Maternal and Newborn Success_ A Q_A Review Applying Critical Thinking to Test Taking contains questions answers and summarised notes

Determine the Signifi cance of the Pathophysiology The second phase of the process is to determine the signifi cance of the pathophysiology. Often the nurse is able to deduce the signifi cance based on knowledge of normal anatomy and physiology. Because the placenta is the highly vascular organ that supplies oxygen and nutrients to the developing baby, it is essential to the well-being of the fetus. If the cervix were to dilate or be injured, the chorionic villi of the placenta would be disrupted. The mother would lose blood, and the baby’s oxygenation and nutrition would be critically affected, resulting in a life-threatening situation for both mother and fetus. Predisposing factors: too little intrauterine space/poor vascularity of the decidua Placenta attaches to area immediately above or adjacent to the internal cervical os Cervical dilation and/or placental injury vaginal bleeding and fetal hypoxia Flow Chart—Determine the Signifi cance of the Pathophysiology. Identify Signs and Symptoms Once the signifi cance of the pathophysiology is deduced, it is essential to identify the signs and symptoms that are expected. In the mother, the nurse would expect to see bleeding with its associated changes in hematological signs (hematocrit and hemoglobin) and vital signs as well as anxiety. Because the placental bleeding will be unobstructed—that is, the blood will be able to escape easily via the vagina—the nurse would expect that the client would be in little to no pain and that the blood would be bright red. In addition, the nurse would expect the client’s hematological signs to be affected and the vital signs to change. However, because women have signifi - cantly elevated blood volumes during pregnancy, the pulse rate will elevate fi rst, and the blood pressure will stay relatively stable. A drop in blood pressure is a late, and ominous, sign. In addition, the nurse would expect the mother to be anxious regarding her own and her baby’s well-being. In the fetus, if there were signifi cant maternal blood loss and placental disturbance, the nurse would expect to see adverse changes in heart rate patterns. Late decelerations result from poor uteroplacental blood fl ow. Predisposing factors: too little intrauterine space/poor vascularity of the decidua Placenta attaches to area immediately above or adjacent to the internal cervical os Cervical dilation vaginal bleeding and fetal hypoxia Mother: bright red, painless bleeding; pulse rate; Hgb and hct; BP late sign; anxiety Fetus: late decelerations seen on external fetal monitor tracing Flow Chart—Identify Signs and Symptoms. 5941_Chapter 1_ 3 9/16/2016 3:26:00 PM4 MATERNAL AND NEWBORN SUCCESS Once the problem and the data concerning it are understood, the signifi cance determined, and expected signs and symptoms identifi ed, it is time for the student (and nurse) to turn to the nursing process. USE THE NURSING PROCESS The nursing process is foundational to nursing practice. To provide comprehensive care to their clients, nurses must understand and use each part of the nursing process—assessment, formulation of a nursing diagnosis, development of a plan of care, implementation of that plan, and evaluation of the outcomes. Assess Nurses gather a variety of information during the assessment phase of the nursing process. Some of the information is objective, or fact based. For example, a client’s hematocrit level and other blood values in the chart are facts that the nurse can use to determine a client’s needs. Nurses also must identify subjective data, or information as perceived through the eyes of the client. A client’s rating of pain is an excellent example of subjective information. Nurses must be aware of which data must be assessed because each and every client situation is unique. In other words, nurses must be able to use the information taught in class and individualize it for each client interaction to determine which objective data must be accessed and which questions should be asked of the client. Once the information is obtained, the nurse analyzes it. (See example above.) Formulate Nursing Diagnoses After the nurse has analyzed the data, a diagnosis is made. Nurses are licensed to treat actual or potential health problems. Nursing diagnoses are statements of the health problems that the nurse, in collaboration with the client, has concluded are critical to the client’s well-being. The nurse now must develop the nursing diagnoses and prioritize them as they relate to the care of a client with placenta previa. Because a woman with placenta previa may begin to bleed, it is essential that the nurse develop two sets of diagnoses: one aimed at preventing complications—that is, “risk for” diagnoses—and one directed at the worst-case scenario— that is, if the client should start to bleed. The “risk for” placenta previa nursing diagnoses are: • Risk for maternal imbalanced fl uid volume related to (r/t) hypovolemia secondary to excessive blood loss • Risk for impaired fetal gas exchange r/t decreased blood volume and maternal cardiovascular compromise • Maternal anxiety r/t concern for personal and fetal health The worst-case scenario (active bleeding) nursing diagnoses are: • Imbalanced maternal fl uid volume r/t hypovolemia secondary to excessive blood loss • Impaired fetal gas exchange r/t decreased blood volume and maternal cardiovascular compromise • Maternal anxiety r/t concern for personal and fetal health Develop a Plan of Care The nurse develops a plan of care, including goals of care, expected client outcomes, and interventions necessary to achieve the goals and outcomes. The nurse determines what he or she wishes to achieve in relation to each of the diagnoses and how to go about meeting those goals. 5941_Chapter 1_ 4 9/16/2016 3:26:01 PMCHAPTER 1 INTRODUCTION 5 One very important part of this process is the development of the priorities of care. The nurse must determine which diagnoses are the most important and, consequently, which actions are the most important. For example, a client’s physical well-being must take precedence over emotional well-being. It is essential that the nurse consider the client’s priorities and the goals and orders of the client’s primary healthcare provider. The nurse caring for the client with placenta previa develops a plan of care based on the diagnoses listed above. Because the physical conditions must take precedence, the nurse prioritizes the plan with the physical needs fi rst. The client’s emotional needs will then be considered. The plan of care to meet the “at risk” nursing diagnoses is shown in Box 1-1, and a plan for the worst-case scenario—active bleeding—is shown in Box 1-2. BOX 1-1 PLAN OF CARE FOR CLIENT WITH PLACENTA PREVIA AT RISK FOR BLEEDING Nursing Diagnosis: Risk for imbalanced fl uid volume (maternal) related to (r/t) hypovolemia secondary to excessive blood loss. Goal: Client will not bleed throughout her pregnancy. Proposed Actions: The nurse will: • Assess for vaginal bleeding each shift. • Assess for uterine contractions each shift. • Assess vital signs each shift. • Assess intake and output during each shift. • Assess bowel function each shift. • Insert nothing into the vagina. • Maintain client on bedrest, as ordered. • Monitor changes in laboratory data. Nursing Diagnosis: Risk for impaired gas exchange (fetal) r/t decreased blood volume and maternal cardiovascular compromise. Goal: The fetal heart rate will show average variability and no decelerations until delivery. Proposed Actions: The nurse will: • Monitor fetal heart rate every shift. • Do nonstress testing, as ordered. Nursing Diagnosis: Anxiety (maternal) r/t concern for personal and fetal health. Goal: The mother will exhibit minimal anxiety throughout her pregnancy. Proposed Actions: The nurse will: • Provide emotional support. BOX 1-2 PLAN OF CARE FOR PATIENT WITH PLACENTA PREVIA WHO IS BLEEDING Nursing Diagnosis: Imbalanced fl uid volume (maternal) r/t hypovolemia secondary to excessive blood loss. Goal: Client will become hemodynamically stable. Proposed Interventions: The nurse will: • Measure vaginal bleeding. • Count number of saturated vaginal pads. • Weigh pads—1 g = 1 mL of blood. • Monitor for uterine contraction pattern, if present. • Assess vital signs every 15 minutes. • Assess oxygen saturation levels continually. • Assess intake and output every hour. • Insert nothing into the vagina. • Maintain client on bedrest. • Monitor changes in laboratory data. • Administer intravenous fl uids, as ordered. • Prepare for emergency cesarean section, as ordered. Nursing Diagnosis: Risk for impaired gas exchange (fetal) r/t decreased blood volume and maternal cardiovascular compromise. continued 5941_Chapter 1_ 5 9/16/2016 3:26:01 PM6 MATERNAL AND NEWBORN SUCCESS Implement the Care Once the plan is established, the nurse implements it. The plan may include direct client care by the nurse and/or care that is coordinated by the nurse but performed by other practitioners. If assessment data change during implementation, the nurse must reanalyze the data, change diagnoses, and reprioritize care. One very important aspect of nursing care is that it be evidence based. Nurses are independent practitioners. They are mandated to provide safe, therapeutic care that has a scientifi c basis. Nurses, therefore, must engage in lifelong learning. It is essential that nurses realize that much of the information in textbooks is outdated before the text was even published. To provide evidence-based care, nurses must keep their knowledge current by accessing information from reliable sources on the Internet, in professional journals, and at professional conferences. Care of the placenta previa patient should be implemented as developed during the planning phase. If a situation should change—for example, should the woman begin to bleed spontaneously during a shift—the nurse would immediately revise his or her plan, as needed. In the example cited, the nurse would implement the active bleeding plan of care. Evaluate the Care The evaluation phase is usually identifi ed as the last phase of the nursing process, but it also could be classifi ed as another assessment phase. When nurses evaluate, they are reassessing clients to determine whether the actions taken during the implementation phase met the needs of the client. In other words, “Were the goals of the nursing care met?” If the goals were not met, the nurse is obligated to develop new actions to meet the goals. If some of the goals were met, priorities may need to be changed, and so on. As can be seen from this phase, the nursing process is ongoing and ever-changing. Throughout the nursing care period, the nurse is assessing and reassessing the status of the client with placenta previa. If needed, the nurse may report signifi cant changes to the health care provider or may determine independently that a change in nursing care is needed. For example, if the client begins to cry because she is concerned about her baby’s health, and physiologically the client is stable, the nurse can concentrate on meeting the client’s emotional needs. The nurse may sit quietly with the client while she communicates her concerns. Conversely, if the client begins to bleed profusely, the nurse would immediately report the change to the client’s health-care provider and implement the active bleeding plan. TYPES OF QUESTIONS There are fi ve “integrative processes” upon which questions in the NCLEX-RN examination are based: “Nursing Process,” “Caring,” “Communication and Documentation,” “Teaching/Learning,” and “Culture and Spirituality” ( 2016 NCLEX-RN Test Plan, 2015, BOX 1-2 PLAN OF CARE FOR PATIENT WITH PLACENTA PREVIA WHO IS BLEEDING Goal: The fetal heart rate will show average variability and no late decelerations. Proposed Interventions: The nurse will: • Monitor fetal heart rate continually via external fetal monitor. Nursing Diagnosis: Anxiety (maternal) r/t concern for personal and fetal health. Goal: The mother will exhibit minimal anxiety. Proposed Interventions: The nurse will: • Provide clear, calm explanations of all assessments and actions. • Provide emotional support. continued 5941_Chapter 1_ 6 9/16/2016 3:26:01 PMCHAPTER 1 INTRODUCTION 7 p. 3). The test taker must determine which process(es) is (are) being evaluated in each question. The test taker must realize that because nursing is an action profession, the NCLEX-RN questions simulate, in a written format, clinical situations. Critical reading is, therefore, essential. Most of the questions on the NCLEX-RN examination are multiple choice. Other types of questions, known as alternate-format questions, include “fi ll-in-the-blank” questions, “multiple-response” questions, “drag-and-drop” questions, and “hot spot” items. In addition, any one of the types of questions may include an item to interpret, including laboratory data, images, and/or audio or video fi les ( 2016 NCLEX-RN Test Plan, 2015, p. 7). The types of questions and examples of each are discussed next. Multiple-Choice Questions In these questions, a stem is provided (a situation), and the test taker must choose among four possible responses. Sometimes the test taker will be asked to choose the best response, sometimes to choose the fi rst action that should be taken, and so on. There are numerous ways that multiple-choice questions may be asked. Below is one example related to a client with placenta previa. A client, 36 weeks’ gestation, has been diagnosed with a complete placenta previa. On nursing rounds, the client tells the nurse that she has a bad backache that comes and goes. Which of the following actions should the nurse perform fi rst? 1. Give the client a back rub. 2. Assess the client’s vital signs. 3. Time the client’s back pains. 4. Assess for vaginal bleeding. Answer: 4 The nurse must realize that, because the backache comes and goes, this client may be in early labor. As dilation of the cervix can lead to bleeding, the nurse must fi rst assess for placental injury—vaginal bleeding. Fill-in-the-Blank Questions These are calculation questions. The test taker may be asked to calculate a medication dosage, an intravenous (IV) drip rate, a minimum urinary output, or other factor. Included in the question will be the units that the test taker should have in the answer. The nurse caring for a client with placenta previa must determine how much blood the client has lost. The nurse weighs a clean vaginal pad (5 g) and the client’s saturated pad (25 g). How many milliliters of blood has the client lost? ____ mL Answer:20 mL The test taker must subtract 5 from 25 to determine that the client has lost 20 g of blood. Then, knowing that 1 g of blood is equal to 1 mL of blood, the test taker knows that the client has lost 20 mL of blood. Drag-and-Drop Questions In drag-and-drop questions, the test taker is asked to place four or fi ve possible responses in chronological or rank order. The responses may be actions to be taken during a nursing procedure, steps in growth and development, and the like. The items are called drag-anddrop questions because the test taker will move the items with his or her computer mouse. Needless to say, in this book, the test taker will simply be asked to write the responses in the correct sequence. The nurse must administer a blood transfusion to a client with placenta previa who has lost a signifi cant amount of blood. Put the following nursing actions in the chronological order in which they should be performed. 5941_Chapter 1_ 7 9/16/2016 3:26:01 PM8 MATERNAL AND NEWBORN SUCCESS 1. Stay with the client for a full 5 minutes and take a full set of vital signs. 2. Compare the client’s name and hospital identifi cation number with the name and number on the blood product container. 3. Check the physician’s order regarding the type of infusion that is to be administered. 4. Regulate the infusion rate as prescribed. Answer:3, 2, 4, 1 Of the four steps included in the answer options, the order should be 3, 2, 4, 1. First, the nurse must check the physician’s order to determine exactly what blood product is being ordered. Second, the nurse must compare the information on the blood product bag with the client’s name band. This must be done with another nurse or a doctor. Third, the nurse must begin the infusion and regulate the infusion. Finally, the nurse must closely monitor the client during the fi rst 5 minutes of the infusion to assess for any transfusion reactions. At the end of the 5 minutes, a full set of vital signs must be taken.