VATI Maternal Newborn Exam Elaborationss (100% Correct Solution)

VATI Maternal Newborn. A nurse notes late decelerations on the fetal monitor. What priority actions should the nurse take? Suggested Maternal Newborn Learning Activity: Fetal Heart Monitoring a nd Interpretation • Change client to side-lying position. • Start IV line if not in place or increase IV rate. • Stop oxytocin (Pitocin) if being infused. • Administer O2 at 8 to 10 L/min. • Notify provider. • Prepare for assisted vaginal or cesarean birth. A priority safety measure of a Maternal Newborn nurse is infant safety in the acute care setting. What measures can the nurse implement to prevent infant abduction? - Always verify the newborn’s ID band against the mother’s ID band when the newborn is brought to the parents -Never to take off the identity bracelet of the infant -When going to the bathroom, take the baby basinet with you or keep infant with you at all times A client asks the nurse what are indications for a cesarean birth. What information should the nurse provide? Suggested Maternal Newborn Learning Activity: Cesarean Birth -Indications for a cesarean birth would include: • Prior cesarean birth • Nonreassuring fetal heart tones • Cephalopelvic disproportion • Malpositioned fetus: breech, transverse lie • Placental anomalies: Placenta previa, Abruptio placenta The nurse is assessing a pregnant client at 20 weeks gestation for risk factors for preeclampsia. What risk factors would the nurse assess for? Suggested learning activity: Medical disorders-Gestational Hypertension Risk factors for preeclampsia would be: • First pregnancy • Age under 19 and over 40 years • African American and Hispanic women • Chronic or essential hypertension • Hypertension in previous pregnancy • Multifetal pregnancy • Morbid obesity • Familial history of preeclampsia • Diabetes Mellitus • Chronic kidney disease • Rh incompatibility • Molar pregnancy • Rheumatoid arthritis • Systemic Lupus Erythematosus A nurse is providing client education regarding the advantages and disadvantages of intrauterine devices. What information should the nurse include? Suggested Maternal Newborn Learning Activity: Contraceptives -Advantages: • Cost-effective • Highly effective for up to 10 years • Reversible • Safe for breastfeeding -Disadvantages: • Increase risk of pelvic inflammatory disease (PID), uterine perforation, and ectopic pregnancy • Client should report if string cannot be located or indications of infection • Does not protect against STIs A nurse is caring for a newborn with fetal alcohol syndrome. What clinical findings should the nurse anticipate? Fetal alcohol syndrome symptoms would include: -Facial anomalies include eyes with epicanthal folds, strabismus, and ptosis; mouth with a poor suck, small teeth, and a cleft lip or palate. -Deafness -Abnormal palmar creases and irregular hair -Heart defects, including atrial and ventricular septal defects, tetralogy of Fallot, and patent- ductus arteriosus. -Developmental delays and neurologic abnormalities -Prenatal and postnatal growth retardation -Sleep disturbances A nurse is caring for the family of a newborn. What are some interventions the nurse can use to facilitate sibling acceptance of the newborn? Suggested Maternal Newborn Learning Activity: Restorative stages of the postpartum period / bonding -Let the sibling be one of the first to see the newborn -Provide a gift to give to the sibling -Arrange for one parent to spend time with the sibling while the other patient is taking care of newborn What are four (4) care measures that the nurse should implement to manage pain for labor clients during the latent phase of labor? Suggested learning activity: Nonpharmacological Pain Management -childbirth preparation education -sensory stimulation (aromatherapy, breathing techniques, imagery, music, use of focal points, and subdued lighting) -cutaneous strategies (back rubs and massage, effleurage, sacral counter pressure, heat or cold therapy, hydrotherapy, and acupressure) -frequent maternal position changes (semi-sitting, squatting, kneeling, kneeling, and rocking back and forth, and supine position only with the placement of a wedge under one of the client's hips to tilt the uterus and avoid supine hypotension syndrome) A nurse is caring for a newborn. One complication that the nurse monitors for is hypoglycemia. Identify the criteria for hypoglycemia in the newborn. Suggested Maternal Newborn Learning Activity: Hypoglycemia in Newborn -The criteria for hypoglycemia in newborns is to a blood glucose level of 40 mg/dL in term newborns and 25 mg/dL in pre term newborns. A nurse is caring for a client prescribed tromethamine (Hemabate) for the treatment of postpartum hemorrhage. What signs of an adverse reaction to this medication should the nurse monitor for? Suggested Maternal Newborn Learning Activity: Postpartum Hemorrhage -The nurse should monitor for tetanic contraction and laceration or uterine rupture if given in excessive doses. It may also cause uterine hypertonus if infused with oxytocin. Other effects include, nausea, vomiting, diarrhea (frequent), fever, chills, facial flushing, headache, hypertension or hypotension, tachycardia, and pulmonary edema. A nurse is caring for a client who has tested positive for Group B Streptococci. What medication should the nurse anticipate administering to this client? Suggested Maternal Newborn Learning Activity: TORCH Screen - Penicillin G or ampicillin (Principen) is most commonly prescribed for Group B Streptococci What are the priority nursing actions for hypotension following placement of epidural regional analgesia? Suggested learning activity: Epidurals in Labor Nursing action would include: • Administer oxygen. • Increase flow of IV fluids. • Possibly administer ephedrine if hypotension is severe. A nurse is caring for a client undergoing a contraction stress test. What is a negative (normal) finding? What is a positive (abnormal) finding? -A negative finding would be indicated if within a 10-min period, with three uterine contractions, there are no late decelerations of the FHR. -A positive finding would be indicated if persistent and consistent late decelerations with 50% or more of the contraction, which is suggestive of uteroplacental insufficiency. Immediately after rupture of amniotic membranes, a client states that she can feel something in her vagina and the nurse is able to visualize the umbilical cord protruding from the introitus. Discuss emergency nursing care measures the nurse should take. Suggested Maternal Newborn Learning Activity: Labor Complications- Prolapsed Cord In order the nurse should: • Call for assistance immediately. • Notify the provider. • Use a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. • Reposition the client in a knee-chest, Trendelenburg, or a side-lying position with a rolled towel under the client’s right or left hip to relieve pressure on the cord. • Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow. • Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia. • Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation. • Initiate IV access, and administer IV fluid bolus. • Prepare for an immediate vaginal birth if cervix is fully dilated or cesarean section A nurse is completing an Apgar score on a newborn. What is assessed when obtaining an Apgar score? What does a score of 5 indicate? Suggested Maternal Newborn Learning Activities: Normal newborn physical assessment and Newborn Vital Signs - The Apgar is a review of systems that is completed soon after birth. It monitors the heart rate, respiratory rate, muscle tone, reflex irritability, and color on a scale of 0-2. An Apgar score of 5 indicates moderate distress and some suctioning and stimulation of the newborn is necessary. Show Less