mouth and facial movement.] Breathing Patterns: 0 - Relaxed (Usual pattern for this infant) 1 - Change in Breathing (Indrawing, irregular, faster than usual; gagging; breath holding) Arms: 0 - Relaxed/Restrained (No muscular rigidity; occasional random movements of arms) 1 - Flexed/Extended (Tense, straight legs; rigid and/or rapid extension, flexion) Legs: 0 - Relaxed/Restrained (No muscular rigidity; occasional random leg movement) 1 - Flexed/Extended (Tense, straight legs; rigid and/or rapid extension, flexion) State of Arousal: 0 - Sleeping/Awake (Quiet, peaceful sleeping or alert random leg movement) 1 - Fussy (Alert, restless, and thrashing) Heart Rate: 0 - Within 10% of baseline 1 - 11-20% of baseline 2 - >20% of baseline O2 Saturation: 0 - No additional O2 needed to maintain O2 sat 1 - Additional O2 required to maintain O2 sat
Newborn endotracheal suctioning
Recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.
A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect?
Renal agenesis
A nurse is obtaining the blood pressure of a client who is pregnant. The client's blood pressure is 142/90 mmHg. Which of the following actions should the nurse take?
Repeat the measurement after allowing the client to sit for 5 to 10 minutes
Diapraghm
Replace every 2 years and with 20% weight fluctuation.
A nurse is reviewing the medical record of a client who is at 20 weeks of gestation. Which of the following findings should the nurse identify as a presumptive indication of pregnancy?
Report of fetal movement by the client
A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations is the newborn indicates toxicity due to the magnesium sulfate therapy?
Respiratory depression
The nurse understands that the newborn of a mom with diabetes mellitus is at risk for which complication?
Respiratory distress - Macrosomic baby (larger than average) at risk for respiratory distress - Newborn is also at risk for hyperbilirubinemia, hypocalcemia, and hypoglycemia.
A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication from the oxygen therapy?
Retinopathy -Retinopathy is a disorder of retinal blood vessel development in the premature newborn. It can reduce vision or result in complete blindness.
A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding?
Rooting
A nurse is planning care for a client who is postpartum. Which of the following strategies should the nurse include in the plan to prevent bladder distention?
Run water in the sink while the client sits on the toilet
Narcotic effects on baby
S/S: -Irritable -Hyperactive -High pitched cry -Tremors -Poor feeding/sucking -Nasal stuffiness -v/d Interventions: -Swaddle -Minimalize handling -Decrease stimuli -Pacifier -Prone position -Cover elbows/knees-prevent skin breakdown, bulb syringe -May need morphine, phenobarbital, etc.
A postpartum nurse is providing care for a client who is breastfeeding and has a perineal hematoma. The nurse should recommend that the client use which of the following breastfeeding positions?
Side-lying
A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement?
Slow-paced breathing
A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider?
Small, pinpoint, reddish-purple spots on the chest -Petechiae can indicate infection or low platelet count
For male sterilization, which is important to discuss with the patient?
Sperm count testing follow up must be completed.
A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include?
Sponge bathe the newborn every other day
A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following actions should the nurse plan to take?
Stand at the client's right side if the nurse is right-handed
Trichomoniasis
Strawberry spots on cervix
Estimated Date of Delivery (Naegele's Rule)
Subtract 3 months, add 7 days EX) Last period on September 9, 2010. - Estimated due date is June 16, 2011. EX) A nurse is caring for a client whose last menstrual period (LMP) began on July 8. Using Naegele's rule, what is the client's estimated date of birth (EDB)? = April 5
A patient has positive urine ketones/acetone, low Na/K/Cl, Metabolic alkalosis, heart rate 116, and blood pressure 110/68. You suspect:
Suspect hyperemesis gravidarum - Vitamin B6
A nurse is planning educational sessions for clients in a childbirth class. Which of the following findings should the nurse plan to instruct the clients to report immediately?
Swelling of face and fingers
A nurse is assessing a newborn who was born at 39 weeks gestation. Which of the following findings should the nurse expect?
Symmetric rub cage
Which immunization is most common for a pregnant woman at 28 weeks?
TDAP
Four hours after the birth of a neonate, the baby is jittery, irritable, and has a high-pitched cry. What is the priority action?
Test for the blood glucose level - Test blood glucose level to rule out hypoglycemia
What is the expected response when eliciting a Babinski reflex?
The big toe moves upward while the others spread/fan out - Dorsiflexion
Give examples of pain management for a client whose fetus was in right occiput posterior position (ROP).
The fetus is in the right occiput posterior position (ROP) at this point and the client could be experiencing pain during this time. In order to help the client manage her pain, we could assist her in various ways such as getting her onto her hands and knees, performing lunges, ambulating, swaying, and performing pelvic tilts/pelvic rocking. She may also benefit from getting into a warm bath, counterpressure if needed, applying cold packs or heat packs depending on her pain level, therapeutic massage, therapeutic communication, sitting on a large ball, music therapy, and breathing exercises. Decreasing the environmental stimuli such dimming the lights and providing noise reduction may also aid in her pain management. It is important to include her partner or person of choice in her pain management so they can support her during this time. They can take part in massaging the client's hands and providing her with love and comfort. When the time is right, she may also be administered medication per the provider's orders to help manage her pain.
A nurse is assessing a client at 27 weeks of gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect?
The fundal height measures greater than gestational age.
What is a nursing consideration for a fetus who is LOP positioned?
The patient will report more back pain.
For the contraceptive vaginal ring, which is true regarding use?
The ring is in place for 3 weeks and then out for 7 days (1 week).
A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced. Which of the following responses should the nurse make?
These feeling are common for expectant fathers in early pregnancy
A nurse is caring for a client who is at 8 weeks of gestation with twins and primigravida. The client states that even though she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurse make?
These feelings are quite normal at the beginning of pregnancy
For female sterilization with tubal ligation, which teaching should be included?
This is a serious surgical procedure and there are risks to be discussed.
Contraceptive sponge
To use, it must be moistened with water before insertion.
What is the priority assessment for the Rh-positive infant with a positive Direct Coombs test?
Total serum bilirubin (TSB) levels
A nurse is caring for a client in labor whose cervix is dilated to 9 cm. She is experiencing strong contractions every 2 min lasting 75 sec. The nurse should recognize that the client is in which of the following phases or stages of labor?
Transition phase of first stage
A nurse is planning care for a newborn who is receiving phototherapy. Which of the following interventions should the nurse include in the plan of care?
Turn and reposition the newborn every 2 hours during phototherapy
A nurse is caring for a client in active labor whose membranes have ruptured. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first?
Turn the client onto her left side
A nurse is caring for a client whose membranes have ruptured and is in active labor. the fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first?
Turn the client onto her left side -veaL choP - Placental insufficiency
A late deceleration is noted on the monitor. What should the nurse do first?
Turn the patient lateral
A nurse is assessing a client receiving magnesium sulfate as treatment for preeclampsia. Which of the following clinical findings is the nurse's priority?
Urinary output 40 mL in 2 hr -Discontinue magnesium sulfate if the hourly output is less than 30 mL/hr. -Urinary output is critical to the excretion of magnesium from the body.
A nurse is assessing a client who is receiving magnesium sulfate as a treatment for pre-eclampsia. Which of the following clinical findings is the nurse's priority?
Urinary output 40 mL in 2 hr -If hourly urine output is <30 mL/hr, discontinue magnesium sulfate
A nurse is caring for a client who is at 16 weeks gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication?
Use a 20-gauge needle and administer the medication using the Z-track method
A nurse is caring for a client who is at 16 weeks of gestation and has severe iron-deficiency anemia. The provider prescribes and injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication?
Use a 20-gauge needle, and administer the medication using the Z-track method -Z-track method prevents straining of tissue
A patient is admitted with abruptio placentae. The nurse expects which symptom?
Uterine tenderness - PAINFUL vaginal bleeding - Uterine tenderness - Uterine HYPERtonicity - Uterus with elevated tone - Abdominal pain - Back pain - Painful contractions (uterine contractions) - Uterus contracts and rises. - Umbilical cord suddenly lengthens. - Gush of blood occurs. NOTE: - Placenta previa = PAINLESS vaginal bleeding - Abruptio placentae = PAINFUL vaginal bleeding
A nurse is teaching a client who is at 30 weeks gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching?
Vaginal bleeding
A patient with placenta previa arrives. The nurse tells the client that which procedure will be deferred?
Vaginal speculum exam
A nurse is caring for a client who is in labor. A vaginal exam reveals this information: 2cm, 50%, +1, right occiput anterior (ROA). Based on this information, which of the following fetal positions should the nurse document in the medical record?
Vertex
A nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2 cm, 50%, +1, right occiput anterior (ROA). Based on this information, which of the following fetal positions should the nurse document in the medical record?
Vertex
A nurse is providing teaching about newborn baths to a client who is 2 days postpartum. Which of the following pieces of information should the nurse include?
Wash the newborn's face with plain warm water
A nurse is determining an Apgar score for a newborn who was born 1 minute ago. For which of the following findings should the nurse assign a score of 1?
Weak cry
Which is true regarding cervical mucus ovulation monitoring?
When mucus is thin and can be stretched, ovulation is most likely
The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider?
Yellowish tinge to the skin -Risk hyperbilrubinemia as hematoma resolves, breaks down RBC's -Promote feeding to decrease risk of jaundice
A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching?
You will have a c section prior to the onset of labor
The nurse is caring for a woman with epidural anesthesia for pain control during a vaginal delivery. A risk for injury related to epidural anesthesia has been identified by the nursing staff. What interventions are appropriate for the nurse to implement related to this diagnosis? (Select all that apply.)
a. Assess leg movement and sensation before ambulating. c. Observe for signs of impending birth. To prevent the risk for injury related to epidural anesthesia the nurse should assess for movement, sensation, and leg strength before ambulating, ambulate cautiously with an assistant, assist the woman to change positions regularly, and observe for signs that birth may be near: increase in bloody show, perineal bulging, and/or crowning.
Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client's blood pressure (Select all that apply)?
b. Place the woman in a lateral position. c. Increase intravenous (IV) fluids. d. Administer oxygen.
If patient is at risk for preterm labor because she has had preterm labor in a past pregnancy...
put her on progesterone supplementation.
Danger Signs
• Gush of fluid from vagina (rupture of amniotic fluid) prior to 37 weeks of gestation • Vaginal bleeding (placental problems--abruption or previa) • Abdominal pain (premature labor, abruptio placentae, or ectopic pregnancy) • Changes in fetal activity (decreased fetal movement may indicate fetal distress) • Persistent vomiting (hyperemesis gravidarum) • Elevated temperature (infection) • Dysuria (UTI) Gestational Hypertension: • Severe headaches • Blurred vision • Edema of face and hands • Epigastric pain
Promoting Sibling Bonding
• Take sibling on tour of OB unit. •Let sibling be one of the first to see the infant. •Provide a gift from the infant to give the sibling. •Arrange for one parent to spend time with the sibling while the other parent is caring for the infant. • Allow older siblings to help in providing care for infant. • Provide preschooler with a doll to care for.
Epidural
•**Given during 2nd phase of labor-(approx. 50%)...4cm dilated •** HYPOTENSION risk (may first have nausea/vomiting) •Risk: CNS depression; bladder distension/retention (catheter) •Prehydrate for BP, psn, nausea/vomiting assoc. with hypotension (LEFT SIDE, O2, IV fluids!)...Restrict PO intake •Monitor vitals and FHR! Baseline and during at least Q15min. -Maintain BP > 100/70 •Stop during transition phase- Prolonged 2nd stage (= risk C-section)/decreased ability to push •POST-Procedure- Monitor for fever and delayed respiratory depression RISK SPINAL HEADACHE- REMEMBER BLOOD PATCH TREATMENT
Phenylketonuria (PKU)
•A disorder related to a defective recessive gene on chromosome 12 that prevents metabolism of phenylalanine (common protein amino acid) •Can Cause: -Mental retardation -Behavior problems -Skin rash -Musty body odor •Baby tested 24 hrs after beginning milk -Retest in 7-10 days to catch earlier false negative •NO: -Meat -Dairy products -Dry beans -Nuts -Eggs •Cereals, fruits, and veggies in moderation
BUBBLEHER (Postpartum Assessment)
•B - Breasts •U - Uterus (fundal height, uterine placement, and consistency) •B - Bowel and GI function •B - Bladder function •L - Lochia (color, odor, consistency, and amount [COCA]) •E - Episiotomy/perineum (edema, ecchymosis, approximation) •H - Homan's sign/DVT screen •E - Emotional status •R - Rogham/rubella vaccine need
Newborn Care
•Erythromycin ophthalmic antibiotic ointment: -Prevents gonorrhea eye infection -May cause minor eye irritation •Vitamin K: -1st hr after delivery -IM - Vastus lateralis -Prevents hemorrhage •** Make sure baby is given ID bands (should have 2) and always check baby and parents!! •Hepatitis B vaccine - IMMUNIZATION
Diaphragm
•Female client fitted by provider. •Must be refitted by provider every 2 years, if there is a 7 kg (15 lb) [20%] weight change, full-term pregnancy, or second-term abortion. •Requires proper insertion and removal. Prior to coitus (sexual intercourse), diaphragm is inserted vaginally over cervix with spermicidal jelly or cream •Diaphragm must remain in place for at least 6 hours AFTER coitus. •Spermicide must be reapplied with each act of coitus. •Empty bladder prior to insertion of diaphragm.
Causes of Bleeding
•First trimester: spontaneous abortion, ectopic pregnancy •Second trimester: gestational trophoblastic disease/molar pregnancy •Third trimester: placenta previa or abruption •Preterm labor
Preterm Baby
•Gavage fed (NG tube) fed baby care: -Insertion: Head slightly elevated. May insert to midway between xiphoid process and umbilicus -Check aspirate for residual, pH < 3, 0.5 mL air? -Gravity, breastmilk, and high calorie formula -Gavage (NG tube) feedings are common for premature infants: •Position right side or prone after feeds •Concern for NECROTIZING ENTEROCLOITITS •ROP/BPD, monitor O2
Newborn Vital Signs/Measurements
•HR 100-160 bpm •Resp 30-60 •Temp 97.7-98.9 •BP 60-80/40-50 •Head circumference (above eyebrows/occiput) 32-36.8 cm *2 cm larger than chest •Chest circumference (nipple line) 31-33cm
Infertility Concepts
•Hysterosalpinogram- Xray •Sperm count/analysis •Medication: Clomiphene citrate- -Risks multiple pregnancies; ovaries becoming enlarged (ovarian hyperstimulation syndrome [OHSS]). Common side effects include hot flashes, headaches, and vomiting, mood changes, and breast tenderness, as well as vision changes
Rubella Vaccine (MMR)
•If mom has low titer prenatal, (<1:8), considered nonimmune, give PRIOR to discharge postpartum. Attempt to prevent congenital rubella syndrome (CRS)- heart defects/nervous system damage •MMR vaccine is SubQ -NOT given during pregnancy -Live virus -Don't get pregnant for at least 1 month. •OK with breastfeeding. Not for those immunocompromised or duck egg allergy •*If both Rhogam and Rubella vaccine, recheck at 3 months for rubella immunity
Characteristics of Lochia
•Initially lochia RUBRA = red, clots up to 3 cm (days 1-3) -Blood, fragments of decidua •Then, lochia SEROSA = pink/brown (days 4-10) -Blood, mucus, and invading leukocytes •Lochia ALBA = yellow/clear (day 10-14, may last 6 weeks!) - Rule out infection or onset of menses -Largely mucus; leukocyte count high
Hyperbilirubinemia (Jaundice)
•Jaundice in first 24 hours is pathologic/non physiologic •Jaundice days 2-4 onset is not pathologic. Physiologic •Often in a warmer -IF PHOTOTHERAPY, COVER EYES -Monitor temp. - Monitor levels (tcb/tsb) Home phototherapy? -Probably bili blanket. Keep against their skin. -No eye covering.
Newborn Etc...
•May place in warmer if <97.6 F - with RUQ abdomen temp sensor (with deflector)/ manual temp Q 1-2 hrs. Only needs diaper. •Reflexes- Moro (startle), step reflex •Latching: -Nipple and areola in baby's mouth. -Audible swallowing. -Breast relief -Baby appears full •Void 1 minimum diaper/day first 5 days. -NOTE: 1g=1mL....Urine output at least 1 mL/kg/hr •Usually 6 wet diapers a day by day 6 •Transitional stools then milk stools (yellow) •Diaper changes: -Warm water after void -Soap/water with BM -Document! •Heelstick- gloves, alcohol swab. Avoid center of heel/plantar artery, wipe 1st drop away •Fontanels -Anterior closes 18-20 months -Posterior closes 2-3 months
Combination Oral Contraceptives (COC)
•Med requires consistent/proper use •NO STI protection •Danger Signs: -chest pain -shortness of breath -leg pain from possible clot -headache -eye problems from a stroke -hypertension •Exacerbates conditions affected by fluid retention such as migraine, epilepsy, asthma, kidney, or heart disease. •**Contraindications!!!!! -history of blood clots -stroke -cardiac problems -breast or estrogen‑related cancers -pregnancy -smoking (if over 35 years of age) -Gallbladder disease •Antibiotics, anticonvulsants, and antifungals can decrease the effectiveness of COC. -Rifampin (antibiotic), St. John's wort, and phenytoin (anticonvulsant)
Postpartum Hemorrhage (PPH) Medications-with ongoing massage and after oxytocin (Pitocin)
•Methylergonovine maleate (Methergine) -Do not give if HTN/preeclampsia -Take BP prior to admin (call Dr if >140/90) •Prostaglandin F2/Carboprost (Hemabate) -Do not give if asthma -Check temp Q 1-2 hours and auscultate breath sounds freq. -*May need antiemetic due to N/V effect -Bronchospasm/wheezing, fever, headache
Postpartum contraception
•No oral contraceptives until breastfeeding well established at 4 weeks postpartum •Progesterone methods- medroxyprogesterone
Newborn Priorities, Interventions, etc.
•Patent airway and keeping warm are priorities •Respiratory distress: -NASAL FLARING -retractions -tachypnea (>60) -dusky/cyanosis -grunt - >15 sec apnea -Determine & report if meconium passed during labor; Keep warm •Cold stress may lead to respiratory distress, hypoglycemia, tachypnea, metabolic acidosis. -MUST KEEP WARM. -ASSESS/Resuscitate under warmer •Labored breathing/cyanosis- CPAP •HR under 100 - positive pressure ventilation (PPV) •HR under 60 - chest compressions with thumbs •Concern for meconium aspiration -Monitor for meconium stained amniotic fluid- may have decreased FHR -Have resuscitative equipment on hand/suction •Bulb suction- depress, mouth first!
Narcotic Withdrawal - Neonatal Abstinence Syndrome (NAS)
•Prenatal drug exposure •Opioid exposure and withdrawal •S/S: -Irritability -Seizure -hyperactive -high pitched cry -tremors -exaggerated moro -hypertonic muscles -poor feeds -dehydration -vomiting -diaphoresis -fever nasal stuffiness -tachypnea •May not be apparent at birth, 48-72 hr post •Urine, hair, meconium sampling •Tx: phenobarbital, buprenorphine, clonidine, methadone, morphine •NAS Care: -decrease stimuli -nutrition -hydration -promote bonding -close contact -wrapped snugly -skin care •Baby with cocaine withdrawal: -NAS every 2-4 hrs -Swaddle snuggly with pacifier -Arms and legs flexed when swaddled snuggly -Low stimuli room -Avoid eye contact with baby -Cluster care •Neonatal abstinence scoring system or Finnegan tool
Second Trimester
•Quickening by 20 wks •20 Wk ultrasound- check FETAL GROWTH, viability, gest, size/date, AFV, placenta, uterus, post-amniocentesis •Colostrum (as early as 16 weeks) •24-28 week testing -Diabetes testing and education •Weight gain 1 lb/wk •Fundus @ umbilicus @ 20 wks •Alpha-feto protein- Triple/Quad screen/MSAFP- *16-18weeks Optional, lab draw. Assess for fetal neural tube (high MSAFP) or chromosomal defects/Down's Syndrome (low MSAFP). Common false results
Coombs Test: Rh Isoimmunization Risk/Hemolytic Anemia
•Rh- negative Mom: -INDIRECT Coombs test -Negative result = Has not developed antibodies against her Rh+ baby (Good; will not attack baby). Give Rhogam to prevent sensitization. -Positive result = Has antibodies against baby's Rh+ blood. Sensitization has occurred. Monitor pregnancy/baby carefully. No need to give Rhogam. •Rh+ positive Baby: -DIRECT Coombs test -Negative result = Good, mom's blood type has not affected baby. Give Rhogam to mom if delivered and baby Rh+ -Positive result = Bad! Antibodies (from mom) are acting against baby's blood type- possible erythroblastosis fetalis. TX blood transfusion/tx jaundice
Subarachnoid Block
•Risks/Contraindications: Same as epidural •Still hypotension risk - Need bolus •Postdural puncture headache -Lay flat/supine, increase fluids, Caffeine -Blood patch treatment
Gestational Diabetes Mellitus (GDM)
•Try to keep blood glucose 70-110 •1-hour glucose tolerance test on all women 24-28 wks; If >140, then need 3-hour glucose tolerance test •HYPOglycemia in 1st trimester (decreased supplemental insulin need) •HYPERglycemia in 2nd/3rd trimester (increased supplemental insulin). •Risk: -preeclampsia -infection -polyhydramnios -*macrosomic (large) baby •Recommend fetal screening such as triple screen/AMNIOCENTESIS -Fetal insulin secretion acts as a growth hormone •Insulin therapy instead of oral hypoglycemics •GDM usually resolves after delivery** Decreased need for insulin •Prenatal education for a preexisting diabetic •Nutrition: Low glucose, good complex carbs and fiber. May teach carb counting
Care Seat Saftey
•Use approved rear-facing car seat in the back seat, preferably in the middle, (away from air bags and side impact) to transport newborn. •Keep infants in rear-facing car seats until age 2 or until the child reaches the maximum height and weight for the seat. •Do not use a used or secondhand car seat.
