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ATI MATERNAL NEWBORN PROCTORED EXAM COMPLETE SOLUTION PACKAGE (2022/2023)
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ATI Maternal Newborn Exam1 Verified Q & A
ATI Maternal Newborn Study Guide Chapter 1- contraception • Contraception refers to strategies or device used to reduce the risk of fertilizatio... [Show More] n or implantation in an attempt to prevent pregnancy • Natural family planning: behavioral methods o Abstinence – no gentialia contact o Withdrawal (coitus interruptus) Choice for monogamous couple Least effective methods Risk for pregnancy o Calendar methods ovulation occurs about 14 days before the onset of her next menstrual cycle, and avoid intercourse during that period count at least 6 cycles o basal body temperature body temperature can drop slightly at the time of ovulation measure oral temperature prior to getting out of bed each morning to monitor ovulation inexpensive, convenient, and no adverse effects Basal body temperature and the symptothermal method are fertility awareness methods. o Lactational amenorrhea method • Barrier o Condoms Only water-soluble lubricants should be used with latex condoms to avoid condom breakage o Diaphragm Dome-shaped cup with a flexible rim made of silicon that fits snugly over the cervix with spermicidal cream or gel placed into the dome and around the rim Client should be properly fitted with a diaphragm by a provider Replaced every 2 years and refitted for a 20% weight fluctuation, after abdominal or pelvic surgery and after every pregnancy Prior to coitus, the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim The diaphragm can be inserted up to 6 hours before intercourse and must stay in place 6 hour after intercourse but for no more than 24 hrs. Spermicide must be reapplied with each act of coitus Patient should empty bladder before insertion Wash with soap and water after use o Cervical cap o Contraceptive sponge o Question Which method would the nurse identify as a barrier method of contraception? a. Basal body temperature b. Transdermal patch c. Diaphragm d. Symptothermal method • Hormonal o Oral contraceptives Adverse effect • Chest pain, shortness of breath, leg pain from a possible clot, headache, eye problems form a stroke, and hypertensive, breast tenderness, nausea, breakthrough bleeding (common adverse effects of estrogen component and progestin component) Can increase the risk of thromboembolism, stroke, heart attack, hypertension, gallbladder disease, liver tumor Effectiveness decrease when taking medications that affect liver enzymes, such as anticonvulsants and some antibiotics o Injectable contraceptives Medroxyprogesterone is an IM or SQ injection given to a female client every 11 to 13 weeks • First injection should be during the first 5 days of period • In postpartum, 5 days after delivery Maintain adequate intake of calcium and vitamin D Very effective and require only 4 injections per year Adverse effects • Decrease in bone mineral density, weight gain, increase depression and irregular vaginal spotting or bleeding Contraindicated for osteoporosis patient Return to fertility can be a long as 18 months after discontinuation o Transdermal patches o Vaginal rings o Implantable progestin Minor surgical procedure to subdermally implant and remove a single rod contain etonogestrel on the inner side of the upper arm Disadvantage • Etonogestrel can cause irregular menstrual bleeding Adverse effects • Irregular and unpredictable menstruation (most common) • Mood changes, headache, acne, depression, decreased bone density and weight gain o Intrauterine contraceptives (IUD) A chemically active T-shaped device that is inserted through the cervix and placed in the uterus by the provider Device must be monitored monthly by clients after menstruation to ensure the presence of small string that hangs form the device into the upper part of the vagina to rule out migration or expulsion of the device IUD can maintain effectiveness for 1 to 10 years Contraception can be reversed Can increase the risk of pelvic inflammatory disease, uterine perforation, or ectopic pregnancy and can be expelled A client should report to the provider later or abnormal spotting or bleeding, abdominal pain or pain with intercourse, abnormal of foul-smelling vaginal discharge, fever, chills, a change in string length or if IUD cannot be located IUD can cause irregular menstrual bleeding Must be removed in the event of pregnancy o Emergency contraception Morning-after pill that prevents fertilization from taking place Pill is taken within 72 hr after unprotected coitus • Surgical methods o Tubal ligation Sterilization for women A laprascope is inserted; fallopian tubes are grasped and sealed o Vasectomy Sterilization for men Usually performed under local anesthesia Involves cutting the vas deferens, which carries the sperm Chapter 3 – Expected physiological changes during pregnancy • Signs of pregnancy o Presumptive, probable, positive • Presumptive: those changes felt by the woman o e.g., breast changes (darkened areolae, enlarged Montgomery’s glands), uterine enlarged, quickening (slight fluttering movements of the fetus feld by a woman, usually between 16 to 20 seeks of gestation) o Skipping period is not reliable sign of pregnancy by itself but if it accompanied by nausea, fatigue, breast tenderness, and urinary frequency, pregnancy would see very likely • Probable: those changes observed by an examiner o Hegar’s sign – softening and compressibility of lower uterine segment or isthmus o Ballottement examiner pushes against the women's cervix during a pelvic exam and feels a rebound from the floating fetus rebound of unengaged fetus o abdominal enlargement o Chadwick’s sign – deepened violet-bluish color of cervix and vaginal mucosa o Broxton Hicks contractions – falls contractions that are painless, irregular, and usually relieved by walking o Positive pregnancy test Human chorionic gonadotropin (HcG) is earliest biochemical marker for pregnancy Production begins as early as day of implantation Can be detected in maternal serum or urine as soon as 7 to 8 days before the expected menses Urine sample should be first-voided morning specimens and follow the direction for accuracy o Fetal outline felt by examiner • Positive: those signs attributed only to the presence of the fetus o Confirm that fetus is growing in the uterus o Fetal heart sound - hearing fetal heart tones (via Doppler) o visualizing the fetus by ultrasound o palpating fetal movements (20 weeks) by examiner o Pulse sock on mom to get mom’s HR to ensure it’s not baby’s heart sound • Calculating delivery date and determine number of pregnancies for pregnant client o Nagele’s rule Date of last menstrual period (LMP) Calculation of estimated or expected date of birth (EDB) or delivery (EDD) • Nagele’s rule • Use first day of LNMP 11/21/07 • Subtract 3 months 8/21/07 • Add 7 days 8/28/07 • Adjust year 8/28/08 = EDB Ultrasound is the best method of dating a pregnancy o Kathy’s rule Add 9 months and 7 days o Measurement of fundal height In centimeters form the symphysis pubis to the top of the uterine fundus (between 18 and 32 weeks of gestation) Approximates the gestational age o Gravidity – number of pregnancies Nulligravid – never been pregnant Primigravida – first pregnant Multigravida – two or more pregnant o Parity – number of pregnancies in which the fetus or fetuses reach 20 weeks of pregnancy Nullipara – no pregnancy beyond the stage of viability Primipara – has completed one pregnancy to stage of viability Multi para o Viability – infant has capacity to survive outside of uterus (22 to 25 weeks) o GTPAL acronym Gravidity Term birth (38 weeks or more) Preterm birth (from viability up to 37 weeks) Abortions/miscarriages (prior to viability) Living children • Blood pressure o Position of pregnant woman affect blood pressure o In Supine position, blood pressure might appear to be lower due to the weight and pressure of the gravid uterus on the vena cava, which pressures venous blood flow to the heart o Maternal hypotension and fetal hypoxia might occur, which is referred to as supine hypotensive syndrome or supine vena cava syndrome o Signs and symptoms include Dizziness, lightheadness, and pale, clammy skin o Encourage client to engage in maternal positioning on the left-lateral side, semi-fowler’s position o if supine, with a wedge placed under one hip to alleviate pressure of the vena cava • fetal heart tone o 110 to 160/min with reassuring FHR accelerations noted, which indicates an intact fetal CNS • By 36 weeks gestation, the top of uterus and the fundus will reach the xiphoid process o This cause pregnant woman to experience shortness of breath as the uterus pushes against the diaphragm • Skin changes o Chloasma – increase of pigmentation on the face o Linea nigra – dark line of pigmentation from the umbilicus extending to the pubic area o Striae gravidarum – stretch marks most notably found on the abdomen and thighs • Client is encouraged to keep all follow-up appointments and to contact the provider immediately if there is any bleeding, leakage of fluid, or contractions at any time during the pregnancy Chapter 5 • Recommended weight gain during pregnancy o Healthy weight BMI: 25 to 35 lb First trimester: 3.5 to 5 lb Second and third trimesters: 1 lb/wk o BMI <19.8: 28 to 40 lb First trimester: 5 lb Second and third trimesters: 1+ lb/wk o BMI >25: 15 to 25 lb First trimester: 2 lb Second and third trimesters: 2/3 lb/wk • Client education o Increase calories Second trimester – increase 340 cal/day Third trimester – increase to 450 cal/day During breastfeeding women should well nourished should be added 450 to 500 cal/day to a balanced diet o Increasing protein intake High in folic acid is important for neurological development and prevent fetal neural tube defects Foods – green leafy vegetables, dried peas and beans, seeds, orange juice Women who wish to become pregnant of childbearing age take 400 mcg of folic acid Women who become pregnant take 600 mcg of folic acid to prevent fetal neural tube defects o Iron supplements Best absorbed between meals and when given with a source of vitamin C (orange juice) Foods – beef liver, red meat, fish, poultry, dried peas and beans and fortified cereals Stool softener might need to be added to decrease constipation with iron supplement o Calcium Foods – milk, nuts, legumes and dark green leafy vegetables Postpartum women who are breastfeeding should continue taking calcium supplement during lactation o Fluid 8 to 10 glasses (2.3 L) of fluids are recommended daily o Limit caffeine Recommend daily intake of no more than 200 mg of caffeine It is recommended that women abstain form alcohol consumption during pregnancy Chapter 6 – Assessment of fetal well-being • Ultrasound o client should have full bladder for the procedure o fetal and maternal structures can be pointed out to the client as the US procedure is performed • Biophysical profile o Uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli o Client presentation Premature rupture of membranes Maternal infection Decreased fetal movement Intrauterine growth restriction o Variables FHR Fetal breathing movements Gross body movements Fetal tone Qualitative amniotic fluid volume o Total score findings 8 to 10 is normal – low risk of chronic fetal asphyxia 4 to 6 is abnormal – suspect chronic fetal asphyxia Less than 4 is abnormal – strongly suspect chronic fetal asphyxia • Nonstress test o Most widely used technique for antepartum evaluation of fetal well-being performed during the 3rd trimester o Noninvasive procedure that monitors response of the FHR to fetal movement o Disadvantage of an NST include a high rate of false nonreactive results with the fetal movement response blunted by sleep cycles of the fetus, fetal immaturity, maternal medications and nicotine use disorder The acoustic vibration device is activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus • Contraction stress test o Nipple-stimulated contraction test Consists of a woman lightly brushing her palm across her nipple for 2 min, which cause the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins o Oxytocin-stimulated contraction test IV administration of oxytocin to induce uterine contractions Oxytocin is used to induce uterine contraction Contraindicated for placenta previa, vasa previa, preterm labor, multiple gestations, previous classic incisions for C-section, reduced cervical competence Can be difficult to stop and may lead to preterm labor Negative results are a normal finding Positive result is an abnormal finding o Indication for contraction stress test (CST) Decreased fetal movement Intrauterine growth restriction (IUGR) Postmaturity • Amniocentesis o Aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client’s uterus and amniotic sac under ultrasound guidance locating the placenta and determining the position of the fetus o It may be performed after 14 weeks of gestation o Indications Prenatal diagnosis of genetic disorder or congenital anomaly of the fetus Alpha-fetoprotein (AFP) level for fetal abnormalities • High AFP – neural tube defect • Low AFP – down syndrome Lung maturity assessment o Instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture o Post procedure Administer Rho(D) immune globulin to the client if she is Rh-negative (standing practice after an amniocentesis for all women who are Rh-negative to protect against Rh isoimmunization) RhoGAM is giving to Rh- moms at 28 weeks gestation after amniocentesis and after delivery to protect mon against baby’s blood of bay is Rh+ o Complications Amniotic fluid emboli Maternal or fetal hemorrhage Maternal or fetal infection Miscarriage or preterm labor Premature rupture of membrane Leakage of amniotic fluid o A test of the L/S ratio is done as part of amniocentesis to determine fetal lung maturity • High-risk pregnancy; chorionic villus sampling o CVS is ideally performed at 10 to 23 weeks of gestation o Indications Risk for giving birth to a neonate who has a genetic chromosomal abnormality • Monitoring for adverse effects of substance use disorders o Substance use is a risk factor that can leads to spontaneous abortion and abruptio placentae o Teach patient to watch for Vaginal bleeding uterine craping, partial/complete expulsion of products of conception sharp abdominal pain, and tender rigid uterus Chapter 7 – Bleeding During Pregnancy • Ectopic pregnancy o Ectopic pregnancy is abnormal implantation of a fertilization ovum outside of the uterine cavity usually in the fallopian tube, which can result in a tubal rupture causing a fetal hemorrhage o Unilateral stabbing pain and tenderness in the lower-abdominal quadrant o Instruct client who is taking methotrexate to avoid alcohol consumption and vitamins containing folic acid to prevent a toxic response to the medication • Molar growth o Bleeding is often dark brown resembling prune juice o Bright red that is either scant or profuse and continues for few days or intermittently for a few weeks and can be accompanied by passage of vesicles • Placenta previa o Placenta a previa occurs when the placenta abnormally implants in the lower segment of the uterus near of over the cervical os instead of attaching to the fundus Complete or total – cervical os is completely covered by the placental attachment Incomplete or partial – cervical os is only partially covered by the placental attachment o Painless, bright red vaginal bleeding during the 2nd and 3rd trimester o Refrain from performing vaginal exams – can exacerbate bleeding o Administer IV fluids blood products, and medications as prescribed Corticosteroids, such as betamethasone, promote fetal lung maturation if early delivery is anticipated (cesarean birth) • Abruptio placentae o Abruptio placentae is the premature separation of the placenta from the uterus o It has significant material and fetal morbidity and mortality and is a leading cause of maternal death o Sudden onset of intense localized uterine pain with dark red vaginal bleeding o Risk factors Blunt external abdominal trauma (motor-vehicle crash, maternal battering) Cocaine use resulting in vasoconstriction Smoking cigarette Maternal hypertension (chronic or gestational) Previous incidence of abruptio placentae Premature rupture of membrane Multifetal pregnancy Chapter 9 – Medical conditions • Cervical insufficiency (premature cervical dilation) o The client can require cervical cerclage (indicated for women who have singleton pregnancy) o Often placed at 12 to 14 weeks gestation and removed at 37 weeks gestation o Provide education about clinical findings to report to the provider for preterm labor rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, and an urge to push • Hyperemesis gravidarum o hyperemesis gravidarum is excessive nausea and vomiting (possibly related to elevated hCG levels) that is prolonged past 12 weeks gestation and results in 5% weight loss from pre-pregnancy weight, electrolyte imbalance, acetonuria and ketosis o Risk factors maternal age younger than 30, history or migraines, obesity, first pregnancy, diabetes, multigestation, GI disorders, or family history of hyperemesis monitor patient I&O, assess skin turgor, weight and vital signs o laboratory test Urinalysis for ketones and acetones (breakdown of PR and fat) is the most important lab test - Elevated urine specific gravity, urine ketone present Chemistry profile Thyroid test – indicate hyperthyroidism CBC (complete blood count) – elevated Hct o Nursing care Monitor I&O Assess skin turgor and mucous membranes Monitor vital signs Monitor weight Have the client remain NPO for 24 to 48 hours Clear liquid after 24 if no vomiting and increase diet if tolerated o Medications Give the client IV lactated ringer’s for hydration Give pyridoxine (vitamin B6) and another vitamin supplement s as tolerated Use antiemetic medications (ondansetron, metoclopramide) cautiously for uncontrollable nausea and vomiting Use corticosteroid to treat refractory hyperemesis gravidarum o Advance the client’s diet as tolerated, with frequent small meals – start with dry toast, crackers, or cereal; then move to a soft diet; and finally, to a normal diet as tolerated • Iron-deficiency anemia o Occurs during pregnancy due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron o Foods – legumes, fruits, green leafy veggies, and meat o Medications Ferrous sulfate iron supplements • Instruct the client to take the supplement on an empty stomach and take with orange juice to increase absorption • Encourage a diet rich in vitamin C- containing foods to increase absorption • Gestational diabetes mellitus o Gestational diabetes mellitus (GDM) is an impaired tolerance to glucose with the first onset or recognition during pregnancy Normal glucose during pregnancy – 70 to 110 mg/dL Women will develop type II diabetes mellitus within 5 years of delivery o Laboratory tests Glucola screening test/1-hr glucose tolerance test • 50 g oral glucose load, followed by plasma glucose analysis 1 hour later perforated 24 to 28 weeks of gestation • Fasting is not necessary • Positive blood glucose screening is 130 to 140 mg/dL or greater • Additional testing with a 3-hr oral glucose tolerance test (OGTT) is indicated Oral glucose tolerance test (OGTT) • Following overnight fasting • Avoid caffeine and abstinence from smoking for 12 hr prior to testing • Fasting glucose is obtained, a 100g glucose load is given and serum glucose levels are determined at 1,2, and 3 hr following glucose ingestion o Diagnostic procedures Biophysical profile to ascertain fetal well-being Nonstress test to assess fetal well-being o Medication Oral hypoglycemic therapy is an alternation to insulin in women who have GDM who require medication in addition to diet for blood glucose control Most oral hypoglycemic agents are contraindicated for gestational diabetes mellitus, but there is limited use of glyburide. • Gestational hypertension o Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the manifestations of pregnancy hyper tensive disorders o Gestational hypertension (GH) After 20th weeks of pregnancy Elevated BP at 140/90 mmHg or greater recorded on 2 different occasions at least 4 hr apart Not proteinuria o Mild preeclampsia GH with addition of Proteinuria of greater than or equal to 1+ o Severe preeclampsia Bp 160/110 mmHg or greater Proteinuria greater than 3+ Elevated serum creatinine greater than 1.1 gm/dL Cerebral visual disturbances (headache and blurred vision) Hyperreflexia with possible ankle clonus Pulmonary or cardiac involvement Extensive peripheral edema Hepatic dysfunction Epigastric and right upper-quadrant pain and thrombocytopenia o Eclampsia Severe preeclampsia manifestation with the onset of seizure activity or coma o Help syndrome H: Hemolysis – resulting in anemia and jaundice EL: Elevated liver enzyme – ALT, AST LP: Low platelet (less than 100,000) o Laboratory Liver enzyme – elevated AST, LDH Serum creatinine, BUN, uric acid, magnesium increases as renal function decreases CBC Clotting studies – thrombocytopenia Chemistry profile – decreased Hgb, hyperbilirubinemia o Medication Anti-hypertensive medication • Methyldopa • Nifedipine • Hydralazine • Labetalol Avoid ACE inhibitors and angiotensin II receptor blockers Anticonvulsant • Magnesium sulfate • Medication of choice for prophylaxis or treatment to lower blood pressure and depress the CNS • Monitor for signs of magnesium sulfate toxicity o Absence of patella deep tendon reflexes o Urine output less than 30 mg/hr o RR less than 12/min o Decrease level of consciousness o Cardiac dysrhythmias • Antidote – calcium gluconate or calcium chloride o Client education Maintain bed rest and encourage side-lying position Promote diversional activities (TV, visits form family or friends, gentle exercise) Avoid foods that are high in sodium Avoid tobacco and alcohol and limit caffeine intake Drink 6 to 8 oz glasses of water a day Maintain dark, quiet environment to avoid inducing a seizure Maintain a patent airway in the event of seizure Administer antihypertensive medications as prescribed Chapter 10 – Early Onset of Labor • Preterm labor o Preterm labor is uterine contraction and cervical changes that occur between 20 and 37 weeks of gestation o Assessment of preterm labor Previous preterm birth Multifetal pregnancy Substance use History of multiple miscarriages or abortions Diabetes mellitus Chronic hypertension Second trimester bleeding History of UTI o o Expected findings – uterine contraction o Diagnostic procedures Obtain swab of vaginal secretions for fetal fibronectin between 24 and 34 weeks of gestation This protein can be found in vaginal secretions and can be related to inflammation of the placenta and that can lead to preterm birth This test is used to determine preterm labor o Nursing care Focusing on stopping uterine contraction Activity restriction • Strict bed rest can have adverse effects • Encourage the client to rest in the left lateral position to increase blood flow to the uterus and decrease uterine activity Ensuring hydration • Dehydration stimulate the pituitary gland to secret and antidiuretic hormone and oxytocin o Medication Nifedipine • Calcium channel blocker • Used to suppress contractions by in habiting calcium form entering smooth muscles • Nursing consideration o Monitor for headache, flushing, dizziness and nausea o These usually are related to orthostatic hypotension that occurs with administration Magnesium sulfate • Commonly used tocolytic that relaxes the smooth muscle of the uterus and thus inhibits uterine activity by suppressing contraction • Nursing consideration o Contraindications for tocolysis include active vaginal bleeding, dilation of the cervix greater than 6 cm, chorioamnionitis, greater then 34 weeks gestation and acute fetal distress o Monitor for client for magnesium toxicity and discontinue for any of the following adverse effects Loss of deep tendon reflexes Urinary output less than 30 ml/hr Respiratory depression (less than 12/min) Pulmonary edema and chest pain o Administer gluconate of calcium chloride as and antidote for magnesium sulfate toxicity • Notify provider – blurred vision, headache, nausea, vomiting, or difficulty breathing Indomethacin • Non-steroidal anti-inflammation drug (NSAID) • Suppress preterm labor by blocking the production of prostaglandins • This inhibition of the prostaglandins suppresses uterine contraction Betamethasone • Enhance fetal lung maturity and surfactant production in fetuses between 24 to 34 weeks gestation • Premature rupture of membranes o Client reports a gush or leakage of clear fluids from the vagina Temperature elevation Increased maternal hear rate or FHR Foul-smelling fluid or vaginal discharge Abdominal tenderness o Positive nitrazine paper test (blue, pH 6.5 to 7.5) or positive forming test is conducted on amniotic fluid to verify rupture of membranes o Medications Ampicillin is an antibiotic uses to treat infection Betamethasone • Glucocorticoid administered IM in 2 injections • Enhance fetal lung maturity and surfactant production o Tell the client to record daily kick counts for fetal movement Chapter 11 – Labor and Delivery Process • Stages of labor o First stage (onset of labor to complete dilation) Latent phase (0 to 3 cm) • Onset of labor – contractions irregular and mild to moderate • Woman is talkative and eager Active phase (4 cm to 7 cm) • Contractions – regular moderate to strong • Woman feeling of helplessness • Anxiety and restlessness increase as contraction become stronger Transition phase (8cm to 10 cm) • Complete dilation • Feeling out of control, client often states “cannot continue” • Urge to push increased rectal pressure and feelings of needing to have a bowel movement o Second stage Full dilation to birth o Third stage Delivery of the neonate to delivery of placenta o Fourth stage Delivery of placenta to maternal stabilization of vital signs • Physiologic changes preceding labor (premonitoring sign) o Backache, weight loss o Lightening fetal head descends into true pelvis about 14 days before labor feeling that the fetus has “dropped” easier breathing but more pressure on bladder resulting urinary frequency o contraction – begin with irregular uterine contractions (Braxton Hicks) o increased vaginal discharge or bloody show o energy burst o gastrointestinal changes – nausea, vomiting and indigestion o Cervical ripening- cervix become soft (opens) and partially effaced and can begin to dilate o Rupture of membrane Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse o Assessment of amniotic fluid [Show Less]
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ATI MATERNAL NEWBORN OB EXAM 2 ACTUAL EXAM (SCREENSHOTS) 100- VERIFIED Q & A (2022-2023) A++
ATI MATERNAL NEWBORN OB EXAM 2 ACTUAL EXAM (SCREENSHOTS) 100- VERIFIED Q & A (2022-2023) A++
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ATI Maternal Newborn Study Guide
ATI Maternal Newborn Study Guide ATI Maternal Newborn Study Guide Chapter 1- contraception • Contraception refers to strategies or device u... [Show More] sed to reduce the risk of fertilization or implantation in an attempt to prevent pregnancy • Natural family planning: behavioral methods o Abstinence – no gentialia contact o Withdrawal (coitus interruptus) Choice for monogamous couple Least effective methods Risk for pregnancy o Calendar methods ovulation occurs about 14 days before the onset of her next menstrual cycle, and avoid intercourse during that period count at least 6 cycles o basal body temperature body temperature can drop slightly at the time of ovulation measure oral temperature prior to getting out of bed each morning to monitor ovulation inexpensive, convenient, and no adverse effects Basal body temperature and the symptothermal method are fertility awareness methods. o Lactational amenorrhea method • Barrier o Condoms Only water-soluble lubricants should be used with latex condoms to avoid condom breakage o Diaphragm Dome-shaped cup with a flexible rim made of silicon that fits snugly over the cervix with spermicidal cream or gel placed into the dome and around the rim Client should be properly fitted with a diaphragm by a provider Replaced every 2 years and refitted for a 20% weight fluctuation, after abdominal or pelvic surgery and after every pregnancy Prior to coitus, the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim The diaphragm can be inserted up to 6 hours before intercourse and must stay in place 6 hour after intercourse but for no more than 24 hrs. Spermicide must be reapplied with each act of coitus Patient should empty bladder before insertion Wash with soap and water after use o Cervical cap o Contraceptive sponge o Question Which method would the nurse identify as a barrier method of contraception? a. Basal body temperature b. Transdermal patch c. Diaphragm d. Symptothermal method • Hormonal o Oral contraceptives Adverse effect • Chest pain, shortness of breath, leg pain from a possible clot, headache, eye problems form a stroke, and hypertensive, breast tenderness, nausea, breakthrough bleeding (common adverse effects of estrogen component and progestin component) Can increase the risk of thromboembolism, stroke, heart attack, hypertension, gallbladder disease, liver tumor Effectiveness decrease when taking medications that affect liver enzymes, such as anticonvulsants and some antibiotics o Injectable contraceptives Medroxyprogesterone is an IM or SQ injection given to a female client every 11 to 13 weeks • First injection should be during the first 5 days of period • In postpartum, 5 days after delivery Maintain adequate intake of calcium and vitamin D Very effective and require only 4 injections per year Adverse effects • Decrease in bone mineral density, weight gain, increase depression and irregular vaginal spotting or bleeding Contraindicated for osteoporosis patient Return to fertility can be a long as 18 months after discontinuation o Transdermal patches o Vaginal rings o Implantable progestin Minor surgical procedure to subdermally implant and remove a single rod contain etonogestrel on the inner side of the upper arm Disadvantage • Etonogestrel can cause irregular menstrual bleeding Adverse effects • Irregular and unpredictable menstruation (most common) • Mood changes, headache, acne, depression, decreased bone density and weight gain o Intrauterine contraceptives (IUD) A chemically active T-shaped device that is inserted through the cervix and placed in the uterus by the provider Device must be monitored monthly by clients after menstruation to ensure the presence of small string that hangs form the device into the upper part of the vagina to rule out migration or expulsion of the device IUD can maintain effectiveness for 1 to 10 years Contraception can be reversed Can increase the risk of pelvic inflammatory disease, uterine perforation, or ectopic pregnancy and can be expelled A client should report to the provider later or abnormal spotting or bleeding, abdominal pain or pain with intercourse, abnormal of foul-smelling vaginal discharge, fever, chills, a change in string length or if IUD cannot be located IUD can cause irregular menstrual bleeding Must be removed in the event of pregnancy o Emergency contraception Morning-after pill that prevents fertilization from taking place Pill is taken within 72 hr after unprotected coitus • Surgical methods o Tubal ligation Sterilization for women A laprascope is inserted; fallopian tubes are grasped and sealed o Vasectomy Sterilization for men Usually performed under local anesthesia Involves cutting the vas deferens, which carries the sperm Chapter 3 – Expected physiological changes during pregnancy • Signs of pregnancy o Presumptive, probable, positive • Presumptive: those changes felt by the woman o e.g., breast changes (darkened areolae, enlarged Montgomery’s glands), uterine enlarged, quickening (slight fluttering movements of the fetus feld by a woman, usually between 16 to 20 seeks of gestation) o Skipping period is not reliable sign of pregnancy by itself but if it accompanied by nausea, fatigue, breast tenderness, and urinary frequency, pregnancy would see very likely • Probable: those changes observed by an examiner o Hegar’s sign – softening and compressibility of lower uterine segment or isthmus o Ballottement examiner pushes against the women's cervix during a pelvic exam and feels a rebound from the floating fetus rebound of unengaged fetus o abdominal enlargement o Chadwick’s sign – deepened violet-bluish color of cervix and vaginal mucosa o Broxton Hicks contractions – falls contractions that are painless, irregular, and usually relieved by walking o Positive pregnancy test Human chorionic gonadotropin (HcG) is earliest biochemical marker for pregnancy Production begins as early as day of implantation Can be detected in maternal serum or urine as soon as 7 to 8 days before the expected menses Urine sample should be first-voided morning specimens and follow the direction for accuracy o Fetal outline felt by examiner • Positive: those signs attributed only to the presence of the fetus o Confirm that fetus is growing in the uterus o Fetal heart sound - hearing fetal heart tones (via Doppler) o visualizing the fetus by ultrasound o palpating fetal movements (20 weeks) by examiner o Pulse sock on mom to get mom’s HR to ensure it’s not baby’s heart sound • Calculating delivery date and determine number of pregnancies for pregnant client o Nagele’s rule Date of last menstrual period (LMP) Calculation of estimated or expected date of birth (EDB) or delivery (EDD) • Nagele’s rule • Use first day of LNMP 11/21/07 • Subtract 3 months 8/21/07 • Add 7 days 8/28/07 • Adjust year 8/28/08 = EDB Ultrasound is the best method of dating a pregnancy o Kathy’s rule Add 9 months and 7 days o Measurement of fundal height In centimeters form the symphysis pubis to the top of the uterine fundus (between 18 and 32 weeks of gestation) Approximates the gestational age o Gravidity – number of pregnancies Nulligravid – never been pregnant Primigravida – first pregnant Multigravida – two or more pregnant o Parity – number of pregnancies in which the fetus or fetuses reach 20 weeks of pregnancy Nullipara – no pregnancy beyond the stage of viability Primipara – has completed one pregnancy to stage of viability Multi para o Viability – infant has capacity to survive outside of uterus (22 to 25 weeks) o GTPAL acronym Gravidity Term birth (38 weeks or more) Preterm birth (from viability up to 37 weeks) Abortions/miscarriages (prior to viability) Living children • Blood pressure o Position of pregnant woman affect blood pressure o In Supine position, blood pressure might appear to be lower due to the weight and pressure of the gravid uterus on the vena cava, which pressures venous blood flow to the heart o Maternal hypotension and fetal hypoxia might occur, which is referred to as supine hypotensive syndrome or supine vena cava syndrome o Signs and symptoms include Dizziness, lightheadness, and pale, clammy skin o Encourage client to engage in maternal positioning on the left-lateral side, semi-fowler’s position o if supine, with a wedge placed under one hip to alleviate pressure of the vena cava • fetal heart tone o 110 to 160/min with reassuring FHR accelerations noted, which indicates an intact fetal CNS • By 36 weeks gestation, the top of uterus and the fundus will reach the xiphoid process o This cause pregnant woman to experience shortness of breath as the uterus pushes against the diaphragm • Skin changes o Chloasma – increase of pigmentation on the face o Linea nigra – dark line of pigmentation from the umbilicus extending to the pubic area o Striae gravidarum – stretch marks most notably found on the abdomen and thighs • Client is encouraged to keep all follow-up appointments and to contact the provider immediately if there is any bleeding, leakage of fluid, or contractions at any time during the pregnancy Chapter 5 • Recommended weight gain during pregnancy o Healthy weight BMI: 25 to 35 lb First trimester: 3.5 to 5 lb Second and third trimesters: 1 lb/wk o BMI <19.8: 28 to 40 lb First trimester: 5 lb Second and third trimesters: 1+ lb/wk o BMI >25: 15 to 25 lb First trimester: 2 lb Second and third trimesters: 2/3 lb/wk • Client education o Increase calories Second trimester – increase 340 cal/day Third trimester – increase to 450 cal/day During breastfeeding women should well nourished should be added 450 to 500 cal/day to a balanced diet o Increasing protein intake High in folic acid is important for neurological development and prevent fetal neural tube defects Foods – green leafy vegetables, dried peas and beans, seeds, orange juice Women who wish to become pregnant of childbearing age take 400 mcg of folic acid Women who become pregnant take 600 mcg of folic acid to prevent fetal neural tube defects o Iron supplements Best absorbed between meals and when given with a source of vitamin C (orange juice) Foods – beef liver, red meat, fish, poultry, dried peas and beans and fortified cereals Stool softener might need to be added to decrease constipation with iron supplement o Calcium Foods – milk, nuts, legumes and dark green leafy vegetables Postpartum women who are breastfeeding should continue taking calcium supplement during lactation o Fluid 8 to 10 glasses (2.3 L) of fluids are recommended daily o Limit caffeine Recommend daily intake of no more than 200 mg of caffeine It is recommended that women abstain form alcohol consumption during pregnancy Chapter 6 – Assessment of fetal well-being • Ultrasound o client should have full bladder for the procedure o fetal and maternal structures can be pointed out to the client as the US procedure is performed • Biophysical profile o Uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli o Client presentation Premature rupture of membranes Maternal infection Decreased fetal movement Intrauterine growth restriction o Variables FHR Fetal breathing movements Gross body movements Fetal tone Qualitative amniotic fluid volume o Total score findings 8 to 10 is normal – low risk of chronic fetal asphyxia 4 to 6 is abnormal – suspect chronic fetal asphyxia Less than 4 is abnormal – strongly suspect chronic fetal asphyxia • Nonstress test o Most widely used technique for antepartum evaluation of fetal well-being performed during the 3rd trimester o Noninvasive procedure that monitors response of the FHR to fetal movement o Disadvantage of an NST include a high rate of false nonreactive results with the fetal movement response blunted by sleep cycles of the fetus, fetal immaturity, maternal medications and nicotine use disorder The acoustic vibration device is activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus • Contraction stress test o Nipple-stimulated contraction test Consists of a woman lightly brushing her palm across her nipple for 2 min, which cause the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins o Oxytocin-stimulated contraction test IV administration of oxytocin to induce uterine contractions Oxytocin is used to induce uterine contraction Contraindicated for placenta previa, vasa previa, preterm labor, multiple gestations, previous classic incisions for C-section, reduced cervical competence Can be difficult to stop and may lead to preterm labor Negative results are a normal finding Positive result is an abnormal finding o Indication for contraction stress test (CST) Decreased fetal movement Intrauterine growth restriction (IUGR) Postmaturity • Amniocentesis o Aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client’s uterus and amniotic sac under ultrasound guidance locating the placenta and determining the position of the fetus o It may be performed after 14 weeks of gestation o Indications Prenatal diagnosis of genetic disorder or congenital anomaly of the fetus Alpha-fetoprotein (AFP) level for fetal abnormalities • High AFP – neural tube defect • Low AFP – down syndrome Lung maturity assessment o Instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture o Post procedure Administer Rho(D) immune globulin to the client if she is Rh-negative (standing practice after an amniocentesis for all women who are Rh-negative to protect against Rh isoimmunization) RhoGAM is giving to Rh- moms at 28 weeks gestation after amniocentesis and after delivery to protect mon against baby’s blood of bay is Rh+ o Complications Amniotic fluid emboli Maternal or fetal hemorrhage Maternal or fetal infection Miscarriage or preterm labor Premature rupture of membrane Leakage of amniotic fluid o A test of the L/S ratio is done as part of amniocentesis to determine fetal lung maturity • High-risk pregnancy; chorionic villus sampling o CVS is ideally performed at 10 to 23 weeks of gestation o Indications Risk for giving birth to a neonate who has a genetic chromosomal abnormality • Monitoring for adverse effects of substance use disorders o Substance use is a risk factor that can leads to spontaneous abortion and abruptio placentae o Teach patient to watch for Vaginal bleeding uterine craping, partial/complete expulsion of products of conception sharp abdominal pain, and tender rigid uterus Chapter 7 – Bleeding During Pregnancy • Ectopic pregnancy o Ectopic pregnancy is abnormal implantation of a fertilization ovum outside of the uterine cavity usually in the fallopian tube, which can result in a tubal rupture causing a fetal hemorrhage o Unilateral stabbing pain and tenderness in the lower-abdominal quadrant o Instruct client who is taking methotrexate to avoid alcohol consumption and vitamins containing folic acid to prevent a toxic response to the medication • Molar growth o Bleeding is often dark brown resembling prune juice o Bright red that is either scant or profuse and continues for few days or intermittently for a few weeks and can be accompanied by passage of vesicles • Placenta previa o Placenta a previa occurs when the placenta abnormally implants in the lower segment of the uterus near of over the cervical os instead of attaching to the fundus Complete or total – cervical os is completely covered by the placental attachment Incomplete or partial – cervical os is only partially covered by the placental attachment o Painless, bright red vaginal bleeding during the 2nd and 3rd trimester o Refrain from performing vaginal exams – can exacerbate bleeding o Administer IV fluids blood products, and medications as prescribed Corticosteroids, such as betamethasone, promote fetal lung maturation if early delivery is anticipated (cesarean birth) • Abruptio placentae o Abruptio placentae is the premature separation of the placenta from the uterus o It has significant material and fetal morbidity and mortality and is a leading cause of maternal death o Sudden onset of intense localized uterine pain with dark red vaginal bleeding o Risk factors Blunt external abdominal trauma (motor-vehicle crash, maternal battering) Cocaine use resulting in vasoconstriction Smoking cigarette Maternal hypertension (chronic or gestational) Previous incidence of abruptio placentae Premature rupture of membrane Multifetal pregnancy Chapter 9 – Medical conditions • Cervical insufficiency (premature cervical dilation) o The client can require cervical cerclage (indicated for women who have singleton pregnancy) o Often placed at 12 to 14 weeks gestation and removed at 37 weeks gestation o Provide education about clinical findings to report to the provider for preterm labor rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, and an urge to push • Hyperemesis gravidarum o hyperemesis gravidarum is excessive nausea and vomiting (possibly related to elevated hCG levels) that is prolonged past 12 weeks gestation and results in 5% weight loss from pre-pregnancy weight, electrolyte imbalance, acetonuria and ketosis o Risk factors maternal age younger than 30, history or migraines, obesity, first pregnancy, diabetes, multigestation, GI disorders, or family history of hyperemesis monitor patient I&O, assess skin turgor, weight and vital signs o laboratory test Urinalysis for ketones and acetones (breakdown of PR and fat) is the most important lab test - Elevated urine specific gravity, urine ketone present Chemistry profile Thyroid test – indicate hyperthyroidism CBC (complete blood count) – elevated Hct o Nursing care Monitor I&O Assess skin turgor and mucous membranes Monitor vital signs Monitor weight Have the client remain NPO for 24 to 48 hours Clear liquid after 24 if no vomiting and increase diet if tolerated o Medications Give the client IV lactated ringer’s for hydration Give pyridoxine (vitamin B6) and another vitamin supplement s as tolerated Use antiemetic medications (ondansetron, metoclopramide) cautiously for uncontrollable nausea and vomiting Use corticosteroid to treat refractory hyperemesis gravidarum o Advance the client’s diet as tolerated, with frequent small meals – start with dry toast, crackers, or cereal; then move to a soft diet; and finally, to a normal diet as tolerated • Iron-deficiency anemia o Occurs during pregnancy due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron o Foods – legumes, fruits, green leafy veggies, and meat o Medications Ferrous sulfate iron supplements • Instruct the client to take the supplement on an empty stomach and take with orange juice to increase absorption • Encourage a diet rich in vitamin C- containing foods to increase absorption • Gestational diabetes mellitus o Gestational diabetes mellitus (GDM) is an impaired tolerance to glucose with the first onset or recognition during pregnancy Normal glucose during pregnancy – 70 to 110 mg/dL Women will develop type II diabetes mellitus within 5 years of delivery o Laboratory tests Glucola screening test/1-hr glucose tolerance test • 50 g oral glucose load, followed by plasma glucose analysis 1 hour later perforated 24 to 28 weeks of gestation • Fasting is not necessary • Positive blood glucose screening is 130 to 140 mg/dL or greater • Additional testing with a 3-hr oral glucose tolerance test (OGTT) is indicated Oral glucose tolerance test (OGTT) • Following overnight fasting • Avoid caffeine and abstinence from smoking for 12 hr prior to testing • Fasting glucose is obtained, a 100g glucose load is given and serum glucose levels are determined at 1,2, and 3 hr following glucose ingestion o Diagnostic procedures Biophysical profile to ascertain fetal well-being Nonstress test to assess fetal well-being o Medication Oral hypoglycemic therapy is an alternation to insulin in women who have GDM who require medication in addition to diet for blood glucose control Most oral hypoglycemic agents are contraindicated for gestational diabetes mellitus, but there is limited use of glyburide. • Gestational hypertension o Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the manifestations of pregnancy hyper tensive disorders o Gestational hypertension (GH) After 20th weeks of pregnancy Elevated BP at 140/90 mmHg or greater recorded on 2 different occasions at least 4 hr apart Not proteinuria o Mild preeclampsia GH with addition of Proteinuria of greater than or equal to 1+ o Severe preeclampsia Bp 160/110 mmHg or greater Proteinuria greater than 3+ Elevated serum creatinine greater than 1.1 gm/dL Cerebral visual disturbances (headache and blurred vision) Hyperreflexia with possible ankle clonus Pulmonary or cardiac involvement Extensive peripheral edema Hepatic dysfunction Epigastric and right upper-quadrant pain and thrombocytopenia o Eclampsia Severe preeclampsia manifestation with the onset of seizure activity or coma o Help syndrome H: Hemolysis – resulting in anemia and jaundice EL: Elevated liver enzyme – ALT, AST LP: Low platelet (less than 100,000) o Laboratory Liver enzyme – elevated AST, LDH Serum creatinine, BUN, uric acid, magnesium increases as renal function decreases CBC Clotting studies – thrombocytopenia Chemistry profile – decreased Hgb, hyperbilirubinemia o Medication Anti-hypertensive medication • Methyldopa • Nifedipine • Hydralazine • Labetalol Avoid ACE inhibitors and angiotensin II receptor blockers Anticonvulsant • Magnesium sulfate • Medication of choice for prophylaxis or treatment to lower blood pressure and depress the CNS • Monitor for signs of magnesium sulfate toxicity o Absence of patella deep tendon reflexes o Urine output less than 30 mg/hr o RR less than 12/min o Decrease level of consciousness o Cardiac dysrhythmias • Antidote – calcium gluconate or calcium chloride o Client education Maintain bed rest and encourage side-lying position Promote diversional activities (TV, visits form family or friends, gentle exercise) Avoid foods that are high in sodium Avoid tobacco and alcohol and limit caffeine intake Drink 6 to 8 oz glasses of water a day Maintain dark, quiet environment to avoid inducing a seizure Maintain a patent airway in the event of seizure Administer antihypertensive medications as prescribed Chapter 10 – Early Onset of Labor • Preterm labor o Preterm labor is uterine contraction and cervical changes that occur between 20 and 37 weeks of gestation o Assessment of preterm labor Previous preterm birth Multifetal pregnancy Substance use History of multiple miscarriages or abortions Diabetes mellitus Chronic hypertension Second trimester bleeding History of UTI o o Expected findings – uterine contraction o Diagnostic procedures Obtain swab of vaginal secretions for fetal fibronectin between 24 and 34 weeks of gestation This protein can be found in vaginal secretions and can be related to inflammation of the placenta and that can lead to preterm birth This test is used to determine preterm labor o Nursing care Focusing on stopping uterine contraction Activity restriction • Strict bed rest can have adverse effects • Encourage the client to rest in the left lateral position to increase blood flow to the uterus and decrease uterine activity Ensuring hydration • Dehydration stimulate the pituitary gland to secret and antidiuretic hormone and oxytocin o Medication Nifedipine • Calcium channel blocker • Used to suppress contractions by in habiting calcium form entering smooth muscles • Nursing consideration o Monitor for headache, flushing, dizziness and nausea o These usually are related to orthostatic hypotension that occurs with administration Magnesium sulfate • Commonly used tocolytic that relaxes the smooth muscle of the uterus and thus inhibits uterine activity by suppressing contraction • Nursing consideration o Contraindications for tocolysis include active vaginal bleeding, dilation of the cervix greater than 6 cm, chorioamnionitis, greater then 34 weeks gestation and acute fetal distress o Monitor for client for magnesium toxicity and discontinue for any of the following adverse effects Loss of deep tendon reflexes Urinary output less than 30 ml/hr Respiratory depression (less than 12/min) Pulmonary edema and chest pain o Administer gluconate of calcium chloride as and antidote for magnesium sulfate toxicity • Notify provider – blurred vision, headache, nausea, vomiting, or difficulty breathing Indomethacin • Non-steroidal anti-inflammation drug (NSAID) • Suppress preterm labor by blocking the production of prostaglandins • This inhibition of the prostaglandins suppresses uterine contraction Betamethasone • Enhance fetal lung maturity and surfactant production in fetuses between 24 to 34 weeks gestation • Premature rupture of membranes o Client reports a gush or leakage of clear fluids from the vagina Temperature elevation Increased maternal hear rate or FHR Foul-smelling fluid or vaginal discharge Abdominal tenderness o Positive nitrazine paper test (blue, pH 6.5 to 7.5) or positive forming test is conducted on amniotic fluid to verify rupture of membranes o Medications Ampicillin is an antibiotic uses to treat infection Betamethasone • Glucocorticoid administered IM in 2 injections • Enhance fetal lung maturity and surfactant production o Tell the client to record daily kick counts for fetal movement Chapter 11 – Labor and Delivery Process • Stages of labor o First stage (onset of labor to complete dilation) Latent phase (0 to 3 cm) • Onset of labor – contractions irregular and mild to moderate • Woman is talkative and eager Active phase (4 cm to 7 cm) • Contractions – regular moderate to strong • Woman feeling of helplessness • Anxiety and restlessness increase as contraction become stronger Transition phase (8cm to 10 cm) • Complete dilation • Feeling out of control, client often states “cannot continue” • Urge to push increased rectal pressure and feelings of needing to have a bowel movement o Second stage Full dilation to birth o Third stage Delivery of the neonate to delivery of placenta o Fourth stage Delivery of placenta to maternal stabilization of vital signs • Physiologic changes preceding labor (premonitoring sign) o Backache, weight loss o Lightening fetal head descends into true pelvis about 14 days before labor feeling that the fetus has “dropped” easier breathing but more pressure on bladder resulting urinary frequency o contraction – begin with irregular uterine contractions (Braxton Hicks) o increased vaginal discharge or bloody show o energy burst o gastrointestinal changes – nausea, vomiting and indigestion o Cervical ripening- cervix become soft (opens) and partially effaced and can begin to dilate o Rupture of membrane Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse o Assessment of amniotic fluid Amniotic fluid is alkaline – Nitrazine paper is deep blue, indicting pH of 6.5 to 7.5 • Laboratory analysis o Group B streptococcus Screening at 35 to 37 weeks If positive, IV prophylactic antibiotic is prescribed, exceptions are planned cesarean birth and membranes intact o Urinalysis Proteinuria, UTI (common diabetic pregnancy) • Characteristics of False Labor o Contraction -Painless, irregular frequency, and intermittent contractions -Contractions decrease in frequency, duration, and intensity with walking or position changes -Contractions are felt in lower back or abdomen above umbilicus -Contractions often stop with sleep or comfort measures such as oral hydration or emptying of the bladder o Cervix (assessed by vaginal exam) -The cervix has no significant changes in dilation or effacement -The cervix often remains in posterior position -The cervix has no bloody show o Fetus -The presenting part of the fetus is not engaged in the pelvis. • Nursing Care During Stages of Labor: Identifying the Need for Reassessment o If there are late declarations o if baby is tachycardic or bradycardia Chapter 12 – pain management • nonpharmacological o Reduce anxiety, fear and tension which are major contributing factors to pain in labor o Hypnosis, biofeedback, music therapy o Cutaneous stimulation strategies Effleurage – light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions o Sacral counterpressure using the heel of the hand or fist against the client’s sacral area to counteract pain in the lower back o hydrotherapy (whirlpool or shower) increases maternal endorphin levels o frequent maternal position changes to promote relaxation and pain relief supine position only with the placement of a wedge under one of the client’s hip to tilt the uterus and avoid supine hypotension syndrome • pharmacological o To avoid slowing the progress of labor, prior to administering analgesic medications, the nurse should verify that labor is well established by performing a vaginal exam and evaluating uterine contraction pattern o Analgesia Sedatives (barbiturates) Secobarbital pentobarbital and phenobarbital can be used during the early or latent phase of labor to relieve anxiety and induce sleep Side effect - Neonate respiratory depression secondary to the medication crossing the placenta and affecting the fetus. This medication should not be administered if birth is anticipated within 12 to 24 hours Nursing action • Assist the mother to cope with labor • Assess the neonate for respiratory depression Opioid analgesics • Meperidine hydrochloride, fentanyl, butorphanol, nalbuphine act in CNS to decrease the perception of pain without the loss of consciousness • Client can receive opioid analgesics IM or IV but the IV route is recommended during labor because the action is quicker • these given early part of active labor • Butorphanol and nalbuphine o Adverse effect Opioid analgesics can cause respiratory depression in the neonate Sedation Hypotension Decreased FHR variability o Nursing action Performing a vaginal exam that reveals cervical dilation of at least 4 cm with a fetus that is engaged Administer antiemetics as prescribed Prepare administer antidotes • Naloxone, an opioid antagonist, should be readily available for reversal of opioid-induced respiratory depression • Epidural and spinal regional analgesia o Fentanyl and sufentanil o Adverse effect Bradycardia or tachycardia Hypotension Respiratory depression o Nursing action Putting side rails up on the client’s bed – client can experience dizziness and sedation, which increases maternal risk for injury Administer Antiemetics as prescribed Continue FHR pattern monitoring o Pharmacological anesthesia Epidural block • Injected into the epidural space at the level of 4th or 5th vertebrae • This eliminates all sensation from the level of umbilicus to the thighs, relieving the discomfort of uterine contractions, fetal descent and pressure and stretching of the perineum • It is administered when the client is active labor and dilated to at least 4 cm • It is suitable for all stages of labor and types of birth and for repair of episiotomy and laceration • Adverse effect o Maternal hypotension o Fetal bradycardia o Loss of the bearing down reflex • Nursing action o Administer a bolus of IV fluids to help offset maternal hypotension as prescribed o Side-lying modified Sim’s position o Encourage the client to remain in the side-lying position after insertion of the epidural catheter to avoid supine hypotension syndrome with compression of the vena cava o Monitor maternal blood pressure and pulse, and observe for hypotension, respiratory depression and decreased oxygen saturation o Assess for orthostatic hypotension. If present, be prepared to administer an IV vasopressor such as ephedrine, position client laterally, increase rate of IV fluid administration and initiate oxygen o Do not allow the client to ambulate unassisted Spinal anesthesia (block) • Injected into the subarachnoid space into the spinal fluid at the 3rd 4th and 5th lumbar interspace • Spinal block eliminates all sensation form the level of the nipples to the feet • Spinal block is administered in the late second stage or before cesarean birth • Adverse effect o Maternal hypotension o Fetal bradycardia o Potential headache form leakage of cerebrospinal fluid at the puncture site o Higher incidence of maternal bladder and uterine atony following birth • Nursing action o Assess maternal vital signs every 10 min o Manage maternal hypotension by administering an IV fluid bolus as prescribed, position the mother laterally, increasing the rate of IV fluid administration and initiating oxygen o To relieve postpartum headache resulting from cerebrospinal fluid leak, placing the client in a supine position, promoting bed rest in a dark room, and administering oral analgesics, caffeine and fluids. An autologous blood patch is the most beneficial and reliable relief measure for cerebrospinal fluid leaks General anesthesia • Delivery complication or emergency • General anesthesia produces unconsciousness • Nursing action o NPO o Apply antiembolic stockings or sequential compression devices o Administer histamine-receptor antagonist – ranitidine to decrease gastric acid production o Administer metoclopramide to increase gastric emptying as prescribed o Assess the client postpartum for decreased uterine tone, which can lead to hemorrhage and be produced by pharmacological agents used in general anesthesia Chapter 13 – Fetal Assessment during labor • Leopold maneuvers o Leopold maneuvers consist of performing external palpations external palpations of the maternal uterus through the abdominal wall to determine the following o Place a small, rolled towel under the client’s right or left hip to displace the uterus off the major blood vessels to prevent supine hypotensive syndrome • Continuous electronic fetal monitoring o A normal fetal heart rate breathing at term is 110 to 160/min excluding accelerations, decelerations and periods of marked variability within a 10 min window. o Fetal heart rate baseline variability is described as fluctuations in the FHR baseline that that irregular in frequency and amplitude • FHR patterns o Accelerations o Fetal bradycardia FHR less than 110/min or 10 min or more Causes/complications • Uteroplacental insufficiency • Umbilical cord prolapses • Anesthetic medications Nursing intervention • Discontinue oxytocin if being administered • Assists the client to a side-lying position • Administer oxygen by mask at 10 L/min via nonrebreather face mask • Notify the provider o Fetal tachycardia FHR greater than 160 /min for 10 min or more Causes/complication • Maternal infection, chorioamnionitis Nursing interventions • Administer prescribed antipyretics for maternal fever • Administer oxygen by nonrebreather face mask o Early deceleration of FHR Causes/complication • Compression of the fetal had resulting form uterine contraction o Later decelerations of FHR Uteroplacental insufficiency causing inadequate fetal oxygenation Nursing intervention • Place client in side-lying position • IV fluid administration • Discontinue oxytocin if being infused • Administer oxygen by mask at 8 to 10 L/min via nonrebreather face mask • Elevate the client’s leg • Notify the provider o Variable deceleration of FHR Umbilical cord compression Nursing interventions • Reposition client form side to side or into knee-chest • Discontinue oxytocin if being infused • Administer oxygen by mask at 8 to 10 L/min via nonrebreather face mask Chapter 14 – Nursing care during stages of labor • Identifying the needs for reassessment each different stage of labor calls for different assessments of the mom • stage one should focus on rupture of membranes, bladder distention, temperature, and FHR • stage two should focus on BP, HR, and RR every 5-30 minutes, uterine contractions, pushing efforts by client, increase in bloody show, shaking of extremities • stage three is focused on BP, HR, and RR every 15 min, clinical findings of separation of placenta, vaginal fullness exam • stage four should focus on assessing maternal vital signs to a steady state Chapter 15 – Therapeutic procedures to assist with labor and delivery • Chapter 16 – Complications related to the labor process • Prolapsed umbilical cord o A prolapse umbilical cord occurs with the umbilical cord is displaced, preceding the presentation part of the fetus, or protruding through the cervix o Nursing care Notify the provider Use 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 Reposition the client in a knee-chest, Trendelenburg or side-lying position with a rolled towel under the client’s right or left 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 Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation Chapter 17 – Postpartum physiological adaptations • Fundus o Immediately after delivery, the fundus should be firm, midline with the umbilicus, and approximately at the level of the umbilicus o At 12 hr postpartum, the fundus may be palpated at 1 cm above the umbilicus o Every 24 hours, the fundus should descend approximately, 1 to 2 cm o It should be halfway between the symphysis pubis and the umbilicus by the 6th postpartum day o After 2 weeks, the uterus should lie within the true pelvis and should not be palpated • Lochia o Lochia is post-birth uterine discharge that contains blood, mucus and uterine tissue o 3 stage of lochia Lochia rubra – bright red color, bloody consistency, fleshy odor, last 1 to 3 days after delivery Lochia serosa – pinkish brown color and serosanguineous, consistency. Last from 4 to 10 days after delivery Lochia alba – yellowish white creamy color, flesh odor. Last 11 days up to 4 to 8 weeks postpartum o Assessment of lochia Excessive blood loss: one pad saturated in 15 min or less, or pooling of blood under buttocks o Manifestation of abnormal lochia Excessive spurting of bright red blood form the vagina Numerous large clots and excessive blood loss (saturation of one pad in 15 min or less) which can indicate hemorrhage Persistent lochia rubra in the early postpartum period beyond day 3, which can indicate retained placental fragments • Breasts o Physical changes of the breasts include the secretion of colostrum – 2 to 3 days immediately after birth o Assessment Colostrum (early milk) transitions to mature milk by about 72 to 96 hr after birth and is referred to as the milk coming in • Cardiovascular system and fluid and hematologic status o Blood loss during childbirth (average blood loss is 300 to 500 mL in an uncomplicated vaginal delivery and 500 to 1000 mL for cesarean birth • Urinary system and bladder function o Urinary retention secondary to loss of bladder elasticity and tone and/or loss of bladder sensation resulting from trauma, medications, or anesthesia o Distended bladder as a result of urinary retention can cause uterine atony and displacement to one side, usually to the right o The ability of the uterus to contract is also lessened o Assessment Assess the client’s ability to void every 2 to 3 hours Assess bladder elimination pattern (client should be voiding every 2 to 3 hr). excessive urine diuresis (more than 3,000 mL/day) is normal within the first 2 ot 3 days after delivery Assess for evidence of a distended bladder o Patient-centered care Encourage the client to empty her bladder frequently (every 2 to 3 hr) to prevent possible displacement of the uterus and atony Chapter 18 – Baby-friendly care • Phase of maternal postpartum adjustment o Dependent – taking-in phase First 24 to 48 hours Rely on others for assistance Focused on meeting personal needs rely on others for assistance Excited, talkative Need to review birth experience with others o Dependent-independent – taking-hold phase Begins on day 2 to 3 Last 10 days to several weeks Focus on baby care and improving caregiving competency o Interdependent – letting-go phase Focus on family as a unit Resumption on role (intimate partner, individual) Chapter 19 - Client education and discharge teaching • Breast care o Lactating client Initiate breastfeeding within the first 1 to 2 hr after birth unless contraindicated To relieve breast engorgement, have client completely empty her breast at each feeding For breast engorgement, apply cool compresses after feedings and apply warm compresses, or take a warm shower prior to breastfeeding. These actions will increase milk flow and promote the letdown reflex o Nonlactating client Wear a well-fitting, supportive bra continuously for the first 72 hr Suppression of lactation is necessary for clients who are not breastfeeding. Avoid breast stimulation and running warm water over the breast stimulation and running warm water over the breast for prolonged period until no longer lactating For breast engorgement, which can occur on the third or firth postpartum day, apply cold compresses 15 min on and 45 min off. Fresh, cold cabbage leaves can be placed inside the bra. Mild analgesics or anti-inflammatory medication can be taken for pain and discomfort of breast engorgement Chapter 20 – postpartum disorders • Deep-vein thrombosis o Greatest risk for a deep-vein thrombosis (DVT) that can lead to a pulmonary embolism o Expected findings Unilateral area of swelling, warmth, and redness Hardened vein over the thrombosis Calf tenderness • Pulmonary embolus o A pulmonary embolism is a complication of DVT that occurs if the embolus moves into the pulmonary artery or one of its branches and lodges in a lung, occluding the vessel and obstructing blood flow to the lungs o Acute pulmonary embolus is an emergent situation o Expected findings Pleuritic chest pain Dyspnea • Postpartum hemorrhage o Postpartum hemorrhage is considered to occur if the client loses more than 500 mL blood after a vaginal birth or more than 1000 mL after cesarean birth o Risk factors Uterine atony, inversion of uterus, subinvolution of the uterus, Retained placental fragments o Expected findings Uterine atony (hypotonic or boggy) Perineal pad saturation in 15 min or less Constant oozing trickling, or frank flow of bright red blood from the vagina Tachycardia and hypotension o Nursing care Firmly massage the uterine fundus Assess bladder for distention. Insert an indwelling urinary catheter to assess kidney function and obtain an accurate measurement of urinary output o Medication – uterine stimulant Oxytocin – promote uterine contractions Methylergonovine – controls postpartum hemorrhage • Assess uterine tone and vaginal bleeding. Do not administer to clients who have hypertension • Monitor for adverse reactions, including hypertension, nausea, vomiting and headache Misoprostol - controls postpartum hemorrhage • Uterine atony o Uterine atony results form the inability of the uterine muscle ot contract adequately after birth o Perform fundal massage is indicated Chapter 21 – postpartum infections • Infections (endometritis, mastitis, and wound infections) • Mastitis o Mastitis is an infection of breast involving the interlobular connective tissue and is usually unilateral o Expected findings Flu-like clinical findings, such as body aches, chills, fever and malaise Painful or tender localized hard mass and reddens area, usually on one breast o Client education Instruct the client to thoroughly wash hands proor to breastfeeding Allow nipples to air-dry Proper infant positioning and latching-on techniques, including both the nipple and the areola Instruct the client about completely emptying her breasts with each feeding to prevent milk stasis, which provides a medium for bacterial growth Chapter 23 – postpartum depression • Postpartum blues o Generally, continues for up to 10 days o Tearfulness, insomnia, lack of appetite, and feeling of letdown o Postpartum blues typically resolves in 10 days without intervention o Feeing sadness o Crying easily for no apparent reason • Postpartum depression o Occurs within 6 months of delivery and is characterized by persistent feelings of sadness and intense mood swings • Postpartum psychosis o History of bipolar disorder o Confusion, disorientation, hallucinations, delusions, obsessive behaviors, and paranoia o The client might attempt to harm herself or her infant Chapter 23 – Newborn assessment • Apgar scoring o HR: Absent (0), less than 100/min (1), greater than 100/min (2) RR: Absent (0), weak cry (1), good cry (2) Muscle tone: flaccid (0), some flexion of extremities (1), well-flexed (2) Reflex irritably: none (0), grimace (1), cry (2) Color: blue, pale (0), pink body, cyanotic hands and feet (1), completely pink (2) • New Ballard scale o New born maturity rating scale that assesses neuromuscular and physical maturity o Neuromuscular maturity - Fully flexed - Square window - Arm recoil, where the neonate’s arm is passively extended and spontaneously return sto flexion - Popliteal angle, degree of the angle to which the newborn’s knees can extend - Scarf sign, which is crossing the neonate’s arm over the chest - Heal to ear, which is how far the neonate’s heels reach to her ears o Physical maturity - Skin texture, ranging from sticky and transparent to leathery, cracked and wrinkled - Lanugo presence - Plantar surface creases, ranging form less than 40 mm to creases ove the entire sole - Breast tissue amount, full areola with a 5 to 10 mm bud - Genitalia development – ranging form flat smooth scrotum to pendulous testes with deep rugae for males and prominent clitoris with flat labia to the labia majora covering the labia minora • Normal deviations o Milia (small raised whit spots on the nose, chin and forehead) can be present. Theses pots disappear spontaneously without treatment (parents should not squeeze the spots) o Mongolian spots (bluish purple spots of pigmentation) are commonly noted on the the shoulder, back and buttocks. Be sure the parents are aware of Mongolian spots, and document location and presence • Head o Head should be 2 to 3 cm larger than chest circumference o Anterior fontanel should be palpated and approximately 5 cm on average and diamond shaped. o Fontanel should be soft and flat o Fontanel can bulge when the newborn cries, coughs or vomits and are flat when the newborn is quiet o Bulging fontanels can indicate increased intracranial pressure, infection, or hemorrhage o Depressed fontanels can indicate dehydration o Caput succedaneum - (localized swelling of the soft tissues of the scalp caused by pressure on the head during labor) an expected finding that can be palpated as a soft edematous mass and can cross over the suture line - Caput succedaneum usually resolves in 3 to 4 days and does not require treatment o Cephalohematoma - Collection of blood between the periosteum and the skull bone that is covers - It does not cross the suture line - It results from trauma during birth such as pressure of the fetal head against the maternal pelvis in a prolonged difficult labor or forceps delivery - It appears in the first 1 to 2 days after birth and resolves in 2 to 3 weeks • Ears – that are low set can indicate a chromosome abnormality such as down syndrome, or a kidney disorder • Mouth [Show Less]
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ATI Maternal Newborn Remediation (Rasmussen University).....
ATI MATERNAL NEWBORN REMEDIATION 1. Management of Care a. Establishing Priorities Requires Further Assessment (Chp 27) tones and re... [Show More] flex responses, and seizures. A term newborn’s blood glucose should be 30-60mg/dL. Hypoglycemia can bring about poor feeding, jitteriness/tremors, hypothermia, diaphoresis, weak cry, and lethargy. tachypnea, nasal flaring, expiratory grunting, retractions, and cyanosis. Newborn infections like sepsis can cause an infant to have temperature instability, suspicious drainage, poor feeding, weak suck, vomiting, diarrhea, hypo or hyperglycemia, respiratory distress, and low BP. membranes, observe the newborns color for yellowish tint as the skin is blanched, and assess if there is an underlying cause that needs to be fixed. Look for hypoxia, hypothermia, hypoglycemia, and metabolic acidosis. Increased risk for brain damage. Congenital anomalies involve cleft lip/palate and tracheoesophageal fistula, excessive mucous secretions and drooling, periodic cyanotic episodes and choking, distended abdomen. PKU can result in cognitive impairment if untreated, not evident at birth and it’s found in newborn screening. Hypothyroidism: hypothermia, poor feeding, lethargy, jaundice, cretinism. Spina bifida is a protrusion of meninges and/or spinal cord, tufts of hair on the spine. Patent ductus arteriosus is another neonate complication that includes murmurs, abnormal heart rate or rhythm, breathlessness, and fatigue while feeding. has respiratory difficulties, cyanosis, tachycardia, tachypnea, and diaphoresis. Down syndrome, also known as trisomy 21, exhibits oblique palpebral fissures or upward slant of the eyes, epicanthal folds, flat facial profile with a depressed nasal bridge and small nose, protruding tongue, short broad hands with a fifth finger that has one flexion crease instead of two, a deep crease across the center of the palm, hyperflexibility, hypotonic muscles. ii. Medical Conditions: Priority Finding That Requires Further Assessment (Chp 9) ● Cervical insufficiency is a painless opening of the cervix that results in delivery of the baby in the 2nd trimester of pregnancy. Some expected findings are pink stained vaginal discharge or bleeding, possible gush of fluid, and uterine contractions w/ expulsion of fetus. The nurse needs to evaluate the client’s support system and if assistance is available for them if they are prescribed activity restrictions or bed rest. Assess the client for any vaginal discharge, monitor client reports of pressure and contractions, and check vital signs. ● For gestational HTN, some expected findings are severe continuous HA, nausea, blurring of vision, flashes of lights or dots before the eyes, HTN, proteinuria, edema, vomiting, and epigastric pain. The nurse should assess their LOC, obtain pulse oximetry, monitor urine output, and obtain a clean catch urine sample to assess for proteinuria. Also, obtain the client’s daily weight, monitor vital signs with careful attention to BP, encourage lateral positioning, perform non-stress test and daily kick counts, and instruct the parents to monitor I&Os. 2. Safety and Infection Control a. Accident/Error/Injury/Prevention Who Has Abstinence Syndrome (Chp 27) exposed to drugs in the womb before birth. Babies can then go through drug withdrawal after birth. The syndrome most often applies to opioid medicines. feedings, swaddle newborn with legs flexed, looser than normal, reduce environmental stimuli (lights off, lower noise level), and educate the mom on SIDS prevention strategies. Safety (Chp 26) until they reach maximum height and weight for seat. Rear facing car seat should preferably be placed in the middle of the back seat because they are away from the air bags and side impact. No hand me downs should be used! Set the seat at a 45-degree angle because if the car seat is too flat, the baby may slide out through the straps. If it is too upright, the head may flop forwards too much and make it difficult for the baby to breathe. b. Standard Precautions/Transmission-Based Precautions/Surgical Asepsis i. Nursing Care of Newborns: Personal Protective Equipment (Chp 24) ● Before caring for a newborn, scrub arms with antibacterial soap from your elbows to your fingertips. For a newborn’s first bath, gloves need to be worn to prevent exposure to body secretions. Individual bassinets need to be equipped with diapers, T-shirts, and bathing supplies. Nurses must follow facility hygiene protocols in between caring for newborns. All nurses must know that cover gowns and special uniforms are used to prevent direct contact with clothes. 3. Health Promotion and Maintenance conditions for up to 8 hr. It may be refrigerated in sterile bottles for use within eight days or frozen in clean containers in a two-door refrigerator's freezer compartment for up to 6 months. Also, mothers may store breast milk in a deep freezer for 12 months. Thawing the milk in the refrigerator for 24 hr preserves immunoglobulins the best. It also can be thawed by holding the container under running lukewarm water or placing it in a container of lukewarm water. Rotate the bottle often but not shaken when thawing in this manner. Do not thaw breast milk in the microwave because it can destroy immune factors and lysozymes that is contained in the milk. Once thawed, do not refreeze, just discard it. fetal heart tones are auscultated the loudest on the woman's abdomen. These tones are best heard directly over the fetal back. In vertex presentation, PMI is either in the right- or left-lower quadrant or below the maternal umbilicus. In breech presentation, PMI is either in the right- or left-upper quadrant above the maternal umbilicus. at the midline, right above the symphysis pubis, by holding the Doppler firmly on the abdomen. FHR can be detected at early appointments by ultrasound. lower-extremity edema, gingivitis, nasal stuffiness, epistaxis, Braxton Hicks contractions, and supine hypotension iv. Postpartum Physiological Adaptions: Rh Incompatibility (Chp 17) ● Administer RhO(D) immune globulin (RhoGAM) IM around 28 weeks of gestation for Rh-negative clients. Administer RhO(D) immune globulin (RhOGAM) to the client if she is Rh-negative (standard practice after an amniocentesis for all women who are Rh-negative to protect against Rh isoimmunization). RhO(D) immune globulin (RhoGAM) suppresses the immune response of Rh-negative clients. ● RhO(D) immune globulin (RhoGAM) is administered within 72 hr to Rh- negative mothers and gave birth to Rh-positive infants to prevent sensitization in future pregnancies. If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, then all the offspring of this union will be Rh positive. The Kleihauer-Betke test determines the amount of fetal blood in maternal circulation if a large fetomaternal transfusion is suspected. If 15 mL or more of fetal blood is detected, the mother should receive an increased RhoGAM dose. Test the client who receives both the rubella vaccine and RhoGAM after three months to determine whether immunity to rubella has been developed. b. Health Promotion/Disease Prevention Hemolytic Disease (Chp 27) the fetal circulation and destroys the fetal red blood cells. A condition in which there is an incompatibility between the Rh types of the mother and the fetus. Less commonly may happen with incompatible blood types between mother and fetus. Rhogam is used to prevent this disease. Some of the signs and symptoms of hemolytic disease are severe hyperbilirubinemia, jaundice, and Kernicterus. Infection (Chp 20) thrombus, history of DM, immunosuppression, anemia, malnutrition, history of alcohol/substance use, C section, prolonged ROM, retained placental fragments, manual extraction of placenta, catheters, chorioamnionitis, internal fetal uterine pressure monitor, multiple vaginal exams after ROM, PP hemorrhage, operable vaginal birth, epidural, hematomas, and episiotomy/lacerations. c. Health Screening that can go above or below the range. It also depends on the baby’s activity level. average temperature in a newborn is 37C or 98.6F up to a 1 year. This reflex happens by stroking the cheek or the edge of their mouth. As a reaction, the newborn would turn their heads to the side where they were touched and start to suck. happens by placing the examiner’s finger in the palm of the newborn’s hand. The reaction should be to have the newborn curl their fingers around the examiner’s fingers. response happens when the examiner places their finger at the base of the newborn’s toes. The appropriate reaction is the newborn curls their toes downward. months. The head and trunk of the newborn is placed in a semi sitting position, in effort to fall backwards at a 30-degree angle. The reaction should be that the newborn symmetrically extends, then abduct their arms at the elbows and fingers spread to form a “C.” newborn is lied in supine position and the examiner turns their head quickly to one side. The newborn’s arm and leg on that side extend and opposing arm and leg flex. [Show Less]
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ATI Maternal Newborn Remediation (Rasmussen University)....
ATI MATERNAL NEWBORN REMEDIATION 1. Management of Care a. Establishing Priorities Requires Further Assessment (Chp 27) tones and re... [Show More] flex responses, and seizures. A term newborn’s blood glucose should be 30-60mg/dL. Hypoglycemia can bring about poor feeding, jitteriness/tremors, hypothermia, diaphoresis, weak cry, and lethargy. tachypnea, nasal flaring, expiratory grunting, retractions, and cyanosis. Newborn infections like sepsis can cause an infant to have temperature instability, suspicious drainage, poor feeding, weak suck, vomiting, diarrhea, hypo or hyperglycemia, respiratory distress, and low BP. membranes, observe the newborns color for yellowish tint as the skin is blanched, and assess if there is an underlying cause that needs to be fixed. Look for hypoxia, hypothermia, hypoglycemia, and metabolic acidosis. Increased risk for brain damage. Congenital anomalies involve cleft lip/palate and tracheoesophageal fistula, excessive mucous secretions and drooling, periodic cyanotic episodes and choking, distended abdomen. PKU can result in cognitive impairment if untreated, not evident at birth and it’s found in newborn screening. Hypothyroidism: hypothermia, poor feeding, lethargy, jaundice, cretinism. Spina bifida is a protrusion of meninges and/or spinal cord, tufts of hair on the spine. Patent ductus arteriosus is another neonate complication that includes murmurs, abnormal heart rate or rhythm, breathlessness, and fatigue while feeding. has respiratory difficulties, cyanosis, tachycardia, tachypnea, and diaphoresis. Down syndrome, also known as trisomy 21, exhibits oblique palpebral fissures or upward slant of the eyes, epicanthal folds, flat facial profile with a depressed nasal bridge and small nose, protruding tongue, short broad hands with a fifth finger that has one flexion crease instead of two, a deep crease across the center of the palm, hyperflexibility, hypotonic muscles. ii. Medical Conditions: Priority Finding That Requires Further Assessment (Chp 9) ● Cervical insufficiency is a painless opening of the cervix that results in delivery of the baby in the 2nd trimester of pregnancy. Some expected findings are pink stained vaginal discharge or bleeding, possible gush of fluid, and uterine contractions w/ expulsion of fetus. The nurse needs to evaluate the client’s support system and if assistance is available for them if they are prescribed activity restrictions or bed rest. Assess the client for any vaginal discharge, monitor client reports of pressure and contractions, and check vital signs. ● For gestational HTN, some expected findings are severe continuous HA, nausea, blurring of vision, flashes of lights or dots before the eyes, HTN, proteinuria, edema, vomiting, and epigastric pain. The nurse should assess their LOC, obtain pulse oximetry, monitor urine output, and obtain a clean catch urine sample to assess for proteinuria. Also, obtain the client’s daily weight, monitor vital signs with careful attention to BP, encourage lateral positioning, perform non-stress test and daily kick counts, and instruct the parents to monitor I&Os. 2. Safety and Infection Control a. Accident/Error/Injury/Prevention Who Has Abstinence Syndrome (Chp 27) exposed to drugs in the womb before birth. Babies can then go through drug withdrawal after birth. The syndrome most often applies to opioid medicines. feedings, swaddle newborn with legs flexed, looser than normal, reduce environmental stimuli (lights off, lower noise level), and educate the mom on SIDS prevention strategies. Safety (Chp 26) until they reach maximum height and weight for seat. Rear facing car seat should preferably be placed in the middle of the back seat because they are away from the air bags and side impact. No hand me downs should be used! Set the seat at a 45-degree angle because if the car seat is too flat, the baby may slide out through the straps. If it is too upright, the head may flop forwards too much and make it difficult for the baby to breathe. b. Standard Precautions/Transmission-Based Precautions/Surgical Asepsis i. Nursing Care of Newborns: Personal Protective Equipment (Chp 24) ● Before caring for a newborn, scrub arms with antibacterial soap from your elbows to your fingertips. For a newborn’s first bath, gloves need to be worn to prevent exposure to body secretions. Individual bassinets need to be equipped with diapers, T-shirts, and bathing supplies. Nurses must follow facility hygiene protocols in between caring for newborns. All nurses must know that cover gowns and special uniforms are used to prevent direct contact with clothes. 3. Health Promotion and Maintenance conditions for up to 8 hr. It may be refrigerated in sterile bottles for use within eight days or frozen in clean containers in a two-door refrigerator's freezer compartment for up to 6 months. Also, mothers may store breast milk in a deep freezer for 12 months. Thawing the milk in the refrigerator for 24 hr preserves immunoglobulins the best. It also can be thawed by holding the container under running lukewarm water or placing it in a container of lukewarm water. Rotate the bottle often but not shaken when thawing in this manner. Do not thaw breast milk in the microwave because it can destroy immune factors and lysozymes that is contained in the milk. Once thawed, do not refreeze, just discard it. fetal heart tones are auscultated the loudest on the woman's abdomen. These tones are best heard directly over the fetal back. In vertex presentation, PMI is either in the right- or left-lower quadrant or below the maternal umbilicus. In breech presentation, PMI is either in the right- or left-upper quadrant above the maternal umbilicus. at the midline, right above the symphysis pubis, by holding the Doppler firmly on the abdomen. FHR can be detected at early appointments by ultrasound. lower-extremity edema, gingivitis, nasal stuffiness, epistaxis, Braxton Hicks contractions, and supine hypotension iv. Postpartum Physiological Adaptions: Rh Incompatibility (Chp 17) ● Administer RhO(D) immune globulin (RhoGAM) IM around 28 weeks of gestation for Rh-negative clients. Administer RhO(D) immune globulin (RhOGAM) to the client if she is Rh-negative (standard practice after an amniocentesis for all women who are Rh-negative to protect against Rh isoimmunization). RhO(D) immune globulin (RhoGAM) suppresses the immune response of Rh-negative clients. ● RhO(D) immune globulin (RhoGAM) is administered within 72 hr to Rh- negative mothers and gave birth to Rh-positive infants to prevent sensitization in future pregnancies. If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, then all the offspring of this union will be Rh positive. The Kleihauer-Betke test determines the amount of fetal blood in maternal circulation if a large fetomaternal transfusion is suspected. If 15 mL or more of fetal blood is detected, the mother should receive an increased RhoGAM dose. Test the client who receives both the rubella vaccine and RhoGAM after three months to determine whether immunity to rubella has been developed. b. Health Promotion/Disease Prevention Hemolytic Disease (Chp 27) the fetal circulation and destroys the fetal red blood cells. A condition in which there is an incompatibility between the Rh types of the mother and the fetus. Less commonly may happen with incompatible blood types between mother and fetus. Rhogam is used to prevent this disease. Some of the signs and symptoms of hemolytic disease are severe hyperbilirubinemia, jaundice, and Kernicterus. Infection (Chp 20) thrombus, history of DM, immunosuppression, anemia, malnutrition, history of alcohol/substance use, C section, prolonged ROM, retained placental fragments, manual extraction of placenta, catheters, chorioamnionitis, internal fetal uterine pressure monitor, multiple vaginal exams after ROM, PP hemorrhage, operable vaginal birth, epidural, hematomas, and episiotomy/lacerations. c. Health Screening that can go above or below the range. It also depends on the baby’s activity level. average temperature in a newborn is 37C or 98.6F up to a 1 year. This reflex happens by stroking the cheek or the edge of their mouth. As a reaction, the newborn would turn their heads to the side where they were touched and start to suck. happens by placing the examiner’s finger in the palm of the newborn’s hand. The reaction should be to have the newborn curl their fingers around the examiner’s fingers. response happens when the examiner places their finger at the base of the newborn’s toes. The appropriate reaction is the newborn curls their toes downward. months. The head and trunk of the newborn is placed in a semi sitting position, in effort to fall backwards at a 30-degree angle. The reaction should be that the newborn symmetrically extends, then abduct their arms at the elbows and fingers spread to form a “C.” newborn is lied in supine position and the examiner turns their head quickly to one side. The newborn’s arm and leg on that side extend and opposing arm and leg flex. [Show Less]
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ATI Maternal Newborn Proctored Exam 2019 (70 Q&A) (100- Verified)...
ATI Maternal newborn 2019 1. A nurse is assessing a newborn following a forceps assisted birth. Which of the following clinical manifestations should the... [Show More] nurse identify as a complication of the birth method? A. Hypoglycemia B. Polycythemia C. Facial Palsy D. Bronchopumonary dysplasia 2. A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statement by client indicates an understanding of the teaching? “The medication could cause me to experience heart paptation” “This medication could cause me to experience blurred vision” “This medication could cause me to experience ringing in my ears” “This medication could cause me to experience frequent …” 4. A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate? Urine Ketones Rapid plasma regain Prothrombin time Urine culture 5. A nurse is caring for a client who is in labor and requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort? A. Assisting the client into squatting position B. Having the client lie in a supine position C. Applying fundal pressure during contractions D. Encouraging the client to void every 6 hr 6. A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect? A. Thick, White Vaginal Discharge B. Urinary Frequency C. Vulva Lesions D. Malodorous Discharge 7. A nurse is caring for a client who is 14 weeks of gestation. At which the following locations should the nurse place the Doppler device when assessing the fetal heart rate? A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis B. Left Upper Abdomen C. Two fingerbreadths above the umbilicus D. Lateral at the Xiphoid Process 8. A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider? A. Urine protein concentration 200 mg/ 24 hr B. Creatnine 0.8 mg/ dL C. Hemoglobin 14.8 g/ dL D. Platelet Count 60.000/ mm3 9. A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include? A. Tinnitus B. Urinary Frequency C. Breast Tenderness D. Chills 10. A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect? A. Bulging Fontanels B. Nasal Flaring C. Length from head to heel of 40 cm (15.7 in) D. Chest circumference 2 cm (0.8 in) smaller than the head circumference 11. A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care. A. Increase the newborn’s visual stimulation B. Weigh the newborn every other day C. Discourage parental interaction until after a social evaluation D. Swaddle the newborn in a flexed position 12. A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take? A. Obtain a blood sample for a serum glucose level B. Feed the newborn immediately C. Administer 50 mL of dextrose solution IV D. Reassess the blood glucose level prior to the next feeding 13. A nurse is providing teaching to a client about exercise safety during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply). A. “I will limit my time in the hot tub to 30 minutes after exercise.” B. “I should consume three 8-ounce glasses of water after I exercise.” C. “I will check my heart rate every 15 minutes during exercise sessions.” D. “I should limit exercise sessions to 30 minutes when the weather is humid.” E. “I should rest by lying on my side for 10 minutes following exercise.” 14. A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider? A. Contraction durations of 95 to 100 seconds B. Contraction frequency of 2 to 3 min apart C. Absent early deceleration of fetal heart rate D. Fetal heart rate is 140/min 15. A nurse in a woman’s health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client’s risk for developing pelvic inflammatory disease (PID)? A. Recurrent Cystitis B. Frequent Alcohol Use C. Use of Oral Contraceptives D. Chlamydia Infection 16. A nurse is teaching a prenatal class about immunizations that newborns receive following birth. Which of the following immunizations should the nurse include in the teaching? A. Hepatitis B B. Rotavirus C. Pneumococcal D. Varicella 17. A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium? A. ½ cup cubed avocado B. 1 large banana C. 1 medium potato D. 1 cup cooked broccoli 18. A nurse in a provider’s office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use Nagele’s rule to calculate the estimated date of delivery. (Use the MMDD format with four numerals and no spaces or punctuation.) 1. To compute the EDD using the naegele's rule, we add 7 days from the last day of LMP then subtract 3 months and add 1 year. Thus the EDD for this patient is December 13, 2021 (1213) 2. D. the client delivers the newborn • The second stage of labor starts with full dilation of the cervix and it ends with expulsion of the fetus 19. A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect? A. The client expels the placenta B. The client experiences gradual dilation of the cervix C. The client begins have regular contractions. D. The client delivers the newborn 20. A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statement by the client requires immediate intervention by the nurse? A. “It burns when I urinate B. “My feet are really swollen today”. C. “I didn’t have lunch today, but I have breakfast this morning”. 21. A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? A. “I should position my baby’s car seat at a 45 degree angle in the car.” B. “I should place the car seat rear facing until my baby is 12 months old.” C. “I should place the harness snugly in a slot above my baby’s sholders.” D. “I should position the retainer clip at the top of my baby’s abdomen.” 22. A nurse is developing an educational program about hermolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hermolytic disease? A. The mother is Rh positive and the father is Rh negative B. The mother is Rh negative and the father is Rh positive C. The mother and the father are both Rh positive D. The mother and the father are both Rh negative 23. A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first? A. A client who has diabetes mellitus and an HbA1c of 5.8% B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L D. A client who has placenta previa and a hematocrit of 36% E. “I have been seeing spot this morning” 24. A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene? a. Molding b. Vernix Caseosa c. Acrocyanosis d.Sternal retractions 25. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider? A client who has a urinary output of 300 ml in 8 hr A client who reports abdominal cramping during breastfeeding A client who is receiving magnesium sulfate and has absent deep tendon reflexes A client who reports lochia rubra requiring changing perineal pads every 3 hr 26. A nurse is caring for a client who has active genital herpes simplex virus type 2. Which of the following medications should the nurse plan to administer? Metronidazole Penicillin Acyclovir Gentamicin 27. A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? Hyperemesis Proteinuria Hypoxia Hemorrhage 28. A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan? Increase the infusion rate every 30 to 60 min. Maintain the client in a supine position. Titrate the infusion rate by 4 milliunits/min. Limit IV intake to 4 L per 24 hr. 29. A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the “Exhibit” Button for additional information about the newborn. There are three tabs that contain separate categories of date.) Administer nitric oxide inhalation therapy to the newborn Insert an orogastric decompression tube with low wall suction. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr. Measure the aadbominal circumference at the level of the newborn’s umbilicus every 2 hr. 30. A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor Tracing. Which of the following action should the nurse take? Decrease maintenance IV solution infusion rate. Place the client in lateral position. Administer misoprostol 25 mcg vaginally Administer oxygen via face mask at 2 L/min 31. A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care? Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation. Use a fetal scalp electrode during labor and delivery. Administer a pneumococcal immunization to the newborn within 4 hr following birth. Bathe the newborn before initiating skin-to-skin contact 32. A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication? Blood pressure 142/92 mm Hg Urine output 100 mL in hr Pulse 58/min Respiratory rate 14/min 33. A nurse is reviewing laboratory results for client who is pregnant. The Nurse should expect which of the following laboratory values to increase? RBC count Bilirubin Fasting blood glucose Bun None of the above 34. A nurse is caring for a client who is experiencing preterm labor and has a prescription for 4 doses of dexamethasone 6 mg IM 12 hr. Available in dexamethasome 10 mg/mL. How mane mL of dexamethasome should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use trailing zero.) 0.6 mL. 35. A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit? A. A client who has an ultrasound that confirms a molar pregnancy B. A client who has a crown-rump length of 7 weeks gestation C. A client who has a positive urine pregnancy test 1 week after missed menses D. A client who has felt quickening for the first time 36. A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? A. Dress the newborn in lightweight clothing. B. Avoid using lotion or ointment on the newborn skin. C. Keep the newborn supine throughout treatment D. Measure the newborn’s temperature every 8hr 37. A nurse is receiving laboratory results for a term newborn who is 24 hr old. Which of the following results require intervention by the nurse? A. WBC count 10,000/mm3 B. Platelets 180,000/mm3 C. Hemoglobin 20g/dL D. Glucose 20 mg/dL 38. A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? ( select all that apply). A. Amnionitis B. Urinary tract infection C. Polyhydramnios D. Leakage of amniotic fluid E. Preterm labor 39. A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures? A. Assisting a mother with breastfeeding B. Performing a newborn’s initial bath C. Administering the measles, mumps, rubella vaccine D. Performing umbilical cord care 40. A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2months of pregnancy . This of the following statements by the client indicates an understanding of the teaching. A. “I will count baby’s lacks every other day. B. “I will alternate the arm use to check my blood pressure. D. I will consume 50 grams of protein daily 41. A nurse is caring for four newborns. Which of the following newborns should the nurse assess first? A. newborn who has nasal flaring B. newborn who has subconjunctival hemorrhage of the left ey C. A newborn who has overlapping suture lines D. A newborn who has not rust-stained urine 42. A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors paces the client at risk for infection. A. Meconium – start fluid B. placenta previa C. Midline episiotomy D. Gestational hypertension 43. A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take? A. Administer indomethacin B. Insert a second using a 22 gauge IV catheter, C. Insert an indwelling urinary catheter. D. Administer oxygen at 4L/min via nasal cannula. 44. A nurse is teaching a client who is 28 weeks of gestation and not up-to date on current immunization. Which of the following immunizations should the nurse inform the client to anticipate receiving following birth. A. Pneumococcal B. Hepatitis C. Human papillomavirus D. Rubella 45. caring for a newborn who is 24 hr old. Which of the following Laboratory findings should the nurse report to the provider? A. Hgb 20 g/dL B. Bilirubin 2mg/dL C. Platelets 200 .000/mm3 WBC count 32.000/mm3 46. A nurse is caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take? A. Give the newborn a warm bath. B. Apply a cap to the newborn head. C. Reposition the newborn. D. Obtain an oxygen saturation level [Show Less]
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ATI Maternal Newborn & Peds Exam (Verified Questions) (2022-2023)
ATI Maternal Newborn & Peds Maternal Newborn A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. W... [Show More] hich of the following findings should the nurse report to the provider? a. BUN 25 mg/dL b. serum creatinine 0.8 mg/dL c. urine output of 280 mL w/ 8 hr d. urine negative for ketones A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which statement should the nurse include in the teaching? a. replace the diaphragm every 5 years b. leave the diaphragm in place for at least 6 hours after intercourse c. use an oil-based product as a lubricant when inserting the diaphragm d.insert the diaphragm when bladder is full A nurse is reviewing the med record of a client who is postpartum and has preeclampsia. Which lab results should the nurse report to the provider? a. Hct 39% b. serum albumin 4.5g/dL c. WBC 9000/mm3 d. platelets 50,000/mm3 A nurse is teaching a client about Rho(D) immune globulin. Which statement by the client indicates an understanding of the teaching? a. I will receive this med if my baby is Rh- b. I will receive this med when I'm in labor c. I will need a 2nd dose of this med when my baby is 6wks old d.I will need this med if I have an amniocentesis A nurse is assessing a client who is 30 weeks gestation during a routine prenatal visit. Which findings should the nurse report to the provider? a.swelling of the face b.varicose veins in the calves c.nonpitting 1+ ankle edema d.hyperpigmentation of the cheeks A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which actions should the nurse include in the plan? a. feed the newborn 1oz of water q4hrs b. apply lotion to newborns skin 3x/day c. remove all clothing from newborn except diaper d. discontinue therapy if the newborn develops a rash A nurse is caring for a client who is 35 weeks gestation and is undergoing nonstress test that reveals a variable deceleration in the FHR. What action should the nurse take? a. give the client oj b. elevate the client's legs c. have the client change positions d. establish IV access A nurse is assessing a client who gave birth vaginally 12hrs ago and palpates her uterus to the right above the umbilicus. What interventions should the nurse perform? a. reassess the client in 2 hrs b. administer simethicone c. assist the client to empty her bladder d. instruct the client to lie on her right side A nurse is performing a routine assessment on a client who is 18 weeks gestation. What findings should the nurse expect? a. deep tendon reflexes 4+ b. fundal height 14cm c. urine protein 2+ d. FHR 152/min A nurse is teaching a new mother about steps the nurses will take to promote security and safety of the newborn. What statement should the nurse make? a. we will prevent unidentified visitors from entering the unit b. we will document the relationship of visitors in your medical record c. your baby will stay in the nursery while you are asleep d. staff members who take care of your baby will be wearing photo identification A nurse is assessing the newborn of a client who took a SSRI during pregnancy. What manifestations should the nurse identify as an indication of withdrawal from and SSRI? a. large for gestational age b. Hyperglycemia c. bradypnea d. vomiting A nurse in an antepartum clinic is providing care for a client who is 26 weeks gestation. Upon reviewing her medical record, what findings should the nurse report to the provider? a. 1-hr glucose tolerance test b. Hematocrit c. fundal height measurement d .FHR A nurse is caring for a client following an amniocentesis at 18 wks gestation. What finding should the nurse report to the provider as a potential complication? a. increased fetal movement b. leakage of fluid from the vag c. upper abd discomfort d. urinary frequency A nurse is caring for a client who is in active labor and has no cervical change in the last 4 hrs. Which statement should the nurse make? a. let me help you into a comfortable pushing position so you can begin bearing down b. going to call the doc to get a script for meds to ripen your cervix c. i will give you some IV pain med to strengthen your contractions d. your provider will insert an intrauterine pressure cath to monitor the strength of your contractions A nurse is caring for a client who is anemic at 32 wks gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. What outcomes should the nurse expect? a. decrease uterine contractions b. increase in client's Hgb levels c. reduction in resp distress in NB d. increase production of antibodies in NB A nurse is teaching a client who is 10 wks gestation about nutrition during pregnancy. What statement by the client indicates an understanding of the teaching? a. increase my protein to 60 g/day b. i should drink 2 L of water/day c. increase my overall caloric intake by 300 calories d. take 600 mcg of folic acid each day A nurse is teaching a client who is in preterm labor about terbutaline. What statement by the client indicates an understanding of the teaching? a.i will get injections of the med once daily until my labor stops b.my blood sugar may be low while I am on this med c. i will have blood tests because my K+ might decrease d. My BP may increase while I'm on this med A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. What cultural practices should the nurse include? a. protect the client's head and feet from cold air b. bathe the client within 12 hr following delivery c. ambulate the client within 24 hr of delivery d. offer the client a glass of milk with her first meal A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, what action should the nurse take next? a. massage the client's fundus b. insert an indwelling urinary catheter c. administer O2 at 10L/mind d. elevate the clients right hip A nurse is caring for a client who is at 36 wks gestation and has a prescription for amniocentesis. For which reason should the nurse prepare the client for an ultrasound? a. estimate fetal weight b. locate pocket of fluid c. determine multiparity d. prescreen for fetal anomalies A nurse is demonstrating to a client how to bathe her newborn. What order should the nurse perform the following actions? a.clean the NB diaper area b.wash the newborn's neck by lifting the NB chin c.wipe the NB eyes from the inner canthus outward d.cleanse the skin around the newborn's umbilical cord stump e.wash the NB legs and feet A nurse is assessing a newborn 12hrs after birth. What manifestation should the nurse report to the provider? a. Acrocyanosis b. transient strabismus c. jaundice d. caput succedaneum a nurse is calculating a client's expected DOB using Naegele's rule. The client says her last menstrual cycle started Nov 27th. What date is the client's expected DOB? a. sept 3rd b. sept 20th c. aug 3rd d. aug 20th A nurse is assessing a newborn following circumcision. What finding should the nurse identify as an indication that the newborn is experiencing pain? a. decreased HR b. chin quivering c. pinpoint pupils d. slowed respirations A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 wks late. The client appears anxious and asks the nurse if she is pregnant. What response should the nurse make? a. you can miss your period for several other reason. Describe your typical menstrual cycle. A nurse is preparing to administer oxytocin to a client who is postpartum. What findings indicate the admin of the med SATA a. flaccid uterus c. excess vaginal bleeding A nurse on the postpartum unit is caring for a client following a c-section. Priority? b. amount of lochia A nurse is observing a new mother caring for her crying newborn who is bottle feeding/ What action by the mother should the nurse recognize as positive parenting behavior? a. lays the newborn across her lap and gently sways b. places the newborn in the crib in a prone position c offers the newborn a pacifier dipped in formula d. prepares a bottle of formula mixed with rice cereal A nurse in a prenatal clinic is assessing a group of clients/ What client should the nurse request the provider to see first? a. 11 wks gestation and reports and cramping b. 15 wks gestation and reports tingling and numbness in her right hand c. 20 wks gestation and reports constipation for past 4 days d. 8 wks gestation and reports having 3 bloody noses in past week A nurse is preparing to administer hep b immune globulin to the newborn. Prescription states, "administer 5mcg Im once today." available is a 5mL vial with 10mcg/mL. How many mL? 0.5 A nurse is assessing a newborn who was born at 26 wks gestation using the New Ballard Score. Which findings should the nurse expect? a. minimal arm recoil b. popliteal angle of 90 degrees c. creases over the entire foot d. raised areolas with 3-4 mm buds A nurse is caring for a client who is 38 wks gestation. What action should the nurse take prior to applying an external transducer for fetal monitoring? a. determine progression of dilatation and effacement b. perform leopold maneuvers c. complete a sterile speculum exam d. prepare a nitrazine paper test A nurse is performing a physical assessment of a newborn. What clinical findings should the nurse expect? SATA a. HR 154/mon b. axillary temp 36 C (96.8F) c. resp rate 58/min d. length 43 cm (16.9 in) e. weight 2.6 kg (5lb 12 oz) A nurse is teaching a client at 35 wks gestation about clinical manifestations of potential preg complications to report to the provider. What manifestations should the nurse include? a. SOB when climbing stairs b. swelling of feet and ankles at the end of the day c. headache that is unrelieved by analgesia d. braxton hicks contractions A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states she is, "happy one minute and crying the next." the nurse should interpret the client's statement as an indication of which? a. emotional lability b. focusing phase c. cognitive restructuring d. couvade syndrome A nurse is caring for a client who is in labor and whose fetus is in the right occiput post position. The client is dilated to 8cm and reports back pain. What action should the nurse take? a. apply sacral counter pressure b. perform transcutaneous electrical nerve stimulation c. initiate slow-paced breathing d. assist with biofeedback A nurse is planning care for a client who is in labor and is to have amniotomy. What assessment should the nurse identify as the priority a. O2 saturation b. Temp c. BP d. urinary output A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. What action should the nurse take first? a. determine resp function b. increase the IV fluid rate c. access emergency meds from cart d. collect maternal blood sample for coagulopathy studies A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in what location to begin assessing for fetal heart tones? a. just above the umbilicus b. just above the symphysis pubis c. the RLQ d. The LLQ A charge nurse on a labor delivery unit is teaching a newly licensed nurse how to perform leopold maneuvers. What indicates the first step of leopold maneuvers? a hands on either side of baby's head b. one hand on baby's head c. hands on either side of baby's bottom d. one hand on baby's back and one on baby's front A nurse is planning discharge for a client who is 3 days postpartum. What nonpharmacological intervention should the nurse include in the plan of care for lactation suppression? a. place warm, moist packs on the breast b. apply cabbage leaves to the breasts c. wear a loose-fitting bra d. put green tea bags on the breasts A nurse is planning care for a client who is to undergo a nonstress test. What action should the nurse include in the plan of care? a. maintain the client NPO throughout the procedure b. place the client in a supine position c. instruct the client to massage the abd to stimulate fetal movement d. instruct the client to press the provided button each time fetal movement is detected A nurse is caring for a client who is 36 wks gestation and has a positive contraction stress test. The nurse should plan to prepare the client for what diagnostic test? a. biophysical profile b. Amniocentesis c. cordocentesis d. kleihauer-betke test A nurse is caring for a prenatal client who has parvovirus b19 (fifth disease). What action should the nurse take? a. administer antiviral meds b. schedule an ultrasound exam c. administer haemophilus influenzae type b vaccine d. schedule an indirect coombs test A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. What statement should the nurse include in the teaching? a. obtain an informed consent prior to obtaining the specimen b. collect at least 1mL of urine for the test c. ensure that the newborn has been receiving feedings for 24 hrs prior to obtaining the specimen d. premature newborns may have a false negative test due to immature development of liver enzymes. A nurse on an antepartum unit is caring for 4 clients. What client should the nurse identify as priority? a. gestational diabetes and a fasting glucose level of 120 b. 34 wks gestation and reports epigastric pain c. 28 wks gestation and has a Hgb of 10.4 g/dL d. a client who is at 39 wks gestation and reports urinary frequency and dysuria A nurse is teaching a new mother about newborn safety. Which of the following instructions should the nurse include in the teaching? a. you can share your room with your baby for the next few weeks b. cover your baby with a light blanket while sleeping c. check the temp of the baby's bath water with your hand d. your baby can nap in her car seat during the day A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. What action should the nurse take? b. maintain the client on bedrest A nurse is instructing a client who is taking an oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which? A.reduced menstrual flow B.Breast tenderness C. SOB D. Headaches. 2. A nurse in a prenatal clinic is caring for four clients. Which of the following clients' weight gain should the nurse report to the provider? B. 3.6 kg (8 lb) weight gain and is in her first trimester A nurse is reviewing a new prescription for iron supplements with a client who is in the 8th week of gestation and has iron deficiency anemia. Which of the following beverages should the nurse instruct the client to take the iron supplements with? D. Orange Juice. A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity? A. Alpha-fetoprotein (AFP) B. lecithin/sphingomyelin (L/S) ratio C. Kleihauer-Betke test D. indirect Coombs' test. A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? C."You should empty your bladder prior to the procedure." A nurse is providing care for a client who is at 32 weeks of gestation and who has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following types of medications should the nurse anticipate the provider will prescribe? A. Betamethasone A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? SATA A. Respirations less than 12/min B. Urinary output less than 30 ml/hr. C. Hyperreflexic deep-tendon reflexes D. decreased level of consciousness E. Flushing and sweating A nursing is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? D. calcium gluconate A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? C. "I plan to drink more orange juice while taking this pill." [Show Less]
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ATI MATERNALNEWBORN TEST BANK QUESTIONS & ANSWERS with RATIONALE 2022/2023
ATI. MATERNAL-NEWBORN 1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow? Inco... [Show More] rrect: Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21. Incorrect: Numerous clots are abnormal and should be reported to the physician. Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage. Correct: Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. The color of the lochia changes from a bright red to white after four days Numerous large clots are normal for the next three to four days Saturation of the perineal pad with blood is expected when getting up from the bed Lochia should last for about 3 weeks, changing color every few days 2. A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action? Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations. Incorrect: Variable decelerations (not late decelerations) are associated with cord compression. Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions. Correct: Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress. The umbilical cord is wrapped tightly around the fetus' neck The fetal cord is being compressed due to rapid descent of the fetal head Maternal contractions are not adequate enough to deliver the fetus The fetus is not receiving adequate oxygen and is in distress 3. Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth? Incorrect: Monitoring O2 saturations and administering pain medications are postoperative interventions. Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions. Correct: Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made. Incorrect: The nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case. Monitor oxygen saturation and administer pain medication. Assess vital signs every 15 minutes and instruct the client about postoperative care. Alleviate anxiety and insert an indwelling catheter. Perform a sterile vaginal examination and assess breath sounds. 4. Which nursing instruction should be given to the breastfeeding mother regarding care of the breasts after discharge? Incorrect: Engorgement occurs on about the third or fourth postpartum day and is a result of the breast milk formation. The primary way to relieve engorgement is by pumping or longer nursing. Giving a bottle of formula will compound the problem because the baby will not be hungry and will not empty the breasts well. Incorrect: Applying lotion to the nipples is not effective for keeping them soft. Excessive amounts of lotion may harbor microorganisms. Correct: In order to stimulate adequate milk production, the breasts should be pumped if the infant is not sucking or eating well, or if the breasts are not fully emptied. Incorrect: Using soap on the breasts dries the nipples and can cause cracking. The baby should be given a bottle of formula if engorgement occurs. The nipples should be covered with lotion when the baby is not nursing. The breasts should be pumped if the baby is not sucking adequately. The breasts should be washed with soap and water once per day. 5. A client in preterm labor is admitted to the hospital. Which classification of drugs should the nurse anticipate administering? Correct: Tocolytics are used to stop labor. One of the most commonly used tocolytic drugs is ritodrine (Yutopar). Incorrect: Anticonvulsants are used for clients with pregnancy-induced hypertension who are likely to seize. Incorrect: The glucocorticoids (e.g., betamethasone and dexamethasone) are used for accelerating fetal lung maturation and production of surfactant. They are commonly used if the membranes are ruptured or labor cannot be stopped. Incorrect: Anti-infective are used if there is infection. Preterm labor may or may not involve ruptured membranes with its accompanying risk of infection. Tocolytics Anticonvulsants Glucocorticoids Anti-infective 6. Which of the following are probable signs, strongly indicating pregnancy? Incorrect: The presence of fetal heart sounds is a positive sign of pregnancy; quickening is a presumptive Sign of pregnancy. Incorrect: These are presumptive signs. They may indicate pregnancy or they may be caused by other conditions, such as disease processes. Correct: These are probable signs that strongly indicate pregnancy. Hegar’s sign is a softening of the lower uterine segment, and Chadwick's sign is the bluish or purplish color of the cervix as a result of the increased blood supply and increased estrogen. Ballottement occurs when the cervix is tapped by an examiner's finger and the fetus floats upward in the amniotic fluid and then falls downward. Incorrect: These are presumptive signs that might indicate pregnancy, but they might be caused by other conditions, such as disease processes. Presence of fetal heart sounds and quickening Missed menstrual periods, nausea, and vomiting Hegar's sign, Chadwick's sign, and ballottement Increased urination and tenderness of the breasts 7. Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action? Correct: Bladder distention can lead to postpartum hemorrhage. A full bladder displaces the uterus causing it not to contract properly. Emptying the bladder allows the uterus to contract more firmly. Incorrect: A distended bladder rises out of the abdomen, causing the uterus to be displaced and increasing the risk of hemorrhage. It does not affect the perineum. Incorrect: Bladder distention can lead to urinary stasis and infection. This, however, does not relate to the soft, boggy uterus or the potential for hemorrhage. Incorrect: Massaging is uncomfortable regardless of whether the bladder is full or not. A full bladder displaces the uterus causing it not to contract properly, which may lead to postpartum hemorrhage. A full bladder prevents normal contractions of the uterus. An overdistended bladder may press against the episiotomy causing dehiscence. Distention of the bladder can cause urinary stasis and infection. It makes the client more comfortable when the fundus is massaged. 8. Which site is preferred for giving an IM injection to a newborn? Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred site for injections in the newborn because of lack of muscle mass. Correct: The middle third of the vastus lateralis is the preferred site for injections. Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred site for injections in the newborn because of lack of muscle mass. Incorrect: Newborns do not receive injections in the dorsogluteal site (gluteus maximus) due to decreased muscle mass. Ventrogluteal Vastus lateralis Rectus femoris Dorsogluteal 9. During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding? Incorrect: Urinary tract infections are common during pregnancy and in the postpartum period. Urinary frequency is a common finding. However, voiding large amounts of urine is not a sign of a UTI. Incorrect: High output renal failure occurs with injury/trauma to the kidneys. There has been no damage to the kidneys. Incorrect: Most women do receive some IV fluids during labor and delivery, however the IV rates are carefully calculated according to weight. Correct: During pregnancy, the circulating blood volume increases by about 50%. In order to get rid of the excess fluid volume after delivery, the woman experiences an increased amount of urine output during the first few hours. Urinary tract infection High output renal failure Excessive use of IV fluids during delivery Normal diuresis after delivery 10. If a pregnant client diagnosed with gestational diabetes cannot maintain control of her blood sugar by diet alone, which medication will she receive? Incorrect: Glucophage is an oral hypoglycemic. Oral hypoglycemic cross the placenta and can cause damage to the fetus. They are not used in gestational diabetes for that reason. Incorrect: Glucagon is a hormone used to raise blood sugar and manage severe hypoglycemia. Clients with gestational diabetes have hyperglycemia. Correct: Insulin is the drug of choice for gestational diabetes. Insulin lowers the client's blood sugar without harming the fetus. Incorrect: DiaBeta is an oral hypoglycemic drug. Oral hypoglycemic agents cross the placenta and can cause damage to the fetus. They are not used for gestational diabetes for that reason. Metformin (Glucophage) Glucagon Insulin Glyburide (DiaBeta) 11. Which assessment finding indicates that placental separation has occurred during the third stage of labor? Incorrect: There is usually an increase in bleeding (a sudden gush of blood) when the placenta separates. Incorrect: Contractions continue in an attempt to expel the placenta. The contractions may not be as intense, but they do not stop. Also, fundal massage helps contract the uterus preventing postpartum bleeding. Incorrect: Shaking and chills occur about 10-15 minutes after the delivery of the baby, but are not related to the placental detachment. They are a result of the release of pressure on pelvic nerves and the release of epinephrine during labor. Correct: As the placenta detaches, the cord that has been clamped becomes longer as it slides out of the vagina. Decreased vaginal bleeding Contractions stop Maternal shaking and chills Lengthening of the umbilical cord 12. The nurse midwife is concerned about a pregnant client who is suspected of having a TORCH infection. Which is the main reason TORCH infections are grouped together? They are: Incorrect: Most TORCH infections can cause mild flu-like symptoms for the mother. Death may or may not occur in the fetus. Incorrect: TORCH is an abbreviation for Toxoplasmosis, Other (syphilis, HIV and Hepatitis B), Rubella, Cytomegalovirus, and Herpes simplex—not all of these are sexually transmitted. Correct: All TORCH infections have the capability of infecting the fetus or causing serious effects to the newborn. Incorrect: A vector is a carrier of the disease such as a mosquito. Not all of the TORCH infections are carried by vector. benign to the woman but cause death to the fetus. sexually transmitted. capable of infecting the fetus. transmitted to the pregnant woman by a vector. 13. During the postpartum period, a hospitalized client complains of discomfort related to her episiotomy. The nurse assigns the diagnosis of “pain related to perineal sutures.” Which nursing intervention is most appropriate during the first 24 hours following an episiotomy? Incorrect: Petroleum jelly will harbor bacteria, which may hinder healing. Incorrect: The client should practice Kegel exercises to increase bladder tone, but these exercises would add to the client's discomfort during the first 24hours.Incorrect: Taking a warm sitz bath is recommended after the first 24 hours. Correct: Ice packs will decrease edema and discomfort, and prevent formation of a hematoma. Instruct the client to use petroleum jelly on the episiotomy after voiding. Encourage the client to practice Kegel exercises. Advise the client to take a warm sitz bath every four hours. Apply ice packs to the perineum. 14. A client asks the nurse about the benefits of breastfeeding. Which response by the nurse provides the most accurate information? Incorrect: Breastfeeding does not help speed up weight loss. The lactating mother requires more calories, but usually has an increased appetite to accommodate that need. Incorrect: Protein amounts are greater in formula and cow's milk. Correct: Breast milk is easier to digest because of the type of fat and protein in the milk. Incorrect: Breastfeeding does not prevent to woman from getting pregnant because it does not prevent ovulation. Most women ovulate within the first 6 weeks after delivery. Breastfeeding helps women lose weight faster. Breast milk contains a greater amount of protein. Breast milk is easier to digest than formula. Breastfeeding is a good method of contraception. 15. Which physiological change takes place during the puerperium? Incorrect: The puerperium is the first 6 weeks after delivery. The client will experience lochia for the first few weeks, and hormone levels will stabilize. Menstruation cannot occur until ovulation occurs. Incorrect: This occurs in stage three of labor. Correct: The uterine changes are called involution. The uterus should return to its pre- pregnancy state within 6 weeks after delivery. Incorrect: This describes the labor process, not the puerperium. The endometrium begins to undergo alterations necessary for menstruation. The placenta begins to separate from the uterine wall. The uterus returns to a pre-pregnant size and location. The uterus contracts at regular intervals with dilation of the cervix occurring. 16. A client delivered two days ago and is suspected of having postpartum "blues." Which symptoms confirm the diagnosis? Correct: These are signs of the postpartum blues, which typically diminishes within three- four days after delivery. Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts. Other symptoms of the blues include: sadness, anxiety about the health of the baby, insomnia, anorexia, anger, feelings of anticlimax. Incorrect: Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts. Depression and suicidal thoughts are signs of postpartum depression, not the blues and should be followed up with psychiatric treatment. Incorrect: Excess anxiety and the inability to care for the family are signs of postpartum depression, not the blues. Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts. Incorrect: Nausea and vomiting are psychosomatic symptoms of postpartum depression and require psychiatric treatment. Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts. Uncontrollable crying and insecurity Depression and suicidal thoughts Sense of the inability to care for the family and extreme anxiety Nausea and vomiting 17. Shortly after delivery, the nursery nurse gives the newborn an injection of phytonadione (Vitamin K). The infant's grandmother wants to know why the baby got “a shot in his leg.” Which response by the nurse is most appropriate? Incorrect: Calcium is needed for bone and muscle growth, not Vitamin K. Incorrect: Vitamin K is used to promote clotting, and does not affect digestion. Incorrect: The B vitamins are responsible for carbohydrate metabolism and the energy derived from glucose, not Vitamin K. Correct: Vitamin K is given to prevent bleeding until the intestinal bacteria can start to produce it. The intestines of a newborn are sterile until it starts to feed. Vitamin K helps with the clotting factors necessary to control bleeding. "Vitamin K promotes bone and muscle growth." "Vitamin K helps the baby digest milk." "Vitamin K helps stabilize the baby's blood sugar." "Vitamin K is used to prevent bleeding." 18. At 10 weeks gestation, a primigravida asks the nurse what is occurring developmentally with her baby. Which response by the nurse is correct? Incorrect: Wrinkles do not form until late in the pregnancy. Fat stores usually do not form until the third trimester. Incorrect: The eyelids are fused until about 26 weeks. Correct: The kidneys are making urine, which is excreted by the fetus into the amniotic fluid. Incorrect: The heart is already formed and beating at 8 weeks. "The skin is wrinkled and fat is being formed." "The eyelids are open and he can see." "The kidneys are making urine." "The heart is being developed." 19. A nurse in the clinic instructs a primigravida about the danger signs of pregnancy. The client demonstrates understanding of the instructions, stating she will notify the physician if which sign occurs? Incorrect: White vaginal discharge is a normal occurrence during pregnancy due to increased amounts of estrogen and increased blood supply to the cervix and vagina. It is not a “danger sign. “ Incorrect: Backache is common in pregnancy due to the alteration of the woman's center of gravity; it is not a “danger sign.” Backaches become worse as the uterus enlarges. Incorrect: Frequent, urgent urination is a common discomfort; it is not a danger sign. The pressure of the enlarging uterus causes frequency and urgency. Correct: Abdominal pain is a danger sign and can be indicative of an abruptio placenta. It is important for a physician to evaluate this symptom. It is one of several danger signs, including: headache, rupture of membranes, vaginal bleeding, edema, epigastric pain, elevated temperature, painful urination, prolonged vomiting, blurred vision, change in or absence of fetal movement. White vaginal discharge Dull backache Frequent, urgent urination Abdominal pain 20. An hour after delivery, the nurse instills erythromycin (Ilotycin) ointment into the eyes of a newborn. The main objective of the treatment is to prevent infection caused by which organism? Incorrect: Erythromycin (Ilotycin) is an antibiotic ointment used to prevent blindness related to gonorrhea. Antibiotics are effective against bacteria. Rubella is a virus. Correct: Ilotycin, an antibiotic, is used for the prophylaxis treatment of gonorrhea and chlamydia. If left untreated, it could result in blindness. Incorrect: Ilotycin, an antibiotic, is not effective in combating syphilis infections. Incorrect: HIV is a virus. Antibiotics are effective against bacteria. Ilotycinis an antibiotic ointment and therefore not effective against HIV. Rubella Gonorrhea Syphilis Human immunodeficiency virus (HIV) 21. A woman in active labor receives a narcotic analgesic for pain control. If the narcotic is given a half an hour before delivery, which effect will the medication have on the infant? It will cause the infant's: Incorrect: Narcotic analgesics cause respiratory depression and do not affect the infant's blood sugar. Correct: Narcotic analgesics can cause respiratory depression for the infant and also for the mother. This is evidenced by low Apgar scores (apnea and bradycardia) in the infant. If respiratory depression occurs, a narcotic antagonist (Narcan) is usually given. Incorrect: Narcotic analgesics, if given too close to delivery, can cause bradycardia, not tachycardia. Incorrect: Narcotics, such as Demerol, cause CNS depression, not hyperactivity. blood sugar to fall. respiratory rate to decrease. heart rate to increase. movements to be hyperactive. 22. For a client in the second trimester of pregnancy, which assessment data support a diagnosis of pregnancy-induced hypertension (PIH)? Incorrect: A decrease in hemoglobin is indicative of anemia, while uterine tenderness may indicate abruptio placenta. Incorrect: Polyuria and weight loss are signs of gestational diabetes. Correct: PIH is characterized by two components: elevated blood pressure and proteinuria. Vasospasm in the arterioles leads to increased blood pressure and a decrease in blood flow to the uterus and placenta. This results in a questionable outcome for the fetus due to placental insufficiency. Renal blood flow is affected, ultimately resulting in proteinuria. Incorrect: Elevated blood glucose is a sign of gestational diabetes. Hematuria may indicate a U.T.I. Hemoglobin 10.2 mg/dL and uterine tenderness Polyuria and weight loss of 3 pounds in the last month Blood pressure 168/110 and 3+ proteinuria Hematuria and blood glucose of 160 mg/dL 23. A 35-week gestation infant was delivered by forceps. Which assessment findings should alert the nurse to a possible complication of the forceps delivery? Correct: A weak, ineffective suck could be a result of facial paralysis which is a major complication of forceps deliveries. Scalp edema is another complication and should subside within 2-3 days. Other complications of forceps deliveries include: cephalohematomas, intracranial hemorrhage (especially in premature infants) and excessive bruising, which increases the risk for hyperbilirubinemia. Incorrect: Molding of the head is a common occurrence with vaginal deliveries. Jitteriness is a sign of low blood sugar, not forceps delivery. Incorrect: A shrill, high-pitched cry and tachypnea are signs of drug withdrawal, not a complication of forceps delivery. Incorrect: Hypothermia is not a complication of forceps deliveries. The hemoglobin level is quite low (should be about 15-16 g/dL), but unless there is excessive bleeding, the hemoglobin level should be unaffected by the forceps delivery. Weak, ineffective suck, and scalp edema Molding of the head and jitteriness Shrill, high pitched cry, and tachypnea Hypothermia and hemoglobin of 12.5 g/dL 24. In which position should the nurse place the laboring client in order to increase the intensity of the contractions and improve oxygenation to the fetus? Incorrect: This position is contraindicated because the fetus creates pressure on the mother's vena cava. Incorrect: Squatting widens the pelvic inlet, but does not improve contractions or fetal oxygenation. Correct: This prevents vena cava compression and, therefore, improves fetal oxygenation; at the same time, it provides a restful position between contractions. Incorrect: High Fowler's (sitting upright) will assist with the intensity of the contractions because of gravity, but it will not help with fetal oxygenation. Supine with legs elevated Squatting Left side-lying High Fowler's 25. A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions? Incorrect: Pulse rates increase due to pain, not because of rupture of membranes. Incorrect: The woman is not reporting pain and ruptured membranes do not cause pain. Lack of fluid (ruptured membranes) has no influence on respiratory rates. Incorrect: Blood pressure is not affected by prolonged rupture of membranes. Correct: The membranes are a protective barrier for the fetus. If the membranes are ruptured for a prolonged period of time, microorganisms from the vagina can ascend into the uterus. The longer the membranes have been ruptured, the greater the risk for infection. Pulse rates rise the longer the membranes are ruptured Respiratory rates decrease due to lack of fluid in the uterus Prolonged rupture of membranes can lead to transient hypertension Infection is a complication of prolonged rupture of membranes 26. A new client's pregnancy is confirmed at 10 weeks gestation. Her history reveals that her first two pregnancies ended in spontaneous abortion at 12 and 20 weeks. She has a4-year-old and a set of 1-year-old twins. How should the nurse record the client's current gravida and para status? Incorrect: Gravida includes the number of times the woman has been pregnant. She has been pregnant 5 times. A parity of 3 would be obtained by incorrectly counting the 20-week spontaneous abortion as a viable infant. Incorrect: The woman has been pregnant 5 times, including the present pregnancy. The abortions count as pregnancies, but not in the parity. Correct: Gravida is the number of times a woman has been pregnant, including the present pregnancy. Para is the number of pregnancies carried past 20 weeks' gestation, regardless of the number of fetuses delivered. The woman has been pregnant five times, including this pregnancy, and has had two pregnancies that have exceeded 20 weeks. Even though she delivered two children as a result of one of those pregnancies, the para for her twin pregnancy remains at 1. The pregnancy after which she delivered her four-year-old child makes her a para 2. Incorrect: A para of 4 would be obtained by incorrectly counting the 2 spontaneous abortions as viable at delivery. Gravida 2, para 3 Gravida 4, para 2 Gravida 5, para 2 Gravida 5, para 4 27. A 16-year-old client reports to the school nurse because of nausea and vomiting. After exploring the signs and symptoms with the client, the nurse asks the girl whether she could be pregnant. The girl confirms that she is pregnant, but states that she does not know how it happened. Which nursing diagnosis is most important? Incorrect: Although this addresses the client's nausea and vomiting, it is not the most important diagnosis at this time. There are no data to indicate that the client actually has a nutritional deficit. Because nausea and vomiting place her at risk for nutritional deficit, a diagnosis of “risk for altered nutrition. . .” would be appropriate. The knowledge diagnosis is an actual problem and should be addressed at this contact with the client; the nutrition problem will be ongoing during the pregnancy. Incorrect: This diagnosis does not address the reason for the lack of client knowledge—she may be at risk for poor parenting, but this is not the priority because there will be time to address that issue as the pregnancy progresses. Incorrect: There is no clear evidence of the denial of pregnancy nor of the lack of coping skills. Correct: This client clearly has a knowledge deficit about the causes of pregnancy and the physiological changes associated with it. It is important for teaching to begin immediately because her understandings essential to her compliance with suggestions for a healthy pregnancy. Altered nutrition: less than body requirements related to nausea and vomiting Risk for altered family processes related to the client's age Ineffective individual coping related to denial of pregnancy Knowledge deficit related to the client's developmental stage and age 28. A client is admitted to the hospital for induction of labor. Which are the main indications for labor induction? Incorrect: These are contraindications for labor induction. Correct: Induction of labor is the stimulation of contractions (usually by the use of Pitocin) before they begin on their own. Maternal indications for induction of labor include: pregnancy induced hypertension, chorioamnionitis, gestational diabetes, chronic hypertension and premature rupture of membranes. Fetal indications include intrauterine growth retardation, post-term dates and fetal demise. Incorrect: These are contraindications for labor induction. Incorrect: These are contraindications for labor induction. They are indications for a C-section. Placenta previa and twins Pregnancy-induced hypertension and postterm fetus Breech position and prematurity Cephalopelvic disproportion and fetal distress 29. A client in active labor receives a regional anesthetic. Which is the main purpose of regional anesthetics? Incorrect: This choice describes general anesthesia. Correct: Regional anesthetics provide numbness and loss of pain sensation to an area. The most common regional blocks are: local, pudendal, epidural, and spinal. Incorrect: Pain sensations travel to the central nervous system not away from it. Incorrect: This choice describes the action for narcotic medications, not regional anesthetics. To relieve pain by decreasing the client's level of consciousness To provide general loss of sensation by blocking sensory nerves to an area To provide pain relief by blocking descending impulses from the central nervous system To relieve pain by decreasing the perception of pain leading to the pain centers in the brain 30. The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant: Incorrect: Usually babies that only need suctioning of the mouth and nose have Apgars that are 8 or 9. Incorrect: If intubation is required, it means that the baby's heart and respiratory rates are not stable, and Apgars would be lower than 5. Incorrect: Apgar scores are used to quickly assess the well-being of the baby. Apgar scores range from 0-10. A score of 0 indicates that the baby is dead. An Apgar score of 5 indicates that the baby needs assistance. Correct: Apgar scores of 5 and 7 indicate that the heart rate was below 100, the respiratory effort was irregular, there was little muscle tone, the baby was pink with blue extremities, and there was a grimace. These scores indicate that the baby needed stimulation in order to breathe, and oxygen to increase its oxygen saturation. needed brief oral and nasal suctioning. required endotracheal intubation and bagging with a hand-held resuscitator. was stillborn and required CPR. required physical stimulation and supplemental oxygen. 31. With routine prenatal screening, a woman in the second trimester of pregnancy is confirmed to have gestational diabetes. How may the nurse explain the role of diet and insulin in the management of blood sugar during pregnancy? Correct: Insulin is given to gestational diabetic clients because their insulin requirements cannot keep up with the metabolic needs of the fetus in the last trimester. Insulin decreases the blood sugar. Incorrect: Oral hypoglycemic agents are not given to clients with gestational diabetes because they cross the placenta and are harmful to the fetus. Incorrect: The client will need frequent follow-up after delivery and into the postpartum period, but she should not need insulin after delivery because in gestational diabetes, blood glucose usually returns to normal after delivery. Incorrect: Clients with gestational diabetes need to eat three balanced meals and three snacks daily. The glucose load is best when maintained at a steady level throughout the day to avoid periodic overproduction of insulin. The last snack of the day should contain protein to stabilize the energy production during the night. "Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs of the baby." "You will need to take an oral hypoglycemic, which is a pill to lower your blood sugar." "There is a good possibility you will be taking insulin for the rest of your life." "You should eat three large meals per day to maintain steady glucose load." 32. A breastfeeding mother complains of cramping. Which is the main cause of the client's afterpains? Incorrect: Infection of the suture line can cause pain and discomfort, but is not the cause of afterpains. Afterpains are postpartum uterine contractions. Incorrect: Constipation and bloating do occur in the postpartum period as peristalsis resumes, but constipation does not cause afterpains, which are uterine contractions. Correct: Afterpains are caused by uterine contractions that occur for the first 2-3 days postpartum. Breast-feeding mothers have more afterpains due to the release of oxytocin stimulated by the nursing baby. Oxytocin strengthens uterine contractions and compresses blood vessels, preventing blood loss. Incorrect: Trauma is not the cause of afterpains. Afterpains are postpartum uterine contractions. Infection of the suture line Constipation and bloating Contractions of the uterus Trauma during delivery [Show Less]
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ATI MATERNAL NEWBORN PROCTORED 2019 (Rasmussen University).
ATI MATERNAL NEWBORN PROCTORED 2019 (All Questions & Answers 100% Correct) A nurse is caring for a client who is 2 weeks postpartum following a cesa... [Show More] rean birth. Which of the following clinical findings should the nurse identify as an indication of postpartum infection? Unilateral breast pain A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider? Urine protein of 3+ A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks gestation and has preeclampsia. Which of the following responses by the nurses is appropriate? “This medication prevents seizures.” A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? “Your contractions will become temporarily regular.” A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy? Obtain an imprint of the infant’s feet prior to taking him to the nursery A nurse is caring for a client who delivered by cesarean birth 6 hrs. ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take? Administer 500 mL lactated ringer’s IV bolus A nurse is providing discharge instructions to a client who is postpartum and has engorged breasts. Which of the following nonpharmacological comfort measures should the nurse include in the teaching? Apply cabbage leaves after feedings A nurse is calculating the estimated date of birth using Nagele’s rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated date of delivery in the next year? March 28 A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take? Prepare the client for what to expect the fetus to look like. A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client’s arms, the mother states, “No, the baby is too tired to be held.” Which of the following actions should the nurse take? Demonstrate how to hold the newborn and allow the client to practice A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client. Progressive sacral discomfort during contractions A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider? Platelet count 60,000/mm HELLP Syndrome A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take? Measure from the upper border of the symphysis pubis to the upper border of the fundus A nurse is caring for a client who is at 20 weeks of gestation and reports constipation. Which of the following recommendations should the nurse make to help relieve this common discomfort of pregnancy? Drink 2 to 3 L of water each day A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in synchronization with the fetal heartbeat. Which of the following terms should the nurse use to document this finding? Funic soufflé Funic soufflé Swishing of blood sound through umbilical cord (fetus) A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? Place newborn bassinets at least 3 feet apart A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. The nurse notes a respiratory rate of 8/min and absent DTR’s. Which of the following medications should the nurse administer? Calcium gluconate A nurse is caring for a client who is 8 hrs. postpartum following vaginal delivery and is unable to void. Which of the following interventions should the nurse use to promote voiding? Insert an indwelling urinary catheter A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? Transmission can occur via the saliva and urine of the newborn cytomegalovirus a herpes type virus that usually causes disease when the immune system is compromised A nurse in a prenatal clinic is caring for a client who has hyperemesis gravidarum. Which of the following is the initial laboratory test used to evaluate this condition? Urine ketones A nurse in a prenatal clinic is reviewing the lab results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take (EXHIBIT QUESTION) Administer ceftriaxone IM A nurse is teaching a client about the basal body temperature method of contraception. Which of the following statements should the nurse include in the teaching? “You should take your temperature before getting up for the day.” A nurse is providing education to a client who is to receive misoprostol for induction of labor. Which of the following instructions should the nurse include in the teaching? “You will lie on your side for 40 minutes after I administer the medication Misoprostol Cytotec A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment? The client will have adequate nutritional intake A nurse in the antepartum clinic is teaching a client who is at 28 weeks of gestation and has preeclampsia. Which of the following instructions should the nurse include in the teaching? “Count your baby’s movements daily.” A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse? “We need to know if you are positive for GBS at the time of delivery.” A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider Transient circumoral cyanosis Circumoral Cyanosis Blue around mouth due to inadequate oxygenation A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect? Cool, clammy skin A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy. Which of the following statements should the nurse make? “You should take 600 micrograms of folic acid per day.” A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan? Increase the infusion rate every 30-60 min A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? “You should expect your uterus to double in size.” A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take? Verify that the informed consent is obtained prior to administration Dinoprostone PGE2 analog causing cervical dilation and uterine contraction, inducing labor A nurse is preparing to administer metronidazole 2 g PO to a client who has pelvic inflammatory disease. Available is metronidazole 500 mg tablets. How many tablets should the nurse administer? (Round to nearest whole number) 2000 mg/500 mg = 4 tabs A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference? A client who is at 35 weeks of gestation and has a biophysical profile of 6 A nurse is planning to teach a group of clients who are pregnant about breastfeeding after returning to work. Which of the following information should the nurse include in the teaching? “Breast milk can be stored in a deep freezer for 12 months.” A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect? Telangiectatic nevi Nuchal Cord An umbilical cord that is wrapped around the infants neck A nurse is assessing a newborn upon admission to the nursery. Which of the following findings should the nurse expect? Chest circumference 2 cm (0.8 in) smaller than the head circumference A nurse is assisting with precipitous delivery of a term newborn. After the head emerges, the nurse palpates the cord around the newborn’s neck. Which of the following actions should the nurse take? Slip the cord over the newborn’s head A nurse is planning care for a newborn who is to undergo a circumcision using a plastic bell device. Which of the following interventions should the nurse include in the plan of care? Monitor for bleeding every 15 min for the first hour A nurse is providing discharge instructions to a client who is 24 hrs. postpartum and has decided not to breastfeed. Which of the following instructions should the nurse include in the teaching? “Apply ice packs to your breasts using a 15 minute on, 45 minutes off schedule.” A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hours postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication? Blood pressure 142/92 mm Hg Do not administer to client with HTN A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider? A newborn who has a high-pitched cry with exaggerated Moro reflex A nurse in a provider’s office is caring for a 20-year old client who is at 12 weeks of gestation and requests an amniocentesis to determine the gender of the fetus. Which of the following responses should the nurse make? “This procedure determines if your baby has genetic or congenital disorders.” [Show Less]
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ATI MATERNAL NEWBORN PROCTORED EXAM REVIEW (2022-2023).
ATI MATERNAL NEWBORN PROCTORED EXAM REVIEW (2022/2023) A nurse is caring for a client who is at 32 wks gestation and is experiencing preterm labor. What m... [Show More] eds should the nurse plan to administer? a. misoprostol b. betamethasone c. poractant alfa d. methylergonovine Correct Answer: b. betamethasone A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that what lab test will be used to confirm her pregnancy? a. urine test for presence of HCG b. urine test for the presence of HCS c. blood test for presence of estrogen d. blood test for the amount of circulating progesterone Correct Answer: a. urine test for presence of HCG A nurse is caring for a client who believes she may be pregnant. What finding should the nurse identify as a positive sign of pregnancy? a. palpable fetal movement b. amenorrhea c. chadwick's sign d. positive pregnancy test Correct Answer: a. palpable fetal movement A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse expect? a. renal agenesis b. atrial septal defect c. spina bifida d. hydrocephalus Correct Answer: a. renal agenesis A nurse is assessing a client who is at 37 wks gestation and has a suspected pelvic fracture due to blunt abd trauma. What findings should the nurse expect? a. uterine contractions b. bradycardia c. seizures d. bradypnea Correct Answer: a. uterine contractions The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma. A nurse is assessing a client who is at 12 wks gestation and has hydatidiform mole. What findings should the nurse expect? a. hypothermia b. dark brown vaginal discharge c. fetal heart tones d. decreased urinary output Correct Answer: b. dark brown vaginal discharge A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters. A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational HTN. What finding should the nurse identify as the priority? a. 480 mL urine output in 24 hrs b. 1+ protein in the urine c. +2 edema of the feet d. BP 144/92 Correct Answer: a. 480 mL urine output in 24 hrs When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding. A nurse is teaching a client who is at 12 wks gestation and has HIV. What statement should the nurse include in the teaching? a. you will be in isolation after delivery b. abstain from sexual intercourse throughout pregnancy c. breastfeed your newborn to provide passive immunity d. you should continue to take zidovudine throughout the pregnancy Correct Answer: d. you should continue to take zidovudine throughout the pregnancy -can be transmitted through breastfeeding -she can continue to have sex The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn. A nurse is providing teaching to a client who is at 8 wks gestation about manifestations to report to the provider during pregnancy. What info should the nurse include in the teaching? a. nausea upon awakening b. blurred or double vision c. increase in white vaginal discharge d. leg cramps when sleeping Correct Answer: b. blurred or double vision A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous IV infusion. The nurse notes that the client is having contractions every 2 min which last 100-110 seconds that the fetal heart rate is reassuring. What action should the nurse take? a. decrease the dose of oxytocin by half b. administer oxygen via nonrebreather mask c. decrease the infusion rate of the maintenance IV fluid d. administer terbutaline 0.25mg subq Correct Answer: a. decrease the dose of oxytocin by half The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole. A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What action should the nurse take? a. prepare the client for emergency c-section b. perform endotrach suctioning as soon as the fetal head is delivered c. prepare equipment needed for newborn resuscitation d. prepare the client for an ultrasound exam Correct Answer: c. prepare equipment needed for newborn resuscitation The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery. A nurse is reviewing the medical record of a client who is at 33 wks gestation and has placenta previa and bleeding. What scripts should the nurse clarify with the provider? a. insert a large-bore IV catheter b. perform a vaginal exam c. perform continuous external fetal monitoring d. obtain a blood sample for lab testing Correct Answer: b. perform a vaginal exam When a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding. A nurse is caring for a client who is at 37 wks gestation and is undergoing a nonstress test. The FHR is 130 without accelerations for the past 10 min. What action should the nurse take? a. request a script for an internal fetal scalp electrode b. auscultate the FHR with a doppler transducer c. report the nonreactive test result to the provider immediately d. use vibroacoustic stim on the client's abd for 3 seconds Correct Answer: d. use vibroacoustic stim on the client's abd for 3 seconds The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR. A nurse is reviewing lab results for a client who is at 37 wks gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood type O neg. What action should the nurse take? a. instruct the client to obtain a rubella immunization after delivery b. request a script for an antibiotic until delivery c. inform the client that she will have to deliver via c-section d. administer a dose of Pho(D) immune globulin Correct Answer: a. instruct the client to obtain a rubella immunization after delivery A nurse is reviewing the med record of a client who is at 39 wks gestation and has polyhydramnios. What finding should the nurse expect? a. total pregnancy wt gain of 3.6 kg b. fetal GI anomaly c. gestational HTN d. fundal height of 34 cm Correct Answer: b. fetal GI anomaly Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios. A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. What adverse effects should the nurse include in the teaching? a. elevated BP b. feeling of warmth c. generalized pruritis d. hyperactivity Correct Answer: b. feeling of warmth The nurse should tell the client to expect the feeling of warmth all over her body while the magnesium sulfate is infusing. A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. What action should the nurse take? a. position the client supine with legs elevated b. instruct the client to pant during contractions c. encourage the client to soak in a warm bath d. apply pressure to the client's sacral area during contractions Correct Answer: d. apply pressure to the client's sacral area during contractions A nurse is teaching a client who is at 12 wks gestation about manifestations of potential complications that she should report to her provider. What info should the nurse include in the teaching? a. intermittent nausea b. white vaginal discharge c. swelling of the face d. urinary frequency Correct Answer: c. swelling of the face A nurse is teaching a client who is at 10 wks gestation about an abd. ultrasound in the first trimester. What info should the nurse include in the teaching? a. you will need to have a full bladder during the ultrasound b. you will have a non stress test prior to the ultrasound c. the ultrasound will determine the length of your cervix d. you will experience uterine cramping during the ultrasound Correct Answer: a. you will need to have a full bladder during the ultrasound MY ANSWER The nurse should tell the client that a full bladder helps to lift the gravid uterus out of the pelvis during the examination. Therefore, it is important to ensure that the client has a full bladder to obtain the most accurate image of the fetus. A nurse is assessing a client who is 34 wks gestation and has mild placental abruption. What finding should the nurse expect? a. decreased urinary output b. fetal distress c. dark red vaginal bleeding d. increased platelet count Correct Answer: c. dark red vaginal bleeding The nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal bleeding. A nurse is caring for a client whose last menstrual period began july 8. Using Nageles rule, the nurse should identify the client's estimated DOB as what? a. oct 15 b. april 15 c. oct 1 d. april 1 Correct Answer: b. april 15 A nurse is caring for a client who is at 39 wks gestation and is in the active phase of labor. The nurse observes late decels in the FHR. What finding should the nurse identify as the cause of late decels? a. umbilical cord compression b. fetal head compression c. uteroplacental insufficiency d. fetal ventricular septal defect Correct Answer: c. uteroplacental insufficiency A nurse is assessing a client who is at 35 wks gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. What finding should the nurse report to the provider? a. DTR 2+ b. resp 16 c. BP 150/96 d. urinary output 20 mL/hr Correct Answer: d. urinary output 20 mL/hr The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia. A nurse is teaching a client who is at 13 wks gestation about the treatment of incompetent cervix with cervical cerclage. What statement by the client indicates an understanding of teaching? a. I should go to the hospital if I think I may be in labor b. I should expect bright red bleeding while the cerclage is in place c. I am sad that I won't be able to get pregnant again d. I can resume having sex as soon as I feel up to it Correct Answer: a. I should go to the hospital if I think I may be in labor Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions she might require tocolytic therapy. A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. What action should the nurse take? a. obtain blood samples for baseline lab values b. place a spiral electrode on the fetal presenting part c. prepare the client for a transvaginal ultrasound d. perform a vaginal exam to determine cervical dilation Correct Answer: a. obtain blood samples for baseline lab values The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels. A nurse is caring for a client who is at 38 wks of gestation and reports no fetal movement for 24 hr. What action should the nurse take? a. auscultate for a FHR b. reassure the client that a term fetus is less active c. have the client drink orange juice d. palpate the uterus for fetal movement Correct Answer: a. auscultate for a FHR Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action. A nurse is caring for a client who is at 35 wks gestation and has severe pre-eclampsia. What assessment provides the most accurate info regarding the client's fluid and electrolyte status. a. daily wt b. bp c. severity of edema d. I&O Correct Answer: a. daily wt A nurse is teaching a client who is at 30 wks gestation about warning signs of complications that she should report to her provider. What finding should the nurse include in the teaching? a. 10 fetal movements per hour b. mild constipation c. vaginal bleeding d. nasal congestion Correct Answer: c. vaginal bleeding Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor. A nurse is teaching a client who is at 8 wks gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. What info should the nurse include? a. you will have to undergo a c-section birth because of the fibroid b. the fibroid can increase the risk for postpartum hemorrhage c. the fibroid will shrink during pregnancy d. you will receive an injection of medroxyprogesterone acetate to shrink the fibroid Correct Answer: b. the fibroid can increase the risk for postpartum hemorrhage A nurse is caring for a client who is at 26 wks gestation and reports constipation. What responses by the nurse is appropriate? a. you should drink 1 ounce of mineral oil q morning b. you should eat at least 3 ounces of red meat/day c. you should walk for at least 30 minutes q day d. you should stop taking your prenatal Correct Answer: c. you should walk for at least 30 minutes q day The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation. A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. What action should the nurse take? a. apply barrier ointment to the newborn's perianal region b. offer the newborn glucose water between feedings c. use photometer to monitor the lamp's energy d. keep the newborn's eye patches on during feedings Correct Answer: c. use photometer to monitor the lamp's energy The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective. A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take? a. check the newborns temp using temporal thermometer b. place the naked newborn on the mothers bare chest and cover both with a blanket c. apply an o2 hood over the newborns head and neck d. give the newborn glucose water between feedings Correct Answer: b. place the naked newborn on the mothers bare chest and cover both with a blanket Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding. A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first? a. place the newborn directly on the client's chest b. administer erythromycin ophthalmic ointment c. give the newborn vit K IM d. perform a detailed physical assessment Correct Answer: a. place the newborn directly on the client's chest the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature. A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching? a. I will use an infant carrier when I drive to places close to the house b. I will tie my baby's pacifier around his neck with a piece of yarn c. I will place my baby on his back when it is time for him to sleep d. I will keep my babys crib close to heat vents to keep him warm Correct Answer: c. I will place my baby on his back when it is time for him to sleep A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp 36, well flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar score should the nurse assign to the newborn? a. 10 b. 9 c. 8 d. 7 Correct Answer: b. 9 A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bm since delivery. What action should the nurse take? a. notify the provider about the elevated temp b. massage the client's fundus c. administer bisacodyl supp d. assist the client to empty her bladder Correct Answer: d. assist the client to empty her bladder When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia. A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse administer? Correct Answer: 0.25 A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow respirations and periods of apnea lasting up to 10 seconds. What action should the nurse take? a. continue routine monitoring b. place newborn prone c. request a script for supplemental o2 d. perform chest percussion Correct Answer: a. continue routine monitoring The nurse should continue routine monitoring because the newborn's assessments findings indicate he is adapting to extrauterine life. placing in sidelying or supine A nurse is caring for a client who reports intestinal gas pain following a c-section. What action should the nurse take? a. encourage client to drink carbonated beverages b. instruct the client to splint the incision with a pillow c. have the client drink fluids through a straw d. assist the client to ambulate in the hallway Correct Answer: d. assist the client to ambulate in the hallway Walking can help stimulate peristalsis, which will promote expulsion of gas. A nurse is caring for a newborn who is premature at 30 wks gestation. What finding should the nurse expect? a. heel creases covering the bottom of the feet b. good flexion c. abundant lanugo d. dry, parchment-like skin Correct Answer: c. abundant lanugo Newborns who are premature have abundant lanugo, fine hair, especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinnas, and forehead. A nurse is assessing a newborn 1 hr after birth. What assessment findings should the nurse report to the provider? a. acrocyanosis b. jaundice of the sclera c. resp rate 50 d. cbg 60 Correct Answer: b. jaundice of the sclera If the newborn has jaundice within the first 24 hr of life, this can indicate a potential pathological process such as hemolytic disease. Pathologic jaundice can result in high levels of bilirubin that can cause damage to the neonatal brain. A nurse is providing teaching to the parents of a newborn about bottle feeding. What instructions should the nurse include? a. discard unused refrigerated formula after 72 hrs b. prop the bottle with a blanket for the last feeding of the day c. dilute ready-to-feed formula if the newborn is gaining wt too quickly d. boil water for powdered formula for 1-2 min Correct Answer: d. boil water for powdered formula for 1-2 min The parents should run tap water for 2 min and then boil it for 1 to 2 min before mixing it with the formula to decrease the risk of contamination. A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. What assessment findings should the nurse monitor to evaluate the effectiveness of the med? a. pulse rate b. bp c. fundal consistency d. output Correct Answer: c. fundal consistency Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective. A nurse is caring for a newborn who is premature in the neonatal ICU. what action should the nurse take to promote development? a. discourage the use of pacifiers b. position the naked newborn on the parents bare chest c. provide frequent periods of visual and auditory stimulation d. rapidly advance oral feedings Correct Answer: b. position the naked newborn on the parents bare chest A nurse is caring for a postpartum client 8hrs after delivery. What factors place the client at risk for uterine atony? select all a. oxytocin infusion b. prolonged labor c. mag sulfate infusion d. small for gestational age newborn e. distended bladder Correct Answer: b. prolonged labor Prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting. c. mag sulfate infusion Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. e. distended bladder After birth, clients can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics, which can result in a distended bladder. The distended bladder displaces the uterus and can prevent adequate contraction of the uterus. A nurse is assessing a newborn for congenital hip dysplasia. What finding should the nurse expect? a. temp of one leg differing from that of the other b. symmetrical gluteal folds c. limited abduction of one hip d. legs that are shorter than the arms Correct Answer: c. limited abduction of one hip A newborn who has congenital hip dysplasia can have limited abduction because the head of the femur might have slipped out of the acetabulum. asymmetrical gluteal folds A nurse is testing the reflexes of a newborn to assess neurologic maturity. What reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? a. moro b. babinski c. rooting d. tonic neck Correct Answer: d. tonic neck To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side when he is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same side that the nurse turned his head while the opposite arm and leg flex. This reflex persists for about 3 to 4 months. A nurse is assessing a newborn who was born at 39 wks gestation. What finding should the nurse expect? a. symmetric rib cage b. lanugo abundant on the back c. dry, wrinkled skin d. vernix over the entire body Correct Answer: a. symmetric rib cage A newborn who is born at 39 weeks of gestation is full-term and should have normal, smooth skin with good turgor and the presence of subcutaneous fat pockets. A postmature newborn, greater than 42 weeks of gestation, will have dry, cracked skin with a wrinkled appearance. A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. What pieces of info should the nurse provide to the mother when she inquires about the finding? a. this will resolve within 3-6 wks without treatment b. this will resolve on its own within 3-4 days c. this is expected at birth so you don't need to worry about it d. the provider might drain this area with a syringe Correct Answer: a. this will resolve within 3-6 wks without treatment A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what finding should the nurse monitor to identify a cervical laceration? a. a gush of rubra lochia when the nurse massages the uterus b. continuous lochia flow and flaccid uterus c. slow trickle of bright vaginal bleeding and a firm fundus d. report of increasing pain and pressure in the perineal area Correct Answer: c. slow trickle of bright vaginal bleeding and a firm fundus The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding,and a firm fundus to identify a cervical laceration. A nurse is planning care for a client who is postpartum and has cardiac disease. For what script should the nurse seek clarification? a. initiate bedrest with HOB elevated b. initiate high-fiber diet for client c. monitor clients wt wkly d. monitor client's I&O Correct Answer: c. monitor clients wt wkly The nurse should weigh the client daily to monitor for fluid overload. A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. What instructions should the nurse include in the teaching? a. stand under hot shower with your breasts exposed b. place ice packs on your breasts c. limit fluid intake to 1 L per day d. wear a loose-fitting, comfortable bra Correct Answer: b. place ice packs on your breasts The nurse should instruct the client to place ice packs on her breasts using a 15 min on and 45 min off schedule, to decrease swelling of the breast tissue as the body produces milk. A nurse is caring for a newborn directly after birth. What medications should the nurse administer to the newborn within 1-2 hr of delivery? a. poractant alpha b. rotavirus immunization c. naloxone d. erythromycin ophthalmic ointment Correct Answer: d. erythromycin ophthalmic ointment Every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent gonorrheal or chlamydial infections that the newborn can contract during birth. A nurse is caring for a newborn who weighs 4lb. How many kg does the newborn weigh? Correct Answer: 1.8 A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina. What following statements should the nurse make? a. blood pools in the vagina when you are lying a bed b. the amount of blood flow will increase during the first few days after giving birth c. you might have retained placental fragments in your uterus d. you might have a damaged blood vessel Correct Answer: a. blood pools in the vagina when you are lying a bed In the early postpartum period, lochia will pool in the vagina when the client is lying in bed and will flow out of the vagina when the client stands up. After the initial gush, the bleeding will slow down to a trickle of bright red lochia. A nurse is providing teaching to a client who is planning to breastfeed her newborn. What statement by the client indicates an understanding of the teaching? a. I must drink milk every day in order to assure good quality breast milk b. drinking lots of fluids will increase my breast milk production c. it is normal for my baby to sometimes feed every hr for several hours in a row d. after the first few weeks, my nipples will toughen up and breastfeeding wont hurt anymore Correct Answer: c. it is normal for my baby to sometimes feed every hr for several hours in a row Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8 to 12 times per day. [Show Less]
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