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138 Cards in this Set
- Front
- Back
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A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is? Which of the following responses should the nurse provide? A. This test will determine if you are likely to deliver within the next week B. This test will help determine if your baby is healthy C. This test can see how your baby responds when you have contractions D. This test will determine if your babies lungs are mature |
B |
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A nurse is caring for a client who is in the first trimester of pregnancy and asks how to manage heartburn. Which of the following responses should the nurse make? A. Reduce the amount of food you eat during meals B. Sip carbonated beverages between meals C. Lie down and rest immediately after meals D. Drink iced tea with meals |
A |
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A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1 to 2 hours of delivery? A. Naloxone B. Erythromycin ophthalmic ointment C. Poractant Alfa D. Rotavirus immunization |
B |
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A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects? A. Diarrhea B. Thromboembolism C. Fetal asphyxia D. Oliguria |
C |
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A nurse is providing breastfeeding education to a client who delivered 12 hours ago. Which of the following client statements indicates an understanding of the teaching? |
I should breastfeed at least 8 to 12 times in a 24 hr period |
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Effacement records? |
At a % (shortening and thinning) |
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Being dilated means your in labor? T or F |
False |
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The perfect passageway for birth? |
Gynecoid pelvis |
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Can’t swallow water, can’t take anything by mouth |
Hyperemesis |
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Normal Hemoglobin for women |
12 to 16 12 to 15 during pregnancy |
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Pregnancy nutrition needed? |
Folic Acid, Iron, prenatal vitamins |
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Known to kill fetus’s |
Toxoplasmosis (cat litter,raw meat) Others (syphilis) Rubella (negative means need after delivery) Cytomegally virus (ok for adult not for fetus) Herpes (should have planned c section) |
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After rubella don’t get pregnant for? |
3 months |
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BMI of 27 should gain how much during pregnancy? |
15 to 25 pounds Considered over weight (25.0 to 29.9) |
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BMI 19 should gain how much during pregnancy? |
25 to 35 pounds Considered normal (18.5 to 24.9) |
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BMI 32 how much weight to gain during pregnancy? |
11 to 20 pounds Considered obese (30.4 to 34.9) |
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Fetus is at +3 position. Should be? |
Pushing |
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Fetus is at 0 position |
Engaged |
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Doing what has to be done to get labor going? |
Induction |
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In latent phase nurse should have client? |
Pee a lot |
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What position for cord prolapse? |
Knee to chest |
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Early deceleration |
Normal No interventions needed heart rate decrease a little is assuring Caused from head compression during contractions |
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Variable deceleration cause |
Cord compression-prolapsed or pressed against something Turn to side |
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Late deceleration |
Cause uteroplacental insufficiency |
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Normal Fetal HR |
110 to 160 |
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Where to hear FHR for breech? |
Above umbilicus |
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Optimal position of fetus for birth? |
LOA Left Occipital Anterior |
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Contractions lasting longer than 90 seconds? |
Tetany |
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What position of fetus during labor/birth is painful? |
Posterior (LOP, ROP, anything ending with a P posterior) |
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What to expect in transition phase of Stage 1 labor? |
Client not happy (exorcist) Cannot give pain meds at this point. |
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Do not massage a ? |
Firm Fundus or bladder |
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You should massage a? |
Boggy Fundus |
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Right after birth the Fundus should be felt where? |
Right at or 1cm below umbilicus |
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Exercise during pregnancy |
Ok if you always have or you can do walking jogging non contact and DO NOT exercise to point of exhaustion |
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Variable deceleration |
Cord compression |
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Early deceleration |
Head squeeze (compression) |
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Accelerations |
Are ok |
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Late deceleration |
Placental insufficiency Turn on side - get blood flowing Someone else call doctor |
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Cord prolapse |
If cord coming out put gloves on emergency. Put wet gauze on it |
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If Fundus is boggy puts client at risk for? |
Hemorrhage Hypotension |
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What helps perineal muscles stretch? |
Keagle exercises |
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What Bishop score favors a successful induction? |
8 or more |
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Palpate and count the maternal radial pulse while listening to the FHR |
Intermittent auscultation of FHR |
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Prolonged deceleration during a uterine contraction is a sign of? |
Cord prolapse Emergency notify MD |
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Indicates well being of baby? |
Accelerations |
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Interventions for late decelerations |
Turn client on side, apply O2, stop pitocin If continues may indicate c section |
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Contractions regular, increase and has cervical changes( dilation/effacement) |
True labor |
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Irregular contractions and cervix not affected |
False labor |
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Sign of lightening |
Baby drops into pelvis Back pain Urinate more frequently Breathe better |
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If client has a negative blood type and baby has positive blood type client will get? |
Rhogam injection |
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DVT Prevention |
Assess for pain, tenderness, warmth, redness, swelling. Ambulation Elevation Warm compresses |
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Mood disorder characterized by feelings of sadness and loss of pleasure in normal activities that can occur shortly after giving birth? |
Postpartum Depression |
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Mood disorder characterized by feelings of sadness and loss of pleasure in normal activities that can occur shortly after giving birth? |
Postpartum Depression |
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A rare and severe form of depression that occurs in women just after giving birth and includes delusional thinking and hallucinations? |
Postpartum psychosis |
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Mood disorder characterized by feelings of sadness and loss of pleasure in normal activities that can occur shortly after giving birth? |
Postpartum Depression |
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A rare and severe form of depression that occurs in women just after giving birth and includes delusional thinking and hallucinations? |
Postpartum psychosis |
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Time immediately after birth when the client needs others to meet her needs? |
Taking in phase |
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Mood disorder characterized by feelings of sadness and loss of pleasure in normal activities that can occur shortly after giving birth? |
Postpartum Depression |
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A rare and severe form of depression that occurs in women just after giving birth and includes delusional thinking and hallucinations? |
Postpartum psychosis |
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Time immediately after birth when the client needs others to meet her needs? |
Taking in phase |
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Less focus on physical discomforts, beginning confidence with infant care: feeling inadequate caring for infant is normal: praise efforts of parents, most receptive to teaching about infant care. |
Taking hold phase |
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Abnormal vital signs after delivery |
Temp > 100.4 Pulse > 100 bpm Resp report outside of norm (12-20) BP - hypotension Pain - severe perineal pain |
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Breast care for breastfeeding mothers |
Initiate breast feeding asap after birth Cleanse w/warm water after each feeding (air dry) Apply ointments/milk for nipple soreness Use heat applications for engorgement |
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Breast care for non breast feeding mom |
Avoid nipple stimulation Wear tight fitting sports bra Use cold ice packs/cabbage leaves |
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Breast care for non breast feeding mom |
Avoid nipple stimulation Wear tight fitting sports bra Use cold ice packs/cabbage leaves |
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Normal vital signs after delivery |
Temp - slight elevation in 1st 24 hrs Pulse - 60 to 80 bpm Resp - 12 to 20 BP - compare with usual range Pain - 0 to 2 out of 10 |
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Danger signs postpartum |
Foul smelling lochia, lg blood clots, saturation of pad in hour, severe headaches, blurred vision, calf pain, dysuria, burning or incomplete emptying of bladder, SOB, depression or extreme mood swings |
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Stimulates growth of the milk ductal system? |
Estrogen |
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Stimulates growth of the milk production system? |
Progesterone |
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Stimulates growth of the milk production system? |
Progesterone |
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Triggers the synthesis and secretion of milk after birth. Milk production |
Prolactin |
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Stimulates milk ejection “let down “ |
Oxytocin |
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Continuous stimulation of prolactin and oxytocin |
Infant sucking |
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They decrease after the placenta is delivered? |
Estrogen and progesterone |
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3 hormones that contribute to colostrum? |
Prolactin, estrogen, progesterone |
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3 types of lochia? |
Rubra - deep red lasts 3 to 4 days Serosa- pinkish brown lasts upto 2 weeks Alba- creamy white, light brown, lasts upto 6 weeks |
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Why do women who have c section births tend to have less lochia flow? |
Because uterine debris is removed during delivery |
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Normal blood loss during delivery vaginal and c section? |
Vaginal - 500ml C-section- 1000 ml |
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Major cause of uterine atony? |
Urinary retention |
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Possible causes of client difficulty voiding after birth? |
Anesthesia block, oxytocin use, perineal laceration, swelling/bruising of perineum, hematomas, decreased bladder tone |
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Possible causes of client difficulty voiding after birth? |
Anesthesia block, oxytocin use, perineal laceration, swelling/bruising of perineum, hematomas, decreased bladder tone |
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Decreased bladder tone increases risk for? |
Incomplete emptying, bladder distended, difficulty voiding, Urinary retention |
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Causes of postpartum diuresis? |
Lg amounts of IV fluids Decreasing antidiuretic effect of oxytocin Buildup/retention of fluids during pregnancy Decreasing production of aldosterone |
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Postpartum diuresis lasts? |
Begins within 12 hrs of birth and continues throughout first week postpartum. Normal function returns within one month. |
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Longest stage of labor? |
First stage |
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How many phases in stage 1 of labor? |
3 phases Early labor (latent phase) cervix dilates to 4cm. Contractions can be mild intensity and typically 5 - 10 minutes apart lasting 45 seconds Active labor (active phase) Begins at 4cm to 8cm. Contractions can be every 2 to 5 minutes lasting 45 to 60 seconds and appear stronger in intensity Transition phase - most difficult stage 8cm to fully dilated at 10cm . Strong urge to push at this stage. |
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Contractions should never be more than? |
90 seconds and relaxation must be > 30 seconds Otherwise can lead to uterine rupture |
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Non invasive way to determine fetal presentation, position, and attitude? |
Leopold Maneuver |
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Referring to the relationship of the presenting part of the fetus to the ischial spines of the pelvis? |
Fetal station |
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Fetal Stations |
F) -3 floating high I) -2 in the right direction S) -1 settling in H) 0 halfway there I) +1 inching out N) +2 Nearly there G) +3 getting the crown |
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Cervical dilation is documented in? |
Centimeters |
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Contractions happen in how many phases? |
3 phases Increment phase - building up longest phase Acme phase- or peak of the contraction Decrement phase - the let down phase , gradual return to baseline |
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Contractions happen in how many phases? |
3 phases Increment phase - building up longest phase Acme phase- or peak of the contraction Decrement phase - the let down phase , gradual return to baseline |
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Second stage of labor |
Expulsion of fetus (20 min to 2 hours) |
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3rd stage of labor |
Expulsion of placenta |
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4th stage of labor |
Recovery |
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How does a full bladder interfere with uterine contractions? |
It pushes the Fundus up and causes it to deviate to one side, usually the right side (but not always) |
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Refers to changes that the reproductive organs, particularly the uterus, undergo after birth to return them to their pre pregnancy size and condition. |
Involution |
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When should the uterus return to pre pregnant size? |
5 to 6 weeks after delivery |
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Intentional initiation of labor before it begins naturally? |
Induction |
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Stimulation of contractions after they have begun naturally? |
Augmentation |
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Conversation from liquid to vapor? |
Evaporation Ex: wet skin from amniotic fluid at birth evaporates from skin |
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Transfer of heat to a cooler surface? |
Conduction Ex: cool surface of bed, scale, stethoscope |
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Transfer of heat to a cooler surface? |
Conduction Ex: cool surface of bed, scale, stethoscope |
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Loss of heat to the surrounding? |
Convection Ex: drafts from window, air conditioning, and oxygen vents |
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Transfer of heat to a cooler surface? |
Conduction Ex: cool surface of bed, scale, stethoscope |
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Loss of heat to the surrounding? |
Convection Ex: drafts from window, air conditioning, and oxygen vents |
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Loss of heat to surrounding cold environment |
Radiation Ex: cold environment of walls and windows |
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Procedure that dr artificially ruptures the membranes? |
Amniotomy |
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Water delivered by shower, tub, or whirlpool relieves tired muscles and relaxes woman? |
Hydrotherapy |
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Client creates a tranquil mental environment by imagining she is in a place of relaxation and peace? |
Guided Imagery |
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Water delivered by shower, tub, or whirlpool relieves tired muscles and relaxes woman? |
Hydrotherapy |
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Client creates a tranquil mental environment by imagining she is in a place of relaxation and peace? |
Guided Imagery |
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Failure of uterus to return to pre pregnant state after 6 weeks? |
Subinvolution |
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Water delivered by shower, tub, or whirlpool relieves tired muscles and relaxes woman? |
Hydrotherapy |
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Client creates a tranquil mental environment by imagining she is in a place of relaxation and peace? |
Guided Imagery |
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Failure of uterus to return to pre pregnant state after 6 weeks? |
Subinvolution |
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Rubins psychological adaptation phases |
Taking-in, taking-hold and letting-go |
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Technique in which IV fluids is infused into the amniotic cavity through a intrauterine pressure catheter,to add fluid cushion around the cord? |
Amnioinfusion |
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Rh-negative mother should receive a dose Rhogam when? |
Within 72 hours after giving birth to aRH-positive infant |
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Over stimulation of uterus |
Hypertonicity |
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Nursing responsibilities related to general anesthesia include: |
Assessment and documentation of oral intake and administration of medications to reduce gastric acidity |
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An opioid antagonist that acts within minutes to help resuscitate a newborn who has respiratory depression d/t narcotic sedation of the mother during labor: also relieves itching as a maternal side effect of narcotics? |
Narcan |
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Green stained fluid may indicate? |
Fetus passed meconium before birth Set up for resuscitation on baby |
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Surgical enlargement of the vaginal opening during birth? |
Episiotomy |
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Uncontrolled tear of the tissues that result in a jagged wound? |
Laceration |
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Cloudy or yellow amniotic fluid with offensive odor may indicate? |
Infection and should be reported immediately |
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Fetal attitude |
Normally on flexion, with head flexed forward and arms and legs flexed. |
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How the fetus is oriented to to the mothers spine? |
Fetal lie Most common orientation is longitudinal lie |
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Fetal presentation fetal head is fully flexed? |
Vertex presentation |
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Fetal presentation: fetal head is neither flexed or extended? |
Military presentation |
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Fetal presentation: fetal head is neither flexed or extended? |
Military presentation |
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Fetal presentation: fetal head is partially extended? |
Brow presentation |
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Fetal presentation: fetal head is neither flexed or extended? |
Military presentation |
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Fetal presentation: fetal head is partially extended? |
Brow presentation |
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Fetal presentation: fetal head is fully extended and face presents? |
Face presentation |
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These occur when the FHR is 15 bpm above the baseline for 15 seconds? |
Reassuring accelerations This is normal This is criteria for a NST |
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A dip in the heart rate in conjunction with a uterine contraction? |
Benign: early deceleration Remains benign as long as FHR goes back up when contraction is over. Main cause: head compression |
