UWorld - Maternal/Newborn

The pediatric nurse is performing an assessment on a 4-week-old client in the clinic. During the assessment, the newborn's mother starts to cry and states, "I am the worst mother in the world." What should the nurse ask next?

"have you felt depressed or hopeless over the last 2 weeks? //// Postpartum depression (PPD) is a perinatal mood disorder that affects women following childbirth. Symptoms may include crying, irritability, difficulty sleeping (or sleeping more than usual), anxiety, and feelings of guilt. Symptoms typically arise within 4 weeks of delivery and can affect the mother's ability to care for herself and the newborn. The nurse should ask specific questions about depression or hopelessness to assess for PPD (Option 4). It is also important to ask about thoughts of self-harm or harm to the newborn.

Pregnancy is a hypercoagulable state that provides protection from hemorrhage after birth, but also greatly augments risk of thrombus formation. Women who give birth by cesarean section are at particularly increased risk for deep venous thrombosis (DVT). Additional risk factors for DVT include obesity, smoking, and genetic predisposition. If unrecognized, DVT may progress to pulmonary embolism (PE), often characterized by anxiety/restlessness, pleuritic chest pain/tightness, shortness of breath, tachycardia, hypoxemia, and hemoptysis. The nurse's priority is rapidly identifying symptoms, assessing respiratory status, administering supplemental oxygen, and notifying the health care provider (HCP)

DVT --> PE

Floppy muscle tone is typical for

Down's syndrome, a genetic disorder.

Early decelerations mirror contractions with an apparent, gradual decrease in FHR (ie, ≥30 seconds from onset to nadir). Early decelerations indicate fetal head compression and are a normal finding

Early decelerations

Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity. The majority of ectopic pregnancies occur in the fallopian tubes. Risk factors include recurrent sexually transmitted infections, tubal damage or scarring, intrauterine devices, and previous tubal surgeries (eg, tubal ligation for sterilization). Clinical manifestations are lower-quadrant abdominal pain on one side, mild to moderate vaginal bleeding, and missed or delayed menses. Signs of subsequent hypovolemic (hemorrhagic) shock from ruptured ectopic pregnancy include dizziness, hypotension, and tachycardia. Free intraperitoneal blood pooling under the diaphragm can cause referred shoulder pain. Peritoneal signs (eg, tenderness, rigidity, low-grade fever) may develop subsequen

Ectopic pregnancy

Epstein pearls are small, white cysts found on the hard palate of newborns. These cysts are considered common findings, and they disappear a few weeks after birth.

Epstein pearls

Erythema toxicum neonatarum is characterized by firm, white or yellow papules or pustules surrounded by erythema. This idiopathic rash, which closely resembles flea bites, appears in the first few days after birth and resolves within 5-7 days. There are no additional systemic effects, and the rash requires no treatment.

Erythema toxicum neonatarum

Fetal tachycardia (ie, FHR baseline >160 beats/min) may be caused by fetal anemia, maternal fever, or infection but is not more concerning than a sinusoidal pattern, particularly in this case because FHR accelerations and moderate variability are present.

Fetal tachycardia

The GTPAL system notational components are G - gravida (number of pregnancies, regardless of outcome and including current pregnancies), T - term (37 wk 0 d gestation and beyond), P - preterm (20 wk 0 d through 36 wk 6 d gestation), A - abortions (before 20 wk 0 d gestation; spontaneous or induced), L - currently living children.

GTPAL system

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)?

H&H levels //// Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia.

Hirschsprung disease occurs when a child is born with some sections of the distal large intestine missing nerve cells; this renders the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. Newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They will also have difficulty feeding and often vomit green bile. (Option 1) An infant with Hirschsprung disease will not have passed meconium. Bright red bleeding from the rectum would not occur. However, rectal bleeding could be a symptom of Meckel's diverticulum, a remnant of the umbilical cord that should have disintegrated at 8 weeks in utero but became an out pouch in the small intestine.

Hirschsprung disease

Hyperemesis gravidarum (HG) is severe, persistent nausea and vomiting during pregnancy. Excessive loss of gastric contents leads to fluid and electrolyte imbalances (eg, hypokalemia, hyponatremia), metabolic alkalosis, nutritional deficiencies, ketonuria, and weight loss (Option 4). The nurse would expect signs and symptoms of dehydration (eg, dry mucous membranes, poor skin turgor, decreased urine output, tachycardia, hypotension) (Option 5). Urine is concentrated with dehydration, indicated by increased specific gravity (>1.030). Ketonuria indicates that the body is breaking down fat to use for energy due to the client's starvation state

Hyperemesis gravidarum (HG)

Ineffective breastfeeding can be attributed to many factors, including prematurity; breast anomaly or previous breast surgery; poor infant latch or sucking reflex; or the use of formula feeding. The use of supplemental formula feedings and artificial nipples should be avoided, as research demonstrates it interferes with the mother's ability to exclusively breastfeed (Option 3). Supplemental formula feeds are only provided for medical indications (eg, newborn hypoglycemia, dehydration, excessive weight loss) and if alternate breastfeeding techniques are unsuccessful. A mother having difficulty with breastfeeding may be able to pump or hand express small amounts of colostrum that can be fed to the newborn by syringe, cup, or spoon. Hand expression may be preferable before the mature milk supply is established and is also useful when a breast pump is not available. If ineffective breastfeeding occurs, the nurse should: Assess the baby's sucking reflex and physical condition Assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding) (Option 1) Teach how to express milk by hand and use an electric pump to enhance milk production (Options 2 and 4) Refer to a lactation consultant for a thorough assessment and breastfeeding plan if ineffective breastfeeding occurs longer than 24 hours

Ineffective breastfeeding

Late decelerations occur after the onset of a uterine contraction and continue beyond its end. They are caused by uteroplacental insufficiency. The lowest point of a late deceleration occurs near the end of the uterine contraction and may occur with marked hypertonia or increased uterine tone caused by oxytocin. Immediate steps must be taken to correct this deceleration. The client should be given oxygen by facemask, repositioned to the right or left side, oxytocin stopped if being administered, and an IV fluid bolus provided. The nurse will need to prepare for delivery if the deceleration pattern persists or variability becomes abnorma

Late decelerations

Leopold maneuvers help determine fetal presentation and involve systematic palpation of the client's abdomen. These maneuvers assist the nurse in locating the fetal back for optimal placement of the ultrasound transducer for external fetal heart monitoring.

Leopold maneuvers

Primitive newborn reflexes help determine the client's neurological status and development. The Moro reflex (ie, startle reflex), present until age 3-6 months, is elicited by quickly lowering the infant's head relative to the body, simulating a falling sensation. It is also a response to sudden loud noises and jarring of the crib. Initially, the newborn extends and raises the arms with fingers fanned out and then curls into the fetal position. Absence of the Moro reflex may indicate an underdeveloped or damaged brain or spinal cord and should be reported to the health care provide

Moro reflex (ie, startle reflex)

Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in the third trimester due to risk of premature closure of the fetal ductus arteriosus. NSAIDs should be taken only under the direction and supervision of a health care provider during the first and second trimester

NSAIDs in pregnancy ////// Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, indomethacin, naproxen) inhibit prostaglandin synthesis and can be taken to decrease pain and inflammation or to reduce fever. NSAIDs are pregnancy category C in the first and second trimesters and pregnancy category D in the third trimester. NSAIDs must be avoided during the third trimester due to the risk of causing premature closure of the ductus arteriosus in the fetus (Option 4). During the first and second trimesters, NSAIDs should be taken only if benefits outweigh risks and under the supervision of a health care provider (HCP)

Normal laboratory values during third trimester Hemoglobin >11 g/dL (110 g/L) Hematocrit >33% (0.33) Red blood cells 5.00-6.25 x 106/mm3 (5.00-6.25 x 1012/L) White blood cells 5,000-15,000/mm3 (5.0-15.0 x 109/L) Platelets 150,000-400,000/mm3 (150-400 x 109/L

Normal laboratory values during third trimester Pregnant women experience a 40%-45% increase in total blood volume during pregnancy to meet the increased oxygen demand and nutritional needs of the growing fetus and maternal tissues. Because the increase in plasma volume is greater than the increase in red blood cells, a hemodiluted state called physiologic anemia of pregnancy occurs, and is reflected in lower hemoglobin and hematocrit values. It is also normal for the white blood cell count to increase during pregnancy; counts can be as high as 15,000/mm3 (15.0 x 109/L).

Nursing interventions for a newborn immediately after delivery include: Standard precautions - The unbathed newborn is covered in maternal blood and bodily fluid. Standard precautions (eg, gloves) are implemented when contact with blood or bodily fluid is anticipated. Maintain a clear airway - Suction the pharynx first followed by the nasal passages to prevent aspiration if the newborn gasps with nasal suctioning. Thermoregulation (97.5-99 F [36.4-37.2 C]) reduces oxygen and stored calorie consumption. Hypothermia predisposes the newborn to metabolic acidosis, hypoxia, and shock. A radiant warmer is used while performing assessments and interventions. Use pre-warmed linens, an infant stocking cap, and a thermal skin sensor for monitoring. Skin-to-skin contact aids in thermoregulation. Vitamin K is administered intramuscularly in the vastus lateralis (midanterior lateral thigh) within 6 hours of birth to prevent bleeding due to absence of vitamin K-producing intestinal bacteria. Ophthalmic ointment - Prophylactic antibiotic eye ointment for Neisseria gonorrhoeae is legally required; application may be delayed up to 1 hour after delivery. Initial bathing of the newborn is limited to removing blood, bodily fluids, or meconium. Vernix caseosa, a waxy, white coating, protects the skin and should not be vigorously removed

Nursing interventions for a newborn immediately after delivery include:

Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle. It is commonly administered to induce or augment labor and to prevent postpartum hemorrhage. Oxytocin, a high-alert medication, is administered cautiously to avoid potential adverse effects, including: Category II or III fetal heart rate (FHR) patterns (eg, late decelerations, bradycardia). Abnormal or indeterminate FHR patterns are very common when using oxytocin and may occur because of reduced blood flow to the fetus during contractions Emergency cesarean birth, which may be required due to persistent abnormal FHR pattern Postpartum hemorrhage - Uterine atony and uterine fatigue may occur if the client experiences prolonged exposure to exogenous oxytocin Water intoxication - Oxytocin has an antidiuretic effect when administered at high doses over prolonged periods. Uterine tachysystole (ie, >5 contractions in 10 minutes) Endogenous oxytocin is excreted by the pituitary gland and triggers the milk ejection/let-down reflex. Administration of exogenous oxytocin (ie, synthetic oxytocin) has no known effect on milk production. Uterine stimulation from oxytocin increases the risk of placental abruption and uterine rupture

Oxytocin (Pitocin)

Perinatal transmission of HIV infection can occur from mother to baby anytime during the antepartum, intrapartum, or postpartum periods. Maternal antiretroviral therapy (ART) during pregnancy is imperative for decreasing viral load (amount of virus detectable in maternal serum) and decreasing risk of transmission to the fetus. (Option 1) HIV can be transmitted to the newborn via breast milk. Breastfeeding is contraindicated for HIV-positive mothers in developed countries, where safe alternatives (eg, commercial formula) are available. (Option 2) In addition to routine newborn care, infants born to HIV-positive clients should receive ART at birth and for at least 4-6 weeks after birth to reduce the chance of developing HIV infection. Infants are tested for HIV infection at birth and again at age 1 and 4 months. Identification of HIV-negative status requires 2 consecutive negative results at age ≥1 month and ≥4 months. (Option 4) Pregnant clients who are HIV positive are immunocompromised and at increased risk for other infections. They should receive all inactivated vaccines that are recommended for the general pregnant population, such as tetanus-diphtheria-pertussis and intramuscular influenza. Live vaccines (eg, measles-mumps-rubella) are not given during pregnancy

Perinatal transmission of HIV infection

Placenta accreta is a condition of abnormal placental adherence in which the placenta implants directly in the myometrium rather than the endometrium. Prenatal ultrasound usually detects placenta accreta, although detection can rarely occur after birth when the placenta is adherent (ie, retained placenta). A cesarean birth before term gestation at a facility with adequate resources (eg, blood products, intensive care unit) is recommended for clients with placenta accreta. The major complication of placenta accreta is life-threatening hemorrhage, which occurs during attempted placental separation. At least two large-bore IVs (eg, 18-gauge) and a blood type and crossmatch are priority concerns in case blood transfusions are necessary (Option 4). (Option 1) Previous cesarean birth is a risk factor for placenta accreta. Knowing the client's medical/surgical history is important but is not prioritized over the client's readiness for a blood transfusion. (Option 2) A hysterectomy during cesarean birth with the placenta left in place may be required to reduce blood loss. The client should understand the implications of the procedure (ie, no future childbearing), but this is not a priority over ensuring readiness for a potential blood transfusion. (Option 3) Metal and, occasionally, contact lenses should be removed prior to surgery to protect the client from injury, but this is not a priority over IV access and blood product availability

Placenta accreta

Postpartum vaginal bleeding that saturates a perineal pad in <1 hour is considered excessive. This client saturated a perineal pad in 20 minutes. Based on the nurse's assessment, the boggy fundus indicates uterine atony. The fundus is also elevated above the umbilicus and deviated to the right, indicating a distended bladder. Bladder distension prevents the uterus from contracting sufficiently to control bleeding at the previous placental site. The client should be assisted to void to correct the bladder distension (Option 1). The nurse should then perform fundal massage. Oxytocin is a uterotonic that increases contraction of the myometrium, constricting vessels at the previous placental implantation site. An oxytocin infusion should be initiated if initial attempts to control postpartum bleeding (relief of bladder distention and fundal massage) have failed. The usual postpartum oxytocin IV dosage is 125-200 milliunits/min

Post Partum Hemorrhage (PPH)

Postpartum urinary retention is commonly related to decreased bladder sensation (eg, due to regional anesthesia, prolonged labor, or perineal trauma) and postpartum diuresis. Urinary retention can cause bladder distension, which may be noted by a displaced and/or boggy uterus, or by a palpable bladder. If bladder distension cannot be resolved with spontaneous voiding, in-and-out (I&O) catheterization may be indicated, especially if the client: Is unable to ambulate to the restroom or void into a bedpan (Option 3) Has not voided within 6-8 hours after delivery or removal of the indwelling urinary catheter after cesarean delivery Has difficulty emptying bladder completely (ie, voiding <100 mL frequently) (Option 1) Postpartum clients are at risk for falls due to regional or general anesthesia, orthostatic hypotension, and changes in center of gravity. Risk of injury is increased in clients who ambulate before full sensory/motor function has returne

Postpartum urinary retention

After delivery of the placenta, the uterus begins the process of involution. The uterus should be firmly contracted, midline, and at or slightly below the umbilicus. A boggy uterus indicates uterine atony, a state in which the uterus fails to contract adequately and compress vessels at the placental detachment site. This may lead to excessive blood loss and clots. The initial nursing action for uterine atony with a midline fundus is fundal massage, which stimulates contraction of the uterine smooth muscle (Option 4). If the uterus becomes firm with massage, the nurse should continue to monitor uterine tone, position, and lochia at least every 15 minutes in the initial hour after birth. (Option 1) The nurse should monitor lochia frequently in the immediate postpartum period, especially underneath the client where blood can pool and go undetected. However, fundal massage is most important because uncorrected uterine atony will eventually result in excessive blood loss. (Option 2) Uterotonics (eg, oxytocin, methylergonovine) stimulate the uterus to contract. If the uterus fails to contract despite massage, further administration of uterotonics is indicated. (Option 3) Monitoring blood pressure and pulse are important interventions for postpartum clients, especially those at risk for excessive blood loss. This intervention may be delayed until after fundal massage to reduce further blood loss

Postpartum uterine atony

The nurse is caring for a client with gestational diabetes mellitus during the second stage of labor. After birth of the head, the nurse notes retraction of the fetal head against the maternal perineum. Which action should the nurse anticipate?

Pressing downward on the symphysis pubis //// Shoulder dystocia is an obstetrical emergency in which the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse may initially observe the fetal head retracting back toward the maternal perineum after birth of the head (ie, turtle sign). The condition is frequently associated with macrosomia (fetal weight >8 lb 13 oz [4000 g]) secondary to gestational diabetes mellitus. However, the occurrence of shoulder dystocia is unpredictable and may be related to maternal factors, such as suboptimal pelvic shape, obesity, or short stature, rather than fetal size. The nurse's primary responsibilities during shoulder dystocia include performing the McRoberts maneuver (ie, sharp flexion of maternal thighs toward abdomen to widen space between pubic bone and sacrum) and applying suprapubic pressure (ie, downward pressure applied to maternal pubic bone to dislodge fetal shoulder) Fundal pressure is contraindicated, as it may wedge the fetal shoulder further into the symphysis pubis or cause uterine rupture.

Proper breastfeeding technique ensures adequate intake for the infant while promoting bonding and comfort for the mother. Breastfeeding should be on demand, whenever the infant displays behaviors of hunger (eg, crying, rooting reflex). Most newborns will feed at least 8-12 times a day. The infant should be fed approximately 15-20 minutes per breast, with both breasts offered at each feeding (Option 2). As growth occurs, the infant will become more proficient and total feeding time will decrease. Key principles of proper breastfeeding and latch technique include: The client should hold the infant "tummy to tummy," with the mouth positioned in front of the nipple. The head should be facing forward keeping the body in alignment (Option 3). Common breastfeeding positions include clutch hold, cradle, cross-cradle, and side-lying. The infant needs to grasp both the nipple and part of the areola to ensure proper latching (Option 4). If the infant grasps the nipple only, breastfeeding will be painful due to pinching. If the infant latches incorrectly or needs to be removed from the breast, the client should insert a finger to break the suction prior to moving the infant away (Option 1). If the infant is pulled off the breast incorrectly, nipple trauma may occur, leading to sore nipples and painful breastfeeding.

Proper breastfeeding technique

SIDS is the sudden unexplained death of an infant age <1 year. It is the leading cause of death among infants, with the highest occurrence at 2-4 months. Smoking cessation, breastfeeding, up-to-date vaccinations, and pacifier use are protective factors against SIDS. Pacifier use has been associated with an increased risk of otitis media and early cessation of breastfeeding; however, its use is also associated with a dramatic reduction in SIDS. Because the data is more beneficial for SIDS reduction, pacifiers can be used at naptime and bedtime for newborns once the breastfeeding technique has been well established (age 1 month).

SIDS

Albuterol, an inhaled beta agonist, has not been conclusively proven to be safe during pregnancy, but should be continued when medically indicated (eg, severe asthma) to prevent the risks of asthma in pregnancy (eg, preterm birth, growth restriction). Insulin is safe for use during pregnancy and is commonly used to treat pregestational or gestational diabetes. Levothyroxine (Synthroid) for treatment of hypothyroidism is safe but should be monitored carefully to ensure an appropriate dose due to physiological changes in pregnancy.

Safe Meds in Pregnancy

Seizures are a potential complication of worsening preeclampsia, also known as eclampsia. Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen should be available at the bedside. During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10 L/min by facemask. Magnesium sulfate is a central nervous system (CNS) depressant commonly prescribed to prevent seizures in clients with preeclampsia. Deep tendon reflexes should be assessed hourly during administration (3+ or 4+). Hyperreflexia or clonus may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be immediately available Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the number of caregivers entering/exiting the client's room

Seizures and Magnesium sulfate Absent or decreased deep tendon reflexes (DTRs) are the earliest sign of magnesium toxicity. DTRs, scored on a scale of 0 to 4+, should be frequently assessed during magnesium sulfate infusion; normal findings are 2+ (Option 1). If toxicity is not recognized early (eg, decreasing DTRs), clients can progress to respiratory depression (<12 breaths/min), followed by cardiac arrest (Option 4). Administration of calcium gluconate (antidote) is recommended in the event of cardiorespiratory compromise. A loading dose of 4-6 g of magnesium sulfate, followed by a maintenance dose of 1-2 g/hr, helps achieve therapeutic magnesium levels of 4-7 mEq/L (2.0-3.5 mmol/L). Magnesium toxicity may occur when magnesium levels are >7 mEq/L (3.5 mmol/L), which causes central nervous system depression and blocks neuromuscular transmission (respiratory paralysis --> cardiac arrest )

When assessing a preterm newborn for cold stress, a graduate nurse in the newborn nursery needs further teaching when stating the need to assess for which finding?

Shivering //// Neonates are unable to generate heat by shivering due to their lack of muscle tissue and immature nervous systems; they therefore produce heat by increasing their metabolic rates through nonshivering thermogenesis. Brown adipose tissue (BAT), developed during the third trimester, is metabolized for thermogenesis when available. Once BAT is depleted, nonshivering thermogenesis is less effective and the neonate may experience cold stress, possibly leading to death. Preterm neonates have fewer stores of BAT and are at higher risk for cold stress. Frequent temperature monitoring is the best method to assess if an infant is cold. In cold stress, metabolism increases to generate heat, causing a greater demand for oxygen and glucose and the release of norepinephrine. If adequate oxygenation is not maintained, hypoxia and acidemia occur. Hypoglycemia develops when available glucose is depleted, and repletion of glucose is impaired by gastrointestinal immotility and poor oral intake. Clinical manifestations of cold stress include: Neurological - altered mental status (irritability or lethargy) (Option 1) Cardiovascular - bradycardia Respiratory - tachypnea early, followed by apnea and hypoxia Gastrointestinal - high gastric residuals, emesis, hypoglycemia (Option 2) Musculoskeletal - hypotonia, weak suck and cry

Clients with preexisting health conditions (eg, asthma, hypertension, diabetes) may require changes to medication therapy if they become pregnant. Specifically, any teratogenic or unnecessary medications should be discontinued (before conception when possible). The nurse should refer a client taking contraindicated medications to a health care provider immediately. For example: Doxycycline, a tetracycline antibiotic, is avoided in pregnancy as it can impair bone mineralization and discolor permanent teeth in the fetus (Option 2). Isotretinoin (Accutane) has a black box warning for severe birth defects. Retinoids may not be prescribed to childbearing-aged women without a formal agreement to participate in iPLEDGE (a prescription tracking program) and a commitment to use two forms of contraception (Option 4). Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril (Prinivil) have a black box warning for use in pregnancy as they can affect fetal renal function and lung development or cause deat

Teratogenic Meds

Trisomy 18 (Edwards syndrome) is a life-threatening chromosomal abnormality that affects multiple organ systems. Many fetuses affected by this condition die in utero. Of the newborns that survive birth, half will die in the first week of life and most do not make it to the first birthday. Before withdrawal of ventilator support, it is appropriate for the nurse to request a collaborative meeting between the health care providers (HCPs) and the palliative care team to help the parents understand their child's condition as well as make decisions about interventions and the potential need for end-of-life care

Trisomy 18 (Edwards syndrome)

Umbilical cord prolapse may occur after rupture of membranes if the presenting fetal part is not firmly applied to the cervix. Cord compression caused by a prolapsed cord will produce abrupt fetal heart rate deceleration, fetal bradycardia, and disruption of fetal oxygen supply. The priority action is to inspect the vaginal area and perform a sterile vaginal examination to assess for a prolapsed cord (Option 2). If a prolapsed cord is visualized or palpated, the nurse should then manually elevate the presenting fetal part off the umbilical cord, leave the hand in place, and call for help. (Option 1) Although IV fluid bolus is part of intrauterine resuscitation, in the presence of prolonged deceleration after rupture of membranes, the first action is to rule out a prolapsed cord. (Option 3) The priority is to quickly identify a prolapsed cord and displace the presenting fetal part off the cord. Someone else should notify the health care provider while the nurse performs emergent interventions. (Option 4) A position change to the alternate side may help improve uteroplacental blood flow but will probably not displace the presenting part off a prolapsed cord. The knee-chest position is optimal but challenging with epidural anesthesia in place.

Umbilical cord prolapse

Variable decelerations are abrupt decreases in the FHR (ie, <30 seconds from onset to nadir) and at least 15 beats/min below baseline for ≥15 seconds to <2 minutes. Variables are usually correctable with maternal position change to relieve umbilical cord compression. If recurrent/prolonged, variable decelerations can impair fetal oxygenation over time.

Variable decelerations

Weight gain during pregnancy should be determined by prepregnancy BMI. Underweight clients need to gain more weight (1 lb [0.5 kg]/wk) during the second and third trimesters of pregnancy than do obese clients (0.5 lb [0.2 kg]/wk). However, weight gain in the first trimester should be 1.1-4.4 lb (0.5-2.0 kg) regardless of BMI.

Weight gain during pregnancy

A nurse is assessing a newborn with an infection due to Candida albicans. Which assessment data support this diagnosis?

White, adherent patches on the tongue and palate ///// Manifestations of oral candidiasis (thrush) include white patches on the oral mucosa, palate, and tongue. The patches are nonremovable and tend to bleed when touched. The affected infant may have difficulty sucking or feeding due to the associated pain. Thrush is generally linked to antibiotic therapy or poor caregiver hand hygiene. The infection is usually self-limiting, but treatment with a fungicide (eg, nystatin) may hasten recovery.

A pregnant client's repeated use of illicit drugs will cause dependence in the neonate. The abrupt withdrawal from the drug due to delivery can cause abstinence syndrome in the neonate. This is most commonly seen with opioid use, although other central nervous system depressant drug use (eg, benzodiazepines) can contribute. The newborn experiences opioid withdrawal typically within 24-48 hours after birth. Manifestations include: Autonomic nervous system symptoms - stuffy nose, sweating, frequent yawning and sneezing, tachycardia, and tachypnea. Treatment includes swaddling and keeping nasal passages clear (Option 5). Central nervous system symptoms - irritability, restlessness, high-pitched crying, abnormal sleep pattern, and hypertonicity/hyperactive primitive reflexes. Treatment includes medication and protecting the skin (Option 1). Gastrointestinal symptoms - poor feeding, vomiting, and diarrhea. These are treated with small, frequent feedings Treatment- opioids (methadone, morphine) Hypersensitivity can make feeding difficult; the newborn should be placed in a side-lying position while swaddled to minimize stimulation and promote nutritive sucking (Option 1). Between feedings, a pacifier may be used to soothe the infant and help establish an organized sucking pattern. Excessive movement places the newborn at high risk for skin excoriation; the infant should be tightly swaddled with arms flexed to minimize irritation and prevent damage to the skin. Hand mittens and barrier skin protection to the knees, elbows, and heels may also be used. The nurse should also organize tasks ("cluster care") to minimize stimulation The newborn should be placed on the right side after feeding to promote gastric emptying and reduce the risk of vomiting

abstinence syndrome

A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes "about 18 hours ago." The client's group B Streptococcus status is unknown. What intervention is a priority for this client?

administration of prophylactic antibiotics ///// Group B Streptococcus (GBS) may be present as part of normal vaginal flora in up to 30% of pregnant clients. Although colonization with GBS rarely poses harm to the client, it can be transmitted to the newborn during labor and birth, resulting in serious complications (eg, neonatal GBS sepsis, pneumonia). Pregnant clients are tested for GBS colonization at 35-37 weeks gestation and receive prophylactic antibiotics during labor if results are positive. If GBS status is unknown, antibiotics are typically indicated when membranes have been ruptured for ≥18 hours, maternal temperature is ≥100.4 F (38 C), or gestation is <37 weeks (Option 1). (Option 2) Part of the client's assessment includes evaluation of the uterine contraction pattern. However, the client and newborn are at risk for infection due to prolonged rupture of membranes and unknown GBS status, so antibiotic administration is the priority. (Option 3) A urine specimen is often collected to evaluate for proteinuria in clients with elevated blood pressure or to assess for urinary tract infection in symptomatic clients. Urine specimen collection is not the priority for this client. (Option 4) Vaginal examinations should be limited in the presence of ruptured membranes. Multiple vaginal examinations in such a client correlate with an increased risk for infection (eg, chorioamnionitis)

When a pregnant client arrives and birth is imminent, the nurse should focus on collecting a brief, focused history to elicit key information relevant to potential neonatal resuscitation. Essential areas of history-taking include: Multiple gestation: To prepare for the potential of multiple newborn resuscitations (Option 1) Meconium-stained amniotic fluid: To prepare for potential intubation and tracheal suctioning (Option 2) Narcotic/illicit drug use (especially within the last 4 hours): To anticipate respiratory depression (Option 3) Preterm labor/birth: To anticipate respiratory immaturity and neonatal ventilation

birth is imminent

A cervical cerclage is placed to prevent preterm delivery, usually in clients with histories of second trimester loss or premature birth. A heavy suture is placed transvaginally or transabdominally to keep the internal cervical os closed. Placement occurs at 12-14 weeks gestation for clients with a history of cervical insufficiency (ie, painless, premature cervical dilation and miscarriage or preterm delivery) or up to 23 weeks gestation if signs of cervical insufficiency (eg, short cervix) are noted. Discharge instructions include activity restriction and recognition of signs of preterm labor (eg, low back aches, contractions, pelvic pressure) and rupture of membranes (Option 2). (Option 1) Bed rest is usually recommended for a few days after the procedure. Long-term bed rest is individualized but uncommon and increases the risk for complications (eg, deep vein thrombosis). Pelvic rest (eg, avoiding sexual intercourse) is determined by the health care provider. (Option 3) Mild abdominal cramping following cerclage placement is common; however, regular contractions, pelvic pressure, and low back aches may indicate preterm labor. (Option 4) The cerclage remains in place until 36-37 weeks gestation. Early removal is indicated by rupture of membranes (to prevent infection) or preterm labor (to prevent damage to the cervix as it dilates).

cervical cerclage

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?

cessation of contractions and maternal tachycardia //// Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery. The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions (Option 1). Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized. (Option 2) Most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture

Meconium ileus is associated with which of the following disorders?

cystic fibrosis (genetic disorder)

A full-term newborn of a mother with gestational diabetes is slightly jittery with a blood glucose level of 45 mg/dL (2.2 mmol/L). What is the nurse's first action?

feed the newborn //// In women with poorly controlled diabetes mellitus during pregnancy, the fetus is subjected to high blood glucose levels. Fetal hyperglycemia leads to insulin hypersecretion by the fetus, which promotes abnormal growth and storage of excess calories as fat (macrosomia). After birth, the infant is no longer exposed to the mother's high blood glucose levels, but a transient hyperinsulinemic state will persist for several days, during which the infant is susceptible to developing hypoglycemia. The normal range for serum glucose in a newborn at day 1 is 40-60 mg/dL (2.2-3.3 mmol/L); however, no standard definition for newborn hypoglycemia currently exists. Treatment plans are based on clinical signs and overall status of the infant. The most common sign of low blood glucose is jitteriness or tremors. If the blood glucose is low, newborns should be fed immediately with formula or breast milk (Option 2). If the infant continues to exhibit signs of hypoglycemia and/or blood glucose levels are <40-45 mg/dL (2.2-2.5 mmol/L) after feeding, the pediatrician should be notified (Option 3). Further treatment, such as oral or IV glucose, may be required. (Option 1) A hypertrophied pancreas is very sensitive to blood glucose levels. Oral glucose administration would cause massive release of insulin and produce rebound hypoglycemia. Feeding the newborn with breast milk or formula would be sufficient in most situations.

The nurse and unlicensed assistive personnel (UAP) are performing rounds on their clients. The nurse notes that a 2-hour post vaginal delivery client has saturated the peripad with rubra drainage. What should the nurse do next?

immediately assess the fundus ///// Saturating a peripad in 1-2 hours could indicate hemorrhage, a life-threatening condition. The nurse should assess the client's fundus and, if it is boggy, massage it. The nurse should also assess the client's vital signs and should never leave the client alone.

A nurse is caring for a pregnant client at 27 weeks gestation after a motor vehicle collision with side airbag deployment. The client's blood type is O negative. Which laboratory test should the nurse anticipate?

indirect Coombs test ///// During pregnancy, the mother and fetus have separate blood supply mechanisms. However, disruption of this separation can occur at delivery or when trauma results in fetomaternal hemorrhage (eg, placental abruption after a motor vehicle collision). If an Rh-negative mother (eg, O negative blood type) is exposed to Rh-positive fetal blood (if the father is Rh positive), the pregnant client develops antibodies to the Rh antigen (ie, Rh sensitization), placing the current fetus and all future pregnancies at risk for serious complications (eg, hemolytic anemia). An indirect Coombs test is performed to screen for Rh sensitization any time hemorrhage secondary to placental abruption is suspected (eg, maternal trauma) Rh immune globulin (eg, RhoGAM) is administered to all Rh-negative pregnant clients at 28 weeks gestation and within 72 hours postpartum, as well as after any maternal trauma, to prevent the development of permanent Rh antibodies. RhoGAM is not effective once sensitization has occurred.

A pregnant client comes in for a routine first prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. Where would the nurse expect to palpate the uterine fundus in this client?

just above the symphysis pubis ///// The enlarging pregnant uterus should be just above the symphysis pubis at approximately 12 weeks gestation (Option 4). At 16 weeks gestation, the fundus is roughly halfway between the symphysis pubis and the umbilicus. It reaches the umbilicus at 20-22 weeks gestation and approaches the xiphoid process around 36 weeks gestation. At 38-40 weeks, the fetus engages into the maternal pelvis and the fundal height drops. After 20 weeks gestation, the fundal height, measured in centimeters from the symphysis pubis to the top of the fundus, correlates closely to the weeks of gestation Uterine growth is assessed by measuring fundal height using a measuring tape. After 20 weeks gestation, the fundal height measurement in centimeters should correlate closely with the number of weeks pregnant (eg, 24 cm = 24 weeks). The client should empty the bladder before having fundal height measured, as a full bladder can displace the uterus and affect measurement accuracy..

The nurse is caring for a baby born at 30 weeks gestation and diagnosed with necrotizing enterocolitis. Which nursing action should be implemented?

measure abdominal girth daily //// Necrotizing enterocolitis occurs predominantly in preterm infants secondary to gastrointestinal and immunologic immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall. Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling. Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. Parenteral hydration and nutrition and IV antibiotics are given. (Option 1) Skin-to-skin care (kangaroo care) promotes bonding with a healthy newborn. It is allowed in some instances for premature infants depending on the condition and week of gestation. Skin-to-skin care should be avoided in infants who are not stable as it may cause additional stress. (Option 3) Taking a client's temperature every 3-4 hours is important; however, rectal temperatures should be avoided due to the risk of perforation of the gangrenous, friable colon. (Option 4) To avoid pressure on the abdomen and facilitate observation for a distended abdomen, clients are placed supine and undiapered.

Gastroesophageal reflux (GER) is attributed to an immature lower esophageal sphincter. It is common in infants age ≤3 months and results in spitting up after feeds. If an infant is gaining weight and meeting developmental milestones, treatment is aimed at controlling the symptoms. Because infants with GER are at risk for aspiration and apnea, caregivers should be instructed in cardiopulmonary resuscitation. Burping the baby frequently helps expel trapped air before milk builds up over it. If there is milk over an air pocket, the milk will come up with the burp. burp during and after meals. Holding the baby upright for 20-30 minutes after feedings allows gravity to assist in keeping the food in the stomach while the stomach settles (Option 4). Feeding the baby smaller but more frequent feeds prevents the stomach from becoming too full and expelling extra milk and allows for more complete emptying before the next feed. It also ensures that the child is getting the required ounces daily (Option 5). (Options 2, 3, and 6) These infants should not be rocked or agitated by active play for at least 30 minutes after feeding and should be kept calm and upright. Placing them on the stomach creates abdominal pressure, which can aggravate the reflux. Infants should not be placed in a car seat after feedings as this can increase intra-abdominal pressure and cause reflux

newborn Gastroesophageal reflux (GER)

During pregnancy, the fetus stores large quantities of glycogen that are used during the transition to extrauterine life. As a result, glucose levels are decreased 1 hour after birth, then rise and stabilize within 2-3 hours. Optimal glucose levels are 70-100 mg/dL (3.9-5.6 mmol/L), but ≥40 mg/dl (2.2 mmol/L) is considered normal (Option 1). A hypoglycemic neonate (<40 mg/dl [2.2 mmol/L]) should be fed immediately. Infants of diabetic mothers are at increased risk for hypoglycemia due to excess intrauterine insulin produced in response to high maternal glucose levels

newborn glucose levels

Newborns normally have respirations of 30-60/min, with periodic pauses lasting <20 seconds. Common characteristics of normal newborn respiratory patterns may include shallow, irregular, or abdominal respirations. Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress. Respiratory distress may be related to retained amniotic fluid in the lungs (more common following cesarean birth), meconium aspiration, or infection. The newborn should be placed on continuous monitoring and may require respiratory support (eg, oxygen, continuous positive airway pressure) until the underlying cause is corrected and respiratory status stabilizes. The apical heart rate should be counted for a full minute and is normally 100-180/min. Stimulated states (eg, crying, activity) may cause increased heart rate, respirations, and blood pressure. The nurse should reassess vital signs when the newborn is calm.

newborn respiratory distress

A nitrazine pH test strip inserted into the vagina can differentiate between amniotic fluid, which is alkaline, and vaginal fluid, which is acidic. A blue-green, blue-gray, or deep blue color indicates a positive result and probable rupture of membranes. A yellow, olive-yellow, or olive green color indicates a negative result and suggests that membranes are intact.

nitrazine pH test strip

A client in active labor who received an epidural 20 minutes ago reports feeling nauseated and lightheaded. Which action should the nurse perform first?

obtain BP reading //// An epidural block (a form of regional anesthesia) can provide effective pain relief during labor; however, it also inhibits the sympathetic nervous system (SNS). SNS inhibition causes peripheral vasodilation, which may produce significant hypotension (ie, systolic blood pressure <100 mm Hg, ≥20% decrease from baseline). If a client exhibits hypotensive symptoms (eg, lightheadedness, nausea) while receiving epidural anesthesia, the nurse should first assess blood pressure to confirm the presence of hypotension before intervening (Option 3). If hypotension is present, initial nursing interventions include administering an IV fluid bolus to increase blood volume and positioning the client in the left lateral position to alleviate pressure on the vena cava. If hypotension persists after initial interventions or fetal distress occurs, further measures include administering IV vasopressors (eg, phenylephrine, ephedrine) and applying 8-10 L/min oxygen via face mask to increase blood flow and oxygen delivery to the fetus.

In placenta previa, the placenta is implanted over or very near the cervix. This causes placental blood vessels to be disrupted during cervical dilation and effacement, which may result in massive blood loss and maternal/fetal compromise. Because of the increased risk of hemorrhage if contractions result in cervical change, a cesarean birth is planned for after 36 weeks gestation and prior to the onset of labor (Option 4). A stable client with no active bleeding and reassuring fetal status may be discharged home and managed in an outpatient setting (Option 3). However, the client must be closely monitored and instructed to return to the hospital immediately if bleeding recurs. As pregnancy progresses, the placenta grows in size and can potentially migrate away from the cervical opening, resulting in complete resolution of the previa. Therefore, an additional ultrasound is usually performed around 36 weeks gestation to assess placental location (Option 1). (Options 2 and 5) Clients with placenta previa should be instructed to remain on pelvic rest. Vaginal examinations, douching, and vaginal intercourse are contraindicated due to the risk of disruption of the placental vessels and subsequent hemorrhage. Modified bed rest (ie, decreasing any physical activity that could cause contractions) is also recommended

placenta previa

The neonate should be placed on the back with the neck slightly extended. This is a neutral or "sniffing" position. A blanket or towel roll can be placed under the shoulders, elevating them 0.75-1.0 in (19-25.4 mm) off the mattress. This is particularly useful if the infant has a large occiput from molding or edema. The nurse must watch that the infant's head does not shift to an improper position during caregiving activities

proper head position of the neonate for rescue breathing

Within thirty seconds after birth, an unresponsive and limp newborn is placed on the warmer in the "sniffing" position (when towel is placed under shoulders to elevate airway). The nurse clears the airway, dries, and stimulates the newborn. At 1 minute of life, the newborn has shallow, gasping respirations with a heart rate of 62/min. What action should the nurse take?

provide positive pressure ventilation (PPV) /// Newborns are evaluated immediately after birth for adaptation to extrauterine life. Newborns requiring resuscitative measures should be cared for using structured, evidence-based interventions, such as the neonatal resuscitation program (NRP) algorithm. Each step of the NRP algorithm requires rapid assessment and decision-making at 30-second intervals. NRP dictates that positive pressure ventilation (PPV) be started when a newborn's heart rate is <100/min. Effective PPV will often result in a rising heart rate and return of spontaneous respirations

A sinusoidal fetal heart rate (FHR) pattern is characterized by repetitive, wave-like fluctuations with absent variability and no response to contractions; it is usually an ominous finding requiring immediate intervention (Option 4). A sinusoidal pattern (ie, a Category III FHR tracing) is suggestive of severe fetal anemia potentially due to fetomaternal hemorrhage (eg, abdominal trauma) or some fetal infections (eg, parvovirus B19). If a sinusoidal pattern is noted, especially after abdominal trauma (eg, fall, motor vehicle collision, injury), the nurse should notify the health care provider immediately, initiate intrauterine resuscitation (eg, positioning, IV fluids, oxygen), and anticipate an expedited birth.

sinusoidal fetal heart rate (FHR)

A pregnant client at 39 weeks gestation is brought to the emergency department in stable condition following a motor vehicle collision. The client, who is secured supine on a backboard, suddenly becomes pale with a blood pressure of 88/50 mm Hg. Which action should the nurse take first?

tilt the backboard to one side ///// During stabilization of a pregnant client after trauma (eg, motor vehicle collision, fall), uterine displacement is the first step to address supine hypotension (due to aortocaval compression and decreased venous return to the heart) and promote blood circulation to the fetus. The client should be tilted laterally while strapped on the backboard to promote venous return and protect the client from further potential spinal injury (Option 4). Manifestations of aortocaval compression (eg, hypotension, pallor, dizziness) may mimic those of other complications of trauma. It is therefore critical to reassess blood pressure after uterine displacement to identify persistent hypotension, which may indicate hemorrhage caused by trauma (eg, placental abruption). An IV fluid bolus of isotonic fluids (eg, lactated Ringer solution) to correct hypotension is appropriate if position changes do not relieve symptoms or hemorrhage is suspected. Client positioning should be considered first. The nurse should first reposition the client to address a potential cause of hypotension (aortocaval compression), which can affect blood flow to the fetus, and then initiate fetal monitoring

Vesicular skin lesions (including on the lips) could be from an infection caused by varicella-zoster virus (chickenpox) or Staphylococcus aureus (impetigo). These lesions are not associated with a fungal infection.

varicella-zoster virus (chickenpox)