NSG 210 Exam 1
signs that placenta is ready to be delivered?
- cord lengthens - contractions - gush of blood
first stage of labor consists of what substages?
1. latent (early) 2. active 3. transition
newborn normal o2 sat?
> 92%
does cytotec act as a cerivical ripening agent or a uterine contraction stimulant?
BOTH
Stage 1 of labor includes which phases in the correct order?A. Transition, Latent, Active B. Active, Latent, Active C. Active, Transition, Latent D. Latent, Active, Transition
D
what does REEDA stand for?
R - redness E - ecchymosis (skin discoloration d/t bleeding under the skin) / edema E - erythema D - dehiscence / drainage A - approximation
prepidil & cervadil are contraindicated in who?
VBACs (hx uterine incision i.e. c-section)
variable decelerations = _____ drop & _____ return when reading on fhr strip
abrupt drop & abrupt return
the nurse understands a preterm infant is at greatest risk for developing which disorder? a. hypoglycemia b. respiratory distress syndrome c. hydrocephalus d. scoliosis
b
In stage 1 of labor, during the active phase, the cervix dilates: a. 0-6 cm b. 7-9 cm c. 6-8 cm d. 8-10 cm
c latent: 0-6 cm active: 6-8 cm transitional: 8-10 cm
function of umbilical vein?
carries oxygenated blood from placenta to fetus
fetal circulation transitions to newborn circulation after initiated by what?
crying/baby's first breath & clamping of umbilical cord
Your laboring patient has transitioned to stage 2 of labor. What changes in the perineum indicate the birth of the baby is imminent? a. Increase in meconium-stained fluid and retracting perineum b. Retracting perineum and anus with an increase of bloody show c. Rapid and intense contractions d. Bulging perineum and rectum with an increase in bloody show
d
how open the cervix is = ???
dilation
when do late decelerations occur in relation to contractions?
start at the peak of the contraction & end when the contraction ends
duration of contraction is when to when?
start of contraction to end of contraction
frequency of contractions is when to when?
start of one contraction to the start of next contraction
how engaged the baby is = ???
station
true or false: anthropoid shaped pelvis is ideal for vaginal childbirth
true
true or false: gynecoid shaped pelvis is ideal for vaginal childbirth
true
true or false: newborn platelet count is same as adults
true
true or false: variable decelerations can occur with or without a contraction (aka occur randomly)
true
newborn normal heart rate range?
110-160 beats/min
how long does cervadil stay in the vagina for?
12 hours
ideal accelerations last for how long and go up how many beats?
15 secs & go up 15 beats
how many vessels are in the umbilical cord?
3 (2 arteries and 1 vein)
how long to wait after removing cervadil before starting oxytocin infusion?
30 mins
newborn normal respiratory rate?
30-60 breaths/min pauses lasting 5-15 secs (aka periodic breathing) = normal
newborn labs: normal blood glucose range for newborns?
40 - 80
how long to wait after prepidil administration before starting oxytocin infusion?
6-12 hours
when the nurse accidentally bumps into a newborn's bassinet, the newborn jumps and pulls the extremities into the trunk. the nurse identifies the newborn is demonstrating which reflex? a. tonic neck b. moro c. babinski d. rooting
b
what is the normal attitude (most favorable for vaginal delivery)?
- moderate flexion of head (chin tucked) - flexion of arms onto chest (arms in against self) - flexion of legs onto abdomen
nursing assessment of laboring woman includes what?
- vitals - emotional status - how well she's coping - pain management - dilation/effacement/station - contractions - fetal monitoring
increased hematocrit in the newborn is caused by what 3 factors?
1. placental transfusion during delivery (normal cause) 2. decreased oral intake (dehydration) 3. decreased extracellular volume (ex. baby bleeding d/t placental abruption)
what is the purpose of the ductus arterosis?
allows blood to bypass the lungs
the nurse provides care for a client in labor about to deliver twins. for which complication does the nurse identify that this client is at higher risk? a. precipitate labor b. uterine dysfunction c. placenta previa d. eclampsia
b
what is the purpose of the ductus venosus?
bypass liver into ivc
early decelerations = _____ drop & _____ return when reading on fhr strip
gradual drop & gradual return
late decelerations = _____ drop & _____ return when reading on fhr strip
gradual drop & gradual return
painless vaginal bleeding most likely suggests what condition in pregnant women?
placenta previa
what is the purpose of the foramen ovale?
shunt blood from the right atrium to the left (avoid pulmonary artery and lungs)
what should the nurse document / assess when the rupture of membranes occurs?
- color - odor - amount - time want the fluid to be clear in color; cloudy = infection, green/brown = meconium
newborn normal temperature range?
36.5 to 37.5 C 97.7 to 99.5 F
meconium-stained amniotic fluid alerts the nurse to the possibility of which problem? a. fetal distress and perinatal asphyxia b. fetal distress and hyperbilirubinemia c. abruptio placenta and asphyxia d. placenta previa and perinatal sepsis
a
the nurse provides care for a client 24 hours after delivery, and the client states "i have been urinating so much!". which response by the nurse is best? a. "you probably have a urinary tract infection" b. "your body is getting rid of the increased fluid" c. "you must be drinking large amounts of fluid" d. "your blood glucose is probably elevated"
b
absent variability & marked variability = good or bad??
bad
function of umbilical arteries?
carry deoxygenated blood from the fetus to the placenta
how thin the cervix is = ???
effacement
true or false: a platypelloid shaped pelvis is ideal for vaginal childbirth
false, bad shape for childbirth flat & oval shaped, most likely will require c-section delivery
true or false: an android shaped pelvis is ideal for vaginal childbirth
false, bad shape for vaginal childbirth android is wedge / heart shaped and is the typical shape of a male pelvis
accelerations = good or bad??
good!!
characteristics of second stage of labor? (what to what is second stage of labor, nursing considerations, how is mom feeling?)
- 10 cm to birth - more coaching & encouragement - contractions a little more spaced out than 1st stage of labor - constant feel of rectal/perineal pressure - burning sensation
characteristics of active stage of labor?? (how many cm dilated, contractions characteristics, how is woman feeling?)
- 6-8 cm dilated - contractions are stronger, longer in duration, more intense, & closer together - pt unable to talk through contractions (more need to focus) - more anxious, feels the need for more energy
characteristics of transition stage of labor?? (how many cm dilated, contractions characteristics, how is woman feeling?)
- 8-10 cm dilated - contractions are the strongest at 1.5-2 min duration - an overwhelming sense of not being able to get through it - nauseous - urge to push - increase in amount of bloody show - rupture of membranes (if hasn't occurred already) - doesn't want to be touched but doesn't want her people to go away - shaky
what are signs of true labor? (contractions characteristics, etc?)
- contractions increase in intensity, duration, and frequency - cervix is dilating - can't relieve contractions with activity or comfort measures - pain radiates - starts in lower portion of back and radiates to abdomen, starts at the top of the uterus and radiates down - vaginal pressure
characteristics of third stage of labor? (what to what is third stage of labor, how long should this stage take MAX., nursing considerations?)
- delivery of baby to delivery of placenta - this stage should take max 30 mins - do not pull on umbilical cord!! gentle traction is ok but do not pull on cord
characteristics of fourth stage of labor? (what to what is fourth stage of labor, assess for what?)
- delivery of placenta to 24 hours after delivery - assess for: bonding, bleeding, uterine involution, monitor HR & BP, pain, peri care, breast/nipple care, emotional care
pain management and care of perineal lacerations/episiotomies?
- motrin/tylenol, maybe narcotics - assess with REEDA - keep clean - pain management - abx if infected
premonitory signs of labor??
- nesting - losing mucus plug - can breathe better (d/t baby lightening) - increases in bloody show - rupture of membranes
nursing management and interventions during the first stage of labor?
- pain management (bathtub/hot shower, massage, pharm options: epidural, narcotics, position changes: best position = upright position - standing, squatting, bouncing on a ball, walking) - nausea management - keep patient hydrated
characteristics of latent (early) stage of labor?? (how many cm dilated, how is woman feeling, contractions characteristics?)
- process of dilation 0-6 cm - irregular mild contractions further apart - can talk through contractions - feeling excited, maybe a little anxious
signs of respiratory distress in newborn?
- retractions - tachypnea (respirations > 60 breaths/min at rest) - nasal flaring - cyanosis - expiratory grunting - cyanosis - apnea (cessation of respirations for >20 secs) / <30 breaths/min at rest
what are the 4 main pelvis shapes?
1. gynecoid 2. platypelloid 3. android 4. anthropoid
5 major changes of fetal circulation & transition to newborn circulation?
1. increased aortic pressure leads to decreased venous pressure 2. increased systemic pressure leads to decreased pulmonary artery pressure 3. closure of foramen ovale 4. closure of ductus arteriosus 5. closure of ductus venosus
critical factors affecting labor and birth (5 p's)?
1. passageway (birth canal: pelvis & soft tissues) 2. passenger (fetus & placenta) 3. physiologic powers (contractions) 4. position (relationship of maternal pelvis & presenting part) 5. psychosocial considerations (fear, anxiety, excitement)
The nurse is performing a vaginal examination on a client in labor. The nurse finds the fetal presenting part 1 cm above the ischial spines. How should the nurse document the fetal position? 1. -1 2. +1 3. Engaged 4. Floating
Answer 1 If presenting part is above the ischial spines 1 cm, the station is -1. If the presenting part is 1 cm below the ischial spines, the station is +1. Engaged and floating are not descriptive of station.
A 24-year-old primigravid client who gives birth to a viable term neonate is in the third stage of labor. Which sign would indicate to the nurse that the placenta is about to be delivered? 1. The cord lengthens outside the vagina 2. There is a decrease in vaginal bleeding 3. The uterus cannot be palpated 4. The uterus changes to discoid shape
Answer 1 The most reliable sign the placenta has detached from the uterine wall is lengthening of the cord outside the vagina. Other signs include a sudden gush of (not decrease) vaginal blood.
Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of active labor? 1. Excitement 2. Loss of control 3. Numbness of the legs 4. Feelings of relief
Answer 2 Assessment findings indicate that the client is in the transition phase of labor. During this phase, it is not unusual for the clients to exhibit a loss of control or irritability. Leg tremors, nausea and vomiting and an urge to bear down also are common.
After a lengthy labor process a primigravid client gives birth to a healthy newborn boy with a moderate amount of skull molding. What information would the nurse include when explaining to the patient about the condition? 1. It is typically seen with breech births 2. It usually last a few days before resolving 3. It is typically when the brow is the presenting part 4. Surgical intervention may be necessary to relieve the pressure
Answer 2 Molding occurs with vaginal births and is commonly seen in newborns. This is especially true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that is not permanent and that it typically last a day or tow before resolving.
A multigravida client is admitted at 4-cm dilated and is requesting pain medication. The nurse gives the client an opioid medication. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. What should the nurse do first? 1. Have naloxone available in the birthing room 2. Complete a vaginal exam 3. Prepare for birth 4. Document the client's relief due to pain medication
Answer 2 The feeling of needing to have a bowel movement is commonly caused by pressure on receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially by completing a vaginal exam to validate current effacement, dilation and station.
The heath care provider has prescribed prostaglandin gel to be administered vaginally to a newly admitted mother. Which finding indicates that the client has had a therapeutic response to the medication? 1. Resting period of 2 minutes between contractions 2. Decrease nausea and vomiting 3. Softening of the cervix and beginning of effacement 4. Leaking of clear amniotic fluid in small amounts
Answer 3 Prostaglandin gel may be used for cervical ripening before the induction of labor with oxytocin. It is usually administered by catheter or suppository or by vaginal insertion. Two or three doses are usually needed to begin the softening process.
Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client has severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in which position. 1. Breech 2. Transverse 3. Posterior 4. Anterior
Answer 3 When the client has severe back pain during labor, the fetus is most likely in an occipitoposterior position. This means that the fetal head presses against the client's sacrum, causing marked discomfort during contractions.
A primigravida client in the second stage of labor feels the urge to push. The client has had no analgesia or anesthesia. Anatomically, which would be the best position for the client to assume? 1. Dorsal recumbent 2. Lithotomy 3. Hands and knees 4. Squatting
Answer 4 Anatomically, the best position for the client to assume is the squatting position because this enhances pelvic diameters and allows gravity to assist in the expulsion stage of labor. This position also provides for natural pressure anesthesia as the fetal presenting part presses on the stretched perineum.
a client receives magnesium sulfate intravenously for treatment of preeclampsia. the client's assessment reveals: BP 110/70, PR 98 beats/min, RR 11 breaths/min, hyporeflexia, and a urine output of 20 ml/hr. which analysis by the nurse is best? a. maternal toxicity has occurred b. an additional dose of magnesium sulfate is needed c. desired systemic results have been reached d. drug therapeutic levels have been attained
a
a fetal heart rate (fhr) tracing shows an early deceleration pattern. the nurse is aware that this indicates which interpretation? a. the fhr slows early in the contraction, which is a normal finding b. the fhr slows early in the contraction, which indicates fetal hypoxia c. the fhr slows at the peak of the contraction, which is a normal finding d. the fhr slows at the peak of the contraction, which indicates maternal hypoxia
a
the nurse assesses four newborns. which characteristics noted by the nurse are most common in a preterm infant? a. red, wrinkled skin, lanugo, and hypotonic muscles b. vernix caseosa, silky hair, and facial edema c. absent nose bridge, depressed fontanels, and absent lanugo d. mottled skin, meconium stools, and hypertonic muscles
a
the nurse provides care for a client in labor. the client's labor progresses with regular contractions until the cervix is 9 cm dilated. the nurse identifies the client is in which stage of labor? a. first stage b. second stage c. third stage d. fourth stage
a
a primigravida diagnosed with type 1 diabetes mellitus reviews the insulin regimen with the nurse. the nurse explains which changes in insulin requirements will occur in pregnancy? a. insulin requirements will increase during pregnancy and decrease after delivery b. insulin. requirements will decrease during pregnancy and increase after delivery c. insulin requirements will increase during pregnancy and remain increased after delivery d. insulin requirements will decrease during pregnancy and remain decreased after delivery
a the need for more insulin is cause by hormones the placenta makes to help the baby grow. at the same time, these hormones block the action of the mother's insulin. immediately after delivery, the insulin requirements usually decrease abruptly.
During the second stage of labor, assessment would include which of the following? a. Complaints of rectal or perineal pressure b. Estimated date of birth c. Fundal height d. Fetal position
a. Complaints of rectal or perineal pressure During the second stage of labor, the nurse would assess for signs typical for this stage, such as complaints of rectal or perineal pressure. Assessment of estimated date of birth, fundal height, and fetal position are assessments for the first stage of labor.
While in active labor, a multigravid client received magnesium sulfate for treatment of gestational hypertension. due to the effects of magnesium sulfate, which newborn symptom is expected? a. bradycardia b. hypotonia c. tachypnea d. hypertension
b
an infant shows a tendency to bleed two days after birth. the nurse understands this is most likely caused by which reason? a. hemophilia b. absence of intestinal bacteria and lack of vitamin k c. an immature liver that is unable to synthesize clotting factors d. delayed production of red blood cells
b
during auscultation of the fetal heart rate (fhr) during labor, the nurse assesses a rate of 59 beats/min. which actions does the nurse take first? a. turns the client on the right side, opens the iv line, and calls the health care provider b. turns the client on the left side, administers oxygen by nasal cannula, and verifies iv access c. places the client in semi-fowler position, provides ice, and calls the health care provider d. places the client in trendelenburg position, administers oxygen, and forces fluids
b
the nurse provides care for a client in the second stage for labor. the nurse notes the client is tiring after a few hours of pushing, and is no longer making progress. which does the nurse anticipate the health care provider will ask for? a. an infusion of oxytocin b. forceps or vacuum c. an infusion of magnesium sulfate d. the or to be prepped for a c-section
b
the nurse provides care for a client receiving an oxytocin infusion to induce labor. the nurse stops the infusion if which occur? a. contractions are at 3 minute intervals and last for 55 to 60 secs b. contractions are at 2 minute intervals and last for 90 to 120 secs c. contractions are at 3 minute intervals and last for 80 to 90 secs d. contractions are at 2 minute intervals and last for 60 to 90 secs
b an adverse effect of the use of oxytocin to induce labor is uterine hyperstimulation. hyperstimulation is defined as single contractions lasting longer than 90 secs, or 5 or more contractions in a 10 min period (less than 2 mins of rest between contractions). if the client exhibits uterine hyperstimulation, the nurse should stop the infusion and notify the health care provider.
the nurse provides care for a neonate born two hours ago. which occurrence initiates the changes that take place in the neonate's circulatory system after birth? a. the space constraints of the uterus are removed b. the newborn begins pulmonary ventilation c. the newborn is exposed to excessive sensory stimuli d. the ambient temperature of the newborn is reduced
b lung inflation causes pressure in the right atrium to decline while pressure is increased n the left atrium. the foramen ovale closes which leads to the ductus arteriosus occluding and becoming a ligament.
a client had a cesarean delivery. the nurse places the highest priority on monitoring the client for which potential complication? a. infection and pain b. hemorrhage and shock c. hemorrhage and pain management d. dehydration and infection
b the client is not only an ob client but also a postoperative client; observe for patent airway, and observe incisional dressing for bleeding and amount of lochia
when do early decelerations occur in relation to contractions?
before the peak of the contraction
the client arrives at the hospital in active labor. the client asks the nurse what is the purpose of the fetal monitor. which response by the nurse is best? a. "the purpose of the fetal monitor is to evaluate the progress of labor" b. "the purpose of the fetal monitor is to assess the strength and duration of contractions" c. "the purpose of the fetal monitor is to determine if the fetus is receiving adequate amounts of oxygen" d. "the purpose of the fetal monitor is to allow the health care provider to decide if an oxytocin drip should be started"
c
the nurse provides care for a client six hours after a vaginal delivery and assists the client to perform perineal care. 15 mins later, the nurse notes the peri pad is soaked and there is blood underneath the client's buttocks. which action does the nurse take first? a. obtains the client's blood pressure b. notifies the health care provider c. assesses the fundus d. administers oxygen at 8-10 l/min
c the nurse needs to assess for uterine atony. he nurse may need to start iv fluid replacement and may need to administer oxytocin if the client's fundus does not respond to fundal massage
which action should the nurse take immediately after the newborn is circumcised? a. leaves the area open to air b. diapers the baby with a cloth diaper c. applies petroleum gauze and observes carefully for bleeding d. administers prophylactic antibiotics
c the nurse should observe for bleeding hourly during the first 4-6 hours. the penis should be washed gently with water and petroleum gauze should be applied around the glans with each diaper change. instruct the parent that yellow exudate should not be removed.
a client calls the clinic and reports a fever, fatigue, and has a hard, reddened area in one breast. the client is breastfeeding. which condition does the nurse understand that the client is most likely experiencing? a. adjustment reaction b. primary engorgement c. a blocked duct d. mastitis
d
the nurse palpates the fundus of a client after the third stage of labor. the nurse expects the fundus to have which characteristics? a. soft and discoid b. firm and discoid c. soft and globular d. firm and globular
d
the nurse provides care for a client in active labor and who is 6 cm dilated. the client is now ready for epidural anesthesia. which position will the nurse assist the client? a. modified knee-chest with upper leg flexed and lower leg extended b. a sitting position with the back straight and feet supported on a stool c. prone position, head on arms, and pillow at pelvic area d. on the left side, shoulders parallel, legs flexed, and back arched
d
a client comes to the hospital in labor. the membranes rupture at 0410. which action does the nurse take first? a. identifies the amniotic fluid by performing a nitrazine tape test b. contacts health care provider and prepares for immediate delivery c. documents admission and notes the time of rupture of membranes d. observes the amniotic fluid for any signs of infection or meconium
d it is important to note the color, amount, and odor of the amniotic dluid. the fluid should be clear and odorless, and may contain white specks (vernix caseosa) and fetal hair. a yellow-green tinged amniotic fluid may indicate infection or fetal passage of meconium, which could possibly have life-threatening complications to the fetus that may require emergency delivery.
opioid analgesics nursing consideration?
do not give if pt is close to delivering; narcotics cross placental barrier to baby, if pt is close to delivering, the baby is likely to have respiratory depression on delivery & will need more resuscitation efforts to get them started; have narcan on hand for baby
moderate variability = good or bad??
good, ideal
oxytocin (pitocin) nursing consideration?
maintain continuous fetal monitoring & contraction monitoring throughout entire pitocin infusion; stop infusion IMMEDIATELY if fetal distress and/or uterine tachysystole is present
stools of formula fed newborn (color, consistency)?
more green-brown, more formed
newborn labs: is leukocytosis in newborn normal or abnormal?
normal finding (increased wbc)
stools of breastfed newborn (color, consistency)?
pale yellow or pasty green, more liquid, more frequent
