NCLEX PN Review

Measuring the Fundal Height

1. place the patient in a supine position 2. place the end of the tape measure at the level of the symphysis pubis 3. stretch the tape to the top of the uterine fundus 4. note and record the measurement

State three ways to identify the chronologic age of a pregnancy

10 lunar months; 9 calendar months consisting of three trimesters of 3 months each; 40 weeks, 280 days

Fetal heart rate can be auscultated by Doppler at ______ weeks' gestation

10 to 12

Normal fetal heart rate in labor is ______________________ Normal maternal BP in labor is _____________________ Normal maternal pulse in labor is ________________________ Normal maternal temperature in labor is ______________________

110 to 160 beats per minute <140/90 <100 beats per minute <100.4 F or 38 C

Ovulation occurs how many days before the next menstrual period?

14 days

During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a patient in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted? 1. 80 beats per minute 2. 100 beats per minute 3. 150 beats per minute 4. 180 beats per minute

150 beats per minute Rationale: FHR depends on gestational age. It is normally 160 to 170 beats per minute during the first trimester, but it slows with fetal growth to 110 to 160 beats per minute near or at term.

A pregnant patient asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? 1. 6 and 8 weeks' gestation 2. 8 and 10 weeks' gestation 3. 10 and 12 weeks' gestation 4. 16 and 20 weeks' gestation

16 to 20 weeks' gestation rationale: quickening is fetal movement that usually first occurs between 16 and 20 weeks' gestation. The expectant mother first notices subtle fetal movements during this time, and these gradually increase in intensity. Options 1, 2 and 3 are incorrect; these gestational time frames are too early for quickening

The nurse is collecting data from a patient who is pregnant with twins. The client has a healthy 5 year old child who was delivered at 38 weeks and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document the GTPAL for this patient as which? 1. GTPAL: 3,2,0,0,1 2. GTPAL: 2,1,0,0,1 3. GTPAL: 1,1,1,0,1 4. GTPAL: 2,0,0,0,1

2, 1, 0, 0, 1 rationale; pregnancy outcomes can be described with the GTPAL acronym.

Hemodilution of pregnancy peaks at ___________________ weeks and results in a/an _________________________________________ in a woman's Hct

28-32 weeks, decrease

The nurse is collecting data from a pregnant patient when the patient asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make? 1. the organ of copulation 2. Where the fetus develops 3. Where fertilization occurs 4. Secrete estrogen and progesterone

3. Where fertilization occurs Rationale: each fallopian tube is a hollow muscular tube that transports a mature oocyte for final maturation and fertilization. Fertilization typically occurs near the boundary between the ampula and the isthmus of the tube. The vagina is the organ of copulation, and the fetus develops in the uterus. Estrogen is a hormone that is produced by the ovarian follicles, the corpus luteum, the adrenal cortex, and the placenta during pregnancy. Progesterone is a hormone that is secreted by the corpus luteum of the ovary, the adrenal glands, and the placenta during pregnancy

Normal blood glucose in the term neonate is _____________________

40 to 80 mg/dL

A term newborn needs to take in _______________________ calories per pound per day. After the initial weight loss is sustained, the newborn should gain ________________ per day

50; 1 ounce or 28.3g

The newborn transitional period consists of the first ___________ of life

6 to 8 years

The goal for diabetic management during labor is euglycemia. How is it defined?

60 to 100 mg/dL

What score is considered a "good" Apgar score

7 to 10

Normal newborn temperature is ___________________ Normal newborn heart rate is _______________________ Normal newborn respiratory rate is ________________________ Normal newborn blood pressure is ____________________________

97.7 F to 99.4 F (36.5 to 37.4 C) 110 to 160bpm; pulse 30 to 60 BP: 80/50

hesi hint #57 for maternity nursing

A high incidence of fetal anomalies occurs in pregnant women with diabetes. Therefore fetal surveillance is very important -ultrasound examination -alpha-fetoprotein (to determine neural tube anomalies) -nonstress and contraction stress tests

hesi hint #38 for maternity nursing

A patient who is 32 weeks' gestation calls the HCP because she is experiencing dark-red vaginal bleeding. She is admitted to the emergency department, where the nurse determines the FHR to be 100bpm. The patient's abdomen is rigid and boardlike, and she is complaining of severe pain. What action should the nurse take? first the nurse must use his or her knowledge base to differentiate between abrutio placenta (this patient) and placenta previa (painless bright red bleeding occurring in the third trimester). The nurse should immediately notify the HCP, and no abdominal or vaginal manipulation or examinations should be done. Administer O2 per face mask. Monitor for bleeding at IV sites and gums because of the increased risk for DIC. Emergency cesarean delivery is required because uteroplacental perfusion to the fetus is being compromised by early separation of the placenta from the uterus.

Nagele's Rule

A way to determine the estimated date of birth that works on the premise that the woman has a 28-day menstrual cycle. Subtract 3 months from the first day of the last menstrual period, add 7 days and then adjust the year

List three symptoms of abruptio placentae and three symptoms of placentia previa

Abruption: fetal distress; rigid, boardlike abdomen; pain; dark-red or absent bleeding. Previa: painless, bright-red vaginal bleeding, fetal heart rate normal; soft uterus

State the objective signs that signify ovulation

Abundant, thin, clear cervical mucus; spinnbarkeit (egg white stretchiness) of cervical mucus; open cervical os; slight drop in basal body temperature and then 0.5 F to 1 F rise; ferning under the microscope

What modalities are thought to increase the production of endogenous opiates

Acupuncture, administration of placebos, TENS

hesi hint #48 for maternity nursing

Although delivery is often described as the "cure" for preeclampsia, the patient can convulse up to 48 hours after delivery

Identify three bioterrorism agents

Anthrax Pneumonic plague Botulism Smallpox Inhalation tularemia Viral hemorrhagic fever ricin sarin radiation

list three nursing interventions for the neonate undergoing phototherapy

Apply opaque mask over eyes leave diaper loose so stools/urine can be monitored turn every 2 hours watch for dehydration

If signs of meconium were observed in the amniotic fluid during ROM, what action must the nurse take in the delivery room

Arrange equipment for possible endotracheal tube placement to maintain airway

What is the major cause of maternal death when general anesthesia is administered

Aspiration of gastric contents

What is the priority nursing action after spontaneous or artificial rupture of membranes

Assessment of the fetal heart rate

hesi hint #7 for maternity nursing

At approximately 28 to 32 weeks' gestation, the maximum plasma volume increase of 25% to 40% occurs, resulting in normal hemodilution of pregnancy and Hct values of 32% and 42%. High Hct values may look "good," but in reality, they represent a gestational hypertension disorder and a depleted vascular space.

hesi hint #59 for maternity nursing

Babies delivered abdominally miss out on the vaginal squeeze and are born with more fluid in the lungs, predisposing the newborn to transient tachypnea and respiratory distress

A baby is delivered blue, limp, and with a heart rate less than 100. The nurse dries the infant, suctions the oropharynx, and gently stimulates the infant while blowing O2 over the face. The infant still does not respond. What is the next nursing action?

Begin oxygenation by bag and mask at 30breaths/min if heart rate is less than 60, start cardiac massage at 120 events/min: 30 breaths and 90 compressions. Assist HCP in setting up for intubation procedure

list symptoms of hyperbilirubinemia in the neonate

Bilirubin levels rising 5mg/day jaundice dark urine anemia high RBC count dark stools

Which women experience afterpains more than others

Breastfeeding women, multiparas, and women who experienced overdistention of the uterus

During the physical examination of the newborn, the nurse notes the cry is shrill, high-pitched, and weak. What are the possible causes

CNS anomalies, brain damage, hypoglycemia, and drug withdrawal

A nursing student is assigned to a patient in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus. 1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cava

Connects the umbiilical vein to the inferior vena cava Rationale: the ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery

hesi hint #53 for maternity nursing

Coumadin may not be taken during pregnancy because of its ability to cross the placenta and affect the fetus. HEPARIN is the drug of choice; it does not cross the placental membrane.

hesi hint #11 for maternity nursing

Danger Signs During Pregnancy Reinforce teaching about immediately reporting any of the following list of danger signs. Early intervention can optimize maternal and fetal outcome. Possible Indications of Preeclampsia/Eclampsia 1. visual disturbances 2. swelling of face, fingers, or sacrum 3. persistent vomiting Signs of infection 1. chills 2. temperature greater than 38 C (100.4 F) 3. dysuria 4. pain in abdomen or back 5. fluid discharge from vagina (anything other than normal leukorrhea) 6. change in fetal movement

What is the first sign of tolerance to pain analgesics

Decreased duration of drug effectiveness

A patient has been told of a positive breast biopsy report. She asks no questions and leaves the HCPs office. She is overheard telling her husband, "the doctor didn't find a thing" What coping style is operating at this stage of grief/

Denial

Identify the five stages of death and dying

Denial Anger Bargaining Depression Acceptance

What contraceptive technique is recommended for diabetic women

Diaphragm with spermicide. Avoid birth control pills that contain estrogen an d IUDs which are an infection risk

List the 3 levels of disaster management

Disaster Preparedness Disaster Response Disaster Recovery

hesi hint #39 for maternity nursing

Disseminated intravascular coagulation (DIC) is a syndrome of abdominal clotting that is systematic and pathologic. Large amounts of clotting factors, especially fibrinogen, are depleted, causing widespread external and/or internal bleeding. DIC is related to fetal demise, infection/sepsis, pregnancy-induced hypertension (preeclampsia) and abruptio placentae.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be appropriate? 1. Have either of you ever had surgery? 2. Do you plan to have any other children? 3. Do either of you have diabetes mellitus? 4. Do either of you have problems with high blood pressure?

Do you plan to have any other children? Rationale: sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility because reversal surgery is not always successful. The nurse would ask he couple about their plans for having children in the future. Options 1, 3 and 4 are unrelated to this procedure

State four risk factors or predisposing factors to postpartum hemorrhage

Dystocia or prolonged labor overdistention of the uterus abruptio placentae infection

State three nursing interventions during forceps delivery.

Ensure empty bladder auscultate FHR before application, during application, and between traction periods observe for maternal lacerations and newborn cerebral/facial trauma

What is a "reactive" nonstress test

FHR acceleration of 15 beats per minute for 15 seconds in response to fetal movement

True or False: the newborns head is usually smaller than the chest

False; head is usually 2cm larger unless severe molding occurred

What immediate nursing actions should be taken when a postpartum hemorrhage is detected?

Fundal massage notify HCP if massage does not firm fundus Count pads to estimate blood loss Assess/record vital signs increase iv fluids and administer oxytocin infusion as prescribed

GTPAL Acronym

G=Gravidity T= Term births P = preterm births A = Abortions/ miscarriages L = live births Example A woman is pregnant for the fourth time. She had one elective abortion during the first trimester, a daughter who was born at 40 weeks' gestation, and a son who was born at 36 weeks' gestation. Therefore, she is gravida 4. Term 1 (daughter born at 40 weeks' gestation P 1 (son born at 36 weeks' gestation) A= 1 abortion is counted in the gravida because it occurred before the 20 weeks' gestation L 2 Therefore she would be considered GTPAL: 4,1,1,1,2

hesi hint #56 for maternity nursing

GLUCOSE SCREEN patient does not have to fast for this test: 50g of glucose is given and blood is drawn after 1 hour. If the blood glucose is greater than 135 mg/dL, then a 3-hour glucose tolerance test is done

Why are oral medications avoided in labor

Gastric activity slows or stops in labor decreasing absorption from oral route; may cause vomiting

What are the common side effects of antibiotics used to treat puerperal infection

Gastrointestinal adverse reactions -nausea -vomiting diarrhea cramping Hypersensitivty reactions: -rashes -urticaria -hives

Your client, an incest survivor, is speaking for her deceased father, the perpetrator. "He was a wonderful man, so good and kind. Everyone thought so." What would be the most useful intervention at this time?

Gently point out the positive and negative aspects of her relationship with her father. Try to minimize the idealization of the deceased.

what factor should the nurse look for in evaluating the newborn's ability to suck and take in adequate nutrition

Good suck, coordinated suck-swallow takes less than 20 minutes to feed, and gains 20 to 30g/day

Hesi hint #1 grief and dying

HCP may refer patients to hospice during the dying process. The goal of hospice is to provide the highest quality of end-of-life care for dying individuals. The care includes comfort and support for the individual as well as for the family.

APGAR Scoring System Criteria

Heart rate absent = 0 under 100 =1 100 or higher = 2 Respiratory effort no cry = 0 weak cry = 1 vigorous cry = 2 muscle tone flaccid = 0 some flexion = 1 total flexion = 2 reflex irritability no response to foot tap = 0 slight response to foot tap (grimace) = 1 quick foot removal = 2 Color dusky, cyanotic = 0 acrocyanotic = 1 totally pink = 2

hesi hint #8 maternity nursing

Hgb/Hct data can be used to evaluate nutritional status. For example, a 22 year old primigravida at 12 weeks' gestation has an Hgb of 9.6g/dL and an Hct of 31%. She has gained 3 pounds during her first trimester. A weight gain of 902 to 1814g (2-4 pounds) during the first trimester is recommended, and this patient is anemic. Supplemental iron and a diet higher in iron are needed. Foods high in iron 1. fish and red meats 2. cereal and yellow vegetables 3. green leafy vegetables and citrus fruits 4. egg yolks and dried fruits

What is the danger associated with regional blocks

Hypotension resulting from vasodilation below the block, which pools blood in periphery, thereby reducing venous return

hesi hint #33 for maternity nursing

Hypothermia (heat loss) leads to depletion of glucose and, therefore, the use of brown fat (special fat deposits fetus puts on in last trimester, which are important to thermoregulation) for energy, resulting in ketoacidosis and possible shock. Prevent by keeping neonate warm

name four causes of decreased FHR variability

Hypoxia Acidosis Drugs Fetal sleep

When may a vaginal birth after cesarean be considered a woman with a previous cesarean section?

If a low uterine transverse incision was performed and can be documented and if the original complication does not recur - that is CPD

What are the major symptoms of preeclampsia

Increase in BP of 30mm Hg systolic and 15mm Hg diastolic over previous baseline hyperreflexia proteinuria (albuminuria) CNS disturbances headache and visual disturbances epigastric pain

hesi hint #50 for maternity nursing

Increased DTRs (deep tendon reflexes) indicates worsening worsening preeclampsia, and decreased DTRs may indicate magnesium sulfate toxicity

If narcotic agonist/antagonist drugs are administered to a patient already taking narcotic drugs, what may be the result

Initiation of withdrawal symptoms

Which route of administration for pain medications has the quickest onset and the shortest duration

Intravenous push or bolus

List the symptoms of neonatal narcotic withdrawal

Irritabiliity hyperactivity high-pitched cry frantic sucking coarse flapping tremors poor feeding

Physiologic jaundice in the newborn occurs ___________ it is caused by ______________________________

Jaundice occurs at 2 to 3 days of life and is caused by immature liver's inability to keep up with bilirubin production of normal RBC destruction

What is the most important determinant of fetal maturity for extrauterine survival

L/S ration (lung maturity, lung surfactant development)

hesi hint #68 for maternity nursing

Laboratory tests measure both total and direct (conjugated, excretable, nonfat soluble) billirubin levels. The dangerous billirubin is the unconjugated, indirect (fat-soluble) billirubin, which is measured by subtracting the direct from the total billirubin

What are the cardinal symptoms of an infection in a newborn

Lethargy temperature instability difficulty feeding subtle color changes subtle behavioral changes hyperbilirubinemia

List the major CNS danger signals that occur in the neonate

Lethargy high-pitched cry jitteriness seizures bulging fontanels

List five prodromal signs of labor the nurse might teach the patient

Lightening Braxton Hicks contractions Increased bloody show loss of mucus plug burst of energy nesting behaviors

What six factors should the nurse include when assessing the pain experience

Location, intensity, comfort measures, quality, chronology, and subjective view of pain

What are the major goals of nursing care related to preeclampsia

Maintenance of uteroplacental perfusion prevention of seizures prevention of complications such as HELLP syndrome DIC abruption

hesi hint #60 for maternity nursing

Many times mastitis can be confused with a blocked milk sinus, which is treated by nursing closer to the lump and by rotating the baby on the breast. Breastfeeding is not contraindicated for women with mastitis unless pus is in the breast milk or the antibiotic of choice is harmful to the infant. If either of these occurs, milk production can still be fostered by manual expression

What modalities are associated with the gate control theory

Massage, heat and cold application, acupuncture, TENS

Name three maternal and three fetal complications of gestational diabetes

Maternal -hypoglycemia -hyperglycemia -ketoacidosis Fetal -macrosomia hypoglycemia at birth -fetal anomalies

Gonorrhea

Maternal Effect -Dysuria -Purulent vaginal discharge -PID Fetal Effects -Ophthalmia neonatorum -Sepsis Treatment -includes both partners: penicillin and/or erythromycin and Ceftriaxone used in pregnancy -Have partner(s) use condoms until cultures negative two times

Chlamydia trachomatis

Maternal Effect -Mucopurulent vaginal discharge -Dysuria -Acute Salpingitis -Pelvic Inflammatory Disease (PID) -Sterility or infertility Fetal Effects -Stillbirth/neonatal death -Preterm birth -Ophthalmia neonatorum -Pneumonia Treatment -treat with erythromycin; may need to treat partner -Azithromycin (Zithromax)

Human Papillomavirus (HPV)

Maternal Effect -Small or large, dry, wart-like growth on vulva, vagina, cervix, and/or rectum (condylomata acuminata) Fetal Effects -Possible chronic respiratory papillomatosis Treatment -Laser ablation or cyrotherapy -When pregnant, lesions usually left alone, unless mild laser treatment needed -Explain need for possible abdominal delivery because of fetal effect

Toxoplasmosis (TORCH)

Maternal effect -effects are absent or manifest as flulike symptoms Fetal effects -Stillbirth -Microcephaly -Hydrocephalus -Blindness -Deafness Treatment -treatment during pregnancy by sulfa drugs -may consider therapeutic abortion if discovered before 20 weeks

Gentle counter pressure against the perineum during an emergency delivery prevents ___________ and ____________________

Maternal lacerations; fetal cerebral trauma

What are the nursing actions for endometritis and parametritis

Measures to promote lochial drainage antipyretic measures (acetaminophen, cool baths) administration of analgesics and antibiotics as prescribed increase fluids with attention to high-protein/high-vitamin C diet

Phases of the Menstrual Cycle

Menstrual phase - days 1 to 5 of cycle. Shedding of the endometrium occurs as uterine bleeding, approx 60mL Proliferation (follicular) phase - day 5 to ovulation. 1. begins the first day of menstruation 2. ends 14 days later in a 28 day cycle Ovulatory phase 1. final maturation of a single follicle and release of its mature ovum occurs 2. ovulation marks the beginning of the luteal phase (occurs about 14 days into the menstrual cycle) Luteal Phase 1. begins immediately after ovulation and ends with menstruation 2. in the absence of implantation the corpus luteum regresses, estrogen and progesterone levels decrease, and the endometrium is shed via menstruation

What characteristics would the nurse expect to see in a neonate with fetal alcohol syndrome

Microecephaly growth retardation short palpebral fissures maxillary hypoplasia

State three priority nursing actions in the post-delivery period for the patient with preeclampsia

Monitor signs of blood loss continue to assess BP and DTRs every 4 hours Monitor uterine atony

All pregnant women should be taught preterm labor recognition. Describe the warning symptoms of preterm labor.

More than five contractions/hour cramps low, dull backache pelvic pressure change in vaginal discharge

What mechanism is involved in the reduction of pain through the administration of nonsteroidal antiinflammatory medications

NSAIDs act by a peripheral mechanism at the level of damaged tissue by inhibiting prostaglandin synthesis and other chemical mediators involved in pain transmission

What is the antidote for narcotic-induced respiratory depression

Naloxone (Narcan)

Hypotension often occurs after the laboring patient receives a regional block. What is one of the first signs the nurse might observe

Nausea

List four side effects of narcotic medications

Nausea/vomiting Constipation CNS depression Respiratory depression

Does insulin cross the placental/breast barrier

No therefore insulin-dependent women may breastfeed

A woman on tolbutamide (Orinase; oral hypoglycemic) asks the nurse if she can continue this medication in pregnancy. how should the nurse respond?

No, oral hypoglycemic medications are teratogenic to the fetus insulin will be used

Are breathing techniques prescribed for use by the stage and phase of labor

No, patients should use these techniques according to their discomfort level and change techniques when one is no longer working for relaxation

Must women diagnosed with mastitis stop breastfeeding

No, women who abruptly stop breastfeeding may make the situation worse by increasing congestion/engorgment and providing further media for bacterial growth. Patient may have to discontinue breastfeeding if pus is present or antibiotics are contraindicated for neonate

hesi hint #52 for maternity nursing

Normal diuresis, which occurs in the postpartum period, can pose serious problems to the new mother with cardiac disease because of the increased cardiac output.

A patient feels faint on the way to the bathroom. What nursing assessments should be made?

Observe BP sitting and lying; assess Hgb and Hct for anemia

State four risk factors or predisposing factors to postpartum infection

Operative delivery intrauterine manipulation anemia or poor physical health traumatic delivery hemorrhage

hesi hint #58 for maternity nursing

Oral hypoglycemics are not taken in pregnancy because of potential teratogenic effects on the fetus. Insulin is used for therapeutic management.

Uterus

Organ located behind the symphsis pubis, between the bladder and the rectum. It has four parts; fundus (upper part); corpus (body), isthmus (lower segment); and cervix.

Menstrual Cycle

Ovarian Changes Preovulatory Phase -the hypothalamus releases gonadotropin-releasing hormone through the portal system to the anterior pituitary system -secretion of follicle=stimulating hormone (FSH) by the anterior lobe of the pituitary gland stimulates growth of follicles -most follicles die, leaving one to mature into a large graafin follicle -estrogen produced by the follicle stimulates increased secretions of lutenizing hormone (LH) by the anterior lobe of the pituitary gland -the follicle ruptures and releases an ovum into the periotneal cavity Luteal Phase -the luteal phase begins with ovulation -body temperature drops and then rises by 0.5 F to 1 F around the time of ovulation -Corpus luteum is formed from follicle cells that remain in the ovary following ovulation -Corpus luteum secretes estrogen and progesterone during the remaining 14 days of the cycle -Corpus luteum degenerates if the ovum is not fertilized and secretion of estrogen and progesterone declines -the decline of estrogen and progesterone stimulates the anterior pituitary to secrete more FSH and LH, initiating a new reproductive cycle Uterine Changes Menstrual Phase -the menstrual phase consists of 4 to 6 days of bleeding as the endometrium breaks down because of the decreased levels of estrogen and progesterone -the level of FSH increases, enabling the beginning of a new cycle Proliferative Phase -the proliferative phase lasts about 9 days -estrogen stimulates proliferation and growth of the endometrium -as estrogen increases, it suppresses secretion of FSH and increases secretion of LH -secretion of LH stimulates ovulation and the development of the corpus luteum -ovulation occurs between days 12 and 15 -the estrogen level is high and the progesterone level is low Secretory Phase -the secretory phase lasts about 12 days and follows ovulation -this phase is initiated in response to the increase in LH level -the graafian follicle is replaced by the corpus luteum -the corpus luteum secretes progesterone and estrogen -progesterone prepares the endometrium for prregnancy if a fertilized ovum is implanted

hesi hint #25 for maternity nursing

Oxytocin (Pitocin) may be given after the placenta is delivered because the drug causes uterus to contract. If the oxytocic drug is administered before the placenta is delivered, it may result in a retained placenta, which predisposes the patient to hemorrhage and infection

When should the postpartum dosage of Pitocin be administered and why is it administered

Oxytocin is given immediately after placenta is delivered to prevent postpartum hemorrhage/atony

What parameters can the nurse observe to prevent problems oxygenating the newborn

PO2 50 to 90 SaO2 60 to 80 mmHg

Patients who have had a cesarean section are prone to what postoperative complications

Paralytic ilues Infection thromboembolism respiratory complications impaired maternal infant bonding

hesi hint #40 for maternity nursing

Patients with abrutio placentae or placenta previa (actual or suspected) should have no abdominal or vaginal manipulation. No Leopold's maneuvers No vaginal examination No rectal examinations, enemas, or suppositories No internal monitoring

hesi hint #36 for maternity nursing

Patients with prior traumatic delivery, history of D&C, multiple abortions (spontaneous or induced), or daughters of diethylstilbestrol synthetic estrogen (DES) mothers may experience miscarriage or preterm labor related to an incompetent cervix. The cervix may be surgically repaired before pregnancy or during gestation. A cerclage (McDonald suture) is placed around the cervix to constrict the internal os. The cerclage may be removed before labor if labor is planned or left in place if cesarean birth is planned.

A nurse discovers a postpartum patient with a boggy uterus, displaced above and to the right of the umbillicus. What nursing action is indicated?

Perform immediate fundal massage. Ambulate to the bathroom or use bedpan to empty bladder because cardinal signs of bladder distention are present

Surfactant

Phospholipid that is necessary to keep the fetal lung alveoli from collapsing; amount is usually sufficient after 32 weeks' gestation

The nurse records a temperature below 36.1 C (97 F) on admission of the newborn. What nursing actions should be taken

Place newborn in isolette or under radiant warmer and attach a temperature skin probe to regulate isolette or radiant warmer temperature. Wrap newborn double if no isolette or warmer available, and put cap on head. Watch for signs of hypothermia and hypoglycemia

What interventions can the nurse implement to main cardiac perfusion in a laboring cardiac patient.

Position patient in a semi- or high-Fowler position Prevent Valsava maneuvers. Position patient in a supine position or R/T for regional anesthesia Avoid stirrups because of possible popliteal vein compression and decreased venous return

List three conditions patients with diabetes mellitus are more prone to develop

Preeclampsia Hydramnios Infection

What complications are pregnant adolescents more prone to develop

Preeclampsia IUGR CPD STIs anemia

Fetal Development

Preembryonic Period -First 2 weeks after conception Embryonic Period -Beginning day 15 through approximately week 8 after conception Fetal Period -Week 9 after conception to birth Week 1 -Blastocyst is free-floating Weeks 2 to 3 -embryo is 1.5 to 2 mm in length -lung bud appears -blood circulation begins -heart is tubular and begins to beat -neural plate becomes brain and spinal cord Week 5 -embryo is 0.4 to 0.5 cm in length -embryo is 0.4g -double heart chambers are visible -heart is beating -limb buds form Week 8 -Embryo is 3 cm in length -Embryo is 2g -Eyelids begin to fuse -Circulatory system through umbilical cord is well established -every organ system is present Week 12 -fetus is 6 to 9 cm in length -fetus is 19g -face is well formed -limbs are long and slender -kidneys begin to form urine -spontaneous movements occur -Heartbeat is detected by Doppler transducer between 10 and 12 weeks -Gender is visually recognizable Week 16 -fetus is 11.5 to 13.5 cm in length -fetus is 100g -active movements are present -fetal skin is transparent -lanugo hair begins to develop -skeletal ossification occurs Week 20 -fetus is 16 to 18.5 cm in length -fetus is 300g -lanugo covers the entire body -fetus has nails -muscles are developed -enamel and dentin are depositing -heartbeat is detected by regular (nonelectronic) fetoscope Week 24 -fetus is 23 cm in length -fetus is 600g -hair on head is well formed -skin is reddish and wrinkled -reflex hand grasp functions -vernix caseosa covers entire body -fetus has ability to hear Week 28 -fetus is 27 cm in length -fetus is 1100g -limbs are well flexed -brain is developing rapidly -eyelids open and close -lungs are developed sufficiently to provide gas exchange -if born, neonate can breath at this time Week 32 -fetus is 31 cm in length -fetus is 1800 to 2100g -bones are fully developed -subcutaneous fat has collected -the L/S ration is 1:2:1 Week 36 -the fetus is 35 cm in length -fetus is 2200 to 2900g -skin is pink and the body is rounded -the skin is less wrinkled -lanugo is disappearing -the L/S ratio is higher than 2:1 Week 40 -the fetus is 40 cm in length -the fetus is 3200g + -skin is pinkish and smooth -lanugo is present on upper arm and shoulders -vernix caseosa decreases -fingernails extend beyond fingertips -sole (plantar) creases run down to the heel -the testes are in the scrotum -the labia majora are well developed

Maternal Physiologic Changes during Pregnancy

Pregnancy length is counted from the first day of last menstrual period (LMP) 1. 280 days (approximately) 2. 40 weeks 3. 10 lunar months (perfect 28 day months) 4. 9 calendar months Pregnancy is divided into three 13-week trimesters 1. first trimester: from the first day of LMP through 13 weeks 2. Second trimester: 14 weeks through 26 weeks 3. third trimester: 27 weeks to 40 weeks

Intraventricular hemorrhage is more common in _________________ and results in symptoms of ___________________________

Premature distress syndrome and VLBW babies; increased intracanial pressure

What is the purpose of eye prophylaxis for the newborn

Prevent ophthalmia neonatorum which results from exposure to gonorrhea in vagina

Magnesium sulfate is used to treat preeclampsia. What is the purpose for adminstration of magnesium sulfate? What is the main action of magnesium sulfate? List three main assessment findings indicating toxic effects of magnesium sulfate

Prevent seizures by decreasing CNS irritability CNS depression (seizure precaution) Calcium gluconate Reduced urinary output, reduced respiratory rate and decreased reflexes

List examples of the three levels of prevention in disaster management

Primary: assist with development of plan, training/education plan, train/educate personnel and public Secondary: triage, treatment shelter supervision Tertiary: follow-up recovery assistance, prevention fo future disasters

Upon admission to the postpartum room, 3 hours after delivery, a patient has a temperature of 35 C (99.5 F). What nursing actions are indicated?

Probably elevated because of dehydration and work of labor; force fluids and retake temperature in an hour; notify HCP if above 38 C (100.4 F)

The patient asks the nurse about the purpose of the placenta. The nurse plans to respond to the patient knowing which about the placenta? 1. cushions and protects the fetus 2. maintains the body temperature of the fetus 3. surrounds the fetus and allows for fetal movement 4. provides an exchange of nutrients and waste products between the mother and fetus

Provides an exchange of nutrients and waste products between the mother and fetus Rationale: the placenta provides an exchange of nutrients and waste products between mother and fetus. The amniotic fluid surrounds, cushions, and protects the fetus and allows for fetal movement. The amniotic fluid also maintains the body temperature of the fetus

How does the nurse differentiate symptomology of cystitis from pyelonephritis

Pyelonephritis has the same symptoms as cystitis (dysuria, frequency, and urgency) with the addition of flank pain, fever, and pain at costovertebral angle

Lecithin-to-sphingomyelin (L/S) ratio

Ratio of two components of amniotic fluid, used for predicting fetal lung maturity; normal L/S ratio in amniotic fluid is 2:1 or greater when the fetal lungs are mature

What does the Silverman-Anderson Index measure

Respiratory difficulty

What conditions make oxygenation of the newborn more difficult

Respiratory distress syndrome alveolar prematurity/lack of surfactant anemia polycythemia

What are the two major complication of O2 toxicity

Retrolental fibroplasias and bronchopulmonary dysplasia

List risk factors for hyperbillirubinemia

Rh incompatibility ABO incompatibility prematurity sepsis preinatal asphyxia

hesi hint #43 for maternity nursing

Rubella is teratogenic to the fetus during the first trimester, causing congenital heart disease and/or congenital cataracts. All women should have their titers checked during pregnancy. If a woman's titers are low, she should receive the vaccine after delivery and be instructed not to get pregnant within 3 months. Breastfeeding mothers may take the vaccine.

What are the signs of endometritis

Subinvolution (boggy, high uterus) lochia returns to rubra with possible foul smell temperature 100.4 F (38 C) or higher unusual fundal tenderness

hesi hint #37 for maternity nursing

Suspect ectopic pregnancy in any woman of childbearing age who presents at an emergency room, clinic, office with unilateral or bilateral abdominal pain. Most are misdiagnosed as appendicitis.

What is the major side effect of beta-arenergic tocolytic drugs?

Tachycardia

State five symptoms of respiratory distress in the newborn

Tachypnea Dusky color Flaring nares Retractions Grunting

What is the most common complication of oxytocin augmentation or induction of labor. List three actions the nurse should take if such complication occurs

Tetany turn off Pitocin Turn pregant woman to side. Administer 02 by mask

hesi hint #65 for maternity nursing

The PO2 should be maintained between 50 and 90mm Hg PO2 less than 50 signifies hypoxia PO2 greater than 90 signifies oxygen toxicity problems

What is the cause of preeclampsia

The exact cause of preeclampsia is unknown, but the underlying pathophysiology appears to be generalized vasospasm with increased peripheral ressitance and vascular damage, this decreased perfusion results in damage to numerous organs

What are the dangers of the nipple-stimulation stress test

The inability to control "oxytocin" dosage and the chance for tetany/hyperstimulation

hesi hint #64 for maternity nursing

The lower score on the Silverman-Anderson Index of Respiratory Distress indicates the respiratory status of the neonate is good. A score of 10 indicates that a newborn is in severe respiratory distress. This is the exact opposite of the Apgar scoring

The nurse working in a prenatal clinic reviews a patient's chart and notes that the HCP documents that the patient has a gynecoid pelvis. The nurse understands that which is characteristic of this type of pelvis? 1. not favorable for labor 2. not normally a female pelvis type 3. a wide pelvis with a short diameter 4. the most favorable for labor and birth

The most favorable for labor and birth Rationale: A gynecoid pelvis is a normal female pelvis, and it is the most favorable for successful labor and birth. An android pelvis would not be favorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, which a normal or moderately narrow pubic arch. The platypelloid pelvis has a wide transverse diameter, but the anteroposterior diameter is short, thus making the outlet inadequate.

Mrs. Green lost her husband 3 years ago. She has not disturbed any of his belongings and continues to set a place at the table for him nightly. Is this response indicative of a normal or complicated grief reaction?

This is a dysfunctional grief reaction. Mrs. Green has never moved out of the denial stage of her grief work.

Your patient feels responsible for his sister's death because he took her to the hospital where she died. "if I hadn't taken her there, they couldn't have killed her." It has been 1 month since her death. Is this response indicative of a normal or complicated grief reaction?

This is a normal expression of anger and guilt that occurs. Try to minimize the rumination of these thoughts.

Define triage

To sort or categorize

hesi hint #42 for maternity nursing

Toxoplasmosis is usually related to exposure to cats, gardening (where cat feces may be found) or eating raw meat

How is true labor discriminated from false labor

True labor: regular, rhythmic contractions that intensify with ambulation; pain in the abdomen sweeping around from the back and cervical changes false labor: irregular rhythm, abdominal pain (not in back) that decreases with ambulation

Vagina

Tubular structure located behind the bladder and in front of the rectum; it extends from the cervix to the vaginal opening in the perineum. If functions as the outflow tract for menstrual fluid and for vaginal and cervical secretions, as the birth canal and as the organ for coitus.

The nurse is describing the process of fetal circulation to a patient during a prenatal visit. The nurse should tell the patient that fetal circulation consists of which? 1. two umbilical veins and one umbilical artery 2. Two umbilical arteries and one umbilical vein 3. arteries that carry oxygenated blood to the fetus 4. veins that carry deoxygenated blood to the fetus

Two umbilical arteries and one umbilical vein Rationale: blood pumped by the fetus's heart leaves the fetus through two umbilical arteries. After the blood is oxygenated, it is then returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus

List the predisposing factors to preterm labor

Urinary tract infections overdistention of uterus diabetes preeclampsia cardiac disease placenta previa psychosocial factors such as stress

hesi hint #46 for maternity nursing

Women with previous uterine scars are prone to uterine rupture, especially if oxytocin or forceps are used. If a woman complains of a sharp pain accompanied by the abrupt cessation of contractions, suspect uterine rupture - a medical emergency. Immediate surgical delivery is indicated to save the fetus and the mother.

Labor

a coordinated sequence of rhythmic, involuntary uterine contractions that result in the effacement and dilation of cervix. This is followed by the expulsion of the products of conception

hesi hint #19 for maternity nursing

a decrease in uteroplacental perfusion results in late decelerations; cord compression results in a pattern of variable decelerations Nursing interventions should include changing maternal position, discontinuing oxytocin (pitocin) infusion, administering oxygen, and notifying the health care provider

hesi hint #28 for maternity nursing

a first-degree tear involves only the epidermis. a second-degree tear involves dermis, muscle, and fascia a third-degree tear extends into the anal sphincter a fourth-degree tear extends up to the rectal mucosa. Tears cause pain and swelling. Avoid rectal manipulations

what is the most common cause of uterine atony in the first 24 hours postpartum

a full bladder

Infant

a human born alive; also, a human from 28 days of age until the first birthday

Newborn;neonate

a human offspring from the time of birth to day 28 of life

Gravida

a pregnant woman. The woman is called gravida I (for primigravida) during the first pregnancy, gravida II during the second and so on

The nurse is reviewing the record of a patient who has just been told that her pregnancy test is positive. The nurse notes that the HCP has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which? 1. a softening of the cervix 2. the presence of fetal movement 3. the presence of human choronic gonadotropin in the urine 4. a soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus

a softening of the cervix rationale: during the early weeks of pregnancy the cervix becomes softer as a result of pelvic vasoconstriction which causes Goodell's sign. Cervical softening is noted by the examiner during a pelvic examination. Goodell's sign does not indicate the presence of fetal movement. Human choronic gonadotropin is noted in maternal urine with a positive urine pregnancy test. a soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus; it is the result of blood circulating through the placenta.

Hesi hint for pain #1

a subjective assessment of pain can be collected by asking the patient to rate his or her pain on a scale from 0-10, where 0= no pain and 10= the worst pain possible

what dynamics prevent a battered spouse from leaving the battering situation

a woman in a relationship of intimate-partner violence may lack self-confidence and feel trapped because she lacks financial support for herself and her children. She is often embarrassed to tell friends and family, so she becomes isolated and dependent on the abuser

Name the four periodic changes of the fetal heart rate, their causes, and one nursing treatment for each

accelerations: caused by burst of sympathetic activity; they are reassuring and require no treatment Early decelerations: caused by head compression, are benign, and caution the nurse to monitor for labor progress and fetal descent Variable decelerations: caused by cord compression; change of position should be tried first Late decelerations: caused by uteroplacental insufficiency and should be treated by placing the patient on her side and administering O2

Name five maternal variables associated with diagnosis of a high-risk pregnancy

age (younger than 17 years or older than 34 years of age) parity (over 5) less than 3 months between pregnancies diagnosis of preeclampsia, diabetes mellitus, or cardiac disease

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which are functions of amniotic fluid? 1. allows for fetal movement 2. is a measure of kidney functions 3. surrounds, cushions, and protects the fetus 4. maintains the body temperature of the fetus 5. prevents large particles such as bacteria from passing to the fetus 6. provides an exchange of nutrients and waste products between mother and fetus

allows for fetal movement; is a measure of kidney functions; surrounds, cushions and protects the fetus; maintains the body temperature of the fetus Rationale: the amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely, it maintains the body temperature of the fetus, and it helps to measure kidney function, because the amount of fluid is based on the amount of urination from the fetus. The placenta prevents large particles such as bacteria from passing to the fetus, and it provides an exchange of nutrients and waste products between the mother and fetus

State the normal psychosocial responses to pregnancy in the second trimester

ambivalence wanes, and acceptance of pregnancy occurs; pregnancy becomes "real"; signs of maternal-fetal bonding occur

hesi hint #66 for maternity nursing

antibiotic dosage is based on neonate's weight in kilograms Peak and trough drug levels are drawn to evaluate whether therapeutic drug levels have been achieved. Closely monitor the neonate for adverse effects of the drug

hesi hint #9 for maternity nursing

as pregnancy advances the uterus presses on abdominal vessels (vena cava and aorta) Reinforce teaching that a side-lying or knee-chest position increases perfusion to the uterus, placenta and fetus

when is the screening test for phenylketonuria done

at 2 to 3 days of life or after enough milk ingestion to determine body's ability to metabolize amnio acid phenylalanine

At 20 weeks' gestation, the fundal height would be ___________, and the fetus would weigh approximately __________________ and would look like ________________________

at the umbilicus; 300 to 400g; a "baby" with hair, lanugo, and vernix, but without any subcutaneous fat

What information should be given to a patient regarding resumption of sexual intercourse after delivery

avoid until postpartum examination. use water-soluble jelly expect slight discomfort because of vaginal changes

hesi hint #21 for maternity nursing

be able to differentiate true labor from false labor true labor -pain in lower back that radiates to abdomen -accompanied by regular, rhythmic contractions -contractions that intensify with ambulation -progressive cervical dilation and effacement false labor -discomfort is localized in abdomen -no lower back pain -contractions decrease in intensity and/or frequency with ambulation -no cervical changes

list three signs of positive bonding between parents and newborn

calling infant by name exploration of newborn head-to-toe in face position

State the advantage of CVS over amniocentesis

can be done between 8 and 12 weeks' gestation with results returned within 1 week which allows for decision about termination while still in first trimester

When is preterm labor able to be arrested

cervix is less than 4cm dilated less than 50% effacement and membranes intact and not bulging out of the cervical os

The nurse anticipates which newborn will be more at risk for problems in the transitional period. State three predisposing factors to respiratory depression in the newborn

cesarean delivery; magnesium sulfate given to mother in labor; asphyxia/fetal distress in labor

The menstrual cycle

composed of 4 phases. The mean age of menarche (first menstruation) in the US is 12.87 years or 1 to 3 years after breast budding. Pregnancy can occur from the very first menstrual cycle; a sexually active girl may conceive before her first menstrual cycle. The normal cycle is 21-45 days in length Most women have ovulatory cycles within 24 months of menarche

a woman's white blood count returns to 17,000; she is afebrile and has no symptoms of infection. what nursing action is indicated

continue routine observations; normal leukocytosis occurs during postpartum period because of placental site healing

What interventions should the nurse implement to prevent further CNS irritability in the preeclampsia patient

darken room limit visitors maintain close 1:1 nurse/patient ratio place in private room plan nursing interventions all together so patient is disturbed as little as possible

hesi hint #35 for maternity nursing

do not feed newborn when the respiratory rate is over 60 inform the RN and/or HCP of respiratory status

hesi hint #2 for grief and dying

do not take away the coping style of denial when it's being used in a crisis state. It can be a very useful and a needed tool at the initial stage for some individuals. Support; do not challenge, unless it hinders/blocks treatment - endangering the patient

When does battering of women often being or escalate

during pregnancy

hesi hint #15 for maternity nursing

early decelerations, caused by head compression and fetal descent, usually occur between 4 and 7cm and in the second stage Check for labor progress if early decelerations are noted

What condition should the nurse suspect if a woman of childbearing age presents to an emergency department with bilateral or unilateral abdominal pain with or without bleeding

ectopic pregnancy

Endorphin/Enkephalin theory

endorphins and enkephalins are naturally occurring neurotransmitters that bind with opiate receptors in the CNS and modulate pain

how often should the nurse check the fundus during the fourth stage of labor

every 15 min x 4 (1 hr) every 30 min x 2 hr if normal

State the most important action to take when a cord prolapse is determined

examiner should position mother to relieve pressure on the cord or push the presenting part off the cord with fingers until emergency delivery is accomplished

Neonates who are "sick" are prone to receive too much stimulation in the form of invasive procedures and handling, and too little developmentally appropriate stimulation and affection. How might such an infant respond.

failure to thrive lack of crying

What is the most important indicator of fetal autonomic nervous system integrity/health

fetal heart rate variability

what does the biophysical profile determine

fetal well-being

hesi hint #10 for maternity nursing

fetal well-being is determined by assessing fundal height, fetal heart tones/rate, fetal movement, and uterine activity (contractions). Changes in fetal heart rate are the first and most important indicator of compromised blood flow to the fetus, and these changes require action. Remember, the normal fetal heart rate is 110 to 160bpm

Hesi hint for pain #2

for narcotic-induced respiratory depression, naloxone (Narcan) 0.1 - 0.4 mg IV can be given every 2 to 3 minutes as needed, until 1 mg is achieved

hesi hint #27 for maternity nursing

full bladder is one of the most common reasons for uterine atony and/or hemorrhage in the first 24 hours after delivery. If the nurse finds the fundus soft, boggy, and displaced above and to the right of the umbilicus, what action should be taken first? First, perform fundal massage; then have the patient empty her bladder. Recheck fundus every 15min x 4 (1 hr); every 30 min x 2 hr

List symptoms of a full bladder, which might occur in the fourth stage of labor

fundus above umbilicus dextroverted (to the right side of abdomen) increased bleeding (uterine atony)

The nurse is collecting data from a patient who is pregnant with triplets. The patient also has a 3 year old child who was born at 39 weeks' gestation. The nurse should document which gravida and para status on this patient? 1. Gravida I, para I 2. Gravida II, para I 3. Gravida II, para II 4. Gravida III, para II

gravida II para I rationale: gravida is a term that refers to a woman who is or who has been pregnant, regardless of the duration of the pregnancy Parity is a term that means the number of births after 20 weeks' gestation; it does not reflect the number of fetuses or infants. Options 1, 3 and 4 are incorrect on the basis of these definitions

List three signs of placental separation

gush of blood lengthening of cord globular shape of uterus

A small for gestational age newborn identified as one who _________________________

has a weight below the tenth percentile for estimated weeks of gestation

A breastfeeding mother complains of very tender nipples. What nursing actions should be taken

have her demonstrate infant position on breast (incorrect positioning often causes tenderness) leave bra open to air-dry nipples for 15 minutes 3x daily express colostrum and rub on nipples

List three necessary nursing actions to be taken before an ultrasound examination for a woman in the first trimester of pregnancy

have patient fill bladder do not allow patient to void position supine with uterine wedge

List the six modalities that are considered noninvasive, nonpharmacologic pain relief measures

heat and cold application TENS massage distraction relaxation techniques biofeedback techniques

Identify three ways to determine the presence of congenital hop dislocation in the newborn

hip click determination, asymmetric gluteal folds, and unequal limb lengths

hesi hint #24 for maternity nursing

hyperventilation results in respiratory alkalosis due to blowing off too much CO2 symptoms include -dizziness -tingling of fingers -stiff mouth

to promote comfort, what nursing interventions are used for a third-degree episiotomy that extends into the anal sphincter

ice pack, witch hazel compresses, and no rectal manipulation

Hesi hint #16 for maternity nursing

if cord prolapse is detected, the examiner should position the mother to relieve pressure on the cord (ie knee-chest position) or pushing the presenting part off the cord until immediate cesarean delivery can be accomplished

hesi hint #29 for maternity nursing

if it was documented that the fetus passed meconium in utero or the nurse noted late passage of meconium in delivery room, the neonate must be attended by a pediatrician, neonatologist, and/or nurse practitioner to determine, through endotracheal tube observation and suction, the presence of meconium below the vocal cords. It can result in pneumonitis/meconium aspiration syndrome, which will neccessitate a sepsis workup including a chest x-ray early in the transitional newborn period

Intractable Pain

includes persistent and intense pain caused by invasive, degenerative or neurologic conditions for example, cancer, arthritis, phantom limb, nerve entrapment, or neuralgias

What factor places the postpartum patient at risk for thromboembolism

increased clotting factors

Signs of Acute Pain

increased heart rate and cardiac output Increased blood pressure Pupillary Dilation Palmar sweating and Diaphoresis Hyperventilation Hypermotility Escape behavior Anxiety state

Describe maternal changes that characterize the transition phase of labor

irritability unwillingness to be touched but does not want to be left alone nausea and vomiting hiccuping

Chronic pain

is insidious and may persist for greater than 3 months

The nurse notes a swelling over the back part of the newborn's head. Is this a normal newborn variation

it depends on the examination if it crosses suture lines and is a caput (edema), it is normal if it does not cross suture lines, it is a cephalohematoma with bleeding between the skull and periosteum this could cause hyperbilirubinemia. this is an abnormal variation

hesi hint #13 for maternity nursing

it is recommended that pregnant women drink 1L (4 cups) of milk a day. This will ensure that the daily calcium needs are met and will help to alleviate the occurrence of leg cramps

Why is regular insulin used in labor?

it is short-acting, predictable, can be infused intravenously, and can be discontinued quickly if necessary

Gate control theory

it is thought that stimulation of large, fast-conducting sensory fibers oppose input from small pain fibers, thus blocking pain perception.

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormone changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen? 1. It maintains the uterine lining for implantation 2. It stimulates the metabolism of glucose and converts glucose to fat 3. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation 4. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed

it stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation Rationale: estrogen stimulates uterine development to provide an environment for the fetus and it stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat. Human choronic gonadotropin prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed

the patient arrives at the prenatal clinic for her first prenatal assessment. The patient tells the nurse that the first day of her last menstrual period was October 20, 2016. Using Nagele's rule, the nurse determines the estimated date of birth is which? 1. july 12 2017 2. july 27 2017 3. august 12 2017 4. august 27 2017

july 27 2017 Rationale: the accurate use of Nagele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months from the first day of the last menstrual period, add 7 days, and then adjust the year as appropriate. In this case, the first day of the LMP was October 20 2016 When you subtract 3 months, you get july 20 2016. if you add 7 days you get july 27 2016. add 1 year to this, and you get the estimated date of birth july 27 2017

list three nursing interventions to ease the discomfort of afterpains

keep bladder empty provide a warm blanket for abdomen administer analgesics prescribed by HCP

hesi hint #22 for maternity nursing

know normal findings for patients in labor: -normal FHR in labor: 110-160bpm -normal maternal BP: less than 140/90 -normal maternal temperature less than 38 C (100.4 F) -slight elevation is often due to dehydration and the work of labor. Anything higher indicates infection and must be reported immediately

hesi hint #17 for maternity nursing

late decelerations indicate uteroplacental insufficiency and are associated with conditions such as postmaturity, preeclampsia, diabetes mellitus, cardiac disease and abruptio placentae

Stages of Labor

latent - from beginning of true labor until 3-4 centimeters cervical dilation -mildly anxious, conversant -able to continue usual activities -contractions mild, initially 10-20 minutes apart, 15-20 seconds duration,; later 5-7 minutes apart, 30-40 seconds duration active - from 4-7 centimeters cervical dilation -increased anxiety -increased discomfort -unwillingness to be left alone -contractions moderate to severe, 2-3 minutes apart, 30-60 seconds duration transition - from 8-10 centimeters cervical dilation -changed behavior -may have sudden nausea, hiccups -extreme irritiability and unwilligness to be touched although desirous of companionship -contractions severe, 1 1/2 minutes apart, 60-90 seconds duration

What is the danger of heat loss to the newborn in the first few hours of life

leads to depletion of glucose (very little glycogen storage in immature liver)

List five signs and symptoms new parents should be taught to report immediately to a doctor or clinic

lethargy temperature greater than 100 F (37.7 C) vomiting green stools refusal of two feeds in a row or poor suck

hesi hint #4 for maternity nursing

look for signs of maternal-fetal bonding during pregnancy. For example, talking to fetus in utero, massaging the abdomen, and nicknaming fetus are all healthy psychosocial activities

What instructions should the nurse give the woman with a threatened abortion

maintain strict bedrest for 24 to 48 hours. Avoid sexual intercourse for 2 weeks

hesi hint #69 for maternity nursing

maintenance of hydration is crucial for all infants. the preterm infant is already at risk for fluid and electrolyte imbalances because of increased body surface area from extended body positioning and larger body area in relation to body weight. Phototherapy treatment for hyperbillirubin (level greater than 12 mg/dL) increases the risk for dehydration

What actions can the nurse take to assist in preventing postpartum hemorrhage

massage the fundus (gently) and keep the bladder emptied

hesi hint #23 for maternity nursing

meconium-stained fluid is yellow-green or gold-yellow and may indicate fetal stress

hesi hint #26 for maternity nursing

methergine is not given to patients with hypertension owing to its vasoconstrictive action Pitocin is given with caution to those with hypertension never give methergine or Hemabate to the patient while she is in labor or before delivery of the placenta

hesi hint #12 for maternity nursing

most HCPs provide prenatal vitamins to ensure that the patient receives an adequate intake of vitamins. Remember that it is the nurse's responsibility to reinforce teaching about proper diet and about taking vitamins as prescribed by the HCP

When the newborn is suctioned with a bulb syringe, which should be suctioned first ----- moth or the nose?

mouth; stimulating the nares can initiate inspiration that could cause aspiration of mucus in the oral pharynx

Hesi hint for pain #4

narcotic analgesics are preferred for pain relief because they bind to the various opiate receptor sites in the CNS. Morphine is often the preferred narcotic. Narcotic antagonists block the attachment of narcotics to the receptors, such as nalaxone (Narcan). Once Narcan has been given, additional narcotics cannot be given until the Narcan effects have passed

Name the major discomforts of the first trimester and one suggestion for amelioration of each

nausea and vomiting; crackers before rising fatigue: teach the need for rest periods/naps and 7 to 8 ours of sleep at night

State two ways to determine whether the membranes have truly ruptured (ROM)

nitrazine testing paper turns dark blue or black demonstration of fluid "ferning" under microscope

May women with a positive HIV antibody or ZIKA virus try and test breastfeed?

no, HIV has been found in breast milk. there is no evidence that mothers transmit Zika Virus via breast milk. Zika virus is also sexually transmitted

Is one ultrasound examination useful in determining the presence of intrauterine growth retardation (IUGR)

no, serial measurements are needed to determine IUGR

State three principles pertinent to counseling and/or teaching a pregnant adolescent

nurse must establish trust/rapport before counseling/teaching begins. Adolescents do not respond to an authoritarian approach. Consider the developmental tasks of identity and social/individual intimacy

hesi hint #51 for maternity nursing

nursing care during labor and delivery for the patient with cardiac disease is focused on prevention of cardiac complications, maintenance of uterine perfusion, and alleviation of anxiety

Describe the schedule for prenatal visits for a low-risk pregnant woman

once a month until 28 weeks, then once every 2 weeks until 36 weeks, and then weekly until delivery

hesi hint #30 for maternity nursing

patient should void within 4 hours of delivery. monitor closely for urine retention. suspect retention if voiding is frequent and less than 100mL per voiding

Referred Pain

perceived at a site remote from its source Deep structures may share the same dermatomes as superfiical areas - for example, MI pain referred down medial aspect of left arm Other referred pain may not share innervations along the same dermatome - for example, angina pain referred to the jaw

what action should the nurse take first when a soft, boggy uterus is palpated

perform fundal massage

APGAR Scoring System

performed at exactly 1 and 5 minutes after birth. cannot just eyeball, must have hands-on examination Score: 7-10 Good 4-6 Needs moderate resuscitative efforts 0-3 severe need for resuscitation Apgar scores of 6 or less at 5 minutes require an additional Apgar assessment at 10 minutes

hesi hint #34 for maternity nursing

physiologic jaundice is caused by unconjugated bilirubin (inability of the immature liver to keep up with normal RBC destruction and bind bilirubin) and occurs on the second to third day of life. this is most common. Pathologic jaundice occurs before 24 hours or persists beyond 7 days and can lead to kernicterus (encephalopathy) and death.

Should the normal newborn have a positive or negative Babinski reflex

positive. the transient reflex is present until 12 to 18 months of age

Hesi hint #6 for maternity nursing

practice calculating EDB (estimated date of birth). If the first day of a women's last normal menstrual period was August 12, what is her EDB using Nagele's rule? EDB is May 19. Count back 3 months and add 7 days, always give February 28 days)

Hesi hint #5 for maternity nursing

practice determining gravidity and parity. A women who is 6 weeks pregnant has the following maternal history 1. had an elective abortion at 9 weeks, 8 years ago 2. had a miscarriage at 18 weeks, 4 years ago 3. Has 2-year old twins, daughter and son With this pregnancy, she is a gravida 4, para 1 (only 1 delivery after 20 weeks' gestation)

hesi hint #47 for maternity nursing

rarely are antiphypertensive drugs used in the preeclamptic patient. They are given only in the event of diastolic blood pressure of 110mmHg (cerebrovascular accident [CVA] danger). Drug of choice is hydralazine HCl (Apresoline)

hesi hint #54 for maternity nursing

recent research has found that Helicobacter pylori (the bacterium that causes stomach ulcers) infection is another possible causative factor in hyperemesis. Other pregnancy and nonpregnancy risk factors for hyperemesis gravidarum include first pregnancy, multiple fetuses, age under 24, history of this condition in other pregnancies, obesity, and high-fat diets

hesi hint #61 for maternity nursing

risk factors for hemorrhage include dystocia prolonged labor overdistended uterus abruptio placentae infection

three days postpartum, a lactating mother has full, warm, taut, tender breasts what nursing actions should be taken

she is engorged; have newborn suckle frequently; use measures to increase milk flow; warm water, breast massage, and supportive bra

Signs of Chronic Pain

sleep disturbances irritability appetite disturbances Constipation Psychomotor retardation Pain intolerance social withdrawal Mental depression

hesi hint #41 for maternity nursing

some maternal infections that harm the embryo or fetus (teratogenic) are known as TORCH infections toxoplasmosis, other infections, Rubella, Cytomegalovirus, and Herpes virus type 2

Hesi hint #2 for maternity nursing

some women do not realize they are pregnant because those women experience implantation bleeding or spotting, which leads to some women to believe they have had a normal menstrual period

Hesi hint #3 for maternity nursing

some women prefer to use the complementary and alternative medicine (CAM) for prevention of nausea. Collaborate with the RN and members of the interprofessional team when a patient expresses a wish to use CAM. Some patients use cranberry juice to prevent UTIs because cranberry juice prevents bacteria from sticking to cell walls in the urinary tract. Ginger may also be used to reduce the nausea and vomiting of pregnancy, and others may use acupuncture for relief of severe vomiting during pregnancy. Some women may use energy healing to reduce labor pain. Use caution and provide supportive care when a women requests CAM. Some Chinese and Ayurvedic herbal medicines have been found to contain metals or prescription drugs that are not on the label. Other CAM therapies that clients may use to alleviate pain during labor include imagery, meditation, music and aromatherapy.

Name three complementary and alternative medicine (CAM) options that may be requested by the patient

some women use ginger to reduce nausea and vomiting, drink cranberry juice to prevent UTIs and energy healing to reduce pain

Name the three most common complication of amniocentesis

spotaneous abortion, fetal injury, infection

Why does the newborn need vitamin K in the first hour after birth

sterile gut at delivery lacks intestinal bacteria necessary for the synthesis of vitamin K; vitamin K is needing in the clotting cascade to prevent hemorrhagic disorders

hesi hint #32 for maternity nursing

suction the mouth first and then the nose. Stimulating the nares can initiate inspiration that could cause aspiration of mucus in oral pharynx

hesi hint #45 for maternity nursing

tachycardia is the major side effect of tocolytic drugs, which are beta-adrenergic agents such as terbutaline (Brethine) used to stop preterm labor. Teach the patient to take her pulse before administration, and withhold medication if pulse is not within the prescribed parameters (usually withheld if pulse is higher than 120 to 140). If administration is via a continuous pump, teach the patient to monitor pulse periodically

Delivery

the actual event of birth the expulsion or extraction of the neonate and the fetal membranes at birth

Hegar's Sign

the compressibility and softening of the lower uterine segment. This occurs at about 6 weeks' gestation and it is considered a probable sign of pregnancy

hesi hint #20 for maternity nursing

the danger of nipple stimulation lies in controlling the "dose" of oxytocin stimulated from the posterior pituitary. The chance of hyperstimulation or tetany (contractions over 90 seconds or contractions with less than 30 seconds in between) is increased

Implantation

the embedding of the fertilized ovum in the uterine mucousa, which occurs 6 to 10 days after conception

How is the fourth stage of labor defined

the first 1 to 4 hours after delivery of placenta

What maternal position provides optimal fetal maternal/placental perfusion during pregnancy

the knee-chest position, but the ideal position of comfort for the mother, which supports fetal/maternal/placental perfusion, is the side-lying position off the abdominal vessels (vena cava, aorta)

hesi hint #49 for maternity nursing

the major goal of nursing care for a patient with preeclampsia is to maintain uteroplacental perfusion and prevent seizures. Withhold adminstration of magnesium sulfate if signs of toxicity exist: respirations less than 12/min, absence of DTRs, and/or urine output less than 30-33 mL/hr

Quickening

the maternal perception of fetal movement, which usually appears around 16 to 20' weeks gestation

Hesi hint #1 for maternity nursing

the menstrual phase varies in length for most women, usually lasting 2 to 8 days.

Parity

the number of pregnancies that have reached viability, regardless of whether the infants were alive or stillborn

Placenta

the organ that provides for the exchange of nutrients and waste products between the fetus and the mother and that produces hormones to maintain pregnancy. It develops by the third month of gestation and is also called the afterbirth

hesi hint #44 for maternity nursing

the outcome of adolescent pregnancy depends on prenatal care. Nutrition is a key factor because the adolescent's physiologic needs for growth are already higher, and the additional stress of pregnancy only increases these needs

amniotic fluid

the pale, straw-colored fluid that surrounds and protects the fetus. The fetus floats in the amniotic fluid, which serves as a cushion against injury from sudden blows or movements. It also helps maintain a constant body temperature for the fetus. The fetus modifies the amniotic fluid through the processes of swallowing, urinating, and movement through the respiratory tract

hesi hint #31 for maternity nursing

the practical nurse should do a daily head-to-toe assessment. An initial detailed assessment is performed by the RN or HCP. Regardless of who performs the physical assessment, the nurse must know normal versus abnormal variations for the newborn. Observations must be recorded and the HCP notified regarding abnormalities

ballottement

the rebounding of the fetus against the examiner's finger on palpation, beginning at 16 to 18 weeks of gestation when the cervix is tapped, the fetus floats upward in the amniotic fluid a rebound is felt by the examiner when the fetus falls back

Goodell's Sign

the softening of the cervix this occurs at the beginning of the second month of gestation and is considered a probable sign of pregnancy

Define cervical effacement

the taking up of the lower cervical segment into the upper segment; shortening of the cervix expressed in percent from 0% tto 100% or complete effacement

Fertilization

the union of an ovum and sperm fertilization occurs within 12 hours of ovulation and within 2 to 3 days of insemination, the average duration of viability of the ovum and the sperm

The nursing student is asked to describe the size of the uterus in a nonpregnant patient. Which response indicates an understanding of the anatomy of this structure? 1. the uterus weighs about 2 ounces 2. The uterus weights about 2.2 pounds 3. The uterus has a capacity of about 50 mililiters 4. The uterus is round in shape and weighs approximately 1000 grams

the uterus weighs about 2 ounces Rationale: before conception, the uterus is a small, pear-shaped organ that is contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60g (2 oz) and it has a capacity of about 10mL (1/3 oz). At the end of pregnancy, the uterus weighs approximately 1000g (2.2lb) and it has a capacity that is sufficient for the fetus, the placenta, and the amniotic fluid

Chadwicks Sign

the violet-bluish coloration of the vaginal mucous membranes that is visible from about 4 weeks' gestation and presents as a result of increased vascularity this is considered a probable sign of pregnancy

What should the fundal height be at 3 days postpartum for a woman who has had a vaginal delivery

three fingerbreadths or three cm below the umbillicus

What location is best for hearing the fetal heart rate

through the fetal back in vertex, occiput anterior positions

hesi hint #67 for maternity nursing

to assess for skin jaundice, apply pressure with thumb over bony prominences to blanch skin. After thumb is removed, the area will look yellow before normal skin color reappears. The best areas for assessment are the nose, forehead, and sternum. In dark-skinned infants, observe conjunctival sac and oral mucosa.

hesi hint #63 for maternity nursing

to avoid metabolic problems brought on by cold stress, the first step ---- and number one priority ---- in management of the newborn is to prevent loss of body heat, followed by ABCs. Neonates produce heat through nonshivering thermogenesis by burning brown fat. The neonate is easily stressed by hypothermia and develops acidosis from hypoxia. Prevent chilling (keep under radiant warmer or in isolette). If cold, the first signs exhibited are prolonged acrocyanosis, warm slowly over 2 to 4 hours because rapid warming may produce glycogen storage and needs to be fed.

Why are serum and amniotic AFP levels done prenatally

to determine whether alpha-fetoprotein levels are elevated, which may indicate the presence of neural tube defects, or are low, which may indicate trisomy 21

what is the purpose of giving docusate sodium (Colace) to the postpartum patient

to soften the stool in mothers with third- or fourth- degree episiotomies, hemorrhoids, or cesarean delivery.

State three principles relative to the pattern of weight gain in pregnancy

total weight gain during pregnancy for a normal-weight woman should be 25 to 35 pounds. Gain should be consistent throughout pregnancy. An average of 1 pound per week should be gained in the second and third trimesters

Hesi hint for pain #3

use complement or noninvasive methods for pain management when possible relaxation exercises distraction imagery biofeedback interpersonal skills physical care: altering positions, touch, hot and cold applications (as ordered by HCP)

Lochia

vaginal discharge from the uterus that consists of blood from the vessels of the placental site, tissue debris from the decidua, and mucus. Lochia lasts for 2 to 6 weeks postpartum and is differentiated by color: rubra; serosa; or alba

when should a laboring patient be examined vaginally

vaginal examinations should be done before analgesia/ anesthesia to rule out cord prolapse, determine labor progress if it is questioned, and determine when pushing can begin

Acute Pain

warns that something is wrong and usually is sudden and localized (usually can identify a precipitating event) 1. chest pain may indicate myocardial hypoxia or other related thoracic structures - for example, broken ribs, intercostal muscles or pulmonary or pleural origin 2. Abdominal pain may reflect pathology from underlying structures - for example, gallbladder, hepatic, gastric or renal problems

hesi hint #62 for maternity nursing

what immediate nursing action should be taken when a postpartum hemorrhage is detected -perform fundal massage -notify the HCP if the fundus does not become firm with massage -count pads to estimate blood loss -assess and record vital signs -increase iv fluids (additional iv fluids may be indicated) -administer oxytocin infusion as prescribed -initiate breastfeeding to allow natural oxytocin to be initiated

hesi hint #14 for maternity nursing

when an amniocentesis is done in early pregnancy, the bladder must be full to help support the uterus and help push the uterus up in the abdomen for easy access. When an amniocentesis is done in late pregnancy, the bladder must be empty to avoid puncturing the bladder

Hesi hint #18 for maternity nursing

when deceleration patterns (late or variable) are associated with decreased or absent variability and tachycardia, the situation is ominous (potentially disastrous) and requires immediate intervention and fetal assessment

what nursing interventions are used to enhance maternal-infant bonding during the fourth stage of labor

withhold eye prophylaxis for up to 2 hours. perform newborn admission/routine procedures in room with patients encourage early initiation of breastfeeding darken room to encourage newborn to open eyes

hesi hint #55 for maternity nursing

women who suffer from hyperemesis gravidarum are often deficient in thiamin, riboflavin, vitamin B6, vitamin A, and retinol-binding proteins