Client teaching is an important part of the maternity nurse’s role. Which factor has the greatest influence on successful teaching of the gravid client?
A. The client’s readiness to learn
A 38-week primagravida who works as a secretary and sits at a computer 8 hours a day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?
C. Move about every hour
During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have
B. lower birth weights
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate?
C. Tachycardia and a feeling of nervousness
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?
C. correctly place the infant on the breast
A full term infant is transferred to the nursery from L & D. Which information is most important for the nurse to receive when planning immediate care for the newborn?
B. Infant’s condition at birth and treatment received.
In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant’s fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the
D. anterior fontanel closes at 12-18 mos and the posterior fontanel by the end of the second month.
When assessing a client who is 12-weeks gestation, the nurse recommends the she and her husband consider attending childbirth preparation classes.
What is the best time for the couple to attend these classes?
D. At 30 weeks gestation.
The nurse should encourage the laboring client to begin pushing when
C. the cervix is completely dilated
The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs
A. two weeks before menstruation.
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?
C. have the client breath into her cupped hands
When preparing a newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation?
C. Vernix is a white, cheesy substance, predominately located in the skin folds.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as
A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks.
An expectant father tells the nurse he fears that his wife “is losing her mind”. He states she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to the expectant father?
D. Let him know that these behaviors are part of normal maternal/fetal bonding which occurs once the mother feels fetal movement.
A new mother asks the nurse, “How do I know my daughter is getting enough breast milk? Which explanation will the nurse provide?
B. “your milk is sufficient if the baby is voiding pale straw-colored urine 6-10 times a day.
A new mother who has just had her first baby says to the nurse, “I saw the baby in the recovery room. She has a funny looking head”. Which response by the nurse is the best?
C. That is normal, the head will return to a round shape within 7-10 days.
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting the mother to bond with her newborn infant?
D. Meet the mother’s physical needs and demonstrate warmth toward the infant.
A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that the woman’s fallopian tubes are patent?
C. shoulder pain
Which nursing intervention is most helpful in relieving postpartum uterine contractions or “afterpains?”
A. Lying prone with a pillow on the abdomen
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
B. Her arms and hands receive the infant and she ten traces the infant’s profile with her fingertips.
On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client’s expected date of delivery (EDD) is
A. November 22
The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates the woman’s next fertile period will be
C. January 30-31
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved?
C. a decrease in RR from 24 to 16.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client’s blood pressure drops from 120/80 to 90/60. What action will the nurse take?
C. place the woman in a lateral position.
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?
A. Come to the clinic today for an ultrasound.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?
D. Put the newborn to breast.
A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse. “Why must I stay in bed all the time?” Which response is the best for the nurse to provide this client?
A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant?
C. Gonorrhea
A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satifactorily but appears dusky. What action should the nurse take first?
C. Check the infant’s oxygen saturation rate.
Just after delivery, a new mother tells the nurse, “I was unsuccessful breastfeeding my first child, but I would like to try with this baby.” Which intervention is best for the nurse to implement first?
D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
The nurse is teaching a woman how to use her basal body temp pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?
A. Between the time the temp falls and rises.
A woman who had a miscarriage 6 mos ago becomes pregnant. Which instruction is most important for the nurse to provide this client?
D. Take prescribed multivitamin and mineral supplements.
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is
C. a persistent cold
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?
A. Edema, basilar rales, and an irregular pulse.
A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement?
A. Describe diet changes that can improve the management of her diabetes.
A client receiving epidural anesthesia begins to experience nausea and become pale and clammy. What intention should the nurse implement first?
A. Raise the foot of the bed.
The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement?
C. Encourage the mother to breast-feed frequently.
A 35-year-old primagravida client with severe preeclampia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity?
D. Urine output 90 ml/4 hours.
A 30-year old gravida 2. para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on am IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of the drug?
B. maternal and fetal heart rates
A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit?
A. choking, coughing, and cyanosis.
The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurser anticipate?
A. Grief related to her perceptions about the loss of this child.
The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content int the class?
C. Feed your baby every 2 to 3 hours or on demand, whichever comes first.
The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding?
C. 3 vessels: 2 arteries and a vein.
A new mother is afraid to touch her baby’s head for fear of hurting the ‘large soft spot.” Which explanation should the nurse give to this anxious client?
D. There’s a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.
The nurse caring for a laboring client encourage her to void at least q2h, and records each time the client empties her bladder.What is the primary reason for implementing this nursing intervention?
B. An over-distended bladder could be traumatized during labor, as well as prolong the progress of labor.
A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse’s response is based on what knowledge?
B. It is difficult to consume 18 mg of additional iron by diet alone.
A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate?
A. a home pregnancy test can be used right after your first missed period.
A full-term infant is transferred to the nursery from L & D. Which information is most important for the nurses to receive when planning immediate care for the newborn?
B. the infant’s condition at birth and treatment received.
A client in active labor complains of cramps in her leg. What intervention should the nurse implement?
B. Extend the leg and dorsiflex the foot.
A client 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?
C. obtain a specimen for urine analysis
A client in active labor is admitted with preeclampsia. Which is assessment finding is most significant in planning this client’s care?
A. Patellar reflex 4+
A 4-week old premature infant has been receiving epoetin alfa for the last 3 weeks. Which assessment finding indicated to the nurse that the drug is effective?
C. changes in apical heart rate from the 180s to the 140s
The healthcare provider prescribes terbulatine (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition?
A. gestational diabetes
A client with no prenatal care arrives at the labor unit screaming, “the baby is coming”. The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain?
C. date of last normal menstrual period.
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
C. monitor bleeding from IV sites.
immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 BPM and respirations of 20 BPM. What action should the nurse perform next?
A. initiate positive pressure ventilation.
The nurse is preparing to give an enema to a laboring client. Which client would require the most caution when carrying out this procedure?
D. a 40-week primagravida who presents at 100% effacement, 3 cm dilation, and a -1 station.
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, “What if I start having red bleeding after it changes?” What should the nurse instruct the client to do?
A. Reduce activity level and notify healthcare provider.
One hour after giving birth to an 8-pound infant, a client’s lochia rubra has increased from small to large and her fundus is boggy despite massage. The client’s pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately?
D. Call the healthcare provider to question the prescription.
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?
C. epigastric pain
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask the client?
D. Do you have a history of rheumatic fever?
A couple has been trying to conceive for 9 months without success. Which information obtained from the clients is most likely to have an impact on the couple’s ability to conceive?
D. They use lubricants with each sexual encounter to decrease friction.
After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil Newborn Formula, a nonfat cow’s milk formula. The pediatric healthcare provider changes the neonate’s formula to Similac Soy Isomil Formula, a soy protein isolate based infant formula. What information should the nurse provide to the mother about the newly prescribed formula?
D. Similac Soy Isomil Formula is a soy-based formula that contains sucrose.
The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard scale. Based on this assessment, the nurse determines that the neonate has a maturity rating at 40-weeks. What findings should the nurse identify to determine if the neonate is SGA?
A. admission weight of 4 lbs.
B. Head to heel length of 17 inches.
C. frontal occipital circumference of 12.5 inches.
The nurse is assessing a client who is having a NST at 41-weeks gestation. The nurse determines that the client is not having contractions, the FHR baseline is 144 bpm, and no FHR accels are occurring. What action should the nurse take?
D. Ask the client if she has felt any fetal movement.
A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first?
A. Bathe the infant with antimicrobial soap.
A pregnant client tells the nurse that the first day of her LMP was 8/2/06. Based on Nagele’s rule, what is the estimated date of delivery?
B. 5/9/07
Which action should the nurse implement when preparing to measure the fundal height of a pregnant client?
A. Have the client empty her bladder.
A client who is in the 2nd trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?
D. It is important that you want to take part in your care.
The nurse is planning preconception care for a new female client. Which information should the nurse provide to the client?
D. Encourage healthy lifestyles for families during pregnancy.
A primagravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important to the nurse to report to the healthcare provider?
D. A platelet count of 67,000/mm3.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?
A. apply cold compresses to both breasts for comfort.
A 30-year old multiparous woman who has a 3-y/o and a newborn tells the nurse,”My son is so jealous of my daughter. I don’t know how I’ll ever manage both children when I get home”. How should the nurse respond?
D. “regression in behaviors in the older child is a typical reaction so he needs attention at this time”.
A 24-hour old newborn has pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement?
C. Document the finding in the newborns record.
The nurse observes a new mother is rooming in and caring for her newborn infant. What observation indicates the need for further teaching?
C. places the infant prone in the bassinet.
When explaining “postpartum blues” to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.)
A. Mood swings. B. Panic attacks. C. Tearfulness. D. Decreased need for sleep. E. Disinterest in the infant.
A. mood swings
C. tearfulness
A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to the infant. The nurse’s response should be based on what information?
B. each pregnancy carries a 50% chance of inheriting the disorder.
The nurse should explain toa 30 y/o gravid client that alpha fetoprotein testing is recommended for which purpose?
B. screen for neural tube defects.
The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
B. observe for an asymmetrical Moro reflex.
A primagravida at 40 weeks gestation is receiving oxytocin (Pitocin) to augment labor. What adverse effect should the nurse monitor for during infusion of Pitocin?
B. hyperstimulation
A 23 y/o client who is receiving Medicaid benefits is pregnant with her 1st child. Based on knowledge of the stats r/t infant mortality, which plan should the nurse implement w/this client?
C. teach the client why keeping prenatal care appointments is important.
A female client w/insulin dependent diabetes arrives at the clinic seeking a plan to get pregnant in approx 6 mos. She tells the nurse that she wants to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client?
B. maintain blond sugar levels in a constant range WNL during pregnancy.
A multigravida client arrives at the L & D unit and tells the nurse tht her “bag of water” has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the FHR is between 140 -150 BPM. What action should the nurse implement next?
A. complete a sterile vaginal exam.
A multigravida at 41-weeks gestation presents in the L & D after a NST indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about eh fetal status?
A. a BPP
While breastfeeding, a new mother strokes the top of her baby’s head and asks the nurse about the baby’s swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother?
D. the scalp edema will subside in a few days after birth.
A client is admitted w/the diagnosis of total placenta previa. Which finding is is most important for the nurse to report to the healthcare provider immediately?
C. onset of uterine contractions
A healthcare provider informs the charge nurse of L & D that a client is coming to the unit w/suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate?
A. dark red vaginal bleeding
D. increased uterine irritability.
F. a rigid abdomen.
A client with gestational hypertension is in active labor and receiving an infusion of mag sulfate. Which drug should the nurse have available for signs of potential toxicity?
B. calcium gluconate
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement?
D. apply firm pressure to the sacral area.
A 42-week gestational client is receiving an IV infusion of oxytocin (Pitocin) to augment early labor. The nurse should d/c the oxytocin infusion for which pattern of contractions?
A. transition labor with contraction every 2 min, lasting 90 seconds each.
What action should the nurse implement to decrease the client’s risk for hemorrhage after a C/S?
D. check the firmness of the uterus Q15 min.
Which assessment finding should the nursery nurse report to the ped healthcare provider?
D. central cyanosis when crying
The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider?
A. yellowish tinge to the skin
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next?
C. palpate the firmness of the fundus
The nurse is calculating the EDC using Nagel’s rule for a client whose LMP started on 12/1. Which date is most accurate?
D. 9/8
A pregnant women comes to the prenatal clinic for an initial visit. In reviewing her childbearing Hx, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. What GTPAL should the nurse document in this client’s record?
D. 3-1-1-0-3
The nurse is preparing a client w/a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client’s bedside?
C. a sterile glove
D. an aminhook
F. lubricant
At 14-weeks gestation, a client arrives at the Er complaining of a dull pain in the RLQ. The nurse obtains a blood sample and initiates and IV. 30 minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. assessment findings include diaphoresis HR 120, BP 86/48. What action should the nurse implement ?
C. increase rate of IV fluids
The nurse is preparing a client w/a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client’s bedside?
C. a sterile glove
D. amniotic hook
F. a doppler
a 30 y/o G2P1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is given a dose of terbulatine sulfate (Brethine) 0.25 mg subq. Which assessment is the highest priority for the nurse to monitor during the administration of this drug?
B. maternal and fetal HRs
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?
A. 3 + DTRs and hyperclonus
During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order.)
- reposition the client
- increase IV fluid
- Provide oxygen via face mask.
Call the healthcare provider.
What position does the Pavlik harness put infants with developmental dysplasia of the hip stay in?
The Pavlik harness keeps the infant in an abducted position allowing the hips and knees flexed
When should jaundice in a newborn be concerning?
If jaundice is present less than 24 hours of delivery, it may indicate excess bilirubin
What is the action of terbutaline sulfate (Brethine)?
Stop labor contractions
Primary side effects of terbutaline sulfate (Brethine)?
Tachycardia and nervousness along with increased CO, restlessness, and headache
When does the anterior fontanel close?
12-18 months
When does the posterior fontanel close?
End of second month
Why is erythromycin indicated 2 hours post-delivery of a newborn?
Prevent opthalmia neonatorum which is an eye infection caused by gonorrhea and conjunctivitis which is an infection caused by chlamydia
Antepartum pt is chewing ice instead of the food on her breakfast tray. What should the nurse do?
Call HCP immediately. Practice of pica will displace nutrients. Evaluate the pt for anemia
28 wk gestation pt calls the antepartal clinic about bleeding a small amount of bright red blood with no uterine contractions, but is not bleeding anymore. What may this possibly be?
Placenta previa
Is bleeding a small amount of bright red blood life-threatening to the fetus?
It is not at risk for hypovolemia or life-threatening.
What may sudden onset bleeding with present uterine contractions indicate?
Abruptio placenta
When is child-birth class recommended?
30 weeks
What should a primigravida who has present leg swelling d/t sitting 8 hrs a day do to minimize the swelling?
Move around every hour
What is important to do for an amniotomy?
Monitor FHR before, during, and after procedure. The fluid should also be assessed for color, odor, and consistency.
When is an amniotomy indicated?
(artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable
How often should maternal blood pressure be done during an amniotomy?
Maternal BP should be assessed every 15 to 20 minutes during labor
Why is maternal temperature important to monitor after an amniotomy?
Maternal temperature is monitored hourly after the membranes are ruptured to detect development of amnionitis.
Is it ok for a breastfeeding mother to drink alcohol?
No, alcohol is excreted through breast milk.
Laboring client is doing accelerated blow breathing and states that she is feeling tingling in her fingers and dizziness. What should the nurse do?
Have the pt breathe into her cupped hands. She is hyperventilating and excreting too much carbon dioxide.
When does ovulation occur?
14 days before first day of menstrual period
What is the goal for labor augmentation (administration of Oxytocin/pitocin)
produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress.
Is it normal for FHR to increase during contractions and return to baseline?
Yes it is normal for FHR to increase, but this is indicative to increase the pitocin infusion to stimulate the intensity and frequency of the contractions
What should be done if fetal stress is present during labor?
-Place a wedge on the pts left side
-Administer 10L oxygen nasal cannula
What is important to tell the HCP during the third trimester of pregnancy?
Signs of preeclampsia–heartburn not relieved by antacids and chronic headaches behind the eye
Normal signs of the last trimester of pregnancy?
-Increase in fetal heart rate
-Shoes and ring are right
-Inability to sleep for more than 2 hours
Milia
White pinpoint spots found on the nose and chin that represent blockage of sebaceous glands
Meconium
First stool that is tarry black
Is pseudostrabismus normal in a newborn?
Pseudostrabismus is normal until about the 3rd or 4th month. It does not require surgery
A baby is born with an abnormal headshape. How long should it take for it to possibly return to normal?
It will take 7-10 days for the head to return to a round shape.
Cephalhematoma
Localized swelling that occurs from forcep trauma between periosteum and skull
At what time after delivery is a cephalhematoma most likely?
Within the first 24 hours of delivery
Molding
Occurs when there is too much pressure on the cranium during vaginal delivery. It is common variation and will last about 5-7 days
Can a subarachoid or subdural hematoma be observed from a physical assessment?
No, these types of hematomas will require further assessment
Signs of hypoglycemia in a newborn
-Shaking during moro reflex assessment
-Hypothermia
-Lethargy
What is a key characteristic of an infant whose mother smoked during pregnancy?
Low birth weight
Nagele’s Rule
Obtain LMP
Subtract 3 months and at 7 days
Umbilical cord care at home:care
Allow to air-dry as much as possible
Is it recommended to take a warm shower after breastfeeding?
Not recommended because warm water will stimulate the production of breast milk. It will be more painful.
What is mastitis?
Plugged milk ducts r/t breast engorgement
What should be told to the breast-feeding mother with mastitis?
It is ok to breastfeed to reduce the engorgement and reduce the inflammation
The blood pressure of a pt in labor drops from 120/80 to 90/60. What should the nurse do?
- Get the pt in a lateral position by placing a pillow or wedge under one hip to deflect the uterus.
- Increase rate of Iv infusion
- Administer O2 via face mask
Signs of possible miscarriage
Cramping and bright red spotting
Lack of breast tenderness
Sign of ectopic pregnancy
Increased right side flank pain
TRIPLE SCREEN shows low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood sample. What may this mean?
Possible chromosomal defect
TRIPLE SCREEN shows high levels of MSAFP and estriol in the blood sample after 15 weeks of gestation
Possible neural tube defect, not chromosomal defect
Will there be traces of MSAFP, estriol, and hCG in the blood sample of a pt past 15 wks gestation?
Yes MSAFP, estriol, and hCG will be present
Caring for an infant post-circumcision
With each diaper change, the glans penis should be washed with warm water to remove any urine or feces and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface.
Are early decelerations FHR an ominous sign?
Not necessarily, nurse must continue to monitor
At what age are infants of HIV-positive mothers tested for HIV?
Tested at 18 months, at this time maternal antibodies are no longer present
Early ROM has FHR several suiddenly decreases with quick return to baseline, with and without contractions. What should the nurse do?
This is indicative of cord compression. Minimize the amount of pressure on the umbilical cord by assisting the pt to Trendelenburg position
Most common cause for nipple soreness?
Incorrect positioning of the infant on the breast for latching on is the most common cause for nipple soreness.
The baby’s body is in alignment with ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast
Silverman-Anderson index
Silverman-Anderson index is an assessment scale that scores a newborn’s respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt.
No respiratory distress is graded 0 and a total of 10 indicates maximum respiratory distress.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color and asks when the flow will stop. How should the nurse respond?
When the placental site has healed–it is about 3-6 weeks.
At 6 weeks, lochia flow should be finished.
What is the primary cause of hot flashes?
Vasomotor instability caused by decreased estrogen levels. Sudden fluctuations between vasodilation to vasoconstriction
Where does a fertilized ovum implant in the uterus?
Endometrium
Depo-provera injection instructions
-Call if experiencing painful headaches
-Delayed return of fertility is common
-Weight gain is a common side effect (3-20 pounds)
-Take the shot every 90 days
What may occur if gonorrhea goes untreated?
Obstructed fallopian tubes from fibrous tissue that hardens and constricts the lumen causing sterility and a high risk for ectopic pregnancy
Where does fertilization normally take place?
Fallopian tubes
Where does sperm production take place?
Testes
What hormones are the reason why pregnant women commonly experience water retention and fatigue?
Increased estrogen and progesterone cause sodium retention–which lead to fluid retention and fatigue
What is the major function of amniotic fluid?
Maintain fetal temperature and stability (cushion, aid in dilation of cervix, temp—ABCs)
What is a suspected reason why pregnancy induced hypertension (PIH) occurs in LES groups?
Less protein involved in the diet
What is a major function of the placenta?
Provides an exchange of nutrients and waste products between the mother and fetus
Key characteristic of placenta previa?
Painless bleeding
A pregnant woman who is a known cocaine user is at risk for developing what condition?
Abruptio placentae–cocaine causes vasoconstriction and contraction of uterine smooth muscle which can result in preterm labor and abruptio placentae (as well as hypertension, CV failure, and other complications)
Ptyalism
Excessive salivation commonly seen with hyperemesis gravidarum
Polyhydramnios
Excessive amniotic fluid
Vena cava syndrome
Compressison of the IVC by the uterus in the third trimester
At what wks gestation can the fetal heartbeat be heard?
18-20 wks. This is also when the mother can feel the fetus move.
How are contractions timed?
From the beginning of one contraction to the beginning of the next
What does pregnancy induced hypertension increase the risk for?
This increases the risk for placentae abruptio
What medication is often given after the delivery of a newborn?
IV oxytocin (pitocin) to allow uterine contractions and deliver the placenta
What is the most common cause of postpartal hemorrhage?
Uterine atony–control the bleeding by staying tightly contracted.
Uterine atony often happens to multiparas
Nurse assesses a patient in labor with a prolapsed umbilical cord. What position should the patient be in?
Knee-chest position or slight trendelenburg position to relieve pressure of the presenting part away from the cord
A patient in labor has FHR of 90 bpm. What intervention must the nurse do next?
Placental insufficiency and late decelerations indicate that the nurse place the patient on her left side and administer oxygen
Fetal presentation is at +1. What does this mean?
1 cm below ischial spine
What will the mother feel when the fetus is in occiput posterior position?
Severe back pain–the largest part of the fetal head is at the back, increasing pressure on the maternal sacral nerves and causing backpain
What will be felt if the fetus is in breech presentation?
Hard round mass palpated in the patient’s upper adbomen or fetal heart sounds heard in the patients upper right abdomen
What type of pelvis is most favorable for labor and birth?
Gynecoid pelvis–a normal female pelvis and is the most favorable for successful labor and delivery
What type of pelvis is the male pelvis?
Android pelvis
What type of pelvis is oval shaped with a narrow pubic arch?
Anthropoid pelvis
What type of pelvis is a wide pelvis with a short diameter
Platypelloid pelvis
What cm is active labor usually?
4-7 cm
What change in FHR would be suspected to have umbilical cord compression?
Variable deceleration–insufficient blood flow to the fetal system. Reposition to her side to help relieve the compression
What is important post-discharge of a newborn?
Call the HCP if the baby does not void within 24 hours–may be a fluid intake, hydration status, body temp, or renal problem.
What hormone stimulates prolactin production so that breast-feeding may begin?
A decrease in progesterone
After delivery of the placenta, high levels of progesterone are lost.
Within the first 12 hours postpartum, the fundus is usually where in relation to the umbilicus?
Approximately 1 cm above the umbilicus.
By postpartum day 3, where should the fundus be in relation to the umbilicus?
Below the umbilicus
How long does the postpartum blues last?
1-2 weeks
During what time frame is postpartum depression likely?
Within 6 months of delivery
How many calories a day should the breast-feeding mother increase to?
Increase to 500 calories a day
1 hour postpartum, the mother complains of chills and has bright red lochia with a firm fundus. What should the nurse do
This is a normal postpartum response since the uterus is still contracting. Documen.
A full bladder is likely to push the uterus in what position?
It will push the uterus to the right of midline.
Taking-in phase
First 24-48 hours after birth
Focus on maternal needs
Taking-hold phase
48 hours-7 days after birth
Maternal need to control her life. She is ready to learn
Letting-go phase
Mother and family move forward as a system with interacting members
Letting-down phase
Let-down reflex seen with lactation and breastfeeding
12 hours postpartum, a patient experiences a temperature of 101F. What may this indicate?
Dehydration
A fever after 24 hours is indicative of what?
Puerperal infection
Is breast-feeding recommended for a patient who is HIV positive?
No. Breastfeeding is not recommended for HIV positive women since it is isolated in breast milk and could be transmitted to the newborn
Neonates looks how much of the birth weight within the first few days of birth?
5-10% of their weigh
PDA, ASD, and VSD may increase the risk of what problem in infants?
Congestive heart failure
The umbilical cord has how many arteries and veins?
2 arteries, 1 vein
Is brain damage directly associated with cranial molding?
No. The molding usually disappears in a few days without any other interventions or long-lasting effects.
In the time of using forceps during a delivery, what must the nurse assess the infant for post-delivery?
Facial paralysis if the forceps compress cranial nerve VII (facial) anterior to the ears.
This paralysis is mild and temporary lasting several days.
Torticollis
Deformity of the neck not associated with newborns
What may occur in the event of dystocia, vacuum extraction, or large birth weight?
A fractured clavicle
What is cephalhematoma
Extravasation of blood from ruptured vessels between the skull bone and its external coverings known as the periosteum. The hematoma does not cross over a cranial suture
What age should the Moro reflex disappear?
4 months, also known as the startle reflex
What defects are involved in Tetralogy of Fallot
-Right ventricular hypertrophy
-Stenosis of the pulmonary artery
-VSD
-Overriding aorta
Are Mongolian spots permanent?
No, they fade over time
What is a sign of postmaturity?
Long, brittle fingernails
An infant has myelomeningocele. What would the nurse expect?
-Impaired bowel and bladder function d/t the innervation of the anal sphincter and the bladder is decreased causing incontinence.
-Paralysis of the legs d/t nerves of the cauda equina.
What is considered physiological jaundice?
Jaundice within 24 hours of birth.
What would be manifested more commonly in a newborn born C-section vs. a newborn born vaginally?
C-section newborns are at higher risk for respiratory distress syndrome
An infant born breech is at risk for what complication?
Brachial palsy–which results from the stretching of nerve fibers in the neck, shoulder, and arm where the shoulder is being pulled away from the neck during a breech delivery.
What are some observations that the newborn is nursing well to breastfeeding?
-Swallowing is audible
-Mother reports a pulling sensation on her nipple
-The tip of the infant’s nose and chin touch the breast
Signs of ineffective nursing of an infant
-Clicking/smacking sound during breastfeeding
-The infant’s cheeks are dimpled
Why do infants need a vitamin K injection immediately after delivery?
Infants have a sterile intestinal tract and cannot synthesize vitamin K