NUR Level 2 Test 6
V in VEAL CHOP represents
variable deceleration
What organisms is opthalmia neconatorum caused by?
gonorrhea chlamydia
What should the temperature of the water approximately be to prevent injury to newborns?
36.6-37.2 (98-99F)
Post partum hemorrhage is classified as________ blood loss from a vaginal birth
500 ml
On which of the postpartum days can the client expect lochia alba
7-21 days PP
What are signs that phototherapy is working?
Bronze discoloration Maculopapular skin rash Dehydration Elevated temperature
A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching?
"I need to stop breastfeeding until this condition resolves."
A nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client says:
"My cervix is completely dilated."
To facilitate feeding and correct latching on, how should the mother hold the infant?
"Tummy to tummy"
Factors that slow uterine involution
* Anesthesia * Prolonged labor * Infection
Complication with psychological response
* Anxiety * Helplessness * Isolation * Weariness
Complications with Passageway
*Pelvic Shape * Cephalopelvic disproportion
A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Considering the client's behavior, the nurse suspects she is dilated:
8 to 10 cm
A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void ever 2 hours. Which of the following statements should the nurse make?
A distended bladder reduced pelvic space needed for birth
A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. The nurse analyzes this data as indicative of:
A normal finding
Tocolytics
Act on uterine muscle to cease contractions. Used to stop preterm labor.
A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered?
Activated partial thromboplastin time. APTT
What is irritability during phototherapy a sign of?
Acute bilirubin and encephalopathy
This labor there is an interruption in the labor process associated with change in contraction
Arrested labor
Zidovudine (AZT)
Antiviral: prototype nucleoside inhibitor of HIV reverse transcriptase (NRTI). Tox: severe myelosuppression. Others: lamivudine, stavudine, didanosine, zalcitabine.
What is fetal flexion?
As vertex meets resistance from the cervix, walls of pelvis, or pelvic floor - baby tucks chin
On completing a fundal assessment, the nurse notes the fundus is situated on the client's left abdomen. Which of the following actions is appropriate?
Ask the client to empty her bladder.
What do post-term infants have an increased risk for in utero?
Aspirating meconium
Occiput anterior
BACK OF THE HEAD FACING FORWARD The most common relationship between the presenting fetal part and the maternal body pelvis.
What is a non-pharmacological method for lactation suppression?
Cabbage leaves
A nurse is assisting with the delivery of a newborn. The fetal head has just emerged. Which of the following would be done next?
Checking for the cord around the neck
A client is brought to the labor unit, and, as the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. The nurse immediately:
Checks the fetal heart rate
A nurse assisting to monitor a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client to reflect an attitude of:
Excitement
When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically:
Facilitate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn (taking hold)
second stage of labor
Full dilation Intense contractions BIRTH!!
Which of the following findings would be expected when assessing the postpartum client?
Fundus 1 cm above the umbilicus 1 hour postpartum
What does a mom's subjective report of "tingling fingers" during labor indicate?
Hyperventilation
The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. The nurse understands that this ointment:
Is effective in protecting the newborn from Neisseria gonorrhoeae and chlamydia
Palpation manuevers to determine fetal position
Leopold
What are nursing responsibilities when caring for a newborn receiving phototherapy?
Maintain eye mask over newborn's eyes for protection of corneas and retinas Keep newborn undressed, surgical mask placed over genitalia Avoid motioning skin (can cause burns) Remove newborn from phototherapy q4hr assessing accordingly Reposition newborn q2hr
What are indications for cesarean birth?
Malpresentation (breech) Fetal distress Placental abnormalities High risk pregnancy (HIV+, Hypertensive disorders, diabetes mellitus, active genital herpes lesions) Previous c-section Multiple gestations Umbilical cord prolapse
A nurse is assigned to care for a client experiencing dystocia. In planning care, the nurse would consider the highest priority to be frequent:
Monitoring for changes in the physical and emotional condition of the mother and fetus
acceleration in labor
O2 is good and baby is ok
A client in labor states to the nurse, "I think my water just broke." On examination of the client, the nurse sees that the umbilical cord is protruding from the vagina. The nurse immediately:
Places a gloved hand into the vagina and holds the presenting part off of the umbilical cord
uterine inertia
absence or weakness of uterine contractions
When administering IV heparin, what lab value should the nurse particularly monitor?
apTT
solution used for perineal care
betadine
A nurse is planning care for a newly admitted client who reports, "I am in labor and I have been having vaginal bleeding for 2 weeks." Which of the following should the nurse include in the plan of care?
defer***DO NOT do vaginal exam*** Vaginal exams should not be performed until placenta previa or abruptio placentae have been ruled out as the cause of vaginal bleeding.
third stage of labor
delivery of placenta
Reva Rubin's Three Phases
taking-in phase taking-hold phase letting-go phase.
This is a type of delivery which results after an unusually rapid labor
Precipitated labor
Which finding in the prenatal client supports the medical diagnosis of placental abruption?
Tender, rigid abdomen
android pelvis
the typical male pelvis; in the woman, the heart shape of the android pelvis is not favorable to a vaginal delivery
RhoGAM is required prenatally, post partum and in the event of trauma to prevent
isoimmunization of the fetus
type of deceleration associated with placental insufficiency
late deceleration
Phases of first stage of labor
latent phase active phase transition phase
Maculopapular rash
rash with a flat red area that also has raised bumps
Lightening
the sensation of the fetus moving from high in the abdomen to low in the birth canal
oligohydramnios
too little amniotic fluid
Which of the following is a priority when caring for a woman during the fourth stage of labor?
Assessing the uterine fundus
Defined as blood flow from the uterus during postpartum period
Lochia
This medication is used in labor and post partum
Pitocin
Betamethasone is used for what
Promote fetal lung maturity
During birth, a baby is at the ____________station
+4 to +5
What is passenger?
The fetus, membranes, and placenta
Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station?
0
At what minutes are apgar scores taken?
1 & 5 minutes
When your baby moves from zero station to +1 station, they have moved about
1 centimeter.
A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is isolated:
1 cm above the ischial spines
The client is in the second stage of labor. As the baby begins to crown, the health care provider administers a pudendal nerve block in preparation for an episiotomy. Which action should the nurse take?
Continue to assess vital signs and fetal heart rate the same as before the nerve block.
A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for:
Eight peripads per day.
What are the greatest risks during the postpartum period?
Hemorrhage Shock Infection
What does the BPP (biophysical profile) measure?
Reactive/nonreactive FHR Fetal breathing patterns Gross body movements Fetal tone Qualitative amniotic fluid volume
presenting part
specific fetal structure lying nearest to the cervical os
IUPC
intrauterine pressure catheter inserted into a mom for contraction strength measurement
The nurse examines a woman one hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to:
massage the fundus until firm
early deceleration looks like _______in the FM strip
mirror contractions
gynecoid pelvis
most favorable pelvis for successful labor.
Anthropoid pelvis
oval shaped, with a wider anteroposterior diameter
Post partum hemorrhage is classified as________ drop in hematocrit
10%
What should the nurse instruct the new parents regarding bathing the newborn?
Avoid bathing the new infant daily because it can cause dryness and alters the acid mantle of the newborn's skin
What is the fourth stage of labor and when does it start?
Postpartum period- starts after the delivery of the placenta
Methergine or Pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the:
Blood pressure.
A client states, I think my waters broke! I felt this gush of fluid between my legs. The nurse tests the fluid with Nitrazine paper and confirms membrane rupture if the paper turns:
Blue
10.A woman telephones her health care provider and reports that her water just broke. Which suggestion by the nurse would be most appropriate?
Come to the clinic or emergency department for an evaluation.
complications of a distended bladder during birth
reduces pelvic space impedes fetal descent places the bladder at risk for trauma during the labor process
A nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101° F, and a urine output of 150 mL during the past 2 hours. The nurse should do which of the following at this time?
Notify the registered nurse of a possible maternal infection.
If the mother's indirect Coombs' test is positive and her Rh+ infant has a positive direct Coombs' test, RhoGAM is:
Not given; in this case the infant is carefully monitored for hemolytic disease.
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is appropriate?
Notify the registered nurse (RN).
preterm labor
Occurence of regular contractions that cause dilation and effacement that starts before 37 weeks of gestation
Defined as scant amount or absence of amniotic fluid
Oligohydramnios
Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum?
Pain in left calf with dorsiflexion of left foot
A nurse is evaluating the effectiveness of meperidine hydrochloride (Demerol) for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief?
Pain level is "4" while a progressive labor pattern continues.
Which of the following characteristics is associated with labor contractions
Painless Progressive in terms of intensity and duration Regular pattern of frequency
What are the five factors that affect and define the labor and birth process?
Passenger passageway Powers position psychological response
Which of the following behaviors characterizes the PP mother in the taking in phase?
Passive and dependant.
type of labs/diagnostic testing for preterm labor
Pelvic exam transvaginal ultrasound Uterine monitoring fetal fibronectin (FFN) swab
How is an apgar score made?
Perfect score: 105 categories, each worth points each Categories: HR, RR, Muscle tone, Reflex irritability, Color
A nurse is assisting a client who, at 38 weeks of gestation reports feeling dizzy, lightheaded, and nauseated when attempting to lie down on the examining table. Her skin is pale and is both cool and moist to the touch. What is the first nursing action?
Place a wedge pillow under the client's right side.
A client newly admitted to the labor unit reports to the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse checks the client and notes that the umbilical cord is protruding from the vagina. Which of the following actions should the nurse take first?
Place the client in the Trendelenburg position.
All of the following are important in the immediate care of the premature neonate. Which nursing activity should have the greatest priority?
Placement in a warm environment
What are some symptoms of postpartum depression
* intense sadness * often happens soon after giving birth * Emotional withdraw
Nursing management of labor induction
*Explain procedure * Monitoring mom and baby heart rates * Provide pain relief and support
What is a normal fetal heart rate (FHR)?
110-160 bpm
A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station
2
• Engagement typically occurs in primigravidas______weeks before term
2
A precipitous labor is one that is within_______ hours of onset
3
The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated?
A manual pelvic examination
Leopold's Maneuvers
A series of four maneuvers designed to provide a systematic approach whereby the examiner may determine fetal presentation and position.
bloody show
A small amount of blood at the vagina that appears at the beginning of labor and may include a plug of pink-tinged mucus that is discharged when the cervix begins to dilate.
A pregnant client in the second trimester of pregnancy is admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding should the nurse expect to note if this condition is present?
Abdominal pain
A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse should take which priority action to assist in preventing a crisis from occurring during labor?
Administer oxygen as prescribed throughout labor.
What are examples of non pharmacological pain management during labor?
Aromatherapy Breathing techniques Guided imagery Music Subdued lighting Back massage/effleurage Sacral counter pressure Heat/cold therapy Hydrotherapy Frequent position changes
A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be prescribed?
Betamethasone
What is the purpose of bethamethasone (Celestone) administration during pre-term labor?
Betamethasone is a glucocorticoid that is given to clients in preterm labor to hasten surfactant production in the infant
When applying the ultrasound transducers for continuous external electronic fetal monitoring, at which location would the nurse place the transducer to record the FHR?
Between the umbilicus and the symphysis pubis
Post a circumcision, what does a nurse need to assess?
Bleeding q15min for first hour & a1hr for 12 hours Assess for first voiding by newborn post procedure
Postpartum assessment BUBBLE
Breast ( nipples, breastfeeding) Uterus ( fundus location) Bowel (gas, hemorrhoids, BM) Bladder ( Voiding 6 hrs after delivery) Lochia ( Color, amount, and odor) Episiotomy ( hematomas)
What does breast feeding cause the release of? What does this prevent?
Breast feeding causes the release of oxytocin which stimulates uterine contractions (will prevent hemorrhage)
On which of the postpartum days can the client expect lochia rubra
Bright red, clots, 1-3 days after delivery
When describing the stages of labor to a pregnant woman, which of the following would the nurse identify as the major change occurring during the first stage?
Cervical dilation
Contributing factors of thromboembolic complications are
Clotting factors High parity Anemia Prolonged bedrest Hx DVT Obesity Increased maternal age
how do you assess Lochia in post partum BUBBLE
Color, amount, and odor
A nurse assists the nurse-midwife to examine the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (−) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which of the following activity for the client?
Complete bedrest
Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply.
Constant fever of 101° F Persistent pelvic heaviness Foul-smelling vaginal discharge
Defined as FHR less than 110/min
Fetal bradycardia
Mechanical methods of cervical ripening
Foley bulb (balloon)
Treatment for shoulder dystocia
McRoberts Maneuver
What medication is given after pitocin is giving and results in boggy uterus?
Methergine carboprost (Hemabate) Misoprostol (cytotec)
One pharmacological method of cervical ripening/ induction is
Misoprostol
Preterm labor and preterm membrane rupture are
Obstetric conditions
This may contribute to dystocia in the laboring patient
Psychological stress
Defined as a newborn whose birth weight is at or below the 10th percentile and who has intrauterine growth restriction
SGA- Small for gestational age
Which of the following factors might result in a decreased supply of breastmilk in a PP mother?
Supplemental feedings with formula.
After teaching a group of students about the maternal bony pelvis, which statement by the group indicates that the teaching was successful?
The pelvic outlet is associated with the true pelvis.
What type of milk is present in the breasts 7 to 10 days PP?
Transitional milk.
Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage?
Urine retention.
What are expected ranges of physical assessments found in newborn?
Weight- 2500-4000 grams Length- 18-22 in Head circumference- 12.6-14.5 in Chest circumference- 12-13 in
Stages of Labor: Third Stage
begins with birth of baby and the delivery of the placenta
The taking-in phase begins immediately following:
birth and lasts a few hours to a couple of days. The woman is excited and talkative during this phase and repeatedly reviews the labor and birth experience. It is important for the nurse to allow her the time to express her feelings.
Color litmus paper turns when exposed to amniotic fluid
blue
Powers of labor
uterine contractions
A nurse employed in a health care provider's office is collecting information from a pregnant client. Which of the following statements made by the client likely indicates the need for psychological referral?
"I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."
fetal dystocia maybe caused by
* Excessive fetal size * Malpresentation
Maternal recovery period nursing assessment
* Frequent vital signs * Fundal checks * Assess vaginal bleeding * Encourage voiding * Encourage diet * Promote breastfeeding
Rhesus (Rh) factor incompatibility during pregnancy is possible when two specific circumstances coexist:
1. the expectant mother is Rh-negative 2. the fetus is Rh-positive. The father of the fetus must have an Rh-positive blood type.
Approximately how long should a mother spend breastfeeding on each breast?
15-20 minutes per breast & 30-40 minutes total feeding
A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return:
3 days PP.
Active phase of labor:
4-7 cm moderate to strong contractions regular q 3-5 min lasts 40-70 sec FHR ck q 15-30 mins
A nurse is caring for a client in the third stage of labor. Which of the following findings indicated placental separation? (Select all that apply)
> Lengthening of the umbilical cord > Appearance of dark blood from the vagina > Fundus firm upon palpation
A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse reviews the woman's medical record to ensure which of the following as being required?
Cervical dilation of 2 cm or more
Select all of the physiological maternal changes that occur during the PP period.
Cervical involution occurs Fundus begins to descend into the pelvis after 24 hours
Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus?
Cervical laceration.
The fetus of a nulliparous woman is in a shoulder presentation. The nurse would most likely prepare the client for which type of birth?
Cesarean
Which of the following histories would place a maternity client at risk for uterine rupture?
Cesarean section birth
Which of the following characteristics is associated with false labor contractions
Decrease in intensity with ambulation
A nurse is assigned to care for a nulliparous client who is having a precipitate delivery. The nurse reports which maternal focused observations?
Decreased periods of uterine relaxation between contractions
The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, the nurse would initially:
Determine the maternal and fetal vital signs.
To prevent complication following a cesarean section , the nurse should encourage
Early ambulation
The advantages of using spinal anesthesia for delivery of a fetus include which of the following? Select all that apply
Ease of administration Absence of fetal hypoxia Immediate onset of anesthesia
Defined as an elevation of serum bilirubin levels resulting in jaundice (especially sclera and mucous membranes)
Hyperbilirubinemia (Hyperbili)
A nurse assisting in the care of a woman in labor should focus primarily on which of the following at the time of delivery?
Infant
What can result from untreated hyperbilirubinemia of levels higher than 25 mg/dL?
Kernicterus (bilirubin encephalopathy)- caused by bilirubin depositing into brain cells
Defined as a newborn who's weight is above the 90th percentile or more than 8 lb 12 oz
LGA- large for gestational age
A nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position?
Lateral Sims'
A nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which of the following is the most important information for the nurse to document on the strip?
Maternal vital signs
What are sub-sternal retractions in a newborn a sign of?
Respiratory distress
Defined as terminated pregnancy before 20 weeks of gestation or fetal weight less than 500 g
Spontaneous abortion
Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique,what is the proper way to use peri bottle?
The peri bottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.
What is fetal attitude?
The relationship of fetal body parts to one another
What is lie?
The relationship of the maternal longitudinal axis to the fetal longitudinal axis (spine)
A nurse is preparing a client for an emergency cesarean delivery. Which of the following information regarding the client has priority?
When was the last time the client ate or drank?
Definition of shoulder dystocia is
Where further maneuvers are required after gentle traction
A nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?
White blood cell count of 35,000 mm3
A nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse immediately places the client in what position?
With the hips elevated
How does a post partum woman do self perineal care
With warm water in a squeeze bottle, cleaning front to back
How might stools of breast fed newborns appear?
Yellow and seedy
Letting go phase
interdependent phase after birth in which the mother and family move forward as a system with interacting members
nursing intervention for late deceleration
left side lying position Increase fluid IV bolus discontinue oxytocin administer terbutaline, nifedipine administer o2 at 8-10 l/min via non rebreather mask
Orifice that should be suctioned first in baby
mouth
The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements immediately postpartum?
Lower than before she became pregnant.
What are nursing responsibilities when educating client about preventing thrombophlebitis?
Maintain antiembolism stockings until ambulation established Perform active/passive ROM if on bed rest Avoid prolonged periods of standing, sitting or immobility Have client elevate legs when sitting Maintain adequate fluid intake Tell client to discontinue smoking
A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. Which action should the nurse include in the plan of care?
Maintain complete bed rest Monitor IV fluid intake Monitor the fetal heart rate.
Which measure would be least effective in preventing postpartum hemorrhage?
Massage the fundus every hour for the first 24 hours following birth.
A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially?
Massage the fundus until it is firm.
A nurse is assisting in conducting a childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the woman to perform the procedure by:
Massaging the abdomen during contractions using both hands in a circular motion
Defined as an infection in a milk duct of the breast with concurrent flulike symptoms
Mastitis
The maternity nurse prepares the client for which of the following techniques commonly used to relieve shoulder dystocia?
McRoberts' maneuver
The client at 38 weeks' gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which as least likely necessary for the care of this client?
Measuring the fundal height
A nurse is caring for a client who is at 42 weeks gestation and in active labor. Which of the following findings is the fetus at risk for developing?
Meconium aspiration
The nurse is reviewing the record of a client in the labor room. The nurse midwife noted the following documentation. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?
Minus (-) 1 station
What are nursing responsibilities after a c-section?
Monitor for bleeding (internal, external) Assess lochia Monitor I&O Monitor vitals Give pain medication as prescribed Encourage ambulation to prevent thrombus Assess client for UTI
A nurse is caring for a client in preterm labor when her membranes rupture. The initial nursing action is to:
Monitor the fetal heart rate.
What are nursing responsibilities if post partum hemorrhage is suspected?
Monitor vital signs Assess for source of bleeding Assess bladder for distention Maintain/initiate IV fluids to replace blood loss Provide o2 at 2-3 L/min via NC Elevate client's legs to increase venous return
A nurse assigned to care for a client with mild preeclampsia would anticipate which specific nursing intervention for this client?
Monitoring fetal movement
What is included in the postpartum nursing assessment?
Monitoring vital signs Assessing uterine firmness & location in relation to umbilicus Uterine position in relation to midline (if deviated, assist mom in emptying bladder) Amount of vaginal bleeding (lochia)
Which of the following responses is most appropriate for a mother with diabetes who wants to breastfeed her infant but is concerned about the effects of breastfeeding on her health?
Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.
After the expulsion of the placenta in a client who has six living children, an infusion of lactated ringer's solution with 10 units of Pitocin is ordered. The nurse understands that this is indicated for this client because:
Multigravidas are at increased risk for uterine atony.
A client is complaining of painful contractions, or after pains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains?
Multiple gestation
A nurse is assessing a woman after birth and notes a second-degree laceration. The nurse interprets this as indicating that the tear extends through which of the following?
Muscles of perineal body
A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?
Naloxone
This type of stress test consists of a woman brushing her palm across her nipple for 2 minutes, which causes the pituitary to release endogenous oxytocin
Nipple stimulated CST (Contraction stress test)
What nursing intervention is required for early decelerations of FHR?
No intervention required - expected findingCause: Compression of fetal head resulting from uterine contraction
What are advantages of external fetal monitoring?
Noninvasive- reduces risk for infection Membranes do not have to be punctured Cervix does not have to be dilated
When assessing fetal heart rate, the nurse finds a heart rate of 175 bpm, accompanied by a decrease in variability and late decelerations. Which of the following would the nurse do next?
Notify the health care provider.
When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?
Notify the physician- clots larger than 1 cm is abnormal
A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following?
Notify the physician.
A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that the primary hormone that stimulates postpartum contractions is:
Oxytocin
What is the most common medication for induction and augmentation of labor
Oxytocin (Pitocin)
What can a group b strep infection lead to during pregnancy/delivery?
PROM (premature rupture of membranes) Preterm labor and delivery Chorioamnionitis Infections of urinary tract Maternal sepsis
How can HIV possibly be transmitted to the fetus?
Perinatally through the placenta and postnatally through the breast milk
Methergine or Pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history?
Peripheral vascular disease.
This disorder is a complication that can result from meconium aspiration; Ductus arteriosus & foramen ovale remain open
Persistent pulmonary hypertension of the newborn
What does the biophysical profile (BPP) measure?
Physical/physiological characteristics of the fetus & fetus response to stimuli
A nurse should prepare to give a prescribed oxytocic medication after delivery of the:
Placenta
After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of:
Placental separation
If a client reports leg pain & tenderness, what should the nurse suspect?
Possible DVT
A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as which of the following?
Possible infection
Defined as a newborn who is born after the completion of 42 weeks of gestation
Post-term infant
Defined as more than 500mL blood loss after a vaginal birth or more than 1000 mL blood loss after a cesarean birth
Postpartum hemorrhage
rapid labor and delivery with 2-3 hours; at risk for uterine rupture, vaginal lacerations, amniotic emboli, and postpartal hemorrhage
Precipitate delivery
Defined as labor that lasts 2 hours or less from the onset of contractions to the time of delivery
Precipitous labor
A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client?
Prepare an ice pack for application to the area.
The nurse is caring for a client who is in the transitional phase of labor and reports that they need to have a bowel movement with the peak of contractions. which of the following actions should the nurse make?
Prepare for impending delivery
A nurse caring for a client diagnosed with placental abruption would plan to:
Prepare the client for a cesarean birth.
At 5:00 AM a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 7:00 AM with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to:
Prepare the client for a cesarean delivery.
A nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily:
Prevent dehydration and hypoxemia.
A nurse is assigned to assist in caring for a client in labor. The nurse would determine that which of the following would least likely indicate dystocia?
Progressive changes in the cervix
The nurse is assigned to assist in caring for a client in labor. The nurse would determine that which sign/symptom would least likely indicate dystocia?
Progressive changes in the cervix
involution of the uterus
Progressive descent of uterus into pelvic cavity by 1 cm/day
A nurse is caring for a client who is in labor. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe?
Prolapsed umbilical cord
What type of deceleration requires IMMEDIATE nursing assessment?
Prolonged decelerations- may result in fetal death if there is no response to intrauterine resuscitation
What are traditional hispanic practices post partum?
Protecting the newborn's head/feet from cold air; Delaying bath for 14 days following delivery; Bed rest for mom for 3 days & drinking warm beverages following birth
A nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention in caring for the client is to:
Provide pain relief measures.
A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. The nurse, recognizing the needs of women during this stage, should:
Provide time for the mother to reflect on the events of and her behavior during childbirth.
A clinic nurse is planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would least likely assist in meeting emotional needs?
Providing the mother with pamphlets and booklets to read about the pregnancy
Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. What is the appropriate action to deliver the placenta?
Pull gently on the cord as the mother bears down.
If a precipitate delivery is imminent, which of the following would be the appropriate nursing action?
Put on sterile gloves, and gently guide the baby's head and shoulders out.
The nurse is caring for a client following a precipitate delivery. In addition to fundal massage, the nurse understands that which nursing action will promote the birth of the placenta?
Putting the baby to the mother's breast and letting the baby suck
Which of the following physiological responses is considered normal in the early postpartum period?
Rapid diuresis.
A client is admitted for an emergency cesarean section delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F and ate 2 hours ago. Which intervention has priority?
Report the time of last food intake to the health care provider.
A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which of the following?
Respiratory depression
A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction?
Respiratory rate of 10 breaths /minute
What are some contraindications for oxytocin therapy during labor?
Sepsis Unripe cervix Genital herpes History of multiple births Uterine surgery
A nurse is assisting in caring for a client in labor. The nurse recognizes that the risks for uterine rupture during labor and delivery include:
Shoulder dystocia
Congenital anomaly defined as neural tube defect in which the vertebral arch fails to close; Protrusion of meninges/spinal cord may be present
Spina bifida
Surgical methods of cervical ripening
Stripping membranes Amniotomy
A nurse is providing care to a woman during the third stage of labor. Which of the following would alert the nurse that the placenta is separating? (Select all that apply.)
Sudden gush of dark blood from the vagina
How should newborns be positioned during sleep to prevent SIDS?
Supine "safe sleep"
A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in the:
Supine position with a wedge under the right hip
After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse would do which of the following to help the woman process what has happened?
Support the mother in her reaction to the newborn infant.
A nurse is describing how the fetus moves through the birth canal. Which of the following would the nurse identify as being most important in allowing the fetal head to move through the pelvis?
Sutures
What are assessment findings of respiratory distress syndrome in a newborn?
Tachypnea (greater than 60/min) Nasal flaring Expiratory grunting Retractions (abdominal) Labored breathing Fine crackles upon auscultation Cyanosis
On the first PP night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases?
Taking-in phase.
Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts?
Teaching how to express her breasts in a warm shower.
During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make?
The client appears interested in learning about neonatal care. (Taking hold 3-10 days PP)
Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching?
The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects.
A nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate?
The client will be able to identify measures to prevent infection.
A nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is a cephalic presentation. The nurse understands that this is:
The common presentation
A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor?
The contractions slow down when I walk around
A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response would best support the client?
"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."
A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly licensed nurses. Which of the following statements by a nurse indicated understanding of the teaching?
"They are tablets administered vaginally"
A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure?
"What an efficient way to record my baby's heart rate."
Post partum psychiatric disorders
* Baby blues *Post partum depression * Postpartum psychosis * Postpartum onset panic disorder
Possible causes for mastitis are
* Bacteria enters through crack or sore on the nipple * Mom doesn't empty breast completely * Time between feedings is excessive
Pharmacologic methods of cervical ripening
* Dinoprostone gel ( prepidil) *Dinoprostone inserts ( cervical) * Misoprostol (cytotec)
Nursing management for preterm labor
* Give tocolytic meds * Educate the patient * Provide support
Nursing assessment for preterm labor
* History and physical * Labs and diagnostic testing
Complication with Powers in labor/delivery
* Hypertonic uterine dysfunction *Hypotonic uterine dysfunction * Protracted disorders * Arrest disorders * Precipitate disorders
Post partum emotional adjust according to Reva Rubin
* Letting go * Taking In * Taking hold
What is a risk factor for preterm labor
* Obesity * Incompetent cervix * Infection
factors affecting the labor process
* Passageway * Passenger * Powers * Position * Psyche
A nurse is caring for a client who is 40 weeks gestation and reports having large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first?
*Check the FHR The greatest risk to the client and fetus is the umbilical cord prolapse, leading to fetal distress following ROM. The firs action to take is to check the FHR for clinical findings of distress.
Post term pregnancy nursing management
*Induction of labor * Providing support education
A nurse is assisting in performing an assessment on a client who is at 32 weeks of gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following?
32 cm
Refers to a thrombus that is associated with inflammation, occurs postpartum
Thrombophlebitis
What is terbutaline (Brethine) used for?
To stop uterine contractions- causes uterine smooth muscle relaxation
A nurse is caring for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits and states, "I've had enough. I can't do this anymore." Which of the following stages of labor is the client experiencing?
Transition Phase The transition phase of labor occurs when the client becomes irritable, feels rectal pressure similar to the need to have a bowel movement, and can become nauseous with emesis
A nurse collecting data on a client during the second stage of labor notes a slowing of the fetal heart rate (FHR) with a loss of variability and determines that these are indicators of possible complications. Which priority interventions should the nurse perform?
Turn client to her side and administer oxygen by mask at 8 to 10 L/min.
In providing initial care to the newborn following delivery, the priority action of the nurse is to:
Turn the infant's head to the side.
How long should a child be back facing in car seat while riding in a vehicle?
Until age 2
How is the newborn identified after birth?
Using two identifiers; Arm band is applied immediately after birth to both mom and father baby to prevent newborn from being given to wrong parents
Defined as inability of the uterine muscle to contract adequately after birth
Uterine atony
Which of the following complications is most likely responsible for a delayed postpartum hemorrhage?
Uterine subinvolution.
Which of the following is a complication of oxytocin to induce labor
Water intoxication (fluid retention) Risk of uterine atony in post partum Uterine hyperstimulation
The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which of the following is the presenting part?
Buttocks
Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which sign as an indication of placental separation?
Change in uterine shape
A nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?
Changes in the shape of the uterus
A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma?
Changes in vital signs due to possible hypovolemia
A nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which of the following?
Characteristics of contractions
Which of the following would be most appropriate for the nurse to suggest about pushing to a woman in the second stage of labor?
Choose whatever method you feel most comfortable with for pushing.
Congenital anomaly where there is failure of the lip or hard/soft palate to fuse
Cleft lip/palate
A nurse is instructing a maternity client how to keep a fetal activity diary. The nurse tells the client to:
Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours.
A nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which of the following at this time?
Continue monitoring the client because the data reflect acceptable progress.
The nurse notes persistent early decelerations on the fetal monitoring strip. Which of the following would the nurse do next?
Continue to monitor the FHR because this pattern is benign
What is an expected finding for an infant experiencing abstinence syndrome (withdraw from the substance opioids after birth)?
Continuous high-pitched cry
What are disadvantages of external fetal monitoring?
Contraction intensity is not measurable Requires frequent repositioning of client Quality of recording is affected by client obesity/fetal position
A client has just delivered a viable newborn. The first nursing action to initiate attachment is to:
Determine the parents' desires for contact with the newborn
stages of labor
Dilation stage 1 (Latent)( Transition)(active) expulsive stage 2 placental stage 3 Restorative stage 4
What are nursing interventions required when FHR is 110bpm or less?
Discontinue oxytocin Assist client to side-lying position Administer o2 at 8-10L/min Insert IV catheter w/tocolytic medication Notify provider
A nurse in the labor room is caring for a client in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?
Document the findings and continue to monitor the fetal patterns.
What is the first action required by the nurse right after delivery of infant?
Dry the newborn
A client is scheduled to have an elective cesarean delivery. The nurse preparing the client for the procedure plans to allay the client's feelings of anxiety by:
Encouraging the client to discuss her concerns and desires regarding anesthesia options
A woman has just entered the second stage of labor. The nurse would focus care on which of the following?
Encouraging the woman to push when she has a strong desire to do so
What are small white nodules on the roof of the newborns mouth (may or may not be present)
Epstein's pearls
What is mandatory post-birth to prevent ophthalmia neconatorum?
Erythromycin (Roycin) - Prophylactic eye care
If an infant is not dried completely at birth, by what mechanism will the infant lose heat?
Evaporation - loss of heat that occurs when a liquid is converted to a vapor
How often should vitals be monitored after delivery?
Every 15 min for the first hour Every 30 minutes for next 2 hours Every 4-8 hr depending on remaining medication regimen
.When planning the care of a woman in the active phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval?
Every 15 to 30 minutes
A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which finding would indicate a need to contact the registered nurse (RN)?
Fetal heart rate of 180 beats per minute
A nurse is assisting in performing Leopold's maneuvers. When the client asks what these are for, the nurse's best response is that these maneuvers help to determine:
Fetal position
What is parallel or longitudinal lie?
Fetal spine is parallel to maternal spine either a cephalic or breach presentation but breach presentation may require a cesarean birth
A nurse palpates a woman's fundus to determine contraction intensity. Which of the following would be most appropriate for the nurse to use for palpation?
Finger pads
When should oxytocin be administered?
Flaccid uterus Excess vaginal bleeding To enhance contractions
A nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has a platypelloid pelvic shape. The nurse understands that this pelvic shape is:
Flat and non favorable for a vaginal birth
A nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse monitors for which adverse effect(s) of this medication? Select all that apply.
Flushing Depressed respirations Extreme muscle weakness
How and in what order are contractions rated?
Frequency, Duration, Intensity
A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which of the following would the nurse expect to include as part of the physical assessment? (Select all that apply.)
Fundal height measurement Membrane status Contraction pattern
Of the following, which would be the appropriate method to use to deliver the placenta after a precipitate delivery?
Gently guide the placenta out after a spontaneous separation.
Post partum hemorrhage is classified as________ blood loss from a cesarean birth
Greater than 1000 ml
Defined as a bacterial infection that can be passed to the fetus during labor and delivery
Group B Streptococcus, beta hemolytic (GBS)
What is transverse lie?
Head is on one side, butt on the other The fetal spine is horizontal and forms the right angle to maternal spine and will not accommodate vaginal birth. The shoulder is the presenting part and may require delivery by cesarean birth if the fetus is not rotate spontaneously
What are laboratory tests/metabolic screenings done after birth?
Hgb & Hct (if prescribed) Blood glucose Newborn genetic screening done by heel stick PKU (phenylalanine) testing Hearing screening
Before a circumcision is performed, what does a nurse need to assess?
History of bleeding tendencies in family (hemophilia, clotting disorders) Hypospadias/epispadias Ambiguous genitalia (have both male/female characteristics) Illness/infection
For the previous 4 hours, a client in labor has been experiencing contractions every 2 minutes, lasting 60 to 70 seconds, and strong to palpation. She is 2 cm dilated and complaining of severe pain. The nurse understands that the client is experiencing which type of dystocia?
Hypertonic
Defined as a serum glucose level of less than 40mg/dL
Hypoglycemia in full term newborn
Defined as a serum glucose level of less than 25 mg/dL
Hypoglycemia in pre-term newborn
A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicates to the nurse the presence of concealed bleeding?
Increase in fundal height
What is the earliest indication of hypovolemia caused by hemorrhage?
Increasing pulse decrease BP
The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which of the following?
Increment
The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is:
Indicates the presence of infection
A nurse-midwife is performing an assessment on a pregnant client and is assessing the client for the presence of ballottement. The nurse who is assisting understands that the nurse-midwife will implement which to test for the presence of ballottement?
Initiate a sudden tap on the cervix.
A nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which of the following at the client's bedside?
Intravenous (IV) supplies
Defined as turning inside out of the uterus and may be partial or complete
Inversion of the uterus
A nurse prepares to explain the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage:
Is light stroking of the abdomen to facilitate relaxation during labor
What is an acoustic vibration device & why is it used during a non stress test (NST)?
It is a vibration device that is used to awaken a fetus from sleeping
Which documentation concerning the characteristics of amniotic fluid supports the determination that the fluid is normal?
It is pale, straw-colored with flecks of vernix.
What is presentation?
It is the position in which an infant is born; The part of the fetus that is entering the pelvic first. It can be the back of the head, Occiput.-It can be the chin which is mentum-it can be the shoulder which is the scapula-or it can be breach which is sacrum or feet
How should you care an infant while umbilical cord is healing?
Keep clean and dry to prevent infection
cephalopelvic disproportion (CPD)
condition preventing normal delivery through the birth canal; either the baby's head is too large or the birth canal is too small
a difficult labor or childbirth
dystocia
Type of deceleration associated with fetal head compression
early deceleration
Braxton Hicks contractions
false labor
Stages of Labor: First Stage
from beginning of labor to complete dilation and effacement of cervix; latent or early phase (0-3 cm) active (4-7 cm) transition (8-10 cm)
post partum
from the end of the recovery period to 6-8 wks after delivery
abruptio placentae
premature separation of the placenta from the uterine wall
A nurse is caring for a client who is in the second stage of labor. The client's labor has been progressing, and a vaginal delivery is expected in 20 minutes. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered?
pudendal
First degree laceration extends through:
skin of perineum
second degree laceration extends through
skin of perineum muscles of perineum
third degree laceration extends through
skin of perineum muscles of perineum anal sphincter
Fourth degree laceration extends through:
skin of perineum muscles of perineum anal sphincter anterior rectal wall
A nurse caring for a client who is receiving oxytocin (Pitocin) for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse would first:
Stop the oxytocin infusion.
A nurse is teaching a pregnant client how to perform Kegel exercises. The nurse tells the client that the purpose of these exercises is to:
Strengthen the pelvic floor in preparation for delivery.
A nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse discontinues the oxytocin infusion and notifies the registered nurse if which of the following is noted on data collection of the client?
Uterine hyperstimulation
The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placenta is accompanied by which additional finding?
Uterine tenderness on palpation
A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." The appropriate response by the nurse is which of the following?
"Tell me what you mean when you say that your baby has moved."
During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which of the following heart rates is noted?
150 beats per minute
A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately:
18 weeks of gestation
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:
2 station
The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn infant. The nurse is monitoring for signs of placental separation, knowing that which of the following indicates that the placenta has separated?
A change in the uterine contour
The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that a routine labor procedure that is contraindicated with this client's situation is:
A manual pelvic examination
Cervix softens and possible cervical dilation with descent of presenting part into pelvix
Cervical changes during labor
A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint, the nurse should first:
Check for signs of thrombophlebitis.
A clients membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. Which of the following would the nurse do next?
Check the fetal heart rate.
When assessing cervical effacement of a client in labor, the nurse assesses which of the following characteristics?
Degree of thinning
A primigravida's membranes rupture spontaneously. The nurse's first action is to:
Determine the fetal heart rate.
Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation?
Frank
A nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?
Have the client empty her bladder.
A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that after this procedure, she will likely have:
Increased efficiency of contractions
Nesting
Increased energy level; usually 24-48 hours before labor thought to be the result of increased epinephrine release from decrease in progesterone
.A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which of the following would the nurse most likely include? (Select all that apply.)
Internal rotation Descent Flexion
A nurse is teaching a pregnant client about the warning signs in pregnancy that require the need to notify the health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the health care provider if which of the following occurs?
Irregular, painless contractions
Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. The nurse responds, knowing that this procedure:
Is a systematic method for palpating the fetus through the maternal abdominal wall
During a follow-up prenatal visit, a pregnant woman asks the nurse, How long do you think I will be in labor? Which response by the nurse would be most appropriate?
Its difficult to predict how your labor will progress, but well be there for you the entire time.
A nurse is documenting fetal lie of a woman in labor. Which term would the nurse most likely use?
Longitudinal
A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings, the priority nursing intervention is to:
Notify the registered nurse (RN) immediately
presenting part at station of 0 to +5
Positive numbers are used when a baby has descended beyond the ischial spines.
A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which of the following would the nurse most likely include when discussing measures to promote coping for a positive labor experience? (Select all that apply.)
Presence of a support partner Low anxiety level Participation in a pregnancy exercise program
The nurse working in a prenatal clinic reviews a client's chart and notes that the health care provider documents that the client has a gynecoid pelvis. The nurse understands that this type of pelvis is:
The most favorable for labor and birth
A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs:
To regain her breathing pattern
A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating
Transition phase of the first stage of labor
A nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should
Turn the client onto her left side.
A nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is:
Wedge-shaped and narrow and non favorable for a vaginal birth
What factor found in maternal history should alert the nurse to the potential for a prolapsed umbilical cord?
presenting part at station of -3
A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of IV fluids. Which of the following statements should the nurse make?
"It is needed to counteract hypotension"
A nursing instructor asks a nursing student to describe the process of quickening. Which statement by the student indicates an understanding of this term?
"It is the fetal movement that is felt by the mother."
A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat a urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response would the nurse make to help reduce the maternal fears that the newborn will be born with an infection?
"Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today."
A woman at 20 weeks of gestation calls the health care provider's office and speaks to a nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which of the following is the least helpful response to the client?
"This is an emergency; you should come to the clinic within the hour."
nonpharmacological methods of cervical ripening
* Evening primrose * Black Haw *Black and blue cohosh * Red raspberry leaves * Sexual intercourse
A nurse is caring for a client having contractions every 8 minutes that are 30 to 40 seconds in duration. The client's cervix is 2cm dilated, 50% effaced, and the fetus is at a -2 station with an FHR around 140/min. Which of the following stages and phases of labor is the client experiencing?
* First stage, Latent phase I stage 1, latent phase, the cervix dilates from 0-3cm and contraction duration ranges from 30-45 seconds
Complications with Passenger
* Persistent occiput posterior * Shoulder dystocia *Prolapsed cord * Macrosomia
What is a contraindication for labor induction?
* Placenta Previa * Non reassuring fetal heart rate tracing * Umbilical cord prolapse
The most appropriate nursing care for a woman having hypertonic labor is
* Rest and comfort
Nursing assessment of labor induction
* Review hx for indications * H/P * Review hx for contraindications * Do vaginal exam to determine cervical status
Post partum depression can be result of
* Stress * Hormone imbalance * Isolation
Thromboembolic complication from post partum
* Superficial thrombophlebitis * Septic pelvic thrombophlebitis
Therapeutic management for Preterm labor
* Tocolytic therapy *corticosteroids
A nurse is completing an admission assessment for a client who is 39 weeks of gestation and reports fluid leaking from the vagina for 2 days. Which of the following conditions is the client at risk for developing?
*Infection rupture of membrane for longer than 24 hours prior to delivery increases the risk that infectious organisms will enter the vagina and then eventually into the uterus
After teaching a group of students about the factors affecting the labor process, the instructor determines that the teaching was successful when the group identifies which of the following as a component of the true pelvis? (Select all that apply.)
*Pelvic inlet *Mid pelvis *Pelvic outlet
nurse intervention for variable deceleration
*change mom and baby position *Amnio infusion via IUPC
Post term pregnancy nursing assessment
*history and physical *expectant management
The "presenting" or most palpable (able to feel) part of the baby is above the woman's ischial spines. Sometimes a doctor can't feel the presenting part. This station is known as the "floating."
-5 to 0 station
Taking in phase
24-48 hours after birth: dependent, passive; focuses on own needs; excited, talkative
Rho(D) is administered to an Rh-negative client at ______ weeks of gestation.
28
What type of bathing should be avoided while umbilical cord is still healing?
Bathing infant by submersion in water; Should be avoided until cord has fallen off
Transition phase of the first stage of labor
8-10 cm dilation of cervix. The body is making the shift from opening the cervix to the beginning of the baby's descent.
A nurse is caring for a client who is at 40 weeks gestation and experiencing contractions every 3-5 min and becoming stronger. A vaginal exam reveals that the client's cervix is 3cm dilated, 80% effaced, and at a -1 station. The client asks for pain medication. Which of the following actions should the nurse take? (Select all that apply)
> Administer opioid analgesic medication > Suggest application of cold > Encourage use of patterned breathing techniques
A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? (Select all that apply)
> It can detect abnormal fetal heart tones early > It allows for accurate reading with maternal movement > It can measure uterine contraction intensity
A nurse is caring for a client who is in active labor. The cervix is dilated to 5 cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150 to155/min that last 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. The client is exhibiting manifestations of which of the following? (Select all that apply)
> Moderate variability (20-25sec) > FHR accelerations (up to 150to 155/min over 25sec) > Normal baseline FHR (110 to 160 min)
The nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie?
> Palpate the fundus of the uterus
A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take?
> Place an O2 mask over the client's nose and mouth due to hyperventilation
A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing?
> Relaxation between uterine contraction A fetus is most oxygenated during the relaxation period between contractions.
A nurse is caring for a client who is in active labor. The client reports lower-back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmalogical nursing interventions should the nurse recommend to the client?
> Sacral counterpressure Sacral counterpressure to the lower back relieves the pressure exerted on the pelvis and spinal nerves by the fetus
What are nursing interventions required when FHR is 160bpm or more?
Administer prescribed antipyretics for maternal fever (if present) Administer o2 by mask at 8-10 L/min Administer IV fluid bolus
A nurse is monitoring a client who is in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, the nurse immediately:
Administers oxygen via face mask to the mother
A nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action would be to monitor:
All vital signs, especially heart rate and blood pressure
What procedures should be avoided for mom's HIV+?
Amniocentesis and episiotomy- risk of maternal blood exposure to newborn
The rupture of the fetal membrane is called by a physician
Amniotomy
A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss?
An increase in the pulse from 88 to 102 BPM.
floppy or boggy uterus
An uterus that has not contracted down well is the main cause of postpartum hemorrhage. Your caregivers will massage the uterus strongly to make sure it is well contracted. If the bleeding stops with massage, they may give you medication to keep it contracted.
A mother experiencing dystocia looks alarmed and asks, "What's going on? Why are you all poking and prodding? Is my baby okay?" Based on the client's statement, the nurse understands that the client is experiencing which of the following problem?
Anxiety and fear
A nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which of the following problems would the nurse expect to note on the plan of care?
Anxiety related to a slow progress of labor
APGAR
Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent)
A nurse is caring for a client in active labor. When last examined 2 hours ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states, "My water broke." The monitor reveals a FHR of 80-85/min, and the nurse performs a vaginal exam, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first?
Apply pressure to the presenting part with the fingers
A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?
Ask the mother to urinate and empty her bladder.
A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to:
Assess for hypovolemia and notify the health care provider.
During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. This action will primarily:
Assist in preventing dehydration and hypoxemia.
A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take?
Assist the client into a left-lateral position to increase uteroplacental perfusion.
A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse should avoid doing which of the following at this time to assist in relieving the back discomfort?
Assist the client to ambulate in the room.
When performing a postpartum check, the nurse should:
Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum.
A pregnant woman admitted to the labor and birth suite undergoes rapid HIV testing and is found to be HIV-positive. Which of the following would the nurse expect to include when developing a plan of care for this women? (Select all that apply.)
Avoidance of scalp electrodes for fetal monitoring Refraining from obtaining fetal scalp blood for pH testing Adminstering zidovudine at the onset of labor.
What are clinical findings found with suspected DVT?
Calf tenderness to palpation Swelling of the extremity Elevated temperature Area of warmth
A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure?
Contraction stress test
What are therapeutic and approved holding positions when breast feeding?
Cradle hold Side-lying hold Football hold
the bulging of the perineum and the appearance of fetal head is called
Crowning
On which of the postpartum days can the client expect lochia serosa?
Days 3 to 10 PP
Which of the following changes best described the insulin needs of a client with type 1 diabetes who has just delivered an infant vaginally without complications?
Decrease
The nurse is caring for a client in labor. The nurse reviews the health care provider's prescriptions and notes that the client has a prescription for butorphanol tartrate. The nurse understands that the action of this medication is to have which effect?
Decrease pain.
A nurse is caring for the nullipara woman in labor. The nurse understands that the health care provider must be contacted if which one of the following becomes apparent?
Decreased periods of uterine relaxation between contractions
A multigravida woman with a history of cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding would be noted if complete rupture occurs?
Decreasing blood pressure
Meperidine
Demerol to help with labor pain
Congenital anomaly common in newborns with Down syndrome, where first part of bowel has not developed and is not open; Contents of digestion are unable to pass; Requires surgery
Duodenal atresia
A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin?
Duration of 90 to 120 seconds
When is colostrum present in the new mother's breasts?
During pregnancy and 2-3 days immediately after birth
Defined as difficult or abnormal labor related to the 5 powers of labor (Passenger, passageway, powers, position & psychologic response)
Dystocia (dysfunctional labor)
What are nursing responsibilities when caring for a patient with thrombophlebitis?
Encourage rest Facilitate bed rest DO NOT massage affected area to prevent thrombus from dislodging and becoming an embolus Administer analgesics (NSAIDs) Administer anticoagulants for DVT
A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present?
Enlarged, hardened veins due to inflammation
A client in labor asks the nurse why it is so important to void frequently during labor. The nurse responds, using knowledge that the important reason is to:
Ensure labor progress and prevent injury.
A nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as:
Fear of losing control
A nurse is caring for a client who is 42 weeks gestation and is having an ultrasound. For which of the following conditions should the nurse plan for an amnioinfusion? (Select all that apply)
Fetal cord compression Oligohydramnios
A nurse is caring for a client who has been in labor for 12 hours with intact membranes. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy
Fetal engagement
Defined as FHR greater than 160 bpm for 10 min or more
Fetal tachycardia
Active phase of the first stage of labor
From 4-7cm cervical dilatation; increased anxiety, increased discomfort, unwillingness to be left alone; contractions moderate to severe, 2-3 minutes apart lasting 30-60 seconds in duration
Latent phase of the first stage of labor
From the beginning of true labor until 3-4cm cervical dilatation; mildly anxious, conversant; continue usual activities; contractions are mild initially 10-20 minutes apart, 15-20 seconds' duration; later 5-7 minutes apart 30-40 seconds duration
A pregnant client tells the nurse that she felt wetness on her peri-pad and that she found some clear fluid. The nurse immediately inspects the perineum and notes the presence of both a clear liquid and a portion of the umbilical cord. The nurse's initial action is to:
Gently hold the presenting part upward.
A client delivers a viable male neonate who is given APGAR scores of 8 and 9 at 1 and 5 minutes. The nurse determines the physical condition of the neonate to be:
Good
Types of pelvic shapes
Gynecoid Android Anthropoid Platypelloid
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress?
Hands and knees
A PP client is being treated for DVT. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for:
Hematuria ecchymosis (skin discoloration) epistaxis. (bloody nose)
A medical condition during pregnancy defined as excessive nausea and vomiting that is prolonged past 12 weeks of gestation. Results in weight loss & electrolyte imbalance
Hyperemesis gravidarum
A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate?
Increase hydration by encouraging oral fluids.
The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate?
Instruct the mother to request help when getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth.
This occurs with contractions of the uterine smooth muscle, whereby the uterus returns to its pre-pregnant state
Involution
A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis to assess fetal lung maturity. What is the test for fetal lung maturity during an amniocentesis?
Lecithin/sphingomyelin (L/S) ratio
A client in preterm labor is placed on bedrest. The nurse assists the client to which of the following advantageous positions?
Left lateral
What nursing interventions are recommended when introducing a new infant to other siblings?
Let sibling be the first one to see new infant Provide a 'gift' from the infant to give the sibling Arrange for one parent to spend time with sibling while other parent cares for infant Allow older sibling to help in providing care for infant
Which type of lochia should the nurse expect to find in a client 2 days PP?
Lochia rubra
A group of nursing students are reviewing the various medications used for pain relief during labor. The students demonstrate an understanding of the information when they identify which agent as the most commonly used opioid?
Meperidine (demerol)
What drugs control postpartum hemorrhage?
Methylergonovine (Methergine) Misoprostol (Cytotec) Carboprost tromethamine (Hemabate)
Prostaglandin drug that's used as a cervical ripening agent. Your doctor will place it in the upper part of the vagina every three to four hours to help promote labor.
Misoprostol (Cytotec)
When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction?
Moderate
What are nursing responsibilities when caring for a patient diagnosed with hyperemesis gravidarum?
Monitor client's I&O Assess client's skin turgor/mucous membranes Monitor vital signs Monitor client's weight Have client remain NPO for 24-48 hours
A nurse is caring for a woman in the delivery room. The health care provider prescribes an oxytocic medication for the woman to stimulate uterine contractions and prevent hemorrhage. The nurse understands that this medication will be administered after delivery of the:
Placenta
A client was admitted to the maternity unit 12 hours ago and has been experiencing strong contractions every 3 minutes, and the fetus is currently at station 0. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent nonreassuring fetal heart rate pattern is present. What is the appropriate nursing action?
Prepare the client for a cesarean delivery.
A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to:
Prepare the client for surgery. The use of an epidural, prolonged second stage labor and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action would be to prepare the client for surgery to stop the bleeding.
The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which of the following is noted?
Presence of accelerations
What does dull, intermittent back pain indicate?
Preterm labor, needs to be reported to provider
McRoberts maneuver
Pull knees to head to open up pelvis.
A nurse is caring for a client following a precipitate delivery. In addition to fundal massage, the nurse understands that which nursing action will promote the birth of the placenta?
Putting the baby to the mother's breast and letting the baby suck
Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should:
Recognize this as a behavior of the taking-hold stage. Mothers need to reestablish their own well-being in order to effectively care for their baby.
A nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder, and the client asks the nurse why this is necessary. The nurse appropriately replies by telling the client that its primary purpose is to:
Reduce the risk of injuring the bladder during the surgery.
A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases risk for which of the following complications?
Reduced fetal oxygen supply
This syndrome is defined as surfactant deficiency in the lungs and is characterized by poor gas exchange and ventilatory failure
Respiratory distress syndrome (RDS)
A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines that the client's primary physiological need at this time is:
Rest between contractions
A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which of the following data would best alert the nurse to early signs of hypovolemic shock?
Restlessness and agitation
Defined when fragments of the placenta remain in the uterus and prevents the uterus from contracting, which can lead to uterine atony or subinvolution
Retained placenta
Following delivery, a client experiences subinvolution of the uterus. The nurse develops a plan of care, recalling that which of the following is the primary cause for this occurrence?
Retained placental fragments
A nurse is caring for a client who had no prenatal care, is Rh-negative, and will undergo an external version at 38 weeks of gestation. Which of the following medications should the nurse plan to administer prior to the version?
Rho(D) immune globulin
If the mother's indirect Coombs' test is negative and the infants direct Coombs' test is negative, the mother is given:
RhoGAM (immune globulin) within 72 hours of birt
Types of Lochia
Rubra (red) - lasts 3 to 5 days Serosa (pink) - lasts 22 to 27 days Alba (white) - continues for 10 to 14 days
A nurse is caring for a client who was admitted to the maternity unit at 8:00 AM with contractions occurring every 2 minutes, lasting 1½ minutes, and is dilated 4 cm with a cervical effacement of 60%. At 10:30 AM, the contractions cease. The client reports chest pain and manifests signs and symptoms of shock. The nurse quickly plans care, suspecting which of the following?
Ruptured uterus
A nurse is collecting data from a client with placenta previa during an office visit. The nurse checks which of the following items as first priority?
Signs of fetal distress
A nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is consistent with dystocia? Select all that apply.
Signs of fetal distress High level of maternal anxiety Failure of the fetus to descend
A nurse assists in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for:
Signs of shock
.After teaching a group of students about fetal heart rate patterns, the instructor determines the need for additional teaching when the students identify which of the following as indicating normal fetal acid/ base status? (Select all that apply.)
Sinusoidal pattern Recurrent variable decelerations Fetal bradycardia
As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is one day postpartum. An expected finding would be:
Soft, non-tender; colostrum is present. Breasts are essentially unchanged for the first two to three days after birth. Colostrum is present and may leak from the nipples.
Defined as when the uterus remains enlarged with continued local discharge and may result in a post partum hemorrhage
Subinvolution of the uterus
Examples of tocolytics meds for preterm labor
Terbutaline sulfate (Brethine), Ritodrine HCl (Yutopar), Nifedipine (Procardia), Magnesium sulfate
What is fetal extension?
The chin is extended away from the chest and extremities are extended
Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that:
The expected weight loss immediately after birth averages about 11 to 13 pounds.
The nurse is assisting in the admission of a woman for induction of labor. The nurse should contact the health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply.
The fetus is in the breech position. Lesions are present on the perineum. The fetus is not settled into the pelvis.
What is fetal position?
The relationship of the point of reference on the fetal presenting part to the mother's pelvis. LOA is left occiput anterior. Left is the mother's left pelvis.
A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching
The temperature of the water should be at least 105 F.
A nurse is caring for a client and partner during the second stage of labor. The client's partner asks the nurse to explain how to know when the crowning occurs. Which of the following responses should the nurse make?
The vaginal area will bulge as the baby's head appears"
A nurse is explaining the use of therapeutic touch as a pain relief measure during labor. Which of the following would the nurse include in the explanation?
This technique redirects energy fields that lead to pain.
Why is vitamin K administered to newborn within 1 hour after birth?
To prevent hemorrhagic disorders; Because vitamin K into produced in the GI tract of the newborn until day 8, it is administered at birth
Congenital anomaly defined as failure of the esophagus to connect to the stomach
Tracheoesophageal atresia
A client calls a provider's office and reports having contractions for 2hr that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did not notice blood when wiping after voiding. Which of the following manifestations is the client experiencing?
True Contractions True contractions do not go away with hydration or walking. They are regular in frequency, duration, and intensity and become stronger with walking
When examining the umbilical cord immediately after birth, the nurse expects to observe:
Two arteries
A nurse is collecting initial data on a newborn in the delivery room. Which observation would the nurse expect to note when examining the umbilical cord of the newborn?
Two arteries and one vein
After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which of the following would indicate the need for additional teaching?
Unfortunately, I'm going to have to stay quite still in bed while it is in place.
What is betamethasone used for in labor and delivery
Used for fetal lung maturation
Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman:
Uses the peri bottle to rinse upward into her vagina.
Subinvolution of the uterus
Uterus remains enlarged with continued lochial discharge which may result in postpartum hemorrhage
variable deceleration looks like _______in the FM strip
V or W
A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which of the following?
Variable decelerations
The primary method of controlling post partum hemorrhage is
Vigorous fundal massage
Which position would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? (Select all that apply.)
Walking with partner support Straddling with forward leaning over a chair Rocking back and forth with foot on chair
How does a nurse go about getting a heel stick blood specimen from a newborn?
Warm newborns heel to increase circulation Cleanse area with appropriate antiseptic, allow for drying Spring activated lancet used on outer aspect of heel After puncture, apply pressure with gauze until bleeding stops Cuddle/comfort newborn after completion of procedure to promote feelings of safety
A nurse is describing the different types of regional analgesia and anesthesia for labor to a group of pregnant women. Which statement by the group indicates that the teaching was successful?
We can get up and walk around after receiving combined spinalepidural analgesia
hypotonic uterine dysfunction
Weak, ineffective uterine contractions usually occurring in the active phase of labor; often related to cephalopelvic disproportion or malposition of the fetus; secondary uterine inertia
A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list.
Wear supportive bra Rest during the acute phase Continue to breastfeed if the breasts are not too sore.
Neonatal Abstinence Syndrome (NAS)
a condition in which a child, at birth, goes through withdrawal as a consequence of maternal drug use
During contractions, the arteries to the uteroplacental intervillous spaces are compressed, resulting in
a decrease in fetal circulation and oxygenation
Methergine or Pitocin are not prescribed for a client with
cardiovascular disease peripheral disease hypertension eclampsia, or preeclampsia.
A condition that causes dystocia
cephalopelvic disproportion
Variable decelerations represents
cord compression prolapsed cord nuchal cord (around baby's neck)
What medication is used for post partum bleeding
cytotec (Misoprostol)
dystocia
difficult labor
Taking hold phase
focuses on maternal role and care of the newborn; eager to learn; may develop blues
A nulliparous woman:
has never delivered a baby.
early deceleration represents
head compression due to uterine contraction vaginal exam fundal pressure
methylergonovine (Methergine) can cause
hypertension, should check BP before administering. Usually given up to 8 hours after birth to promote uterine contractions to prevent postpartal hemorrhage.
symptoms associated with rapid breathing
hyperventilation
amniotomy
incision into the amnion
Why are pregnant woman and post partum women at higher risk of developing DVT
increased clotting factor
chorioamnionitis
inflammation of the fetal membranes
Nursing intervention for early deceleration
no intervention needed baby is ready to be born
platypelloid pelvis
pelvis that is flat in its dimensions with a very narrow anterior-posterior diameter and a wide transverse diameter; this shape makes it extremely difficult for the fetus to pass through the bony pelvis
Leading cause of maternal morbidity is
post partum hemorrhage
What is lochia?
postbirth uterine discharge/bleeding
preterm labor risk factors
smoking young mom multiple gestations ppROM abn uterine anatomy
position of presenting part above or below maternal ischial spines
station
Lower landmark when measuring fundal height
symphysis
Palpating the fundus of the uterus identifies
the fetal part that is present, indicating the fetal lie (longitudinal or transverse)
Having the client assume a hands and knees position can help
the fetus rotate from a posterior to an anterior position
fourth stage of labor
the first 1-4 hours of recovery after delivery of the placenta
hypertonic uterine dysfunction
to many uncoordinated uterine activity/contractions, administer demerol and phenergan to start "therapeutic rest"
What is methylergonovine (Methergine) used for?
used to prevent postpartal hemorrhage.
The most common cause of post partum hemorrhage is
uterine atony (no contractions to stop bleeding)
Late decelerations represents
uteroplacental insufficiency causing inadequate oxygenation preeclampsia maternal diabetes placental abnormalities
Type of deceleration associated with cord compression
variable deceleration
The instillation of amnioinfusion reduces the severity of
variable deceleration caused by cord compression
Amnioinfusion
when normal saline or lactated ringers is instilled into the amniotic cavity through a transcervical catheter that is introduced into the uterus to supplement the amount of amniotic fluid
The fetus is said to be "engaged" in the pelvis when the presenting part reaches ________ station and at the level of the__________
zero, maternal ischial spines to prevent prolapse of the umbilical cord
Fetal Engagement (Passenger)
• signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the smallest diameter of the maternal pelvis. • multiparas may experience engagement several weeks before the onset of labor or not until labor begins.
The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?
Left lateral
The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to note documentation that the fundus of the uterus is located at which of the following areas?
Midway between the symphysis pubis and the umbilicus
A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which of the following?
Moderately strong contractions every 4 minutes, lasting about 1 minute
A client is admitted to the labor and birthing suite in early labor. On review of her medical record, the nurse determines that the clients pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal delivery. Which pelvic shape would the nurse have noted?
Gynecoid
The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. A priority nursing action is to:
Keep the client in a side-lying position.
A nurse is assisting to care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by:
Placing external fetal monitors so that each fetal heart rate is monitored separately
Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in:
Latent phase of the first stage
The nurse is collecting data from a client who has been diagnosed with placenta previa. Choose the findings that the nurse would expect to note. Select all that apply.
Bright red vaginal bleeding Soft, relaxed, nontender uterus
.A nurse is caring for several women in labor. The nurse determines that which woman is in the transition phase of labor?
Contractions every 1 minute, cervical dilation 9 cm
A nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which of the following most appropriately describes the mother's problem at this time?
Fear about what is happening
The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first?
Feel for the fetal buttocks or head while palpating the abdomen.
A nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which of the following is noted?
Fetal tachycardia
The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client, knowing that the placenta:
Provides an exchange of nutrients and waste products between the mother and the fetus
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on data collection?
Respirations of 10 breaths per minute
The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse places the client in the:
Supine position with a wedge under the right hip
presenting part at station of 0
This is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis.
A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor?
Upright
Which of the following would indicate to the nurse that the placenta is separating?
Uterus becomes globular
A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure , cramping and lower back pain. The nurse determines that which of the following has most likely occurred?
Lightening
A nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse includes which of the following in the plan of care?
Maintain continuous electronic fetal monitoring.
