ATI Rationales OB Maternity
When and why should the eye mask be removed for a newborn under phototherapy lights?
Infants placed under phototherapy lights must have an opaque eye mask placed securely to prevent retinal damage This mask should be removed during feedings to assess the eyes and provide for visual stimulation
HELLP syndrome indications
Platelet count below 150,000-400,000. Clients who have hypertension are at increased risk for the development of HELLP syndrome HELLP syndrome is characterized by low platelet count, elevated liver enzymes, and hemolysis
Trichomoniasis medication Candidiasis Medication
Metronidazole or tinidazole: Orally Metronidazole is not given during the first trimester of pregnancy due to the teratogenic effects on the fetus Fluconazole Can be prescribed as a single low dose to clients who are not pregnant or lactating *Educate client to avoid tight-fitting clothing and eat food with probiotics
Nursing care for TORCH infections
Monitor fetal well-being For rubella, immunization of clients who are pregnant is contraindicated because rubella infection can develop. These clients should avoid crowds and young children Clients who have low titers prior to pregnancy should receive immunizations Rubella vaccination is received postpartum due to the effects on fetus in utero. Clients should avoid pregnancy for 4 weeks (28 days) after receiving the vaccine
Client who has experienced a precipitous birth -what should the nurse monitor?
Monitor for manifestations of respiratory distress. Clients who have experienced hypertonic rapid labor associated with a precipitous delivery are at the risk for experiencing anaphylactoid syndrome of pregnancy, or amniotic fluid embolism. This condition presents with sudden respiratory distress and circulatory collapse.
Medications used for neonate withdrawal manifestations Nursing actions
Morphine sulfate (Opioid) Phenobarbital (Anticonvulsant) Assess IV site frequently Check for any medication incompatibilities Decrease environmental stimuli Cluster cares to minimize stimulation Swaddle the newborn to reduce self-stimulation and protect the skin from abrasions Monitor and maintain fluids and electrolytes Administer frequent, small feedings of high-calorie formula, can require gavage feedings ***Elevate the newborns head during and following feedings, and burp the newborn to reduce Try various nipples to compensate for a poor suck reflex Have suction available to reduce the risk for aspiration For newborns who are withdrawing from cocaine, avoid eye contact and use vertical rocking and a pacifier Prevent infection Initiate a consult with child protective services Consult lactation services to evaluate whether breastfeeding is desired or contraindicated to avoid passing narcotics in breast milk *Methadone is not contraindicated during breastfeeding
Common discomforts that may occur during the first trimester of pregnancy with a client who is at 6 weeks of gestation -Epistaxis
Nasal stuffiness and epistaxis are common manifestations during the first trimester. Epistaxis is related to increased levels of estrogen
Newborn (less than 24 hour old) lab reference range: Platelet count Hemoglobin Bilirubin Blood glucose
Platelet count: 150,000- 300,000 Hemoglobin: 14-24 Bilirubin: 2-6 (newborn less than 24 hour old) Glucose: 40-60
Early decelerations
The nurse should continue to monitor the client. The nurse should recognize that early decelerations result rom fetal descent and head compression. This condition and fetal heart rate is commonly seen during labor and requires no interventions
Neonatal abstinence syndrome expectations
The nurse should expect to see chest retractions. A newborn experiencing neonatal abstinence syndrome can exhibit respiratory distress including chest retractions, nasal flaring, tachypnea, and irregular respirations
Increase the IV fluid rate for a client with late decals
The nurse should increase the IV fluid rate for a client who is having late decelerations. Providing a fluid bolus can improve fetal hypoxia
A prolapsed umbilical cord occurs when the umbilical cord is displaced, preceding the presenting part of the fetus, or protruding through the cervix. This results in cord compression and compromised fetal circulation Risk Factors: FRH:
- Rupture of amniotic membranes - Abnormal fetal presentation (any presentation other than vertex (occiput as presenting part)) - Transverse lie: presenting part not engaged, which leaves room for the cord to descent - Small for gestational age fetus -Unusually long umbilical cord -Multifetal pregnancy -Unengaged presenting part -Hydramnios of polyhydramnios FHR monitoring shows variable of prolonged deceleration Excessive fetal activity followed by cessation of movement; suggestive of severe fetal hypoxia
Sitz bath after midline episiotomy nursing education
"Fill the sitz bath half full with water" The nurse should instruct the client to fill the sitz bath one-half to one-third with water
"A nurse in a clinic is caring for a client who is postoperative following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification?
"It is good to know that I won't have a tubal pregnancy in the future" -WRONG_ The risk of recurrence of an ectopic pregnancy is increased following an ectopic pregnancy Infertility can occur as a result of an ectopic pregnancy A salpingectomy does not involve the removal of the ovaries, a salpingectomy involves the removal of a fallopian tube
A nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicates understanding of the infertility assessment process?
"The male is the easiest to assess, and the provider will usually begin there" A sperm analysis is one of the first steps in the infertility assessment process and can identify a cause of infertility in a less invasive and costly manner
Nursing care for prolapsed umbilical cord
-using a sterile gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. Stay in this position until delivery of the baby -reposition the client in a knee-chest, Trendelenburg, or a side-lying position with a rolled towel under the clients right hip to relieve pressure on the cord -Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow -provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia -Administer ox 8-10 L via face mask -Prepare for an immediate vaginal birth if cervix is fully dilated or cesarean if it is not
Evaluating a postpartum client who has pain and fever
1. Administer IV antibiotics 2. Collect vaginal and blood cultures 3. Collect vaginal and blood cultures 4. Endometritis uterine tenderness and enlargement, dark, profuse lochia, temperature greater than 38'C (100.4 F), tachycardia
What does generalized petechiae indicate?
Generalized petechiae can indicate clotting factor deficiency or infection. The nurse should immediately report this manifestation to the provider Remember that rust stained urine is NOT a complication
When do you screen for GBD status? What medication is most commonly prescribed for GBS?
35-38 weeks (Group b strep) Penicillin G or ampicillin
The newborns source of glucose stops when the umbilical cord is clamped. If the newborns have other physiological stress, they can experience hypoglycemia due to inadequate gluconeogenesis or increased use of glycogen stores What is a healthy term newborn's blood glucose? What can untreated hypoglycemia result in?
40-60 mg/dL seizures, brain damage, or death
A nurse is caring for a client who is pregnant with a male child and expresses concern to the nurse about the possibility of the child having hemophilia. The client is a carrier of the gene mutation for this condition. Which of the following percentages the chance that the child will have this disorder?
50% Hemophilia is an X linked recessive inheritance disorder, which means that the female clients who are carriers have a 50% chance of passing the gene mutation to their children If the child is a female, she will be a carrier If the child is male, he will have the disorder
A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection?
A client who does not wash their hands between perineal care and breastfeeding. -The client who does not wash their hands between perineal care and breastfeeding is at an increased risk for developing mastitis. Therefore, they are at most risk for developing a postpartum infection
Medications for TORCH infections
Administer antibiotics as prescribed Treatment of toxoplasmosis includes a sulfonamides or a combination of pyrimethamine and sulfadiazine (potentially harmful to the fetus, but parasitic treatment is essential) ***Note any SULFA allergies for client****
A nurse is caring for a client who has HIV and is in labor Which of the following actions should the nurse take?
Administer zidovudine IV during the intrapartum period. This medication should be administered 3 hr prior to a cesarean birth During the antepartum period, the recommendation is for the client to have periodic WBC, hematocrit and platelet count assessments
What condition can develop after treatment for syphilis?
After treatment, report headache, fever, tachycardia and myalgia. This could be indicative of Jarisch-Herxheimer reaction and should be reported to the provider
What is a contraindication to the dye used in hysterosalpingography?
An allergy to seafood
A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make?
Apply cold compresses between feedings -Cold compresses applied to the breasts after the feedings can help with breast engorgement -Taking warm shower prior to feedings, not immediately after, can assist with the letdown reflex and milk flow -Applying breast milk to the nipples and airdrying is recommended for the client who has sore nipples, but has no effect on engorgement -Using various positions for feedings helps to prevent nipple soreness but has no effect on breast engorgement.
Nursing care during dysfunctional labor (dystocia)
Assist with application of fetal scalp electrode and/ or intrauterine pressure catheter (Uterus is either hypotonic or hypertonic) Assit with amniotomy (artificial rupture of membranes) Encourage client to engage in regular voiding to empty bladder Encourage position changes to aid in fetal descent or to open up the pelvic outlet. Assist the client into a position on both hands and knees to help the fetus to rotate from a posterior to anterior position Encourage ambulation to enhance the progression of labor Apply counterpressure using fist or heel of hand to sacral area to alleviate discomfort Assist the client into a beneficial position for busing and coach them about how to bear down with contractions Prepare for a possible forceps assisted vacuum assisted or cesarean birth Continue monitoring FHR in response to labor
Newborn with blood glucose level of 28 -which actions should the nurse take?
Assist with breastfeeding The nurse should assist the mother with breastfeeding her newborn. The nurse should recheck the newborns blood glucose level 1 hour after feeding to assess for hypoglycemia The nurse might have to administer an infusion of dextrose IV if other interventions fail to increase the newborn's blood glucose levels
To relieve breast engorgement , take a warm shower or apply warm compresses before breastfeeding to promote letdown and milk flow. Empty each breast completely at feedings, using a pump if needed after the infant has finished feeding. Apply cool compresses after feedings (If client is breastfeeding) If the client is not breastfeeding, what are client education for engorged breasts?
Avoid breast stimulatio and running warm water over the breasts for prolonged periods until no longer lactating For breast engorgement, which can occur on the third or fifth postpartum day, apply cold compresses 15 minutes on and 45 min off. Fresh, cold cabbage leaves can be placed inside bra Wear well-fitting, supportive bra continyously for the first 72 hours
A nurse is providing care for a client who has HIV and her newborn. Which of the following actions should the nurse take first when providing care to the newborn immediately following birth?
Bathe the newborn Evidence-based practice indicates the nurse should first bathe the newborn of a client who has HIV. The priority action is to remove the amniotic fluid and any maternal blood prior to administering any IM injections or preforming heel sticks.
A nurse in a prenatal clinic is preforming telephone triage for several clients. Which of the following client reports should the nurse identify as an expected physiological adaptation to pregnancy?
Breast tenderness -Breast tenderness is common during the first and third trimesters of pregnancy. The nurse should explain that this is expected and that the client should wear a well-fitting, supportive bra to help alleviate the tenderness -Spotting with urination could indicate either vaginal spotting or hematuria, both of which should be reported to the provider -Vaginal secretions increase during pregnancy; however, they are typically thin, white, odorless secretions. A thick, cottage-cheese-like or malodorous discharge can indicate a yeast or bacterial infections and should be reported to the provider
Lab tests used to differentiate between neonatal drug withdrawal and central nervous system disorders
CBC Blood Glucose Thyroid-stimulating hormone, thyroxine, triiodothyronine Drug screen of urine or meconium to reveal substance used Hair analysis
Neonatal substance withdrawal expected findings
CNS: High-pitched, shrill cry; incessant crying, irritability; tremors; hyperactivity with an increased Moro reflex; increased deep-tendon reflexes; increased muscle tone; disturbed sleep pattern; hypertonicity; convulsions Metabolic, vasomotor and reparatory findings: Nasal congestion with flaring, frequent yawning, skin mottling, retractions, apnea, tachypnea greater than 60/ min, sweating, temperature greater than 37.0 C (99F) Gastrointestinal: Poor feeding; regurgitation (projectile vomiting); diarrhea; excessive, uncoordinated, constant sucking
Medication for chlamydia and gonorrhea during pregnancy Risk factors
Ceftriaxone IM and azithromycin PO Premature rupture of membranes (PROM) Preterm birth Postpartum sepsis and endometritis Chorioamnionitis Neonatal sepsis
Abrupt onset of variable decelerations in FHR
Check the client for a prolapsed umbilical cord. The nurse should perform a vaginal examination to assess the client for a prolapsed umbilical cord. Compression of the umbilical cord causes abrupt onset of variable deciliations in the FHR. A prolapsed umbilical cord is a medical emergency, and the fetus should be delivered as soon as possible
Discharge instructions for client with HIV
Do not breastfeed Consider meeting with providers specializing in care of clients who have HIV All states have a reportable disease list. HIV/AIDS is a commonly reported condition. It is the responsibility of the provider to report cases of these diseases to their local health department
What medications are used to treat chlamydia?
Doxycycline Used as treatment, but contraindicated during pregnancy *Doxycycline might reduce the effectiveness of oral contraceptives *Instruct clients to use condoms *Report cases to local health department
G T P A L
G -indicates the client has had prior pregnancies (and is pregnant now) T- T indicates the client as delivered newborn(s) P- P indicates the client has had preterm deliveries A- Indicates the client has had abortions L- Indicates the client has had living children
Medications for syphilis
Penicillin G IM in a single dose, or 3 doses if the duration of syphilis is unknown *Safe during pregnancy Doxycycline or tetracycline orally if allergic to penicillin as alternative therapy
Nursing care for maternal substance use and neonatal effects or withdrawal include the following in addition to normal newborn care:
Perform ongoing assessment of newborn using the neonatal abstinence scoring system assessment, as prescribed Elicit and assess the newborns reflexes Monitor the newborns ability to feed and digest intake. Offer small frequent feedings Swaddle the newborn with legs flexed Offer non-nutritive sucking Monitor the newborns fluids and electrolytes with skin turgor, mucus membranes, fontanels, daily weights, and I&O Reduce environmental stimuli
Anaphylactoid Syndrome (Amniotic fluid embolism) Risk Factors:
Placentia previa or abruption Preeclampsia Eclampsia Hypertensive disorders Oxytocin administration Diabetes mellitus Cesearean birth Labor induction Forceps=assisted birth Uterine rupture Cervical laceration Meconium stained amniotic fluid
Manifestations of newborn of gestational diabetes mom
Poor feeding is a manifestation of hypoglycemia in a newborn. If the newborn is unable to feed, the nurse should administer IV dextrose. Other manifestations of hypoglycemia include an abnormal cry, lethargy, respiratory distress and jitteriness
Risk factors for early onset neonatal GBS
Positive GBS culture in current pregnancy Prolonged (18 hr or more) rupture of membranes Preterm delivery Low birth weight Use if intrauterine fetal monitoring Intrapartum maternal fever
Biophysical profile results of 3/10 at 37 weeks gestation Which of the following actions should the nurse plan to take?
Prepare for the birth of the fetus A biophysical profile of 3 out of 10 indicates the presence of probable fetal hypoxia. Because the fetus is near term, the nurse should plan to prepare for birth of the fetus.
Group B Strep (GBS) in labor -what should the nurse anticipate?
Prepare to administer prophylactic IV antibiotics. Group B Strep can spread to the fetus. Prior to birth, the client is given prophylactic IV antibiotic therapy to decrease the risk of transmission to the fetus (penicillin, amoxicillin, or cephalexin (Keflex))
Physical assessment findings GBS (maternal and fetal)
Preterm labor and delivery Chorioamnionitis Infections of the urinary tract Maternal sepsis Endometritis after delivery
A nurse is providing discharge teaching for a nonlactating client. Which of the following instructions should the nurse not include in the teaching?
Pump your breast every 4 hours to relieve discomfort -Do not recommend using a breast pump for the non-lactating client -Instruct the client to wear a well-fitting support bra continuously for the first 72 hours -Recommend using a breast shell for clients who have flat or inverted nipples -Instruct the nonlactating client to avoid application of warm compresses. Cold compresses can be applied to relieve discomfort
What is administered to clients who have mild hyperemesis gravidarum?
Pyridoxine Hyperemesis gravidarum is excessive vomiting during pregnancy which can lead to an imbalance of fluids and electrolytes. The nurse should administer pyridoxine to correct the fluid and electrolyte imbalances
A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licenses nurse. Which of the following risk factors should the nurse include?
Respiratory distress syndrome -Respiratory distress syndrome is a risk factor for NEC. Respiratory distress causes intestinal ischemia secondary to hypoxia Preterm birth is a risk factor for NEC. Aprox 90% of cases of NEC occur in preterm newborns Low birth weight and iugr are risk factors for NEC Maternal gestational diabetes is not a risk factor for NEC. Risk factors include asphyxia, gastrointestinal infection, and polycythemia
Normal Lochiel flow patterns: Rubra: Serosa: Alba:
Rubra: dark red vaginal drainage for 1-3 days Serosa: Brownish red or pink vaginal drainage from days 3-10 Alba: Yellowish white vaginal discharge after day 10-8 weeks *Report to the provider any change in vaginal discharge with increased amount, large clots, change to a previous lochia color, such as bright red bleeding, and a foul odor
A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings?
Sore nipple with cracks and fissures -A sore nipple that has cracks and fissures is an indication of mastitis -Lochia alba, a white vaginal discharge, is normal from the 11th day postpartum to approximately 6 weeks following birth -Oxytocin, which is released with breastfeeding, causes the uterus to contract and can cause discomfort -physiological reactions to sexual activity can be slower and less intense for the first 3 months following birth
Fetal distress is present when:
The FHR is below 110/min or above 160/ min the FHR shows decreased or no variability There is fetal hyperactivity or no fetal activity Additional manifestations of fetal distress are late decelerations associated with absent or minimal variability, recurrent variables and prolonged decelerations
Gestational nutrition during pregnancy "you should consume 6 ounces of protein foods daily"
The nurse should instruct the client to consume 5.5 to 6.5 oz. of protein daily. The client should select high-protein foods, such as legumes, nuts, eggs and lean meat or poultry -The nurse should instruct the client to consume 3 cups of dairy daily. The nurse should instruct the client to consume 6-8 oz of grains. At least 1/2 of servings as whole grains consume 2.5-3 cups of vegetables daily
Hyperemesis gravidarum snacks
The nurse should instruct the client to eat a high-protein snack at bedtime and avoid having an empty stomach. Eating foods that are low in fat and high in protein can minimize nausea and vomiting The nurse should instruct the client to drink liquids separately from meals to decrease nausea
Group B Streptococcus Culture at 35 weeks
The nurse should instruct the client to expect a culture of the vagina and rectum to test for group B strep between 35 and 37 weeks of pregnancy
Nursing instructions for a glucose tolerance test
The nurse should instruct the client to fast overnight prior to the test The nurse should instruct the client to plan to have the test between 24 and 28 weeks of gestation The nurse should instruct the client to have an unrestricted diet with at least 150g of carbohydrates prior to the test The nurse should instruct the client to avoid smoking at least 12 hours prior to the test because it can increase glucose levels
Phototherapy repositioning
The nurse should reposition the newborn every 2 to 3 hours while undergoing phototherapy to maximize skin exposure. This increases the rate at which bilirubin can be broken down, which decreases the serum bilirubin level
A nurse is teaching a client about squatting exercise during pregnancy. Which of the following statements should the nurse include?
These exercises should be done for 15 minutes each day to strengthen the perineal muscles -Squatting exercises help stretch the perineum, allowing stretching during delivery and improving functional efficiency after delivery
Tocolytic medications
Tocolytic medications cause uterine muscle relaxation and are administered to treat premature labor contractions.
Risk factors for TORCH infections
Toxoplasmosis is caused by consumption of raw or undercooked meat or handling cat feces. Manifestations are similar to influenza or lymphadenopathy Rubella is contracted through children who have rashes or neonates who are born to clients who had rubella during pregnancy Cytomegalovirus (member of herpes virus) is transmitted by droplet infection from person to person, through semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces and blood. Latent virus can be reactivated and cause disease to the fetus in utero or during passage through the birth canal HSV is spread by direct contact with oral or genial lesions. Transmission to the fetus is greatest during vaginal birth if the client has active lesions
What are TORCH infections?
Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infections Rubella can cause fetal consequences (miscarriage, congenital anomalies, death) HSV can cause miscarriage, preterm labor and intrauterine growth restriction
What should be avoided for clients in labor with HIV? Planned c-section and vaginal birth considerations: PPE and infant care after birth HAART medication name
Use of internal fetal monitors, vacuum extraction and forceps should be avoided during labor due to the risk of fetal bleeding scheduled cesarean birth at 38 weeks for maternal viral load of more than 1,000 copies/mL. vaginal birth can be option for client who has a viral load of less than 1,000 copies/mL at 36 weeks of gestation Standard precautions, gloves, bathe baby after birth Intrapartum: IV zidovudine 3 hrs prior to c section Administer zidovudine to infant at delivery and for 6 weeks following birth
Client 32 weeks gestation (third trimester) lab values: WBC HGB Platelets BUN
WBC: 5,000-15,000 during pregnancy (due to leukocytosis) the WBC count can increase to 25,000 within a few days after birth HCB -a reference range odf11.2 is within the expected reference range for a client in their third trimester. anything less than 10.5 can indicate anemia Platelet count reference range of 150.000-400,000. A decreased platelet count may indicate preeclampsia or HELLP syndrome BUN reference range 10-20 during pregnancy. An increase in BUN may indicate preeclampsia or HELLP syndrome
A nurse is teaching a client who has active genital herpes simplex virus type 2. Which of the following statements should the nurse include in the teaching?
You will have a cesarean birth prior to the onset of labor -Whenever possible, a cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of harpies The client who has active herpes should recieve a prescription for acyclovir. Metronidazole should be prescribed for bacterial vaginosis
What neonate condition develops with untreated gonorrhea?
ophthalmia neonatorum, which can cause blindness Administer erythromycin to all infants following delivery. This antibiotic is both bacteriostatic and bactericidal, and thus provides prophylaxis Report to local health department
If chlamydia is left untreated in females, what can it lead to?
pelvic inflammatory disease (PID), which can cause infertility and ectopic pregnancy If not treated during pregnancy, chlamydia can cause premature rupture of membranes, preterm labor and postpartum endometritis If transmitted to the neonate, it can cause conjunctivitis and pneumonia after delivery ***assess lung sounds for crackles and apply eye ointment (ghonerria)*** All pregnant clients should be screened at the first prenatal visit and rescreened in the third trimester if younger than 25 and/or at high risk
