Nurs 215 labs

Optimal range for plasma glucose in neonoates

70-100 mg/dL

What blood glucose level is considered hypoglycemic in the neonate?

< 40 mg/dL

What is an acceleration?

A visually abrupt, transient increase (onset to peak < 30 seconds) in the FHR above baseline

The nurse in the newborn nursery is monitoring a late preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to possibility of this syndrome? A. Tachypnea and retractions B. Acrocyanosis and grunting C. Hypotension and bradycardia D. Presence of a barrel chest and acrocyanosis

A. Tachypnea and retractions

Which of the following would the nurse most expect to assess in a neonate delivered at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? A. Increased muscle tone B. Hyperbilirubinemia C. Bulging fontanels D. Hyperactivity

C. Bulging fontanels

While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted? A. Bronze-colored skin B. Maculopapular chest rash C. Urine specific gravity of 1.018 D. Absent Moro reflex

D. Absent Moro reflex

One serious complication to circumcision

Hemorrhage

What is the priority side effect of epidural anesthesia?

Hypotension

What does an Apgar score of 4-6 indicate?

Moderate difficulty transitioning to extrauterine life

How would you instruct a patient to bear down and push?

Perform open glottis pushing for 4-6 seconds followed by a slight exhale Repeat this pattern for 5-6 pushes per contractions

What is Pitocin?

Pitocin = oxytocin Given IV Stimulates uterine smooth muscle that produces intermittent contractions. Has vasopressor and antidiuretic properties

What does an Apgar score of 0-3 indicate?

Severe distress

What does an Apgar score of 7-10 indicate?

Stable status

What is the gate-control theory of pain?

States that the sensation of pain is transmitted from the periphery of the body along ascending nerve pathways to the brain Since there is a limited number of sensations that can travel along these pathways at a given time, an alternate activity can replace travel of the pain sensation, thus "closing the gate" control at the spinal cord and reducing pain impulses traveling to the brain

What does moderate variability mean when referring to fetal heart rhythms?

The amplitude from peak to trough is 6-25 BPM

Station

The relationship of the ischial spines to the presenting part of the fetus Ranges from -3 to +3

Effacement

The shortening and thinning of the cervix

Umbilical cord compression can lead to what type of deceleration?

Variable deceleration

VEAL CHOP

Variable deceleration Early deceleration Acceleration Late deceleration Cord compression Head compression Okay! (may need oxygen) Poor placental perfusion

Signs that a neonate is in respiratory distress

-Cyanosis -Abnormal respiratory pattern (apnea/tachypnea) -Retractions of the chest wall -Grunting -Flaring of nostrils -Hypotonia

Signs and symptoms of neonatal hypoglycemia

-Jitteriness -Hypotonia -Irritability -Apnea -Lethargy -Temperature instability

List important nursing actions during the active phase of labor

-Monitor FHR and contractions every 15-30 min -Monitor maternal vital signs every 2 hours; every 1 hour if ROM -Perform intrapartal vaginal exam as needed to assess cervical changes and fetal descent -Assess location/degree of pain -Promote comfort measures

When is intrapartum GBS prophylaxis indicated?

-Previous infant with GBS disease -Positive GBS vaginal-rectal screening culture during current pregnancy -Unknown GBS status at onset of labor < 37 weeks, ROM > 18 hours, temperature > 100.4 degrees F

List 4 outcomes in which water immersion is helpful during labor

-Relaxation -Reduced length of labor -Less painful contractions -Increased spontaneous birth

Name 4 common CAM (complementary and alternative medicine) practices used for pain management in labor

-Yoga -Hypnosis -Homeopathy -Acupuncture

What is the narrowest diameter the fetus must pass through during a vaginal birth?

0

What are 5 premonitory signs of labor?

1. Lightening (descent of fetus in true pelvis) 2. Braxton-Hicks contractions (irregular uterine contractions that do not result in cervical change) 3. Cervical changes (soft cervix, partially effaced, begins to dilate) 4. Surge in energy 5. Backache

What are the 4 Ps essential in the outcome of labor and delivery?

1. Powers (involuntary uterine contractions + voluntary pushing) 2. Passage (bony pelvis + soft tissues of the cervix, pelvic floor, vagina and introitus) 3. Passenger (fetus) 4. Psyche (response of the woman during the intrapartum period)

How many cm is considered completely dilated?

10 cm (can no longer be palpated on vaginal examination)

Normal range of fetal heart rate

110-160 BPM

What is a normal acceleration?

15 beats above the baseline, lasting from 15 seconds to < 2 minutes

How much urine are full term neonates expected to excrete per day?

15-60 mL/kg

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist, reddened and that discharge was present. What is the most appropriate nursing instruction for this mother? A. Bring the infant to the clinic B. This is a normal occurrence C. Increase the number of times that the cord is cleaned per day D. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues

A. Bring the infant to the clinic

Which types of activities can replace sensation of pain regarding the closed-gate theory?

Application of pressure Cutaneous stimulation Effleurage (gentle stroking of abdomen) Use of heat/cold Breathing, focusing, visual/auditory stimulation

A full-term neonate is admitted to the normal newborn nursery. The nurse notes a normal Moro reflex. What should the nurse do next? A. Call a code B. Identify this reflex as a normal finding C. Place the neonate on seizure precautions D. Start supplemental oxygen

B. Identify this reflex as a normal finding

A healthy neonate was just delivered in stable condition. In addition to drying the infant, what is the preferred method to prevent heat loss? SELECT one answer below. A. Place the infant under a radiant warmer B. Place the infant skin-to-skin on the mother C. Obtain a heal stick to assess for hypoglycemia

B. Place the infant skin-to-skin on the mother

A multigravida client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. Which fetal heart rate pattern would the nurse find is most concerning? a. Early deceleration pattern b. Sinusoidal pattern c. Variable deceleration pattern d. Late deceleration pattern

B. Sinusoidal pattern

After circumcision, the nurse instructs the neonate's mother to cleanse the circumcision with which of the following? A. Antibacterial soap B. Warm water C. Providone-iodine (Betadine) solution D. Diluted hydrogen peroxide

B. Warm water

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? A. Warming the crib pad B. Closing the doors to the room C. Drying the infant with a warm blanket D. Turning on the overhead radiant warmer

C. Drying the infant with a warm blanket

Nursing care of the neonate post-delivery (Erythromycin). The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? A. Protects the newborn's eyes from possible infections acquired while hospitalized. B. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. C. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. D. Prevents an infection called opthalmia neonatorum from occurring after the delivery in a newborn born to a woman with an untreated gonococcal infection.

D. Prevents an infection called opthalmia neonatorum from occurring after the delivery in a newborn born to a woman with an untreated gonococcal infection.

What fetal circulatory structure do murmurs in neonates relate to?

Ductus ateriosus

Why is hypoglycemia common immediately after birth in neonates of diabetic mothers?

During intrauterine life, neonates of diabetic mothers produce high levels of insulin in response to high levels of circulating maternal glucose. During the first few hours after birth, the neonate's insulin levels remain higher than normal, leading to hypoglycemia

When do the membranes rupture?

Either active/transition phase of stage 1

Why do newborns require Vitamin K injections after birth?

Fetuses receive Vitamin K in the womb from the mother. After birth, the neonate experiences a decrease in Vitamin K which puts it at risk for hemorrhage. The Vitamin K injection will prevent the neonate from abnormal bleeding

What are the types/characteristics of Leopold's maneuvers?

First maneuver: determine what part of the fetus is located in the fundus of the uterus Second maneuver: determine location of fetal back Third maneuver: determine the presenting part Fourth maneuver: determine the location of the cephalic prominence

Which stage of labor is the longest?

First stage. Typically lasts 12 hours for primigravidas and 8 hours for multigravadas

Name and briefly describe the stages of labor

First stage: begins with onset of labor and ends with complete cervical dilation Second stage: begins with dilation of cervix and ends with delivery of baby Third stage: begins after delivery of baby and ends with delivery of placenta Fourth stage: begins after delivery of the placenta and is completed 4 hours later

What is the frequency/duration/intensity of contractions in the 3 phases of stage 1 labor?

Frequency: 5-15 min (latent) 3-5 min (active) 1-2 min (transition) Duration: 10-30 sec (latent) 30-45 sec (active) 40-60 sec (transition) Intensity: mild (latent) moderate/strong (active) strong (transition)

What is GPTAL and what does each term mean?

GPTAL is a comprehensive set of terms describing a woman's obstetrical status G= gravidity= number of times the woman has been pregnant P= number of preterm births T= number of term births A= number of abortions/miscarriages L= number of children currently living

What are prolonged accelerations?

Greater than or equal to 2 minutes, but < or equal to 10 minutes

What is GBS?

Group B streptococci 10-30% of pregnant women are colonized with it in the vagina or rectum Can be transmitted to fetus during delivery and cause invasive infection

What 3 phases make up the first stage of labor?

Latent phase (0-3 cm) Active phase (4-7 cm) Transition phase (8-10 cm)

Why is it important to perform a Leopold's maneuver before applying the fetal heart monitor?

Leopold's 2nd maneuver is used to locate the fetal back and the FHR ultrasound is placed on the woman's abdomen at the location of the fetus's back

Where should the nurse obtain a blood sample for glucose testing in a term neonate?

Medial or lateral aspect of the heel in order to decrease the risk of nerve damage

What drug(s) is used to treat GBS?

Penicillin- drug of choice Ampicillin- alternative

How is degree of effacement measured?

Percentage (0-100%)

What fetal heart rhythm would you see in abruptio placenta?

Prolonged decelerations

Describe the purpose of Leopold's maneuvers

Purpose: to inspect and palpate the maternal abdomen to determine the fetal position, station and size

What is the primary purpose of EFM?

Records fetal heart rate, uterine contractions, and is important for the interpretation and monitoring of fetal oxygenation

Dilation

The enlargement or opening of the cervical os

Why are neonates at increased risk for water intoxication and over-hydration?

The glomerular filtration rate is initially low in a neonate but doubles by 2 weeks of age. A decreased filtration rate means a decreased ability to excrete water, which puts the neonate at an increased risk for water intoxication and over-hydration

Prolonged deceleration

Visually apparent, abrupt decrease in FHR below baseline that is greater than or equal to 15 bpm, lasting greater than or equal to 2 minutes but less than 10 minutes

Are murmurs upon auscultation of a neonate normal?

Yes, murmurs may be heard but most are not pathological and disappear by 6 months

The nurse assesses a primiparous client with ruptured membranes in labor for 20 hours. The nurse identified late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which interventions should the nurse perform? Select all that apply. a. Administering oxygen via mask to the client b. Questioning the client about the effectiveness of pain relief c. Placing the client on her side d. Readjusting the monitor to a more comfortable position e. Applying an internal fetal monitor

a. Administering oxygen via mask to the client c. Placing the client on her side e. Applying an internal fetal monitor

A multigravida in active labor is 7cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse to next? a. Perform a vaginal examination b. Notify the healthcare provider of the decelerations. c. Reposition the client and continue to evaluate fetal heart rate. d. Administer oxygen via mask at 2L/min.

a. Perform a vaginal examination

A laboring client smiles pleasantly at the nurse when asked simple questions. The client only speaks Mandarin, and the interpreter is busy with an emergency. At her last vaginal examination, the client was 5cm dilated, 100% effaced, and at 0 station. While working with this client, which response indicated that the client might be approaching birth? a. The fetal monitor strip shows late decelerations. b. The client begins to speak to her family in her native language. c. The fetal monitor strips shows early decelerations. d. The client's face becomes animated.

c. The fetal monitor strips shows early decelerations.

A 30-year-old G3, T2, P0, A0, L2 is monitored internally and she is being induced with IV oxytocin because she is post-term. The nurse noted the pattern below. The client is wedged to her side while lying in bed and is approximately 6 cm dilated and 100% effaced. The nurse should first: a. Continue to observe the fetal monitor b. Anticipate rupture of the membranes c. Prepare for fetal oximetry d. Discontinue the oxytocin infusion

d. Discontinue the oxytocin infusion