Maternal Child HESI
Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. However, clots larger than ________ need to be reported to the HCP, as they are considered abnormal.
1 cm
stages of labor
1st: dilating stage 3 phases: Latent (0-3cm) Active (4-7cm) Traditional (8-10cm w/ urge to push) 2nd stage: delivery 3rd: placental delivery 4th: recovery- primary goal to prevent hemorrhage from uterine atony, 1st void within 1 hour and then q2-3 hrs, Rhogam
Normal bowel elimination usually returns how many days postpartum?
2 to 3 days postpartum.
Fundal height should be at the umbilicus at _____________ gestation. This early fundal height increase indicates a hydatidiform mole, a multiple gestation, or a fetal congenital anomal
20 Weeks
The normal aPTT varies between
28 and 35 seconds (28 and 35 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (42 to 52.5) and 2.5 (70 to 87.5) times normal.
The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus?
"It connects the umbilical vein to the inferior vena cava."
The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?
"It promotes the fertilized ovum's normal implantation in the top portion of the uterus."
A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?
"The vaginal discharge may be bothersome, but is a normal occurrence." Rationale: Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health clinic or emergency department.
The nurse should make which statement to a pregnant client found to have a gynecoid pelvis?
"Your type of pelvis is the most favorable for labor and birth."
What is the optimal nursing intervention to minimize perineal edema after an episiotomy?
Apply ice to affected area
Valvular hematomas intervention
Applying ice to wound
Chadwick's sign
Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion.
The antidote for magnesium sulfate is ________________
Calcium gluconate
The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn?
Constant crying Irritability Difficult to comfort
Nitrazine paper will turn ___________________ if amniotic fluid is present; it remains the same color in the presence of urine.
Dark blue
Insulin needs (Increase?/Decrease) in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin
Decrease
The nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond?
During the 8th week Rationale: During the eighth week of pregnancy the organ systems and other structures are developed to the extent that they take the human form; at this time the embryo becomes a fetus and remains so until birth.
The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is utilized in order to do what?
Estimate fetal age
What nutritional tips would a nurse give a pregnant woman who is complaining of bleeding gums when perfoming oral care?
Fresh fruits and vegetables provide vitamins and minerals needed for healthy gums
A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.
Increased efficiency of contractions The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
heavy bleeding; the cervical os is open and tissue is present. Which type of abortion is the client experiencing?
Inevitable abortion
A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan?
Isoniazid plus rifampin will be required for 9 months. Rationale: More than 1 medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months
Effleurage massage
Light in stroke/produces reflexive response.
The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?
Maintaining safety because of low blood glucose levels Rationale: The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority.
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care?
Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches.
The nonstress test is used to evaluate the response of the fetus to ....
Movement and activity
A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does this test do?" The nurse responds that this test can reveal what?
Neural tube defects
The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate?
Notify HCP Rationale:Low or oddly placed ears are associated with various congenital defects and should be reported immediately
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action?
Notify the HCP
When taking iron supplements, how is it best absorbed?
On an empty stomach.
Foods containing ascorbic acid will increase the absorption of iron. ___________________ is the only item that contains ascorbic acid and will increase the absorption of iron supplement
Orange juice
Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Primary intervention for this?
Pain relief management.
A grand multipara at 34 weeks' gestation is brought to the emergency department because of vaginal bleeding. The nurse suspects that the client has a placenta previa. Which characteristic typical of placenta previa supports the nurse's conclusion?
Painless vaginal bleeding in the third trimester
The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply.
Proteinuria 2.Hypertension
On a routine prenatal visit, what is the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time?
Quickening - recognition of fetal movement; it is felt about 2 weeks earlier in multigravidas.
Signs of umbilical cord infection
Signs of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If signs of infection occur, the client should be instructed to notify a health care provider (HCP).
triple screen test
The Triple Test combines the AFP, beta hCG, and estriol serum level values. The hormone level results are used in a formula to figure out the risk for a Down's syndrome infant. Diagnostic test for genetic anomalies is chromosome testing.
A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor?
The appearance of the fetal external genitalia
A woman who is 28 weeks pregnant calls the clinic to report that she is frightened because she has begun leaking breast milk. What is the best response?
This can be a normal event of pregnancy
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
Variable decelerations
labor dystocia
an abnormally slow progression of labor
The first recognition of fetal movements, or feeling life, by the multiparous woman may occur as early
as 14 to 16 weeks' gestation.
platyelloid pelvis
flat shape that may impede fetal descent, making vaginal delivery more difficult.
HELLP syndrome
hemolysis, elevated liver enzymes, low platelets
Signs and symptoms of preterm labor
increased vaginal dischange, pelvic pressure, backache, menstrual like cramping, obvious uterine contractions, fluid leaking from vagina, vaginal bleeding, diarrhea, intestinal cramping
Prolonged rupture of membranes of more than 18 hours increases the risk of ...
maternal and newborn sepsis.
abruptio placentae
premature separation of the placenta from the uterine wall. Uterine tenderness is a symptom.
Nursing care for the client with a possible ectopic pregnancy is focused on
preventing or identifying hypovolemic shock and controlling pain
Ovulation ceases during pregnancy because ?
the circulating levels of estrogen and progesterone are high, inhibiting the release of follicle-stimulating and luteinizing hormones, which are necessary for ovulation
findings associated with hydatiform mole?
vaginal bleeding, excessive nausea and vomiting, larger-than-normal uterus for gestational age, elevated levels of hCG, failure to detect fetal heart activity even with sensitive instruments, and early development of gestational hypertension. Fetal activity would not be noted.
