maternity ch 25

placenta

The _______________ produces hormones that assist in maintaining the pregnancy

Encourage the new mother to discuss her feelings by sitting next to her and stating, "Having a baby can be overwhelming

The nurse observes a new mother turning away from her infant and sighing deeply. Which intervention would be most appropriate for the nurse

Sperm

What does zygote mean

Amenorrhea Breast changes Chadwick sign

Which of the following maternal changes are presumptive signs of pregnancy? (Select all that apply.)

pregnant female has lost her mucus plug.

A "bloody show" indicates the:

Hypovolemic shock

A new mother reports feeling weak, light-headed, and being sick to her stomach. The LPN/LVN also notes that the patient's perineal pad is soaked since she last checked it 15 minutes ago. The patient's skin is cool and clammy. The pulse is 110 bpm and the blood pressure is 80/60. What complication do these symptoms indicate

3+

A patient has been admitted with preeclampsia. Following an assessment, the nurse notes the patient has edema of the face, hand, and abdomen. How would the nurse document this finding

Incomplete spontaneous abortion

A patient who is 9 weeks pregnant comes to the hospital complaining of vaginal bleeding. An ultrasound reveals no heartbeat or uterine growth. The patient is to be scheduled for a D & C. What type of abortion is this

Termination of the pregnancy

A patient with a family history of PIH asks the nurse if there is a cure. What information will the nurse give to this patient

Deep blue

A pregnant patient comes to the hospital saying she thinks her water has broken. The nurse checks the fluid with Nitrazine test paper to determine if the fluid is amniotic fluid or vaginal secretions. What color will the nurse expect the paper to turn if the fluid is amniotic

Perform Kegel exercises

A pregnant patient complains of having to go to the bathroom frequently and sometimes even has stress incontinence. What can the nurse teach the patient to do to increase the tone of the perineum muscles

Cesarean section

A surgical operation for delivering a child by cutting through the wall of the mother's abdomen

Low birth weight (LBW)

After delivery, a newborn is classified according to weight at any given gestational age. What would a newborn weighing 2500 g or less be classified as?

Gravida III, para II

Based on the definitions of gravida and para, what documentation best describes a woman in the clinic who is currently pregnant and has had two prior children

Lochia Rubra

Bright red; lasts for 2 days Amount: scant to small is normal; less for C/Section

Lochia: Rubra 1-2 days

Data collect fundal height, consistency, location, if too much activity may increase flow

Uterus: height, consistency, location

Data collect q4h in 1st 24 hours; q8h then after until discharge

6-8 weeks

If a woman has not gained a lot of weight during her pregnancy, when might she return to her prepregnancy weight

Assess for a positive or negative Homan sign

The LPN/LVN is assessing a postpartum patient when the patient reports pain in her right calf. The LPN/LVN notes the area is reddened and edematous. What is the LPN/LVN's next intervention

Left lateral side lying

The nurse is caring for a patient in labor. While assessing the patient's vital signs, the nurse notes a drop in the patient's blood pressure. To prevent supine hypotension, the nurse should encourage the patient to be in what position

I will need to stop breastfeeding until the infection is gone

The nurse is instructing a new mother about treatment for mastitis. Which statement by the patient indicates the need for further teaching

Realize these vital signs are normal for a newborn and document the data on the flow sheet

The vital signs of a newborn baby girl are: T-97.9, P-140, R-34 with brief periods of apnea, and B/P-80/40 with an increase in systolic pressure when crying. What is the nurse's next intervention

Breast: data collect nipples for cracks, soreness

Use breast milk to clean, air dry, do not use soap when bathing get Lanolin prescribed, application

VBAC

Vaginal birth after cesarean

Imbalanced nutrition: less than body requirements related to the demands during lactation Anxiety related to lactation expectations Potential for infection related to dry, cracked nipples

What are the most appropriate nursing diagnoses for a breastfeeding mother? (Select all that apply.)

Fatigue Frequent urination Flushed hot skin

What are the signs and symptoms of maternal hyperglycemia? (Select all that apply.)

Lochia

What can increase when the postpartum mother is at home and exerting herself

Umbilical cord

What contains two arteries and one vein

Non-English-speaking patient

What cultural situation requires assistance from another

Sitz bath

What helps to reduce discomfort and promote healing of the perineum

Chloasma

What is called the mask of pregnancy

Effacement

What is the term for shortening and thinning of the cervix during the first stage of labor

Pain

What is usually a major concern of the patient who is in labor

Postpartal period

What maternal cycle begins after the delivery of the placenta

Amniocentesis

What procedure can diagnose fetal sex, maturity, health, and genetic defects

Smoking

What should be avoided during pregnancy

less than 3 counts per hour

When a pregnant patient is being monitored for preeclampsia, fetal condition is also monitored. If the physician requests a kick count, how many counts per hour would be considered to be a concern

Father is not present

When assessing cultural preferences of a laboring patient, the nurse remembers to ask about traditional birth practices. Which birth practice is most common in non-American cultures

Only when the mother is Rh negative and the fetus is Rh positive

When does Rh incompatibility occur?

Third stage

When the delivery of the placenta is complete, which stage of labor is complete

Drink 8 to 10 glasses of fluids daily Continue her prenatal vitamins and minerals until they are gone Avoid spicy foods, chocolate, and onions

Which actions by the nursing mother will support milk production and promote infant comfort? (Select all that apply.)

Contractions follow a regular pattern. The cervix softens, effaces, and dilates Contractions get stronger with ambulation

Which characteristics are indications of true labor

Progesterone

Which hormone causes the uterus to contract?

Temperature 100.4° F or higher

Which is a normal finding for 2 days postpartum

Amenorrhea

Which is a presumptive sign of pregnancy

There is no effacement or dilation of the cervix

Which is an indication of false labor

Full bladder

Which may interfere with the progress of labor

Increased urination beginning 4 to 6 hours after delivery Increased diaphoresis, most commonly at night A normal bowel movement within 2 to 3 days

Which physical signs and symptoms might the postpartum patient experience following delivery? (Select all that apply.)

Supine

Which position is best when assessing the postpartum woman's perineum

Ectopic

Which type of pregnancy is considered a serious problem

Late deceleration

While assessing a laboring patient, which fetal heart tone (FHT) would the nurse consider cause for further or constant monitoring

14 to 16 weeks' gestation

While in the clinic, a first-time pregnant patient asks the nurse when she should be able to feel the fetus move. What is the nurse's best response

Fundus

Within 12 hours after delivery, what rises to the umbilicus?

Homan's sign: data collect for clot

dorsiflexion of the foot and ask if pain in calf

Involution

return of uterus to prepregnant size takes 6 weeks

Bowel: decreased motility leads to constipation, fear of pain

take scheduled stool softener, increase fluids and fiber, C/section patient must data collect bowel sounds and flatus

Emotional: nursing interventions

1. Taking in: 1st 24 hours, sleeps, eats 2. Taking hold: concerned with learning and caring for neonate 3. Letting go: reestablishes relationship with others

serious problems

A low Apgar score indicates

28 cm

A nurse is collecting data on a patient who is 28 weeks pregnant. What would the nurse expect the fundal height to measure in centimeters

Breast Uterus Bladder Bowel Lochia Episiotomy Homan's sign Emotional

BUBBLE-HE (NI= nursing interventions)

Gently massage the fundus to increase contractility

During a postpartum check, the nurse assesses the new mother's uterus and notes it to be boggy. What is the nurse's first intervention

FHT

Fetal heart tones

Lochia Serosa

Pink to brown; lasts for 5 days

Para

The number of births

Third

The placenta is delivered in which stage of labor

Full bladder

What can affect the level of the fundus

Bladder: diuresis with hormonal changes post placental delivery

empty bladder q2h while awake

I can stop taking my vitamins if I have hemorrhoids

A pregnant patient comes into the clinic complaining of constipation. Which statement by the patient indicates the need for further teaching

Gravida

A pregnant woman

lochiah

The term for vaginal discharge after delivery is

Fertilization

What occurs when the sperm fuses with the ovum

Lochia Alba

Slightly yellow to white; lasts 10 days to 2 weeks

Molding

The changes in the fetal skull during delivery are called

Engrossment

The father's behavior when introduced to his new baby is typically an intense fascination. What is this behavior considered

Passage of meconium stool by the fetus

The laboring patient has just had membranes ruptured by the physician. The amniotic fluid is greenish-brown in color. What does this abnormal finding indicate

LOA

The physician is performing the Leopold maneuver on a laboring patient to check for fetal position. What is the most common position for delivery?

TOLAC

Trial of Labor After Cesarean section

Vagina

After a patient's membranes have ruptured, what should the nurse assess

Apply alcohol on the cord stump daily to keep it dry until it falls off.

The nurse teaches care of the umbilical cord to a new mother. What instruction will the nurse provide

Hot shower

What will help with engorgement

Episiotomy: pain, edema, evisceration

data collect area, ice (1st 24 hours, sitz bath after 24 hours)

Hyperemesis gravidarum

A nurse is writing a care plan for a diagnosis of imbalanced nutrition: less than body requirements. What is the most common nutrition-related discomfort of pregnancy

Retained fragments of the placenta

A patient delivered her infant 36 hours ago. She is sitting in bed when she feels a gush of warm fluid between her legs. She calls the nurse, who finds her bleeding. This is an example of late postpartum hemorrhage. What is the most common cause of late postpartum hemorrhage

That is linea nigra, a darkened line from the pubis to the umbilicus, as a result of increased hormones.

A pregnant patient asks the nurse about a darkened line that is seen on her abdomen. What would be the best response

10 weeks

A pregnant patient comes to the clinic for a prenatal visit. At how many weeks' gestation would the patient need to be to hear fetal heart tones using a Doppler scan

Dorsiflex her foot when the cramp occurs.

A pregnant patient comes to the clinic for a prenatal visit. She complains of being frequently awakened at night by leg cramps. What instructions should the nurse give this patient

April 17, 2005

A woman comes to the clinic for her first prenatal visit. The nurse asks when her first day of her last menstrual cycle was. The woman reports July 10, 2004. What would the nurse calculate her estimated date of delivery to be using the Naegele rule

Lightening

A woman who is pregnant informs her friends that the fetus has dropped. The medical term for this is: