PrepU Maternity
Mrs. Smith asks the nurse to compute her expected due date. Based on the fact that her last menstrual flow began on July 20, which due date would the nurse estimate?
A Following Nagel's Rule you would subtract 3 months Add 7 days and add 1 year. 7-3 = 4 20+7 = 27 4/27
A client in labor has received a spinal epidural block. Which nursing intervention should the nurse prioritize after assessing maternal hypotension and changes in the fetal heart rate (FHR)?
Administer supplemental oxygen. Complications of a spinal epidural block include maternal hypotension, which affects the FHR. Supplemental oxygen should be administered to keep oxygenation levels appropriate for the mother and the fetus. The client should be placed in a semi-Fowler's position. Stopping the IV fluid may cause dehydration, and other positions may not have a positive effect on the blood pressure. Raising not lowering the woman's legs would be appropriate.
When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?
Ask the client when she last changed her perineal pad. Explanation: If the morning assessment is done relatively early, it is possible that the client has not yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, would not be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse would not want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client's status.
The nurse will be performing the Leopold's maneuver to determine the position of the fetus. List in order the steps that the nurse would take. All options must be used.
Determine presentation. Determine position. Confirm presentation. Determine attitude.
A client is Rh-negative and has given birth to her newborn. What should the nurse do next
Determine the newborn's blood type and rhesus. The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.
A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?
Fourth-degree laceration. First-degree = only skin & superficial structures above muscle; second-degree extends through perineal muscles; third-degree extends through the anal sphincter muscle but not through the anterior rectal wall.
A woman presents to the clinic in the first trimester of pregnancy. She has three children living at home. One of them was born prematurely at 34 weeks. The other two were full-term at birth. She has a history of one miscarriage. How does the nurse record her obstetric history on the chart using the GTPAL format?
G5 T2 P1 A1 L3 One of the most common methods of recording the obstetric history is to use the acronym GTPAL. "G" stands for gravida, the total number of pregnancies including the current one. "T" stands for term, the number of pregnancies that ended at term (at or beyond 38 weeks' gestation); "P" is for preterm, the number of pregnancies that ended after 20 weeks and before the end of 37 weeks' gestation. "A" represents abortions, the number of pregnancies that ended before 20 weeks' gestation. "L" is for living, the number of children delivered who are alive at the time of history collection.
During contractions, the electronic fetal monitor (EFM) shows variable V-shaped decelerations in the FHR lasting about 30 seconds with accelerations of about 5 bpm before and after each deceleration. Overshoot is absent, and the baseline FHR is within normal limits. What should the nurse do first?When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
Help the woman change positions. Changing positions is a first intervention to determine if this will improve the oxygen to the fetus. Supplemental oxygen should be maintained until the mother is stable. Placing the client on her side may increase the work of breathing. Pharmacological interventions are premature.
The nurse would prepare a client for amnioinfusion when which action occurs?
Severe variable decelerations occur and are due to cord compression. Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.
Which of these cardiac variations, if found in the client who is pregnant, should the nurse recognize as a normal finding in pregnancy
Soft systolic murmur A soft systolic murmur is common in pregnancy secondary to the increased blood volume. The other findings are not normal and require further assessment by the nurse.
The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place?
The uterus contracts and squeezes the cord against the fetus. Explanation: Cord compression is not continuous when variable decelerations are occurring. The compression occurs when the uterus contracts and squeezes the cord against the fetus. It is relieved when the uterus relaxes between contractions. Prematurity and fetal sleep will cause decreased or absent variabilty.
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?
Turn her or ask her to turn to her side. The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.
Which finding would the nurse describe as "light" or "small" lochia?
Typically the amount of lochia is described as follows: Scant: a 1- to 2-inch lochia stain on the pad or a 10 ml loss; Light or small: 4-inch stain or a 10 to 25 ml loss; Moderate: 4- to 6-inch stain with an estimated loss of 25 to 50 ml; Large or heavy: a pad is saturated within 1 hour after changing it.
Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:
assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.
AA client has just received combined spinal epidural. Which nursing assessment should be performed first? client has just received combined spinal epidural. Which nursing assessment should be performed first? A client has just received combined spinal epidural. Which nursing assessment should be performed first?
assess vital signs
The nurse is assessing a client who has given birth within the past hour. The nurse would expect to find the woman's fundus at which location
at the level of the umbilicus After birth, the fundus is located midline between the umbilicus and symphysis pubis but then slowly rises to the level of the umbilicus during the first hour after birth. Then the uterus contracts, approximately 1 cm (or fingerbreadth) each day after birth.
Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature
dehydration Explanation: Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.
The nurse is assessing a client at a postpartum visit who reports constipation. The nurse should point out this is likely related to which factor?
discomfort due to hemorrhoids The nurse should inform the client that the pain of hemorrhoids can contribute to constipation postpartum. Distention of abdominal muscles, separation of rectus muscles, and relaxation of abdominal muscles are pregnancy-related developments and take time to heal; however, they are not related to constipation
The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?
duration Explanation: Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction.
The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness?
increased coagulation factors The woman is showing signs of thromboembolism or deep vein thrombosis which is a risk for the postpartum client due to the increased hypercoagulable state which occurs during the pregnancy. This hypercoagulable state is the result of increased coagulation factors which the body uses as a protective device, however, it also increases the risk of blood clots in the lower extremities. Increased white blood cell count would be suspicious for an infection. Decreased red blood cell count would be expected due to the loss of blood; however, if it continues, then the client should be evaluated for anemia. The stirrups should not cause an injury.
The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring?
intermittent fetal heart rate auscultation
The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?
one fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.
While caring for a woman in labor, the nurse notes that the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is:While caring for a woman in labor, the nurse notes that the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is:
uteroplacental insufficiency. Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?
venous duplex ultrasound of the right leg Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.
Gestational diabetes occurs around the 24th week of gestation. When should every woman be screened for gestational diabetes?
24-28 weeks
A woman states that she still feels exhausted on her second postpartal day. The nurse's best advice for her would be to do which action
Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged
WWhen providing preconception care to a client, the nurse would identify which medication as being safe to continue during pregnancy?
famotidine Famotidine is a category B drug that has been used frequently during pregnancy and does not appear to cause major birth defects or other fetal problems. Isotretinoin and warfarin are category X drugs and should never be taken during pregnancy. Lithium is a category D drug with clear health risks for the fetus and should be avoided during pregnancy.
The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins?
softening of cervix
A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as:A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as:
d) -2 Rationale: When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A 0 station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.
The nurse is analyzing the readout on the EFM and determines the FHR pattern is reassuring based on which recording?
Acceleration of at least 15 bpm for 15 seconds A reassuring active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and reassuring periodic change in fetal heart rates as a response to fetal movement. Normal variability is noted to occur within 6 to 25 bpm from the baseline FHR. There should be no decelerations.
After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching?
"Unfortunately, I'm going to have to stay quite still in bed while it is in place." With continuous internal electronic monitoring, maternal position changes and movement do not interfere with the quality of the tracing. Continuous internal monitoring is considered the most accurate method, but it can be used only if certain criteria are met, such as rupture of membranes. A spiral electrode is inserted into the fetal presenting part, usually the head.
The expected fetal heart rate response in an active fetus is:
of at least 15 bpm for 15 seconds. A reassuring active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and reassuring periodic change in fetal heart rates as a response to fetal movement.
A nursing student is learning about intermittent fetal heart rate monitoring during labor. The student correctly chooses which of the following as used routinely for this procedure? (Select all that apply
Doppler fetoscope fetal monitor Intermittent fetal heart rate ascultation uses fetoscope, Doppler, or fetal monitor. An intrauterine pressure catheter is inserted into a pocket of amniotic fluid and is a continuous internal monitoring of contractions.
A client's maternal serum alpha-fetoprotein (MSAFP) level was unusually elevated at 17 weeks. The nurse suspects which of the following?
Open spinal defects Elevated MSAFP levels are associated with open neural tube defects. Fetal hypoxia would be noted with fetal heart rate tracings and via nonstress and contraction stress testing. MSAFP in conjunction with marker screening tests would be more reliable for detecting Down syndrome. Maternal hypertension would be noted via serial blood pressure monitoring.
roles of progesterone etc
The function of progesterone is to suppress uterine irritability throughout pregnancy. The function of estrogen is to promote oxytocin production and to sensitize the uterus to the effects of oxytocin. Prostaglandin, and not progesterone, stimulates the smooth muscle contractions in the uterus.
When measuring the diagonal conjugate of a woman's pelvis, the distance between which anatomic landmarks would be used?
anterior surface of the sacral prominence and the anterior surface of the symphysis pubis
A nA nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?
atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.
The nurse is caring for a client is who 24-hours post delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time?
hemoglobin and hematocrit Explanation: The health care provider will order a hemoglobin and hematocrit (H&H) levels to assess the woman for potential anemia. A decreased result may indicate the woman has suffered post-delivery hemorrhage and is also common with cesarean deliveries. The maternal blood type will be determined before the delivery. The H&H may be ordered as part of the complete blood count or may be ordered separately. The complete blood count may be order to evaluate for infection if the client has a fever. The iron level may be ordered at a later date if the H&H continues to remain low after a few days, but is not a priority within the first 24 hours after delivery.
Based on the incidence of disease in women, which assessment of lower extremities would be most important to make in a pregnant woman?
presence of varicosities Explanation: During pregnancy, women are prone to develop varicosities because of uterine pressure on lower-extremity veins.
Before administering Rho(D) immune globulin (RhoGAM), a nurse reviews a pregnant client's laboratory data. What combination of factors in the blood directs the need for RhoGAM?
Amniocentesis is an invasive procedure whereby a needle inserted into amniotic sac to obtain a small amount of fluid. This places the pregnancy at risk for a woman with RhD-negative blood, and she should receive RhoGam after the procedure. The CST, NST, and a biophysical profile are noninvasive tests Before administering Rho(D) immune globulin (RhoGAM), a nurse reviews a pregnant client's laboratory data. What combination of factors in the blood directs the need for RhoGAM? 1 Rh positivity and a positive Coombs test result Incorrect2 Rh negativity and a positive Coombs test result 3 Rh positivity and a negative Coombs test result Correct4 Rh negativity and a negative Coombs test result Rho(D) immune globulin (RhoGAM) is administered to prevent active formation of antibodies when an Rh-negative individual is at risk for sensitization. RhoGAM is contraindicated in Rh-positive women because it will cause hemolysis of red blood cells; it is never given to an individual with Rh antibodies. A positive Coombs test result indicates that the woman has Rh antibodies. RhoGAM never is given to an individual with Rh antibodies. RhoGAM is contraindicated in Rh-positive women because it will cause hemolysis of red blood cells.
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations Explanation: Prolonged decelerations are associated with prolonged cord compression, abruptio placentae, cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.
During a nonstress test, when monitoring the fetal heart rate, the nurse notes that when the expectant mother reports fetal movement, the heart rate increases 15 beats or more above the baseline. The nurse interprets this as:
reactive pattern. A reactive nonstress test indicates fetal activity, as evidenced by acceleration of the fetal heart rate by at least 15 bpm for at least 15 seconds within a 20-minute recording period. If this does not occur, the test is considered nonreactive. An increase in the fetal heart rate does not indicate variable decelerations. Fetal tachycardia would be noted as a heart rate greater than 160 bpm.
While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?
taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.
