OB EXAM 2|143 Questions with Verified Answers
BUBBLE-LEB - CORRECT ANSWER Breasts
Uterus
Bowel
Bladder
Lochia
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Episiotomy/lacerations/incisions
Lower extremities
Emotions
Bonding
breasts assessment - CORRECT ANSWER Anatomic/Physiologic Changes: Increase of Blood and Lymphatic Fluid/Tissue
Colostrum: Early Milk - A Clear, Thick Yellow Fluid - "Liquid Gold"
-Assessment: Are Breasts Soft?, Can Milk Be Expressed? Any Nipple Integrity Concerns?
Engorgement: "Milk Coming In"; Occurs Day 2-4; Lasts 24-48 Hours
-Assessment: Breasts Firm/Full, Heavy, Warm, Tender, Nodular, & Low Grade Temp*
Mature Milk: White in Color; Higher in Fat Content
-Mastitis Assessment: Assess for Warmth, Pain/Tenderness, Temperature AFTER Engorgement Period
Breast Health History/Lactation History
breasts: nursing care - CORRECT ANSWER Formula Feeding Mother:
-Breast Binder or Supportive Bra
-Ice Packs (Constriction)
-Cabbage Leaves (Reduces Fluid)
-Mild Analgesics
-Avoid Nipple Stimulation
Breastfeeding Mother:
-Frequent Breastfeeding
-Heat (Dilation)
-Sore Nipples: Lanolin, Ensure Proper Latch, Hydrogel Pads
-Initiate First 1-2 Hours Following Delivery: Oxytocin Helps Maintain Contraction of Uterus to Prevent Hemorrhage Stay Hydrated
Tandem Nursing Mother:
-Let Infant Feed First the 1st Few Days to receive Colostrum
Uterus/Fundus - CORRECT ANSWER Involution
-Return of the uterus to a nonpregnant state after birth
Subinvolution
Failure of the uterus to return to a nonpregnant state.
*Indicates Retained Placenta or Infection*
Uterus / Fundus Assessment - CORRECT ANSWER ***Documentation:
-Tone: Firm/Boggy
-Location: Midline/Deviation
-Relation to Umbilicus:
--EX:
U - @ Umbilicus;
(1/u) 1 Fingerbreadth Above Umbilicus;
(U/2) 2 Fingerbreadths Below Umbilicus
Fundus Landmarks
-By Birth-12 Hours: at Umbilicus
-Descends ~1-2cm Every 24 Hours
-By Postpartum (PP) Day 6: Halfway Between Umbilicus and Pubic Symphisis
-By PP 2 Weeks: Not Palpable
-By PP 6 Weeks: Return to Nonpregnant State
Oxytocin - CORRECT ANSWER -Stimulates Uterine Contractions & Milk Production
-Hormone Released from Pituitary Gland
-Used PP to Maintain Firmness of Uterus
-Afterpains Increase Each Pregnancy or When Uterus Overextended/Overworked (Macrosomic Infant, Multifetal Gestation, Polyhydramnios; Prolonged Labor)
--Nursing Care: Apply Warmth, Ambulation
Bowel - CORRECT ANSWER -Hungry
-Assess Bowel Sounds
-Assess for Flatus
-Assess for Last BM
-Education on Constipation Prevention: Ambulation, Fluids, Fiber, Stool Softener
-Hemorrhoids: Increased Occurrence with Prolonged Pushing
-Perineal Laceration Considerations
Bladder - CORRECT ANSWER -Assessment: Last Void, Burning or Difficulty Urinating
-Diuresis: Increased Urine Output from Fluid Accumulation During Pregnancy
-Decreased Urge to Void
****Bladder Distention: Maintain Empty Bladder!!****
-Assess for Displaced, Upright Uterus (2/U and Deviated to Right)
-Deviation: Keeps Uterus from Remaining Firm and Contracted, Increasing Bleeding
Stress Incontinence: R/T Trauma of Pelvic Floor
-Pelvic Muscular Support: Up to 6 Months to Regain Tone (Kegel Exercises)
Lochia Rubra - CORRECT ANSWER Normal Discharge:
-bloody; small clots; fleshy, earthy odor, red or red/brown
-characteristics: heavy flow, small/medium clots
Abnormal discharge:
-large clots; saturated perineal pads; foul odor
Timeframe: PP Day 1-3
Lochia Serosa - CORRECT ANSWER Normal discharge:
-decreased amount; serosanguineous; pink or brown tinged
-Contents: Old Blood, Serum, Leukocytes, and Tissue Debris
-characteristics: Less blood, more discharge, fewer clots
Abnormal discharge:
-excessive amount; foul odor; continued or recurrent reddish color
Timeframe: PP Day 4-10
Lochia Alba - CORRECT ANSWER Normal discharge:
-further decreased amounts; white cream, or light yellow
-Contents: Leukocytes, Epithelial Cells, Mucus, Serum, and Bacteria.
-Characteristics: very little blood, some discharge, no clots
Abnormal discharge:
-persistent lochia serosa; return to loch rubra, foul odor; discharge continuing
Timeframe: PP day 11-14 - up to 6 weeks
Red flags of Lochia - CORRECT ANSWER -soaking through a pad in 1 hour or less
-passing clots bigger than a golf ball
-bleeding that stops then starts again
-fever
-abdominal pain more then usual
Lochia expectations - CORRECT ANSWER -Lochia Increases with Activity
-Can Pool in Vagina While Lying in Bed for Prolonged Period of Time (Gravity)
-Gush: Normal to Have a "Gush" of Lochia with Fundal Massage and First Time Ambulating
-Firm Fundus and Spurting Blood: Abnormal; Indicative of Laceration
-Odor - Infection
-Can Persist 4-8 Weeks PP
Lochia: Nursing Care - CORRECT ANSWER -Excessive Bleeding: ***Uterine Atony is the Most Frequent Cause***
-Signs of Hemorrhage:
--Early: Uterine Atony, Increased Lochia with Clots, Lightheadedness, Dizziness, "Seeing Stars"
--Later: Hypotension, Increased Temperature, Tachycardia, Diaphoresis, Pallor
QBL vs EBL
Pad Counts:
-Check Peripads and Under Buttocks (Gravity Pulls)
-Know When Pads Last Changed
-Ensure Accuracy (QBL)
-Excessive:
---1st 2 Hours PP: Pad Saturation <15Min After Delivery
--->2 Hours PP: Pad Saturated < 1 Hour
---Clots Larger Than Size of Egg
what is the number one cause of maternal mobility and mortality? - CORRECT ANSWER Postpartum hemorrhage
Postpartum hemorrhage criteria - CORRECT ANSWER 1:
>500mL blood loss (vaginal birth)
>1000mL blood loss (C-section)
2:
-change in BP, HR, O2 sat, restless, cool, clammy
3:
-10% or more fall in HCT -> takes time to be reflected on labs so not an immediate indicator
Postpartum Hemorrhage causes: think 4 T's - CORRECT ANSWER 1: Tone aka uterine atony - lack of uterine tone due to
-distention: multiple pregnancies, multiple babies (twins), LGA
-Muscle fatigue: long delivery
-Uterine relaxants
treatment: fundal massage- uterus should NOT be soft, boggy uterontnios
2: Trauma - damage to any part of moms pelvis, uterus, vagina due to
-baby coming through birth Canal
-medical forceps, vacuum, episiotomy
-C-section incision
S/S: persistant bleeding, severe pain
Treatment: surgical
Alarming: Hematomas can form and go untreated for hours
3: Tissue - retained placental fragments - prevents contractions - leads to atony
-ensure placenta comes out entirely
-remove fragments immediately - D&C procedure
4: Thrombin - clotting conditions form mom that prevent normal clotting. includes:
-Accreta
-DIC
treatment: Give blood, fluids, factor repletion
Primary PPH - CORRECT ANSWER occurs within first 24 hrs after delivery
Secondary PPH - CORRECT ANSWER occurs after 24 hrs if delivery
Fundal Assessment: - CORRECT ANSWER Immediate postpartum, fundus should be: midline, firm, at or near the umbilicus
-The fundus will continue to descend 1cm (1 finger length) per day for the next 2 weeks
If the fundus is soft, boggy, or displaced: fundal massage, empty bladder
things to know for Episiotomies/lacerations/incisions - CORRECT ANSWER REEDA
-Redness, Edema (Hematomas), Echymosis, Discharge, Approximation
Cervical Changes:
-External Os Will Not Return to Prepregnancy Shape
Assessment:
-Lithotomy Position or Side with Upper Buttocks Raised
Hematomas: Pain
Episiotomies/lacerations/incisions Degrees and types - CORRECT ANSWER Perineal Lacerations:
-1st Degree: Skin Deep
-2nd Degree: Muscle and Skin Deep
-3rd Degree: Tear of Anal Sphincter, Muscles, and Skin
-4th Degree: Extends Into the Rectum
Episiotomy: Midline
-Classical C/S Incision
-Low Abdominal Transverse
Episiotomies/Lacerations: Nursing Care - CORRECT ANSWER Prevent Infection
-Hand Hygiene
-PeriCare with PeriBottle
-Pat Dry Front to Back
Position to Side
Ice/Sitz Baths
Topical Anesthetic Sprays/Pads (Witch Hazel)
Ambulate (Increases Circulation to Site)
C/S Incisions: Monitor Drainage on And Pads; Keep Site Clean and Dry; When dressing removed, document what is keeping incision approximated and what the site looks like.
Lower Extremities: VTE Risk - CORRECT ANSWER -Increased Clotting Factors 2-3 Weeks PP
-Evaluation of Venous Thromboembolic Diseases: DVTs and PEs
-S/Sx: Pain/Tenderness, Warmth, Redness, and Edema Unilaterally in Lower Extremities
-Risk Factors: C/Sections (Doubles Risk), Obesity BMI>35, Multiparity, Smoking
-Prevention: Early and Frequent Ambulation; SCDs, TED Hose/Compression Stockings
Skin to Skin contacts - CORRECT ANSWER Postpartum Benefits:
-Helps Facilitate Affection and Attachment Behaviors (Mom and Support Person)
-Improves Feedings
-Infant Sleeps Better! Cries Less!
-Increased Oxytocin Hormone Release: PPH Prevention, Quicker Milk Production, "Feel Good" Hormone.
Assessment of attached behaviors - CORRECT ANSWER Feel (Touch)
-Holding, Touching, Patting Back/Stroking, Grasp Reflex, Rocking
See (Eye Contact)
-Tracking/Following Parents; Helps Parents Feel Closer to Infant; Creates Trust
Hear (Voice)
-Infants Can Distinguish Mother's Voice
Smell (Odor)
-Smells Mother/Breastmilk; Mother's Smell Baby
Speak
-Say Infant's Name, Speak of the Baby, Talk to Infant
**Be Mindful of Cultural Differences***
Maternal adaptation - CORRECT ANSWER Taking In
-focused on self/delivery
-first 24 hours
Taking Hold
-desire to take charge; focused on infant care
-day 2 - couple weeks PP
Letting go
-independent
-emphasis shifts to family
postpartum blues - CORRECT ANSWER NORMAL
-Usually Begins PP Day 5-10; Rarely Lasts Longer than 10-14 Days
-Can Continue to Care for Self and Infant
Symptoms: Cry Easily for No Reason, Mood Swings, Feeling Overwhelmed, Unable to Cope, Oversensitive, Decreased Appetite, Anxiety, Fatigue, Anger
Treatment: No Medical, Encouragement/Support, Rest, Fresh Air, Exercise, Community Resources, Verbalize Feelings, EDUCATE ON S/SX of Progression to Postpartum Depression
Nursing care and role - CORRECT ANSWER Assess for Physiologic/Psychologic Adaptation
Assess for *Warning Signs for Abnormalities/Complications Breasts, Firm, Warm (Outside of Engorgement Period) - Mastitis
-Uterus Soft/Boggy, Displaced, Not Descending Appropriately
-Decreased BP, Increased Temp, Increased Pulse - Hypovolemic Shock
-Lochia Increasing in Amount, Clots, Odor - Endometritis
-DVT Symptoms
Cluster Care: Assist with Rest and Recovery
Support of Transition to Parenthood
EDUCATION r/t Self-Management and Infant Care
Rubella (MMR) - CORRECT ANSWER -For women who have not had Rubella or who are serologically nonimmune.
-Given PP prior to Discharge to prevent the possibility of contracting Rubella in future pregnancies.
-Teratogenic: Do not get pregnant for 28 Days Following Vaccine. Titer >1:8 Indicated Immunity
varicella - CORRECT ANSWER -For women who have no immunity.
-Given Prior to Discharge and Again at PP Follow-Up (2 Doses)
-Teratogenic: Do not get pregnant for 28 Days Following Vaccine.
Postpartum A&P changes - CORRECT ANSWER -normal for WBC to be elevated
-increased clotting factors
Tdap - CORRECT ANSWER -Given Prior to Discharge for women who have not previously had vaccine.
-Decrease Risk of Infant Exposure of Pertussis
-Advise Family/Visitors to Ensure Vaccination as Well.
Postpartum Hemorrhage (PPH) - CORRECT ANSWER Leading Cause of Maternal Death Worldwide; Demands Prompt Recognition and Intervention; Very Preventable
Definition:
-Blood Loss: >500 mL after Vaginal Birth; >1000 mL after Cesarean Birth
->10% Change in Hematocrit from Admission
***Predisposing Factors***
-High Parity, Prolonged Labor/Extended Use of Uterotonics, Dystocia, Operative Delivery, Uterine Overdistention (Poly, Multiple Gestation, Macrosomia), Placental Abruption/Previa, Hx PPH, Infection
PPH assessment findings - CORRECT ANSWER Dizziness/Lightheadedness Excessive Uterine Bleeding Signs of Hypovolemic Shock:
-Weak, Increasing Pulse,
-Cool and Clammy Skin
-Diaphoresis
-Restlessness
-Decreased BP (Late Sign)
PPH nursing interventions - CORRECT ANSWER -Fundal Massage!!!!!
-Pad Counts
-Vital Signs
-Place Foley/Empty Bladder
-Increase IV Fluids
-Medications
-Consider Oxygen
-Monitor LOC
-Monitor I&O
-Notify Physician
medical interventions:
-bakri tamponade balloon surgery
PPH medications (know generic and trade name, and classifications - CORRECT ANSWER -Pitocin
-Cytotec
-Methergine
-Hemabate (don't give with history of asthma)
-TXA
acronym (Please Call my Husband Thanks)
Postpartum Depression - CORRECT ANSWER -Sadness with severe and labile mood swings, depressed mood, guilt
-Affects Care of Infant
-Lasts Longer than 2 Weeks; More Severe than Postpartum Blues
-Assess for S/Sx of Harm to Self/Others; Assess for Loss of Appetite, Sleep Disturbances
-Paternal PPD: Occurs in Father (Increased Risk if Partner has PPD)
-Can Lead to Postpartum Psychosis (More Severe, Requires Inpatient Treatment)
Postpartum psychosis - CORRECT ANSWER a rare and severe form of depression that occurs in women just after giving birth and includes delusional thinking and hallucinations
case study
A 39-year-old G7 P4216 gave birth by repeat cesarean 12 hours ago. The newborn was admitted to the neonatal intensive care unit for observation. The client has a history of tobacco smoking and diabetes. Her pre-pregnancy BMI was 35 and she had a 20-pound weight gain during this pregnancy. She experienced a shoulder dystocia and a deep vein thrombosis after her second birth.
Question 1
Based on the available data noted above, for which potential complications would the nurse need to provide additional monitoring during the postpartum hospital stay?
Select all that apply.
1. Postpartum hemorrhage
2. Preterm labor
3. Wound infection
4. Venous thromboembolic disorders
5. Hyperemesis gravidarum
6. Retained placenta - CORRECT ANSWER 1. Postpartum hemorrhage
3. Wound infection
4. Venous thromboembolic disorders
The postpartum nurse receives the report below from a labor and delivery nurse.
Question 1:
Highlight or place a check mark next to the findings that are potential risk factors for this client during the postpartum period.
A. The client is a G6P4115
B. Blood pressure 115/75
C. Pulse 88
D. Pregnancy complicated by polyhydramnious
E. Pregnancy complicated by pre-term labor
F. Pregnancy complicated by positive group b streptococcus in third trimester
G. Client gave birth by repeat cesarean
H. Client plans to breastfeed
I. Client has a history of depression - CORRECT ANSWER A. The client is a G6P4115
D. Pregnancy complicated by polyhydramnious (overextended uterus)
G. Client gave birth by repeat cesarean
I. Client has a history of depression
Passenger - CORRECT ANSWER MOVEMENT OF THE PASSENGER IS EFFECTED BY THE:
-SIZE OF THE FETAL HEAD
-FETAL PRESENTATION
-FETAL LIE
-FETAL ATTITUDE
-FETAL POSITION
Passenger: Fetal Lie - CORRECT ANSWER LIE: RELATION OF LONG AXIS (SPINE) TO SPINE OF THE MOTHER
TYPES:
Longitudinal Lie:
-mom and baby are parallel
Transverse Lie:
-mom and baby are horizontal to eachother
Passenger: fetal attitude - CORRECT ANSWER ATTITUDE: RELATION OF THE FETAL BODY PARTS TO ONE ANOTHER
WANT GENERAL FLEXION: BACK ROUNDED, CHIN/THIGHS, AND LEGS FLEXED TO CORE
Flexion attitude:
-normal fetal postion
Extension attitude:
-fetus is spread out
Passenger: Fetal Position - CORRECT ANSWER POSITION: RELATIONSHIP OF A REFERENCE POINT ON THE PRESENTING PART TO THE FOUR QUADRANTS OF THE MOTHER'S PELVIS.
3 LETTER ABBREVIATION:
FIRST: LOCATION OF THE PRESENTING PART IN THE RIGHT (R) OR LEFT (L) SIDE OF THE MOTHER'S PELVIS.
MIDDLE: SPECIFIC PRESENITNG PART
-OCCIPUT (O) (back of head)
-SACRUM (S) (botton or foot first, breech)
-MENTUM (M),
-SCAPULA (SC)
LAST: LOCATION OF PRESENTING PART IN RELATION TO THE ANTERIOR (A), POSTERIOR (P), OR TRANSVERSE (T) PORTION OF MATERNAL PELVIS.
STATION: RELATIONSHIP OF PRESENTING PART TO IMAGINARY LINE DRAWN BETWEEN METERNAL ISCHIAL SPINES
-SCORE OF -5 TO +5
-DETERMINES DECENT OF FETUS THROUGH BIRTH CANAL
ENGAGEMENT:
-CORRESPONDS TO STATION 0.
-LARGEST DIAMETER OF PRESENTING PART HAS PASSED INTO THE TRUE PELVIS.
Passenger: Fetal Presentation - CORRECT ANSWER PRESENTATION: PRESENTING PART OF THE FETUS THAT ENTERS THE PELVIC INLET FIRST AND LEADS THROUGH THE BIRTH CANAL DURING LABOR.
CEPHALIC (HEAD FIRST): MOST COMMON
-VERTEX: PRESENTING PART OCCIPUT
BREECH: (BUTTOCKS/FEET FIRST)
-PRESENTING PART: SACRUM
SHOULDER
-PRESENTING PART: SCAPULA
SVE (STERILE VAGINAL EXAM): - CORRECT ANSWER DILATION (0-10CM)
EFFACEMENT (0-100%)
STATION (-5 TO +5)
COMPLETE = 10/100/+1
signs of preceding labor - CORRECT ANSWER -LIGHTENING
-Braxton Hicks
-BLADDER PRESSURE/URINARY FREQUENCY RETURN
-BACKACHE
-STRONG BRAXTON HICKS
-Energy Spurt
-BLOODY SHOW, MUCUS PLUG, INCREASED VAGINAL DISCHARGE
true vs. false labor - CORRECT ANSWER True Labor:
-Requires cervical change
-Contractions have consistent pattern and increase in frequency duration, and intensity.
-Contractions increase Frequency and intensity with ambulation
False Labor:
-No cervical changes
-Inconsistent frequency, duration, and intensity of contractions.
-Activity does not alter contractions
-More annoying than painful
False labor signs - CORRECT ANSWER Contractions:
-inconsistent in frequency, duration, and intensity
-change in activity, such as walking, does not alter contraction, or activity may decrease them.
discomfort:
-felt in the abdomen and groin
-may be more annoying than truly painful
Cervix:
-no significant change in effacement or dilation of the cervix after an observation period 1-2h
True labor signs - CORRECT ANSWER Contractions:
-a consistent pattern of increasing frequency, duration, and intensity usually develops
-walking tends to increase frequency and strength of contractions
Discomfort:
-begins in lower back and gradually sweeps around to the lower abdomen like a girdle
-back pain may persist in some women. Early labor often feels like menstrual cramps
Cervix:
-effacement and/or dilation of cervix occurs. Progressive effacement and dilation of cervix are most important characteristics
External fetal monitoring - CORRECT ANSWER FHR Monitoring: ultrasound transducer
Uterine activity: tocotransducer
*Can be effected by obesity or baby's position/ movement
Internal fetal monitoring - CORRECT ANSWER *Membranes have to be ruptured; avoid with HSV, HIV, GBS*
Fhr monitoring : fse: fetal scalp electrode
Spiral electrode to fetal scalp
Uterine activity: iUPC: intrauterine pressure catheter
*Not Effected by obesity or baby's position/ movement*
Tachysystole - CORRECT ANSWER >5 contractions in 10 minutes.
-can lead to uterine rupture
Hypertonic uterus - CORRECT ANSWER single contraction >2minutes
-may result in fetal heart rate abnormalities, uterine rupture, or placental abruption.
resting tone - CORRECT ANSWER tension in the uterine muscle between contractions.
frequency - CORRECT ANSWER Beginning of one contraction to the beginning of the next
Ranged Value: over the course of 3-5 contractions
Intensity - CORRECT ANSWER External/Palpation:
-Mild (Nose)
-Moderate (chin)
-Severe (forehead)
Internal pressure: 40-70mm Hg (most accurate)
Duration - CORRECT ANSWER Length of each contraction (from beginning to end)
Ranged value: 40-50 seconds
Baseline - CORRECT ANSWER Normal :
110-160 BPM
-Average rate during a 10 minute period
-*Round to the closest 5 beat interval*
-*Indicates healthy fetal cns*
Tachycardia:
>160 BPM for <10 min
-*can Indicate an early sign of fetal hypoxia; maternal/ fetal infection (chorio); fetal anemia; drugs (caffeine, meth, cocaine), dehydration, response to a medication (terbutaline)*
Bradycardia:
<110 for > 10 min
-*can indicate a late sign of fetal hypoxia, a fetal cardiac problem (heart block); viral infections (CMV); maternal hypoglycemia/tension/thermia; response to a medication (Mag, narcotics)*
Variablility - CORRECT ANSWER Irregular waves or fluctuations in the baseline FHR; displays fetus' oxygen reserves
Moderate:
6-25 BPM from baseline
normal
-means the fetus is good and oxygenated and the CNS is intact
Minimal:
<5 bpm from baseline *Abnormal*
-can indicate fetal hypoxia:
Reasons:
-Sleep, sedation, sick
Interventions: Wait and recheck
Absent: BAD
-no movement
Reasons:
-severe hypoxia
-CNS not intact
VEAL CHOP MINE - CORRECT ANSWER V = Variable decelerations
E = Early decelerations
A = Acceleration
L = Late decelerations
C = Cord Compression
H = Head Compression
O = OK!
P = Placenta Insufficiency
M = Move position
I = Initiate secondary measures
N = Nothing!
E = Emergency Delivery
Accelerations - CORRECT ANSWER -Visually apparent, abrupt increase in fhr above the baseline
-*15 X 15: peaks at least 15 beats above the baseline for at least 15 seconds*
-<32 weeks: 10X10 is sufficient
-Indicates fetal well-being and oxygenation
Early decelerations - CORRECT ANSWER Onset and recovery correspond with contraction (mirrored image)
*normal*
Indicates fetal head compression
-tightening of uterus causes baby head to be compressed resulting in decrees O2 and decals
Nursing actions:
-ID labor progress
-continue to monitor
Late decelerations - CORRECT ANSWER NOT GOOD
Gradual decrease and return to baseline begins after a contraction has started; the lowest point occurs after the peak of the contraction; returns to baseline following the end of the contraction
*requires intervention*
Indicates placental insufficiency (often from maternal hypotension or uterine tachysystole*)
Nursing actions:
-move mom to side (usually left lateral position)
-Stop Pitocin (bc it creates contractions and stresses baby)
-apply oxygen to mom (10L non-rebreather)
-administer LR bolus (increases blood flow, opens blood vessels wider, increases O2)
-Emergent Deliver (c-section)(notify physician)
Variable decelerations - CORRECT ANSWER Visually abrupt decrease in FHR (at least 15bpm below baseline), unrelated to contraction (shaped like U, V, W)
-Blood flow completely blocked
-HR in unsafe range
Common (40-50% of all labors)
Indicates cord compression
*requires intervention*
Nursing actions:
-move mom (Trendelenburg, knee to chest)
-ID labor progress (feel for prolapsed cord)
-amnio infusion
Recurrent = disruption in oxygen supply to fetus
First stage of labor: Latent phase - CORRECT ANSWER -Onset of True labor (regular contractions creating cervical change) to 5cm
-Excited, Mild anxiety that intensifies, discomfort increases, open to instructions
-Able to continue usual activities (walk and talk through contractions)
-Contractions:
Strength: Mild to Moderate
Frequency: 2-3 minutes apart
Duration: 30-40 seconds
First stage of labor: Active stage - CORRECT ANSWER -From 6-10 cm dilation
-More Serious, fear of loss of control, self-focused and self-doubting, difficulty following directions
-Don't want to be left alone or touched, desires companionship and encouragement
-Contractions:
Strength: moderate to severe
Frequency: 1.5-5 minutes apart
Duration: 40-90 seconds
nursing care for first stage of labor - CORRECT ANSWER -Watch vital signs and for signs of infection
-Monitor pain and offer medications appropriately
-Infection preventative measures (limits SVEs, sterile technique, pericare, clean linens/pads)
-Fetal FHR/contraction monitoring (Especially prior to Amniotomy Procedure)
-Take to bathroom or place on bedpan every two hours
-breathing exercises and position of comfort
-Clear fluids only
Second Stage of Labor: Latent Phase - CORRECT ANSWER -Time from complete dilation to actively pushing; time of descension through the birth canal. Period of rest
-Laboring down/Delayed pushing/ passive descent: increase in spontaneous vaginal births, decease in C/S, decrease in active pushing time, less maternal fatigue
-Station: 0-+2
-Quiet, Minimal urge to push
Second Stage of Labor: Active Phase - CORRECT ANSWER -Time From actively pushing until the birth of the baby.
-Assessment findings: vomiting, increased bloody show, uncontrolled shivering, verbalization of loss of control, inability to cope
-Station: +2 to +4 (on the Floor)
-Grunting/Screaming, increased urge to bear down
nursing interventions for second stage of labor - CORRECT ANSWER -Monitor Vitals, FHR, contractions, bearing down efforts, Fetal Descent, and Mother's Appearance
-Latent: encourage rest to conserve energy and position to comfort
-Active: do not leave the woman, encourage rest between contractions, provide positive reinforcement, position for delivery, peri care
-Education: avoid holding breath while pushing, can trigger Valsalva maneuver
---increases intrathoracic and cardiovascular pressure that reduces cardiac output and decreases perfusion of the uterus and the placenta.
Third stage of labor - CORRECT ANSWER Goal:
-Prompt separation and expulsion (With slight push) of the placenta achieved in the easiest, safest manner.
-A placenta cannot detach itself from a flaccid/relaxed uterus; you cannot force removal
Longer the stage = greater chance of hemorrhage
Retained after 30 minutes
Birth of baby - CORRECT ANSWER -CLEAR AIRWAY FIRST (mouth then nose)
-warm/dry baby
-stimulate baby
Assessment findings for the third stage of labor - CORRECT ANSWER Observe for signs of placental separation:
-Lengthening of the umbilical cord
-Gush of dark blood
-Uterus shape change: discoid to a globular shape as the placenta moves into the lower uterine segment.
Observe/assess bleeding
Monitor vital signs frequently
Fourth Stage of Labor - CORRECT ANSWER first 4 hours after birth of placenta
Nursing care: all about mom
-monitor HR/BP (increased risk of hemorrhage)
-monitor temp (increased risk of infection)
-assess fundus (increased risk of uterine atony)
-monitor loch and peri-pad usage
-pain relief
-peri care and c-section care
-encourage bonding
Preterm labor medications - CORRECT ANSWER -Glucocorticoids (Betamethasone, Dexamethasone)
-Tocolytic (Terbutaline, Mag)
Glucocorticoids - CORRECT ANSWER accelerate fetal lung maturity by stimulating fetal surfactant production; typical course - 2 shots IM 24 hours apart
-betamethasone
-dexamethasone
Tocolytics - CORRECT ANSWER medications to arrest labor
-Magnesium sulfate: relaxes smooth muscles (given for preeclampsia or preterm labor), monitor for toxicity and decreased HR, helps with infant neural development.
-Terbutaline: given to stop contractions, can cause fetal tachycardia
-Nifedipine (Procardia): calcium-channel blocker (prevents calcium from entering smooth muscle cells); observe for orthostatic hypotension
Chorioamnionitis - CORRECT ANSWER -Bacterial infection of amniotic cavity
-Diagnosed by maternal fever, maternal and fetal tachycardia, and purulent amniotic fluid
-Risk factors: prolonged labor, multiple vaginal exams, internal FHR monitors
-----occurs in 1-5% of all births but 25% of preterm births
-Risks to infant: pneumonia, bacteremia, and meningitis
-Give broad spectrum antibiotics to prevent complications if suspected (ampicillin, gentamicin)
Postterm pregnancy - CORRECT ANSWER After 42 weeks 0 days
Complications:
-labor dystocia,
-chorioamnioitis,
-Macrosomic fetus /need for cesarean section
-postpartum hemorrhage and perineal injury
-Meconium stained fluid and aspiration
Breech delivery - CORRECT ANSWER -external cephalic Version (attempt to turn the fetus)
-Increased Risk with Twins
-C-Section Delivery Needed
-Infant will need hip ultrasound at 6 weeks
Dystocia / dysfunctional labor - CORRECT ANSWER -Lack of progress in labor for any reason.
-Responsible for over half of all cesarean births
-Causes: ineffective uterine contractions or maternal pushing efforts, abnormalities of presentation or pelvic structures
---Cpd (cephalopelvic disproportion)
Shoulder Dystocia - CORRECT ANSWER -Head is born but anterior shoulder cannot pass the pubic arch
-High risk for asphyxia and fracture of clavicle or humerus (often the right arm)
-Nursing care: mcroberts maneuvers (hyperflexion of legs), suprapubic pressure, gaskin maneuver (hands-and-knees position), document time of dystocia
Prolapsed cord - CORRECT ANSWER -Cord lying below presenting part of fetus
-Frequently happens after ROM
-Fetal hypoxia can lead to central nervous system damage or death of fetus
-Care management: Relieve pressure, Lift head off cord, Emergency cesarean section,
Uterine rupture - CORRECT ANSWER Common finding is abnormal FHR tracing, sudden, sharp abdominal pain described as "ripping", signs of hypovolemic shock (hypotension/tachycardia)
VBAC (vaginal birth after cesarean) - CORRECT ANSWER vaginal birth of an infant to a woman who has had at least one previous cesarean delivery.
-high risk for uterine rupture
-contraindicated of previous rupture classical or vertical incision were made
Preterm labor - CORRECT ANSWER -Preterm labor: true labor (regular contractions with changes in cervical effacement or dilation) that occurs between 20+0 and 36+6 weeks.
-Risk factors: infection (UTIs), history of previous preterm delivery, multifetal gestation, smoking, drug abuse, high levels of personal stress, dehydration, gdm, preeclampsia, low/high bmi, placental issues
Diagnostics:
-Fetal fibronectin test
----Glucoprotein "glue" found in plasma and produced during pregnancy
----Appears in vaginal secretions in early and late pregnancy ; Presence during late 2nd into early 3rd trimester indicates placental inflammation increasing the risk for preterm labor
----A negative result indicates lower risk of preterm labor
-Cervical length measurement on ultrasound
----Shortening of cervix often occurs before uterine activity
S/S of preterm labor - CORRECT ANSWER -Change or increase in vaginal discharge
-Ruptured membranes
-Cervical changes
-Pelvic/lower abdomen pressure
-Low, dull backache
-Mild cramps
-Regular, frequent contractions
amniotomy - CORRECT ANSWER Artificial rupture of the amniotic sac (fetal membranes)
nursing considerations before and after amniotomy - CORRECT ANSWER Nursing considerations before:
-The FHR is assessed with auscultation or electronic monitoring to identify a reassuring rate and pattern before the amniotomy. A minimum of 20 to 30 minutes is needed for adequate fetal base-line evaluation and can be obtained with other admission information
Nursing considerations after:
-Asses the FHR for at least 1 full minute after the membrane rupture, whether spontaneous or artificial. Chart the quantity, color, and odor of amniotic fluid. Assess the women's temperature every 2 hours after membranes rupture. Report elevations greater then 100.4 F. Amniotic fluid leaks from the women's vagina after membranes rupture. Change the underpad regularly for comfort to reduce the moist environment that favors bacterial growth.
epidural administration - CORRECT ANSWER Maternal Hypotension is a major side effect of an epidural. This occurs because the sympathetic nerves are blocked along with pain nerves, which result in vasodilation and hypotension. Maternal hypotension along with possible reduction in placental perfusion is most likely to occur within the first 15 minutes after an epidural initiation. With maternal hypotension the fetus is more likely to have non reassuring fetal heart pattern on an electronic fetal monitoring strip, such as a rising baseline, tachycardia, or late decelerations.
Oxytocin indication and nursing considerations - CORRECT ANSWER indication:
-Induction or augmentation of labor at or near term. Maintenance of firm uterine contraction after birth to control postpartum bleeding.
Nursing considerations:
-Assess FHR for at least 20 minutes before induction to identify non reassuring or reassuring patterns.
-Observe uterine activity for establishment of of effective labor pattern; contraction frequency every 2-3 min, duration 40-90 s, intensity of 50-80 mm Hg.
-If uterine hypertonicity or non reassuring FHR patterns occurs, intervene to reduce uterine activity and increase fetal oxygenation.
Immediate medications to administer to newborns (within 2 hours of life) - CORRECT ANSWER -Erythromycin
-Vitamin K
(give both on different sides)
Erythromycin - CORRECT ANSWER -Prevents Passage of Bacteria During Delivery and Passage of Birth Canal
-Prevention of ophthalmia neonatorum (neonatal conjunctivitis) in newborns of mothers who are infected with Neisseria gonorrhoeae
-Required by TX State Law
-1-2cm Ointment Ribbon to Lower Conjunctival Sacs
Vitamin K - CORRECT ANSWER -Newborns are born with sterile gut and no enteric bacteria present for Vitamin K Synthesis (Synthesis occurs at ~ 1 Week of Life) .
-Prevents against Vitamin K Deficiency or Hemorrhagic Disease of the Newborn
-Promotes formation of clotting factors.
-Required by TX State Law
-Given IM Vastus Lateralis
Initial newborn assessment: APGAR - CORRECT ANSWER -Done at 1 and 5 Minutes of Life.
Evaluates:
-Heart Rate: Count Heart Beats for 6 Seconds X10
-Respiratory Effort: Observed Movement of Chest Wall
-Activity/Muscle Tone: Degree of Movement and Flexion of Extremities
-Reflex Irritability/Grimace: Response to Stimulation
-Skin Color: Pink, Pale, Cyanotic
Score >7 = Normal = Minimal Difficulty Adjusting to Extrauterine Life.
-If Score <7 at 5 Minutes, Continue Scoring Q5Min Until >7 or X 20 Minutes.
Physical assessment - CORRECT ANSWER General Appearance
•Color
•Respiratory Efforts
•Activity/Tone
•Alertness
Vital Signs
•Temperature: 36.5-37.5C; 97.7-99.5F *Never Performed Rectally*
•Respirations: 30-60 breaths/minutes *Auscultate X 1 Full Minute*
•Heart Rate: 110-160beats/minute *Increases with Crying; Decreases in Deep Sleep*
Measurements
•Weight - Averages 2500-4000gm
•FOC - Frontal-Occipital Circumference; Widest Part of Head; Just Above Eyebrows.
•Length; Abdominal Girth; Chest Circumference
Immediate care after birth - CORRECT ANSWER Airway/ Breathing
-Priority: Infant Establishing Effective Respirations
-Airway First: Suction Nasal/Oral Secretions as Needed (mouth first, then nose)
-Sniffing Position
-Tactile Stimulation
Warm/ Dry
-Remove Moisture to Prevent Evaporative Heat Loss
-Remove Wet Linens
-Cap on Head
Skin to Skin
-Bonding
-Regulation
-The Magical Hour
Heat loss methods - CORRECT ANSWER radiation, conduction, convection, evaporation
Evaporation - CORRECT ANSWER -Water is Lost from the Skin as Liquid is Converted to Gas/Vapor
Ex: Amniotic Fluid at Birth
Convection - CORRECT ANSWER -Air Currents Carry Heat Away from Body Surface
Ex: Cool Room Temperature
Conduction - CORRECT ANSWER -Direct Contact with a Cooler Surface
Ex: Cold Mattress
Radiation - CORRECT ANSWER -Indirect Contract With Cooler Surfaces
Ex: Nearby: Cold Wall/Window
caput succedaneum - CORRECT ANSWER -Generalized, Edematous Area of the Scalp (fluid filled)
-Crosses Sutures
-Disappears Within 3-4 Days
-caused by head compression
Cephelahematoma - CORRECT ANSWER -Collection of Blood Between the Skill Bone and Periosteum
-Does Not Cross Suture Lines; Firmer
-Resolves within 2-8 Weeks
-caused by head compression
Gestational Age Assessment: Ballard Scoring System - CORRECT ANSWER -Assess 6 Neuromuscular Maturity and 6 External Physical Maturity Signs Cummulative Score Correlates with Maturity Rating. Higher the Score = Greater the Maturity/Gestational Age Key Concepts: Breast Tissue, Sole Creases, Skin, Posture, Genitalia, Vernix, Lanugo
sucking reflex in newborn - CORRECT ANSWER elicit response: place nipple or gloved finger in mouth, rub against palate
response: infant will begin to suck, may be weak if recently fed
time reflex disappears: 1 year
Rooting reflex in newborn - CORRECT ANSWER elicit response: touch or stroke from side of mouth toward cheek
expected response: infant turns head to the side touched; difficult to elicit if infant is sleeping or just fed.
time reflex disappears: 3-4 months
swallowing reflex in newborn - CORRECT ANSWER Elicit response: place fluid on back of the tongue
Expected response: infant swallows fluid; should be coordinated with sucking
Time reflex disappears: present throughout life
palmar/plantar grasp - CORRECT ANSWER Elicit response: place finger against base of infants fingers or toes.
Expected response: fingers curl tightly; toes curl forward
Time reflex disappears:
-palmar grasp: 2-3months
-plantar grasp: 8-9 months
Tonic neck reflex - CORRECT ANSWER Elicit response: gently turn head to one side while the infant is supine
Expected response: infant extends extremities on side to which head is turned, with flexion on opposite side
Time reflex disappears: may be weak at birth, disappears at 4 months
moro reflex - CORRECT ANSWER Elicit response: let infants head drop back approx. 30 degrees
Expected response: sharp extension and abduction of arms followed by flexion and adduction to "embrace" position
Time reflex disappears: 5-6 months
stepping reflex - CORRECT ANSWER Elicit response: hold infant so feet touch solid surface
Expected response: infant lifts alternate feet as if walking
Time reflex disappears: 3-4 months
Babinski reflex - CORRECT ANSWER Elicit response: stroke lateral sole of foot from heel to across base of toes
Expected response: toes flare with dorsiflexion of the big toes
Time reflex disappears: 8-9 months
Jaundice - CORRECT ANSWER -excess bilirubin in the blood
-bilirubin is a byproduct of RBC destruction
-Risk Factors: Exclusive Breastfeeding, <38 Weeks, Cephelahematoma or Bruising, Sibling with Jaundice, ABO Incompatability, Rh Isoimmunization, Coombs Positive Antibody.
treatment of jaundice - CORRECT ANSWER Feedings / Promote Stooling
Indirect Sunlight
Phototherapy: Most Common; Utilizes Light Energy to change the shape and structure of unconjugated bilirubin to allow it to be in a form that is excretable by urine and stool.
-Monitor Temperatures and Feedings
-Monitor Irradiance Levels
-Keep Eyes and Genitalia Covered with Eye Mask and Diaper
-Keep Hydrated to Compensate for Insensible Water Loss
-Avoid Lotions or Creams (Can Cause Burns)
-Exchange Transfusion: Infant's Blood is Replaced with Donor's Blood (if bilirubin levels are too high)
pathologic jaundice - CORRECT ANSWER Occurs First 24 Hours of Life; Can Accumulate to Dangerous Levels
physiologic jaundice - CORRECT ANSWER Jaundice Occurs at 2-3 Days of Life: Most Common
-Immature Liver's Normal Inability to Keep Up with RBC destruction and to bind to Bilirubin
-Usually Resolves without Treatment
risk factors for cold stress - CORRECT ANSWER -Larger Body Surface Area
-Blood Vessels Superficial
-Less Adipose Tissue for Insulation
-Cannot Shiver
(Generate Heat By Increasing Muscle Activity and Metabolism, Prevent Heat Loss through Flexion)
Brown fat metabolism - CORRECT ANSWER -Deposits on Back and Interthoracic Region
-Brown Fat Stores Increase with Gestation; Present for Couple of Weeks After Birth
-Produces Heat for Infant By Increases Metabolic Activity in Brain, Heart, and Liver
-Hypothermia Depletes Brown Fat Stores
Hypothermia/cold stress - CORRECT ANSWER Increase in Oxygen Demands:
-Decrease in Temperature Leads to Vasoconstriction to Conserve Heat
-Energy Is Diverted From Brain and Heart
-Leads to Respiratory Symptoms (Tachypnea)
Increase in Metabolic Demands
-Metabolizes Glucose in Order to Generate Heat
-Leads to Hypoglycemia
hypoglycemia - CORRECT ANSWER risk factors:
-Hyperinsulinemia
-Decreased Glycogen Stores
-Increased Glucose Utilization
Symptoms: Jitteriness, Lethargy, Poor Feeding, Abnormal Cry, Hypotonia, Seizures
-Can Occur Without Clinical Manifestations
Treatment:
-Early and Regular Feeding
-Dextrose Gel (40%)
-IV Dextrose Infusion
Complications: Neurologic Injury** The Brain Needs Sugar
Expected diaper counts and stool changes - CORRECT ANSWER -Urine should increase in Amount and Lighten In Color
-6-8 Wet Diapers/Day and 3 Stools/Day After Day 4
prolactin - maternal hormone in breastfeeding - CORRECT ANSWER -After Birth, a fall in progesterone triggers the release of prolactin from the anterior pituitary gland.
-Prolactin prepares the breasts to secrete milk and during lactation to synthesize and secrete milk in response to suckling and emptying of breasts (Supply & Demand System)
-Prolactin Levels are Highest First 10 Days PP
Oxytocin - maternal hormone in breastfeeding - CORRECT ANSWER Nipple Stimulation results in the posterior pituitary gland to be prompted by the hypothalamus to produce oxytocin.
Oxytocin is responsible for the Milk Ejection Reflex/Let Down Reflex, which:
-Responds to thoughts, sounds, cries, etc...
-Causes Myoepithelial Cells Around the Alveoli to Contract and Send Milk forward Through the Milk Ducts
Same Hormone that Causes Uterine Contractions; Increases Afterpains.
Colostrum - CORRECT ANSWER "liquid gold"
-high in antibodies and protein but lower in fat than mature milk
indicators of effective breastfeeding - CORRECT ANSWER Latch: Baby Should have as much areola in mouth as possible, not just the nipple.
-Midline Neck
-Audible Swallowing
-Content after Feeding
-Tugging Sensation
-Breasts Soften
-Uterine Contractions
-lips flanged
Urine/Stool Outputs:
-Urine should increase in Amount and Lighten In Color
-6-8 Wet Diapers/Day and 3 Stools/Day After Day 4
newborns weight loss calculation and interpretation - CORRECT ANSWER Example: baby weighs 3000g at birth and weighs 2700g after 2 days.
Difference in weight 300. (300/3000 X 100) = 10% weight loss
-10% of weight loss or more is a red flag
mastitis - CORRECT ANSWER occurs weeks after birth
-Infection Within
Assessment: Flu-Like Symptoms, Breast Pain/Tenderness, Hot Red Area (Past Engorgement Period)
Care: Treat with Antibiotics, Frequent Pumping/Feedings, Analgesics, Warm Compresses
Continue to Feed*** - Do Not Have to Stop Due to Infection
engorgement - CORRECT ANSWER occurs 48-72 hours after birth
Breasts become Firm, Full, Tender, and Hot R/T Inflammation of Milk Ducts and Increased Milk Production
Interventions: Cabbage Leaves, Increase Feeding Frequency, Anti-Inflammatories
Endometritis - CORRECT ANSWER -infection of the uterine lining
-peri care is very important
-look for foul odor
infant hunger cues - CORRECT ANSWER -Rooting
-Smacking lips, sucking motions
-Bringing hands to mouth
-Opening mouth
-CRYING IS A LATE SIGN OF HUNGER
Neonatal abstinence syndrome (NAS) - CORRECT ANSWER Assessment:
-Caffeine, Nicotine, Codeine, Medications, Alcohol, Cocaine, Methamphetamine, Marijuana
S/Sx:
-Irritability, Hyperactivity/Excessive Moro Reflex, Tremors, Increased Muscle Tone, Tachypnea, Fever, Excoriations on Knees and Face, Excessive Sucking, Poor Feedings, Regurgitations, Loose Stools, Excessive Sneezing/Yawning
-NAS Scoring: Can Begin Normal and Develop Symptoms Overtime
Labs:
-Urine Toxicology, Meconium Drug Screening, Umbilical Cord Toxicology, Hair Sampling
Treatment:
-Minimize Stimulation, Swaddling, Monitor Neurologic Status (Seizure Precautions), Administer Medications (Methadone, Clonidine)
Fetal alcohol syndrome (FAS) - CORRECT ANSWER -Microcephaly
-Small Eyes
-Thin Upper Lip
-Flat Midface/Nose
-Growth Restrictions
Long Term Complications:
-Mental Retardation
-Hyperactivity
-Developmental Delays
-Poor Coordination
Hematomas - CORRECT ANSWER -look at ways mom losses blood loss
-concealed blood
-like a blister on the perineum (can hold liters of blood)
If fundus is firm, midline, and at umbilicus but blood is present this can mean.... - CORRECT ANSWER peritoneal trauma
If fundus is boggy, above umbilicus, and deviated this can mean.... - CORRECT ANSWER their bladder is full
(do not massage fundus until after she empty bladder)
Fundus is boggy, at the level of the umbilicus or below, and its midline - this can mean - CORRECT ANSWER uterine atony - massage fundus
The Fundus is boggy, midline, and its staring to ascend this means... - CORRECT ANSWER there is still placental fragments in the uterus
After checking and doing assessment everything is good. The fundus is firm, midline, at or below umbilicus. She is a c-section and has been laying down for a long time. We are about to get her up to walk for the first time. When we get her up there is a big gush of blood. What does this mean? - CORRECT ANSWER This is normal when they have been laying down for a long period of time.
Mom comes in and is dilated to a 3. She says her contractions are occurring every 4-6 minutes. —-have her walk and recheck her in an hour. Now her contractions are every 10 minutes and she is still dilated to a 3.
What type of labor is this? - CORRECT ANSWER This is false labor.
Postpartum Fundal Height - CORRECT ANSWER After birth- midlind; 2 cm below umbilicus
12 hours post birth- 1 cm above umbilicus
24 hours post birth- 1-2 cm at or below umbilicus (descends 1-2 cm per 24 hrs) [Show Less]