Maternal newborn nursing (concept map and practice quizzes)
Signs of Magnesium sulfate toxicity
* absence of patellar deep tendon reflexes * Urine output < 30 mL/hr * Respiration <12/min * Decreased LOC * Cardiac dysrhythmias
Nursing care for newborns with abstinence syndrome
* assess/monitor IV site frequently * check for any medications incompatibilities * reduce external stimuli * swaddle the newborn to reduce self-stimulation and protect the skin from abrasions * administer frequent, small feeding of high calorie formula (may need gavage feedings) * elevate the infant's head during and following feedings and burp the infant to reduce vomiting and aspiration. * trying various nipples to compensate for a poor suck reflex. * have suction available to reduce the risk for aspirations * for newborns who are addicted to cocaine, avoid eye contact and use vertical rocking and pacifier. * prevent infection * initiate a consult with child protective services * consult lactation services to evaluate if breastfeeding is contraindicated or desired.
Diagnostic procedures for Gestational Hypertension
* dipstick testing for urine for proteinuria * 24-hr urine collection for protein and creatinine clearance * Non-stress test, biophysical profile, and serial ultrasounds to assess fetal status * Doppler blood flow analysis to assess fetal well-being.
signs of newborn's tobacco withdrawal
* prematurity * low birth weight * increased risk for sudden infant death syndrome * increased risk of bronchitis * pneumonia * developmental delays
Nursing Care/Medication administration for Gestational Hypertension
* use infusion device to maintain a regular flow rate. * inform the client that she will feel flushed, hot and sedated with the bolus of magnesium sulfate * Monitor BP, Pulse, RR, deep tendon reflexes, LOC, Urinary output, presence of headache, visual disturbances, epigastric pain, uterine contractions, FHR, and activity. * Place on fluid restrictions of 100 to 125 mL/hr, and maintain a urinary output of 30 mL/hr or greater * monitor for signs of magnesium sulfate toxicity.
newborn's signs of opiate withdrawal
*Rapid changes in mood * hypersensitivity to noise and external stimuli * dehydration * poor weight gain
Newborn's heroin withdrawal signs
*low birth weight and SGA * decreased moro reflexes * hypothermia or hyperthermia
A nurse is collecting data on newborn. Which of the following is an expected finding? Select one: a. Babinski reflex present b. Pulse rate 70 to 80/min c. Respirations 21 to 24/min d. Decorticate reflex
a. Babinski reflex present The Babinski reflex is present for the first year of life. The reflex is elicited by stroking the outer edge of the sole of an infant's foot up toward the toes. The infant's toes fan upward and out.
A client in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The nurse recognizes that the behaviors must likely indicate which of the following? a. Positive mother-infant bonding. b. Postpartum role transition. c. The taking-in phase of maternal postpartum adjustment. d. The taking-hold phase of maternal psychosocial adaptation
c. The taking-in phase of maternal postpartum adjustment.
Discharge teaching for client who has postpartum depression
* advise the client to get plenty of rest and nap when the infant sleeps * reinforce the importance of the client taking time out for herself. * Schedule a follow up visit prior to the traditional 6 week postpartum visit for client who are at risk for developing postpartum depression. * encourage the client to seek counseling and make referrals to social agencies as indicated. * provide information about community resources such as la leche league or community mental health centers.
What should you do for newborns who are addicted to cocaine?
* avoid eye contact * use vertical rocking * give pacifier.
Physical changes of mother's breast postpartum
* breast will secrete colostrum * colostrum will occur 2-3 days immediately after birth * milk is produced 2-3 days after the delivery of the infant
nursing interventions regarding breast feeding
* encourage early demand breastfeeding for the mother who is lactating, which will also stimulate the production of natural oxytocin and help prevent uterine hemorrhage. * assist the client into comfortable position and have her try various positions during breastfeeding and explaining how varying positions can prevent nipple soreness. - cradle hold - side lying, football hold * teach/reinforce to the client the importance of proper latch techniques (the newborn take in part of the areola and nipple, not just the tip of the nipple) to prevent nipple soreness. * inform the client that breastfeeding causes the release of oxytocin, which stimulates uterine contractions. this is normal occurrence and beneficial to uterine tone.
Signs of fetal alcohol syndrome
* facial anomalies: - mouth with small suck, small teeth, cleft lip or palate. * prenatal and postnatal growth retardation * abnormal palmar creases and irregular hair * developmental delays and neurologic abnormalities * deafness * sleep disturbances * many vital organ anomalies
subjective data from a client who is suffering postpartum depression
* feeling of guilt and inadequacies. * irritability and intense mood swings * anxiety * persisting feeling of fatigue and sadness * feeling of loss * lack of appetite * sleep pattern disturbances
Risk factors for postpartum depression
* hormonal changes with a rapid decline in estrogen and progesterone levels * postpartum physical discomfort and/or pain. * individual socioeconomic factors * decreased social support system * anxiety about assuming new role as a mother. * unplanned or unwanted pregnancy * history of previous depressive episode * low self-esteem * history of domestic violence.
Signs of Newborn's methadone withdrawal
* increased incidence of seizures * higher risk of sudden infant death syndrome * higher birth weight * sleep pattern disturbances
Discharge instructions to a client with Gestational Hypertension
* maintain on bed rest and encourage the side-lying position. * Promote diversional activities * Avoid foods that are high in sodium * avoid alcohol and limit caffeine * instruct to increase fluid intake to 8 glasses/day * maintain a dark quiet environment to avoid stimuli that may precipitate a seizure * maintain a patent airway in the vent of a seizure * administer anti hypertensive medications if prescribed.
Nursing interventions for a client with postpartum depression
* monitor interactions between mother and baby. * encourage bonding activities * Reinforce with the client that feeling down in postpartum period is normal and self-limiting. Encourage to notify primary health provider if the condition persist. * encourage to communicate feelings, validate and address personal conflicts, and reinforce personal power of autonomy * Reinforce the importance of compliance with any prescribed antidepressant medication regimen. * contact a community resource to schedule a follow up visit after discharge for women who are at high risk for postpartum depression.
Signs of of Newborn's Marijuana withdrawal
* preterm birth * meconium staining
Signs of newborn's amphetamine withdrawal
* preterm or SGA * drowsiness * jitteriness * sleep pattern disturbances * respiratory distress * frequent infections * poor weight gain * emotional disturbances * delayed growth and development
A nurse is caring for a neonate who is 34 weeks gestation. The nurse correctly understands which of the following are consistent with prematurity? Select all that apply. Select one or more: a. Prominent clitoris and labia minora b. Large amount of vernix present c. Abundant lanugo d. Mongolian spots on shoulders e. Inner eye canthus level with pina
Abundant lanugo, Prominent clitoris and labia minora, Large amount of vernix present General Feedback: Abundant lanugo is noted in abundant amounts with a premature newborn. Prominent clitoris and labia minora are seen with prematurity. Large amounts of vernix are noted with prematurity.
What is the newborn's Apgar score if these are the findings? HR= absent RR= absent Muscle tone= flaccid reflex irritability= none color= blue, pale
Apgar Score is 0 for each
The newborn's HR: <100, RR: slow, weak cry, Muscle tone: some flexion; Reflex irritability: grimace; Color: pink body, cyanotic hands and feet. what is the Apgar score for this assessment?
Apgar score for each is 1 (total of 5)
The newborn's assessment result are: HR= >100 RR= Good cry Muscle tone= well-flexed Reflex irritability= cry Color= completely pink what is the apgar score?
Apgar score for each is 2 (total of 10)
An infant has been born 5 minute and the nurse notices that the infant is experiencing these signs and symptoms: HR= <100 RR= good cry Muscle tone= flaccid Reflex irritability= grimace Color= blue/pink
Apgar score is 4 this indicate moderate distress
A nurse is reinforcing teaching of breastfeeding techniques with a new mother. Which of the following teaching tips are appropriate to reinforce with a new mother who is breastfeeding? Select all that apply. Select one or more: a. Burp the newborn between each breast b. Dark, firm stools are the norm c. Avoid a specific length of time to breastfeed d. Avoid use of a pacifier to prevent nipple confusion e. Two to three wet diapers per day are the norm.
Avoid a specific length of time to breastfeed., Burp the newborn between each breast., Avoid use of a pacifier to prevent nipple confusion. General Feedback: Avoid educating mothers regarding the duration of newborn feedings. Mothers should be instructed to evaluate when the newborn has completed the feeding, including slowing of newborn suckling, a softened breast, or sleeping. Show the mother how to burp the newborn when she alternates breasts. The newborn should be burped either over the shoulder or in an upright position with his chin supported. The mother should gently pat the newborn on his back to elicit a burp. tell the mother to avoid nipple confusion in the newborn by not offering supplemental formula, pacifier, or soothers. Supplementation can be provided using a small feeding or syringe feeding, if needed.
What are characteristics of the fetus that are reviewed to determine the biophysical profile (BPP) during an ultrasound? Select all that apply. a. Fetal tidal volume b. Fine body movement c. Reactive FHR d. Fetal tone e. Qualitative amniotic fluid volume
Fetal tone, Reactive FHR, Qualitative amniotic fluid volume - Fetal tone, relative FHR, fetal breathing movements, gross body movements, fetal tone and qualitative amniotic fluid volume are physical and physiological characteristics of the BPP.
A nurse is caring for a neonate who exhibits abstinence syndrome and demonstrates clinical manifestations of the condition. Which assessment finding is associate with this condition? a. Diminished tendon reflexes b. Increased drowsiness c. Hypothermia d. Negative Startle reflex
Hypothermia
A breastfeeding mother develops engorgement on her third postpartum day. Which of the following statements by the client indicates a need for further teaching? a. I will offer my baby a bottle following each feeding. b. I will apply warm packs to each breast prior to feeding. c. I will use a breast pump if my breasts do not soften. d. I will feed my baby every 2 hours
I will offer my baby a bottle following each feeding. Bottle feeding while breastfeeding could lead to nipple confusion and interfere with successful breastfeeding. This mother needs further teaching.
A nurse is teaching a client the correct use a diaphragm as a method of contraception. Which of the following statements is correct? a. Do not use any cream or jelly with the diaphragm b. Leave diaphragm in place for at least 6 hours post coitus c. Douche promptly after removing the diaphragm d. Insert diaphragm at least 8 hours prior to sexual intercourse
Leave diaphragm in place for at least 6 hours post coitus
A nurse is caring for a newborn client who is experiencing severe hyperbilirubinemia. Which of the following are symptoms of kernicterus? Select all that apply. a. Lethargy b. Low birth weight c. Temperature instability. d. Backward arching of the neck and trunk e. Hypotonic
Lethargy, Hypotonic, Backward arching of the neck and trunk General Feedback: Kernicterus (bilirubin encephalopathy) can result from untreated hyperbilirubinemia with bilirubin levels at or higher than 25 mg/dL. It is a neurological syndrome caused by bilirubin depositing in brain cells. Survivors may develop cerebral palsy, epilepsy, or mental retardation. They may have minor effects such as learning disorders or perceptual-motor disabilities. Symptoms can inlcude letheragy, hyoptonia, high-ptiched cry and tonic motions such as backwards arching of the next and trunk. Low birth weight and temperature instabilty are not symptoms associated with kernicterus.
Medication for gestational hypertension
Magnesium sulfate
Thirty minutes after admission to the nursery an infant appeared jittery and exhibits a weak, high pitched cry. Which of the following would be the nurse's priority action? Feed the infant oral feeding. b. Hold and comfort the infant to stop the crying. c. Obtain an order for a drug screening blood test. d. Perform a heel stick to check serum glucose.
Perform a heel stick to check serum glucose.
A nurse is positioning a client on the operating room table in preparation for a cesarean birth. What is the correct position for cesarean birth?
Supine position with foam wedge positioned under one hip.
A nurse is caring for a client who has been prescribed magnesium sulfate as tocolytic therapy. Several hours after the infusion was started, contractions ceased. Which of the following is the best analysis of this data? Select one: a. The medication dose should be decreased b. Deep tendon reflexes should be assessed c. The drug is having a therapeutic effect d. The medication dose should be increased
The drug is having a therapeutic effect A cessation of labor is the desired therapeutic effect of a tocolytic.
A nurse is performing a fundal assessment on the client's second postpartum day. Which of the following should the nurse expect if the client is experiencing normal involution? a. The fundus will be one centimeter below the umbilicus. b. The fundus will be at the level of the umbilicus. c. The fundus will be two centimeters below the umbilicus d. The fundus will be one centimeter above the umbilicus.
The fundus will be one centimeter below the umbilicus.
the nurse should assess/monitor mom's breast for?
The nurse should assess/monitor the breast as well as the ability to assist the newborn with latching on if breastfeeding. - colostrum secretion in lactating and non-lactating mothers - engorgement of the breast - redness and tenderness - cracked nipples and indications of mastitis - ascertain that newborn is latched on correctly to prevent sore nipples. - ineffective newborn feeding patterns r/t maternal discomfort, newborn positioning, or difficulty latching on.
A client in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The nurse recognizes that these behaviors likely indicate which of the following? a. The taking-hold phase of maternal psychosocial adaptation. b. The taking-in phase of maternal postpartum adjustment. c. Postpartum role transition d. Positive mother-infant bonding
The taking-in phase of maternal postpartum adjustment.
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response? a. The purpose of the NST is to assess the fetal CNS. b. The purpose of the NST is to determine fetal lie. c. The purpose of the NST helps to determine gestational age. d. The purpose of the NST is to determine fetal breathing
a. The purpose of the NST is to assess the fetal CNS.
A nurse is assessing a client during her first prenatal visit. The client reports that her last normal period began on April 22. Use Nagele's rule to calculate this client's expected date of birth (EDB). Use the MMDD format to enter exactly four numerals, with no spaces or punctuation between the numbers. a. 0729 b. 0129 c. 0722 d. 0122
b. 0129 - To use Nagele's rule subtract 3 months and add 7 days to the first day of the client's last normal menstrual period.
The client asks the nurse to explain the difference between true and false labor. Which of the following is an example of true labor? a. In true labor contractions are felt in the abdomen above the umbilicus b. In true labor the cervix will dilate and efface c. In true labor walking will cause contractions to slow down d. In true labor the presenting part is engaged
b. In true labor the cervix will dilate and efface - Progressive changes in dilation and effacement are the ultimate signs of true labor.
how to tell if a newborn is receiving adequate feeding?
baby is gaining weight, voiding 6 to 8 diapers a day, and contentedness between feedings.
A client reports awaking from sleep by contractions that are occurring every 5 minutes and lasting 30-40 seconds. Which of the questions should the nurse ask to assess for true labor versus false labor? a. "Have you felt fetal movement over the last 24 hours?" b. "When did your contractions begin?" c. "Have you noticed any bloody show or fluid coming from your vagina? d. "What happens to your contractions when you move about?"
c. "Have you noticed any bloody show or fluid coming from your vagina?" - Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially rupture of membranes. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. Contractions are felt in the lower back or above the umbilicus and often stop with comfort measures (like oral hydration). There is usually no vaginal discharge with false labor.
A nurse is caring for a client who has been prescribed magnesium sulfate for pregnancy induced hypertension. On admission the client's B/P is 160/90 mm Hg and urine output is 25mL/hr. Following initiation of magnesium sulfate, which of the following symptoms should be reported to the provider? Select one: a. The client is voiding 40 mL/hr b. The client reports feeling flushed and warm c. The client is drowsy and difficult to rouse d. The client's blood pressure is 130/70 mm Hg
c. The client is drowsy and difficult to rouse - If the client is sleepy and difficult to rouse she may be experiencing symptoms of magnesium sulfate toxicity. This should be immediately reported to the provider.
What is the antidote for magnesium sulfate?
calcium gluconate
3 objective signs of a client who is suffering postpartum depression.
crying weight loss flat affect
A laboring client reports suddenly feeling something in her vagina. Upon evaluation, the nurse notes clinical manifestations potentially related to a prolapsed umbilical cord. Place the following interventions in the correct order that they should be performed for this client. A. Prepare the client for a cesarean birth. B. Administer oxygen at 8-10L via face mask. C. Notify primary care provider of the prolapsed cord. D. Reposition the client in either a knee-ches or Trendelenburg position. E. Using a sterile glove insert two fingers into the vagina to reduce pressure off the cord.
d. C, D, E, B, A Correct order: C. Notifying the health care provider and staff is the first priority and facilitates readiness for further interventions. D. Next step will be to remove pressure from the cord by repositioning client. E. Inserting fingers into the vagina and applying finger pressure to the fetal presenting part reduces pressure on the umbilical cord and provides oxygenation to the fetus. B. Administration of supplemental oxygen will further improve fetal oxygenation. A Emergent care of the client and fetus is priority and if all other measures fail, the client should be prepared for a cesarean birth.
A client with gestational diabetes gave birth to a 9 pound neonate 12 hours ago. The neonate is presenting with a high pitched cry and jitteriness. Which of the following is the nurse's priority intervention? Select one: a. Administer subcutaneous insulin b. Provide oxygen via oxyhood c. Place the neonate under a radiant warmer d. Offer the neonate breast milk or formula
d. Offer the neonate breast milk or formula A neonate of a diabetic mother is at risk for hypoglycemia. High glucose loads are present in the infant in utero. When maternal blood glucose via the placenta abruptly stops at birth, the neonate experiences a rapid drop in blood sugar. Signs of hypoglycemia in the neonate are jitteriness, lethargy, poor muscle tone, apnea, high pitched cry, and vomiting. Nursing interventions should focus on monitoring for sign of complications associated with hypoglycemia.
what is the normal stool of a newborn baby?
he newborn may have loose, pale, and/or yellow stools during breastfeeding, and that this is normal
signs of hypoglycemia in neonate
jitteriness, lethargy, poor muscle tone, apnea, high pitched cry, and vomiting.
False labor is characterized by
painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes