maternity: unit 1
Rh Alloimmunization
Mom RH- Father RH+ 1st baby is RH+ Mom develops antibodies to RH+ Antibody screen (indirect Coombs test)/administer Rhogam At 28 wks/PP
A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with "latch on" and recommends that the mother do which of the following?
rotate infant's position at each feeding
Goodell's sign
softening of the cervix
When receiving the 15th dose of an antibiotic IV, the child begins scratching at the IV site on the forearm and develops small, circumscribed, elevated areas on the same arm. Which of the following would the nurse do first?
stop the antibiotic infusion but continue the IV fluids
For the child who exhibits signs of discomfort and swelling in the region where an IV catheter is inserted, the nurse would suspect which of the following?
the catheter has come out of the vein
BMI calculation
weight (kg) / height (m^2) OR lbs/height (inches^2) * 703
Vaccinations during pregnancy
● No live vaccines (live flu, MMR, varicella) ○ No pregnancy for minimum 1 month, recommended 3 months ● Tdap every pregnancy (3rd trimester) ● can get flu vaccine during pregnancy
A woman, 40 weeks gestation, calls the labor unit to see whether or not she should go to hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital?
"the contractions are a minute long and i am unable to talk through them"
what to supplement iron w/
-vitamin C source to increase absorption (OJ or cranberry juice) -fiber rich foods (veggies, beans, oats, nuts) -laxatives if stools become hard or constipation occurs **iron may turn stools black
danger signs during pregnancy
-vaginal bleeding (w or w/o discomfort) -blurred vision, headache -rupture of membranes -severe abdominal pain -fever, persistent vomiting, painful urination
NST (non-stress test)
-15 beats lasting 15 sec; need 2 per 20min -needed for HTN/diabetic moms & those w/ twins -negative stress test=good; positive=C-section needed
what happens if the mom has excessive weight gain during pregnancy?
-HTN -diabetes -C-section -macrosomia (big head) -birth trauma -cephalopelvic disproportion
A physician writes the following order - administer ampicillin 1 Gm IV every 4 hours until delivery - for a newly admitted laboring client with ruptured membranes. The client had positive vaginal and rectal cultures for group B streptococcal bacteria at 36 weeks gestation. Which of the following is a rationale for this order?
-The baby is at high risk for neonatal sepsis -if (+), IV antibiotic q.4.h. delivered from the time membrane ruptures up until delivery
20 weeks gestation symptoms
-baby starts to move -20cm measurement from pubic bone to umbilicus
contraindicated meds during pregnancy
-cannot take accutance
epidural + side effects
-catheter threaded in the spinal cord to deliver pain medication -hypotension & bladder distention
What is the correct procedure to remove the catheter?
-completely deflate the balloon by inserting the syringe into the balloon valve and aspirating the fluid -ask pt. to take a few deep breaths as you slowly withdraw the catheter from the urethra -qrap the catheter in the drape and discard
preconceptional nutrition/supplementation
-daily multivitamin -1000mg/day iron (take w/ vitamin C source to increase absorption, such as OJ or cranberry juice) -vitamin d to aid in calcium absorption -400mcg folic acid -limit caffeine to <200mg/day -eliminate vitamin A supplementation
gestational diabetes
-develops between 24-28weeks -test via 1hr glucola; if abnormal, do 3h glucola -greater than 140
quad screening
-down syndrome test (trisomy 18) -done 16-18 weeks (2nd trimester) -if abnormal, diagnose w/ amniocentesis
What is the next nursing intervention that is done once the foley catheter is removed?
-explain the need to monitor first few voidings & signs of UTI + to notify you if experiencing them -place a receptable in the toilet and once the client voids monitor the output -signs=burning while urinating, polyuria, elevated WBC
amniotomy: what to assess when membrane ruptures?
-fetal HR -mother's temp (high temp=high fetal HR)
amniotic fluid
-fluid within the amniotic sac that surrounds and protects the fetus -composed of urine; fetus swallows urine
A woman who has just delivered has decided to bottlefed her full term baby. Which of the following should be included in the patient teaching?
-hold the bottle to keep the nipple filled with formula & reduce the ingestion of large amounts of air
physiologic changes r/t pregnancy
-increase in breast size (estrogen) & nipple size (progesterone) -decreased ph (acidic environment protects fetus from infection) -increased discharge (risk for yeast infections) -colostrum (yellow precursor of milk- contains large amounts of protein and antibodies) -shortness of breath (increased pressure on diaphragm) -slight decrease in BP -increase WBC, RBC, fibrinogen (clotting factor) -increase cardiac output by 30-50%
After you have inserted the foley catheter what is the next 2 steps?
-inflate the balloon of the catheter using 10ml syringe sterile water or the amount of balloon size written on the valve port. -then place leg strap to secure catheter
aminiocentesis
-inject needle to get amniotic fluid to check for disorders -done at 15-20 weeks -RH-=administer rhogam afterwards
28 weeks gestation symptoms
-kick counts; need at least 10 in 3h
mucous plug
-mass of mucous which occludes the cervix of the uterus during pregnancy -protects fetus from infection -discharged at the beginning of labor
MSAFP
-maternal alpha serum protein test -performed around 16-20wk (2nd trimester) -elevated levels=neural tube defect (NFT) (conduct ultrasound to diagnose)
fetal kick counts
-need 10 in 3h
Ballotment
-rebounding of the fetus against the examiner's finger on palpation -when the examiner taps the cervix, the fetus floats upward in the amniotic fluid.
what position to put pregnant patients in
-side lying position -never flat on their back; causes dizziness & dyspnea r/t pressure on diaphragm
What is the correct technique of insertion of foley catheter in a woman?
-slowly insert into the meatus -insert until urine flows 2-3in -after seeing urine, insert catheter another 1-2in
chorionic villus sampling (CVS)
-small sample of the fetal portion of the placenta removed to detect defects -done at 10-13weeks -contraindicated in women w/ vaginal infection -RH-=administer rhogam afterwards
Which of the following is the correct procedure regarding lubrication of the catheter?
-squeeze lube on kit tray & roll the first 1-2in of the catheter in it -leave in sterile field until ready for use
A 3 day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of the following must the nurse include in her discharge teaching regarding the vaccine?
-the woman should not be pregnant for 3 months b/c it is a live vaccine
The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure?
-the woman sprays her perineum from front to back w/ warm water after toileting or changing peripads
group b strep (GBS)
-treat w/ IV penicillin -spread from perineum to vagina
12 weeks gestation symptoms
-urinary frequency -nausea/vomiting (r/t HCG [human chorionic gonadotropin]) -PICA -breast tenderness -amenorrhea -fetal heat sounds are heard (10-12 weeks)
A client informs the nurse that she intends to bottlefeed her baby. Which of the following actions should the nurse encourage the client to perform?
-wear a supportive bra 24h/day for a few weeks -breasts must be unstimulated to suppress milk production; refrain from massaging or applying warm compresses/water
A woman who is hepatitis B surface antigen positive is in active labor. Which action by the nurse is appropriate at this time?
-within the first 12h of birth, give baby hep B vaccine and hep b immunoglobulin
How long to avoid pregnancy after Rubella immunization
1-3 months
normal fetal HR
110-160
normal fetal heart rate (FHR)
110-160
What size and length of catheter would you insert in a women?
14 french, 22cm in length
Which gauge needle should be inserted to administer packed RBC?
18 gauge
Maternal Mortality Rate
1: 100,000 -rate women die per birth
infant mortality rate
1:1000 -rate newborns die
how many calories to add during pregnancy
1st trimester=0 2nd&3rd=additional 300
stages of labor
1st: dilating stage 3 phases: Latent (0-3cm) Active (4-7cm) Transition (8-10cm w/ urge to push) 2nd stage: delivery of newborn 3rd: placental delivery 4th: recovery- primary goal to prevent hemorrhage, massage uterus q.15min; 1st void within 1 hour and then q2-3 hrs, Rhogam
fetal landmarks: embryonic period
2-8weeks -4 weeks: neural tubes close
fundal height at the level of the umbilicus at how many weeks?
20 weeks
viability
22-25 weeks
fetal movements felt at?
28weeks
A nurse is caring for a client who has 0.9% NaCl infusing intravenously. An order had been written the previous day to change the IV solution to 0.9% NaCl with 10 mEq KCL. Which action should the nurse initiate first?
check serum potassium
1st trimester symptoms
nasal congestion breast tenderness fatigue urinary frequency backache heartburn
HCG causes?
nausea during 1st trimester
fetal landmarks: fetal period
8 -12 weeks: heartbeat by doppler & sex determined by external genitalia 16 weeks: fetus swallows amniotic fluid and eliminates urine week 21-24: fetal lungs produce surfactant
Toxoplasmosis titer
needed for cat owners before pregnancy
2nd & 3rd trimester symptoms: normal vs abnormal
normal=constipation, hemmorhoids abornormal=edema of hands & feet, decreased fetal movements contractions, bleeding, fever
Homan's sign
pain in calf when pressing on foot
biophysical profile
A test that assess five variables: fetal breathing fetal movement fetal tone amniotic fluid volume NST
Chadwick's sign
Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion
The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal?
Fundus 3 cm below the umbilicus, lochia serosa.
Gravida/Para
Gravida (gravidity): # of Pregnancies Para (parady): # of live births WOMAN HAS TWO KIDS, ONE ABORTION, AND IS CURRENTLY PREGNANT: G4P2
GTPAL
Gravida, Term, Preterm, Abortions, Living
medicaid vs medicare
Medicare = 65 and older Medicaid = For individuals with low income and limited resources
the hormone relaxin causes?
Mild relaxation of pelvic joints in preparation for birth
direct OP vs OA vs breech
OP=face face up **severe back pain OA=face down; preferred breech=feet, knees or butt first; c-section needed
sign of preeclampsia?
Proteinuria plus 2
Which of the following is the priority nursing action during the immediate postpartum period?
palpate the fundus to prevent hemorrhage
A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly?
The nurse stabilizes the base of the uterus with his or her dependent hand -uterus may invert or prolapse if not stabilized
normal platelet, hematocrit, & hemoglobin levels during pregnancy
platelet=200,000 HCT=33+ HBG: 11+
mcdonald's measurement
plus or minus 2cm by week=acceptable fundal height -ex: 28cm=either 26 or 30 weeks
Which of the following procedure is correct to cleanse and prep the perineal area?
Wipe in this order: far labium majora, near labium majora, inside far labium, inside near labium, and directly down the center over the urinary meatus
WIC
Women, Infants, and Children; program that provides nutritious food to women and children
how long to breastfeed
at least one year and longer if beneficial for mother & baby -introduce solid food @6mo
weight change during pregnancy
avg 25-35lb increase in weight; depends on BMI
contractions start from?
back to front
abortion: how many weeks
before 20weeks; can be therapeutic or spontaneous
Rogan
blood product that prevents the mother's body from producing antibodies that will attack the fetal blood cells -needed if mother is Rh- and baby is Rh+
2 vessels in umbilical cord means?
possible kidney, heart, GI issues; ultrasound needed
how do you get group b strep
contamination from the rectum to the vagina; r/t back to front wiping, not washing hands
more than 4 contractions/hr=?
dangerous; going into labor
common maternal symptom when laying supine
dizziness
hormones during pregnancy vs after labor
during pregnancy=estrogen & progesterone after labor=prolactin (stimulates milk production) & oxytocin (stimulates contractions)
A patient, G2P1, who delivered her baby 8 hours ago, now has a temperature of 100.2 degrees F. Which of the following is the appropriate nursing intervention at this time?
encourage intake of water & other fluids
what to assess immediately after performing an amniotomy?
fetal HR
normal fetal HR, maternal HR/RR/temp
fetal HR: 110 - 160, Maternal HR: 60 - 90 RR: 16 - 24 Temp: 98 - 99.6 F (36.2 - 37.6 C)
preterm vs term vs postterm
preterm=20-37 weeks term=38-42 weeks postterm=after 42 weeks
Hemoglobin and Hematocrit levels during pregnancy
hemoglobin=11 hematocrit=33 *values less than these=anemia r/t pregnancy
normal hemoglobin & hematocit levels
hemoglobin=11 (if below 11, iron supplement needed) hematocrit=33
What is the most common cause of nosocomial infections?
indwelling urinary catheter
A multigravida, postpartum woman reports severe abdominal cramping whenever she nurses her infant. Which of the following responses by the nurse is appropriate?
it is normal; discuss how oxytocin stimulates milk to eject from the breast and the uterus to contract in the postpartum period in order to reduce blood loss at the placental site
LDR stands for
labor, delivery, recovery
What allergies do you need to check for prior to insertion of a foley catheter?
latex, iodine, teflon
What do you do if you insert the foley catheter in the vagina instead of the meatus?
leave the catheter in the vagina while you insert a new one
A multigravid client is 22 weeks pregnant. Which of the following symptoms would the nurse expect the client to exhibit?
leg cramping
Naegle's Rule: how to find expected date of confinement (EDC)
minus 3 months, plus 7 days
