7400 exam 2
after repositioning the pt multiple times and based on additional info, for which intervention would the nurse anticipate preparing the pt? Assessment data: term laboring pt 4 cm dilated, 75% effaced, 0 station ruptured membranes with clear fluid recurrent episodic variable decelerations FHR baseline 138 bpm and minimal variability
amnioinfusion rationale: an amnioinfusion or infusion of sterile isotonic solution into the uterus can be used to increase fluid around the fetus and cushion the cord in an attempt to resolve variable decelerations. there is no indication that the pt requires a c-section. vibroacoustic stimulation would not resolve the issue. fetal scalp blood sampling is invasive and unnecessary.
which intervention would the nurse anticipate for a fetal heart tracing with unresolved absent variability and recurrent late decelerations?
analysis of umbilical cord gases
the nurse is reviewing comfort measures for a pt who vaginally delivered 6 hours prior and has a second-degree perineal laceration and small hemorrhoid. which info will the nurse include in the teaching?
apply an astringent pad after the use of the perineal cleansing bottle
a pt 3 months postpartum tells the nurse that she is experiencing pain during intercourse. which initial question will the nurse ask the pt?
are you breastfeeding? rationale: b/c ovarian function and thus estrogen production, is not well established during lactation, breastfeeding mothers are likely to experience vaginal dryness and may experience dyspareunia.
based on review of the EHR, which intervention would the nurse include in the plan of care? History: gravida 1, para 0 35 6/7 weeks gestation presents with ruptured membranes, moderate amount of clear fluid noted, no uterine contractions speculum exam reveals a cervix that is thick and closed assessment: amniotic fluid eval: lecithin/sphingomyeline (l/S) ratio 2:1 FHR: baseline 148, moderate variability, nonperiodic accelerations, variable decelerations temp: 97.5F pulse: 74 BP: 112/56 RR: 18
cervical ripening rationale: an L/S ratio of 2:1 indicates that the fetus' lungs are mature. B/c the pt's cervix is not favorable and no infection is present, she is a candidate for cervical ripening.
which statement reflects the nurse's understanding of the maternal-infant effect of preterm premature rupture of membranes (PPROM) at 33 weeks gestation?
chorioamnionitis can occur after ROM chorioamnionitis is a risk factor during the peripartum period a pt whose membranes seal over has a decresed risk for chorioamnionitis
which count method describes obtaining a FHR baseline during intermittent auscultation?
from the beginning of the contraction to the end
which info would the nurse plan to discuss when providing discharge teaching for a pt who is at 33 weeks gestation with ruptured membranes?
handwashing oral antibiotics avoiding breast stimulation
which info would be provided to a pt when monitoring for early postpartum hemorrhage?
hemorrhage typically occurs 1 hour after birth
which statement made by the nurse demonstrates the promotion of paternal adaptation?
how do you feel about becoming a father? let me show you how to pick up the baby safely you are doing an excellent job changing diapers you can participate in the infant feeding by burping the baby i will be showing you and your wife how to give the baby a bath
the nurse is caring for a pt 1 day post c-section. which statement made by the pt demonstrates the taking hold phase?
how will i know my baby is done feeding? rationale: during the taking hold phase, the mother begins to shift her attention to the behaviors of the infant. during the taking in phase, the mother is more focused on her own needs, such as food and sleep. while in the letting-go phase, the mother undergoes a period of relinquishment. this includes giving up idealized expectation of childbirth
the rn is assessing a pregnant pt's vital signs and FHR every 2 hours as her membranes are ruptured. which info would these assessments provide the nurse?
identification of intrauterine infection
which intervention would be the nurse's initial focus when a non-reassuring FHR pattern develops?
improving fetal oxygenation identifying the cause of the problem
during a cervical exam of a laboring pt at 37 weeks of gestation, the FHR tracing denotes minimal variability with an increase from a baseline of 148 to 164 bpm for 10 seconds during a cervical exam,followed by a return to baseline. based on this observation, which appraisal would the nurse take?
indeterminate finding rationale: a tracing with minimal variability and a 10 second acceleration for a fetus at more than 32 weeks gestation is indeterminate. a reassuring sign is an acceleration for a fetus at more than 32 weeks gestation for at least 15 bpm above the baseline for 15 seconds. periodic patterns are temporary, recurrent changes from the baseline FHR that are associated with uterine contractions; this includes accelerations and decelerations. FHR variability is associated with functioning of the ANS
a pt 72 hours after a c-section has a vertical skin incision with staples intact. which action would the nurse take in regard to the incision before discharge?
inform the pt that the staples will be removed at a later date
which intervention would the nurse recommend for the pt based on a review of the EHR? History: gravida 1, para 0 40 weeks gestation 4cm dilated, 100% effaced, -1 station occiput anterior fetal position assessment data: uterine contractions every 3-3.5 mins, 60 to 90 seconds in duration, moderate to palpation category 1 FHR tracing
instructing the pt to move her hips back and forth while sitting on a birthing ball rationale: the fetus is in a normal presentation but requires the facilitation of descent. sitting on a birthing ball not only provides many of the benefits of squatting but also promotes fetal descent by straightening the pelvic curve and enlarging the pelvic outlet
which incident would require surgery for early postpartum hemorrhage resulting from trauma to the birth canal?
large hematoma lacerations vaginal tear cervical tear
the nurse is assessing apt in labor. the nurse documents the progress in the effacement of the cervix and little increase in descent. in which phase of labor is the pt?
latent phase rationale: the pt is in the latent phase of the first stage of labor. in this phase, there is more progress in effacement of the cervix and little increase in the descent of the fetus. in the active and transition phases, there is more rapid dilation of the cervix and increased rate of descent of the presenting part of the fetus. the descent phase, or active pushing phase, occurs in the second stage of labor. in this phase, the pt has a strong urge to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor.
the nurse is preparing to provide teaching to a pt who is 2 days postpartum. for the learning to be most effective, which statement will the nurse offer the pt?
let me know when you and your partner are ready to review some infant care
which nursing discharge instruction would be appropriate for a pt who had a postpartum hemorrhage?
limit your physical activity alternate activity and rest periods increase dietary iron and protein
which factor can affect the printing of the intensity of a uterine contraction printed on a fetal monitor strip? SATA
maternal position fetal gestational age amount of amniotic fluid rationale: different maternal positions can either increase or decrease the pressure against the transducer. fetal gestational age and amount of amniotic fluid can affect the intensity of a uterine contraction printed on a strip. an immature fetus floats in a relatively larger quantity of amniotic fluid, and a pt with polyhydramnios has a larger volume of amniotic fluid. both of these factors prevent the uterus from pushing firmly against the abdominal wall with each contraction, making the contractions appear less tense of the tracing. fetal activity and position are not correlated with altering the recording of the intensity of uterine contractions on a strip.
the nurse assessing a pt finds prominent rugae erythema and edema in the vaginal introitus. the pt reports having mild afterpains. what does the nurse interpret about the pt's clinical status from this assessment?
nulliparous
when reviewing the medical record of a pt 48 hours postdelivery, which cue would the postpartum nurse identify as predisposing the pt to develop DVT?
obesity smoking prolonged labor
a pt who delivered vaginally and who is 2 hours postpartum tells the nurse that she has developed a headache. the pt had prolonged labor and received spinal-epidural combined anesthesia. based on this info, which priority action will the nurse take?
obtain maternal vital signs
for a pt at 30 weeks gestation with ruptured membranes, which clinical assessment finding would the nurse anticipate for delivery by section?
oligohydramnios rationale: a fetus at 30 weeks gestation in a uterine environment with very little amniotic fluid is at risk for umbilical cord compression, reduced lung volume, and fetal deformities. therefore, after the pt has received adequate corticosteroid and antibiotic tx, the rn would anticipate the infant be delivered by c-section
the nurse notes that a pt 8 hours postvaginal delivery has voided 3 times, for a total of 165ml, since 150 ml void 1 hour after delivery. the fundal height is u/u, firm, midline, with heavy lochia. which action will the nurse take?
palpate the bladder
when admitting a laboring pt the unit, which assessment technique would the nurse choose to obtain an accurate evaluation of the contractions?
palpating the fundus with the fingertips rationale: the nurse would palpate the fundus with the fingertips to obtain an accurate assessment of the frequency, duration, and strength of contractions. evaluating a a tracing with recorded contractions would not provide info regarding the strength of the contractions unless an internal pressure monitor is used. placing a hand over the abdomen or placing the palms of both hands on the sides of the uterus are not techniques used to obtain accurate data. contractions are best felt in the fundal area using the fingertips because they are the most sensitive part of the hand
a laboring pt who has been ambulating states to the nurse, "my contractions have gotten stronger, i am not getting any break between them, and i think my water just broke." which initial assessment would the nurse perform? SATA
palpating uterine contractions auscultating the FHR rationale: the rn would auscultate the FHR and assess the uterine contractions to evaluate both fetal well-being and the pattern of contractions. there is not indications that the pt requires cervical exam. the nurse can assess the color of the fluid after evaluating the FHR in relation to the contractions. maternal vital signs would be assessed between contractions, which can be done after evaluation of the FHR and uterine contractions.
based on review of EHR for a newly admitted pt, which complication would be a concern? history: gravida 1, para 0 47 weeks gestation 1cm dilated, 25% effaced, 0 station spontaneous rupture of membranes/clear fluid category 1 FHR tracing occasional uterine contractions VS: FHR: 15 Temp: 98.7 RR:18 BP: 124/68 HR: 88 pain: 1/10 "cramping"
perinatal infection rationale: a primigravida with ruptured membranes in the absence of labor is at risk for perinatal infection. the fetal head is engaged; therefore, the risk for a prolapsed cord is decreased.
for which clinical situation would the nurse avoid fetal scalp stimulation?
placenta previa fetal tachycardia category 3 tracing maternal temperature of 100.4F fetus 34 weeks of gestation rationale: fetal scalp stimulation would be avoided in pts with a placenta previa b/c it may cause hemorrhage. the cause of fetal tachycardia warrants investigation. fetal scalp stimulation would not be helpful b/c the baseline variability can be decreased when tachycardia is present. a category 3 tracing requires intrauterine resuscitation efforts or delivery. scalp stimulation is contraindicated when a maternal fever is present b/c of the risk for introducing microorganisms into the uterus. scalp stimulation is contraindicated when a pregnancy is preterm as it may cause or intensify contractions, or it may rupture intact membranes
the nurse would tell a primigravida pt that which is the definitive sign indicating that labor has begun?
progressive uterine contractions with cervical change rationale: regular, progressive uterine contractions that increase in intensity and frequency are the definitive sign of true labor along with cervical change. lightening is a premonitory sign indicating that the onset of labor is getting closer. rupture of membranes usually occurs during labor itself. passage of the mucus plug is a premonitory sign indicating that the onset of labor is getting closer.
which change in the intensity of the uterine tone during the interval period of a contraction pattern occurs during labor?
relaxed rationale: the uterine muscle would be relaxed during the interval period of a uterine contraction. the interval period is also known as the resting tone. During this period, most fetal exchange of oxygen, nutrients, and waste products occurs.
after reviewing the EHR for a pt who states " I am exhausted and I want something for pain," which action would the nurse take?
repositioning the pt
which maternal assessment findign would the nurse correlate with a pt who is 10cm dilated; 100% effaced, at +2 station, and has been pushing with contractions for the past 45 minutes?
resting between contractions rationale: although the contractions are stronger during the second stage of labor, the pt may feel more in control because she is actively pushing. B/c the pt exerts intense effort to push the baby out, it is not unusual for the pt to become oblivious to her surroundings and appear to be sleeping between contractions. the pt generally feels increased anxiety during the transition period of the first stage of labor b/c the increased intensity of the contractions. perineal burning is a sensation that is associated when the fetus is crowning. the fetus is at a +2 station; therefore, it is not crowning. labored breathing between contractions most likely occurs when the pt is experiencing intense pain or during the transitional period if she becomes anxious, irritable, and helpless as the contractions intensify.
during the first 24 hours post c-section, which assessment will the nurse monitor hourly for a pt who received intrathecal morphine immediately afer delivery?
sedation level
the nurse is preparing to assess the perineum of a pt 2 hours postpartum with a second-degree labial laceration. which position will the nurse place the pt in to evaluate her perineum?
side lying dorsal recumbent
which assessment finding is associated with a possible causative factor of PPROM?
smoking history of preterm labor recent sexual intercourse active sexually transmitted infection
which prescribed treatment will the nurse include when discussing measures to reduce the discomfort of a pt with a fourth-degree perineal laceration?
stool softener oral analgesic application of ice topical anesthetic
which info regarding postpartum hemorrhage is accurate?
subinvolution is a common cause the initial treatment is to control bleeding hemorrhaging occurs 24 hours-12 weeks after birth advanced maternal age is considered a risk factor oxytocin is commonly used for management of bleeing
based on the info, which action would be appropriate for the nurse to take? assessment data: gravida 1, para 0 1500: 4 cm dilated, 75% effaced, +1 station, membranes intact 1630: spontaneous rupture of membranes/clear fluid, FHR 144 bpm
taking a temperature rationale: the nurse would take the patient's temperature and then every 2 hours thereafter
which info would the nurse include in the teaching of a pt who expresses concern that an IUPC will harm her baby?
the catheter will be placed beside the baby
what change has occurred in the cervix of a pt 10cm dilated and 100% effaced?
the cervix merges with the lower uterine segment rationale: the cervix merges with the lower uterine segment when it is 100% effaced; therefore, it will lose the characteristic of a distinct cylindrical structure. the cervix is not a muscle that pushes the fetus into the birth canal. the cervis is drawn up into the body of the lower uterine segment, allowing for the passage of the baby into the birth canal. the cervix does not create opposing contractions with the upper uterine segment.
which statement relates to fetal oxygenation during a uterine contraction?
the fetus relies on the oxygen reserve in the body rationale: during a uterine contraction, the fetus relies on the oxygen supply already present in the body cells, fetal erythrocytes, and intervillous space. the spiral arteries are temporarily compressed during a contraction; so the fetus does not receive blood from there. the fetus requires oxygen during a contraction and has enough oxygen supply in the body to last 1-2 mins. freshly oxygenated maternal blood reenters the intervillous space after the contraction relaxes/
what assessment does the nurse expect to find in a postpartum pt 12 hours after childbirth?
the fundus is approximately 1cm above the umbilicus
which info is accurate regarding bipolar II disorder?
the pt exhibits or expresses little need for sleep periods of irritability are often experienced by the pt the pt has poor judgment and experiences confusion
the charge nurse instructed a group of student nurses about the monitoring of uterine activity (UA) during labor. which statement by the student nurse is accurate regarding the calculation of montevideo units?
they can be calculated with an intrauterine pressure catheter (IUPC) rationale: montevideo units can only be calculated using internal monitoring of UA.
for which clinical finding would the nurse correlate with a potential disruption of the cicrulatory path between the placenta and fetus?
vasa previa rationale: a vasa previa increases the risk for disruption of the circulatory path between the placenta and fetus. the fetal blood vessels in the fetal membranes over or near the cervical opening are unprotected by the placenta and umbilical cord.
which assessment will the nurse include in the immediate postpartum period for a pt who has received buprenorphine during labor and delivery?
vital signs urinary output IV site
a newly admitted pt states "I do not want any pain meds at all during labor." in which way would the nurse respond based on the additional assessment data? Assessment data: gravida 1, para 0 3cm dilated, 80% effaced, 0 station pain with contractions 8/10
we can discuss several options to promote comfort rationale: nursing measures to empower families include teaching them about their choices in childbirth in an unbiased way and supporting the choices they make. the nurse would discuss options to promote comfort to support the pt's decision for nonpharmacologic pain management.
the postpartum nurse is preparing to administer warfarin 5mg/day by mouth to a pt with a thromboembolic disorder. the medication available is warfarin 2 mg per tablet. calculate how many tablets the nurse would administer.
2.5 tablets
after the initiation of a labor epidural, the nurse notes that the FHR baseline is 106 bpm. which maternal vital sign would the nurse initially assess?
Blood pressure rationale: epidural anesthesia causes arterial and venous dilation, which can result in maternal hypotension, resulting in fetal bradycardia
the nurse is preparing to admit a full-term laboring pt who has received regular prenatal care throughout her pregnancy. which testing would the nurse anticipate to be prescribed?
CBC blood type and Rh factor rationale: a cbc and blood type and Rh factor would be included in the admission process for a full-term laboring pt. the cbc allows for evaluation of platelets, hemoglobin, hematocrit, and WBCs, and the blood type and Rh factor would be obtained both for the mother and infant after delivery to determine if there is a risk for incompatibility. a pt who has received regular prenatal care would not generally require a drug screen, hepatitis panel, or testing for bacterial vaginosis. a hepatitis panel is routinely obtained at the initial prenatal visit, whereas testing specifically for hep b is performed with a pt is admitted for delivery. the decision to test for bacterial vaginosis is based on the presentation of symptoms.
which info would the nurse include in the teaching of a multiparous pt at 39 weeks of gestation who is being discharged howe after it is determined that she is not in labor?
Call your HCP if the baby does not move as frequently
Which physiologic change is associated with an increased risk for peripartum venous thrombosis?
Increased number of clotting factors Rationale: fibrinolysis decreases during labor to promote coagulation at the placental site, and the increase in clotting factors raises the mothers risk for venous thrombosis during and after pregnancy.
after notifying the HCP of the maternal temperature (99.2), which action would the nurse take?
Increasing Intravenous fluid
Which physiologic change would the nurse anticipate in the active phase of labor
Internal fetal rotation Rationale: transitional phase: maternal tremors, complete cervical dilation; second stage of labor: involuntary pushing response
based on the EHR, which action would be the nurses priority? category 3 FHR tracing
administer a tocolytic rationale:a category 3 tracing identifies a fetus that may be acidotic and requires immediate intrauterine resuscitation
which initial treatment is appropriate for a postpartum pt who is diagnosed with superficial venous thrombosis?
administering NSAIDs
after reviewing a pt's assessment after admission, which intervention would the nurse anticipate integrating into the plan of care? history: gravida 4, para 3 admitted with ROM cervical exam on admission-5cm dilated, 80% effaced, 0 station fetus right occiput anterior IUPC placed after 3 hours of no cervical change assessment: FHR tracing baseline 142, minimal variability uterine contractions every 2-5 mins, 45-70 seconds in duration, baseline resting tone 15 mmhg pain: 2/10 cramping BP: 128/72 HR: 72 RR:18 temp: 98.9
administering oxytocin rationale: the nurse would augment the pt's hypotonic labor pattern with oxytocin
a postpartum pt due for a fundal assessment tells the nurse that she is cramping, and her pain is at a 4/10. which action will the nurse take?
ask the pt when she last voided
which action would the nurse take based on review of the EHR? History: gravida 3, para 1 5 cm dilated, 100% effaced, 0 station dysfunctional labor pattern as a result of persistent left occiput posterior fetal position prescriptions: oxytocin currently running at 6mUnit/min with a prescription to titrate to an adequate labor pattern receiving continuous epidural anesthesia but continues to experience back pain
assisting the pt to the right lateral position rationale: the nurse would assist the pt to the right lateral position to facilitate internal fetal rotation
which initial assessment would the nurse perform on a laboring pt who is 5cm dilated, 80% effaced, at 1+ station, and thinks her water broke?
auscultating fetal heart rate tones rationale: b/c of the risk for cord prolapse or cord compression, the RN would assess the FHR for 1 minute after the membranes rupture. the color of the fluid, the estimated amount of amniotic fluid, and the maternal temperature can be evaluated after the FHR.
which statement would the nurse include in the teaching regarding elevated blood glucose for a pt who does not understand how her T1DM can interfere with blood flow to her unborn baby?
damages the vascular walls rationale: T1DM is associated with poor circulation. the elevated glucose damages the maternal vascular endothelial wall, which can restrict blood flow to the placenta,
which cue would be observed when evaluating a pt with signs of postpartum OCD?
depression avoiding the infant compulsive behavior obsessively checking on the infant fearfulness of being alone with the infant
which cue would the nurse observe before massaging the fundus?
excessive clots expelled fundus difficult to locate excessive bright red lochia
which problem describes the direct effect of a full bladder for a laboring pt?
failure of fetal descent
a laboring pt receiving continuous fetal monitoring tells the nurse she is concerned bc the sound of the FHR occasionally disappears. which info would the nurse include in response to the pt?
fetal movement can make it difficult to hear the HR
which FHR pattern is a contributing factor to fetal hypoxia?
fetal tachycardia prolonged fetal bradycardia
which immediate action would the nurse take when the fetal head retracts against the perineum during the second stage of labor?
flexing the thighs against the abdomen rationale: the rn would perform McRoberts maneuver to straighten the pelvic curve so the anterior fetal shoulder can slip under the symphysis pubis.
with regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware of what?
fluid loss through perspiration and increased urinary output account for a weight loss of more than 2kg during the puerperium
which fetal position would the nurse correlate with the possibility of a fetal anomaly?
frank breech transverse lie
which therapeutic management would the nurse anticipate when evaluating a pregnant pt exhibiting signs of peripartum depression?
medication social support group psychotherapy electroconvulsive therapy
which action would the nurse integrate into the plan of care when administering betamethasone to a pt at 31 weeks gestation in preterm labor>
monitoring the pt carefully for infection
during a breast assessment on a pt who is 1 day postpartum, the nurse notes that the pt;s areolas are reddened. which additional assessment is important for the nurse to obtain?
newborn latch
which statement by the pregnant pt may contribute to a slow progress in labor or a hypotonic labor pattern?
"I am worried a lot this time; I had a lot of problems in my last labor"
the nurse is caring a pt 1 day post c-section who is breastfeeding. which statement made by the pt correlates with increased risk for impaired adjustment to the maternal role?
"I will get the baby on a better feeding schedule before i am discharged from the hospital"
the nurse removes the external monitors from a laboring pt who is 5 cm dilated, 40% effaced, and -1 station to allow the pt to ambulate. when discussing the plan of care, which info would the nurse include in the teaching?
"if your water breaks, please let me know immediately" "i will be back in 30 mins to listen to your baby's heart rate" "when you are ready for your epidural, i will have to monitor the baby continuously" "your HCP has prescribed oxytocin to be started in a few hours, so i would like to monitor the baby for a while before"
which statement indicated a need for further instruction when the postpartum nurse is teaching a pt how to prevent thromboembolic disorders after a cesarean delivery?
"it's best not to walk too much"
a postpartum pt states, "I had no idea i would still look pregnant 2 days after delivery." which response will the nurse provide to address the pt's concern about her appearance?
"the uterus takes a few weeks to return to the prepregnant size"
the nurse is caring for a pt 2 days post c-section who is breastfeeding on demand. the pt states to the nurse, "I did not get much sleep last night, and i am so incredibly exhausted." which response would the nurse provide to the pt?
"would you like me to help limit your visitors"
a 3-day postpartum pt with a BMI of 24 expresses concern over losing the 33lb she gained during pregnancy. based on the evaluation of the pt's history, which response will the nurse provide the pt?
"you will have lost a significant amount of your pregnancy weight gain in 2 weeks"
the postpartum nurse is preparing to administer heparin 5000 units SQ to a pt with a thromboembolic disorder. the medication available is heparin 10,000 units/ml. calculate how many ml the nurse would administer.
0.5ml
which intervention would the nurse choose to facilitate the process of labor for a pt who is 6cm dilated and 100% effaced, at 1+ station, contracting every 4 mins, and has a pain rating of 6/10?
Assisting the pt in relaxing Rationale: maternal catecholamines are secreted in response to anxiety and fear and can inhibit uterine contractility and placental blood flow. However, relaxation augments the natural process of labor.
Which position would the nurse instruct the patient to assume during labor to promote fetal oxygenation?
Lateral
based on the pt's history, for which complication would the nurse anticipate monitoring? Assessment data: 39 weeks gestation gravida 9, para 6 1 spontaneous abortion 1 elective termination
Postpartum hemorrhage Rationale: the pt has a high parity. a parity of 5 or more is associated with a risk of postpartum hemorrhage. women who have had several spontaneous abortions or who have given birth to infants with abnormalities may have an increased risk for having an infant with a birth defect. the pt is not at risk for prolonged labor or placental abruption.
which statement describes a fetal protective mechanism that allows for tolerance of interrupted blood supply during a contraction? SATA
The fetal cardiac output is high the fetal hematocrit is elevated fetal hemoglobin more readily takes on oxygen carbon dioxide is easily released from the hemoglobin rationale: the placental circulation usually has a high enough reserve over the fetal base needs to tolerate the intermittent interruption of blood flow. an elevated FHR is not intended to be a protective mechanism that allows for the tolerance of interrupted blood supply during a contraction.
Which statement demonstrates the physiologic change that must occur in the uterus to preserve the cervical changes during labor?
The myometrial cells become longer with each contraction Muscle cells in the uterus remain shorter at the end of a contraction
which info about the amniotic fluid would the nurse include in a documented summary for a pt with ruptured amniotic membranes? SATA
Time odor color clarity amount
which pregnant woman is at risk for a hypotonic labor pattern?
a multiparous pt at 39 weeks of gestation who is expecting twins rationale: over-distention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction b/c the stretched uterine muscles contract poorly
the nurse is preparing to assess several postpartum pts in the clinic. which patient would concern thenurse?
a pt 5 days postpartum with lochia rubra rationale: should be lochia serosa by day 4 postpartum
a primigravida pt asks the nurse about signs she can look for that indicate that the onset of labor is getting closer. what would the nurse describe?
bloody show rationale: passage of the mucus plug (operculum) also termed pink/bloody show occurs as the cervix ripens. women usually experience a weight loss of 1-3 lbs. quickening is the perception of fetal movement by the mother, which occurs at 16-20 weeks of gestation. women usually experience a burst of energy or the nesting instinct.
which cue would the nurse expect in a postpartum pt diagnosed with panic disorder?
chest pain palpitations tachycardia shortness of breath fear of dying of "going crazy"
the primary HCP has asked the nurse to draw blood for an umbilical cord acid-base determination test. what would be the appropriate nursing action in this situation?
collecting blood from both the umbilical artery and vein
which device would the nurse use for monitoring the intensity of uterine contractions in a pregnant patient?
intrauterine pressure catheter (IUPC)
which factor would adversely affect fetal oxygenation?
placental abruption iron-deficiency anemia gestational hypertension umbilical cord compression
which factor is associated with precipitous labor and delivery?
preeclampsia maternal drug use placental abruption rationale: a multiple-gestation pregnancy is associated with preterm labor. maternal infection is associated with prolonged labor
the postpartum nurse is planning care for a pt 48 hours after delivery via c-section. assessment data reveal stable vital signs, hourly urination, and burning pain with urination. Which goal is the priority when caring for this pt?
pt will report decreased pain with urination
which result demonstrates the purpose of the use of an internal fetal monitor?
records a printing of the beat-to-beat electrical heart signals
when caring for a pt with dysfunctional labor, which clinical finding would the nurse associate with suspected shoulder dystocia?
retraction of the head toward the perineum
a pt who is 24 hours post-cesarean delivery is at risk for development of DVT. on entering the room, which observation would concern the postpartum nurse?
the pt is placing a pillow under the knees
which condition is a risk factor for puerperal infection?
trauma cesarean delivery catheterization prolonged labor excessive vaginal exams
which clinical finding would the nurse anticipate for a pt who is 5cm dilated, 90% effaced, at 0 station, and experiencing hypotonic labor dysfunction?
uncoordinated uterine contractions
which statement is accurate regarding a pt currently on LMWH at 36 weeks gestation?
unfractionated heparin (UH) would replace LMWH
which action would the postpartum nurse encourage when caring for a pt with an infected episiotomy?
using a sitz bath perform good handwashing performing frequent perineal care
the consumption of which nutrient would the postpartum nurse include when planning care for a pt with a puerperal infection?
vitamin c
