Maternal Newborn 2023/2024

Maternal Newborn 2023/2024 Causes of Late Decelerations - CORRECT ANSWER-Decreased blood flow to uterus or placenta resulting in fetus not receiving enough oxygen Cause of Variable decelerations - CORRECT ANSWER-umbilical cord compression Cause of Early Decelerations - CORRECT ANSWER-fetal head compression in birth canal Manifestations of Early Decelerations - CORRECT ANSWER-- uniform shape - slow onset - mirror contractions - return to baseline at end of contraction Manifestations of Late Decelerations - CORRECT ANSWER-- loss of HR variability - begin after peak of contraction - slow return to baseline - resolves after contraction Manifestations of Variable Decelerations - CORRECT ANSWER-- irregular and jagged appearance - no regard to contractions - potentially caused by: fetal movement, umbilical cord wrapped around neck, maternal position, ruptured membranes Nursing Interventions for fetal heart rate decelerations - CORRECT ANSWER-- Assess FHR baseline, variability, and reactivity Q15min during active labor - Contraction pattern, labor progress, and vital signs (including pain) Q15mins during active labor Nursing interventions for Variable decelerations - CORRECT ANSWER-- reposition mom (Left lateral position) - vaginal exam - administer oxygen - increase IV fluid intake Nursing intervention for Late Decelerations - CORRECT ANSWER-- Notify HCP - Change maternal position - increase IV rate - administer oxygen - decrease or stop oxytocin - emergent delivery by C-section Preeclampsia - CORRECT ANSWER-- begins after 20 weeks - BP 140/90 - proteinuria - transient headaches - irritability - edema Risk factors for Preeclampsia - CORRECT ANSWER-- Hx of Preeclampsia - Chronic HTN - Obesity - DM - Multiple gestation pregnancy - kidney disease - Autoimmune disease - clotting disorders - baby conceived invitro - very young or older than 35 y/o Manifestations of Preeclampsia - CORRECT ANSWER-- proteinuria 500mg/24hrs - elevated liver enzymes and thrombocytopenia - severe headaches not relieved by analgesics - changes in vision: blurred vision, flashing lights, floaters - right upper quadrant pain - sudden weight gain ( 2lb in 24hrs or 5lb in 1 week) Assessment for Preeclampsia - CORRECT ANSWER-- vital signs and pain - assess fetal status - nonstress test - collection of 24 hr urine specimen - document findings - dim lights - limit visitors Priorities in Preeclampsia - CORRECT ANSWER-- maintain adequate fetal oxygenation and nutrition - address elevated BP - limit long-term complication Nursing Interventions for Preeclampsia - CORRECT ANSWER-- Monitor urine output and daily weights - monitor vital signs - monitor deep tendon reflexes - encourage lateral positioning - perform daily nonstress test and kick counts - decrease environmental stimuli - monitor labs and dx findings - closely monitor I/O - educate pt. and family Postpartum hemorrhage - CORRECT ANSWER-- loss of 500 ml after vaginal birth - loss of 1 L after C-section - greatest risk after first hour of birth - results in anemia and hypovolemic shock Risk factors of PPH - CORRECT ANSWER-- uterine atony - prolonged labor - precipitous labor - 5 or more pregnancies to term - oxytocin induced labor - placenta previa or abruptio placenta - MgSO4 - Retained placental fragments 4 T's of PPH - CORRECT ANSWER-Tone Trauma Tissue Thrombin Manifestations of PPH - CORRECT ANSWER-- increase or change in lochia pattern - uterine atony - passing blood clots larger than a quarter - perineal pad saturation in 15min or less - constant vaginal blood oozing, trickling or flow - Tachycardia - Hypotension - skin pale, cool and clammy - pale mucous membranes - oliguria Assessment in PPH - CORRECT ANSWER-- Boggy uterus, midline - saturated perineal pad - S/S of hypovolemia - assess source of bleeding Goals of Care for PPH - CORRECT ANSWER-- determine and correct underlying cause - fundal massage and bladder evaluation - catheterization if patient is unable to void Nursing Interventions in PPH - CORRECT ANSWER-- assess source of bleeding - ensure empty bladder - fundal massage - express clots - monitor VS and O2 (2-3L/min) - IV fluids - Medications to promote contractions or control hemorrhage Medications for PPH - CORRECT ANSWER-Oxytocin Methylergonovine Misoprostol Carboprost tromethamine APGAR scoring: Heart rate - CORRECT ANSWER-0 = absent 1 = slow; below 100/min 2 = above 100/min APGAR scoring: Respiratory effort - CORRECT ANSWER-0 = absent 1 = slow or weak 2 = good cry APGAR scoring: Reflex irritability - CORRECT ANSWER-0 = no response 1 = grimace 2 = cry Apgar scoring: Muscle tone - CORRECT ANSWER-0 = flaccid 1 = some flexion of the extremities 2 = well flexed APGAR scoring: Color - CORRECT ANSWER-0 = pale or blue 1 = pink body with blue extremities (acrocyanosis) 2 = completely pink APGAR scoring Indications - CORRECT ANSWER-0 - 3 = severe distress 4 - 6 = moderate difficulty 7 - 10 = minimal to no difficulty Potential indications for C-Section - CORRECT ANSWER-- malpresentation - nonreassuring FHT - placental abnormalities - high risk pregnancy - previous C-Section - multifetal gestation - umbilical cord prolapse - congenital malformations - maternal cardiac or respiratory disease A client asks the nurse what are indications for a cesarean birth. Provide three (3) reasons a cesarean birth may be necessary - CORRECT ANSWER-- malpresentation - cephalopevlic disproportions - high risk pregnancy - placental abnormalities - nonreassurring fetal heart tones - previous cesarean birth - dystocia - multiple gestations - umbilical cord prolapse - congenital malformations - maternal cardiac or respiratory disease A nurse is caring for a client in the postpartum phase. How should the nurse assess fundal height following delivery? - CORRECT ANSWER-- the fundus should be palpable midline and 2cm below the umbilicus - 1hr postpartum, the fundus will rise to the level of the umbilicus A nurse is caring for a postpartum client who is breastfeeding her newborn. Identify three (3) teaching points to discuss with the client regarding the postpartum infection, mastitis. - CORRECT ANSWER-1. use ice pack or warm packs for discomfort nue breastfeeding frequently every 2-4hrs especially on affected side (completely empty milk to prevent stasis) 3. rest, take analgesics, and maintain fluid intake of at least 3L/day A nurse is providing discharge information to a postpartum client. Identify three (3) teaching points to discuss with the postpartum client prior to discharge regarding breastfeeding - CORRECT ANSWER-1. Frequently pump or feed to prevent engorgement and stimulate milk production 2. Wear supportive bra to prevent clogged milk ducts 3. To relieve engorgement, take a warm shower or apply a cool compress before feedings to promote milk flow 4.For sore nipples, apply a small amount of breast milk to the nipple and allow to air dry A nurse is providing prenatal education. What common findings of pregnancy should be discussed in routine prenatal teaching? - CORRECT ANSWER-- N/V, fatigue, backache, varicosities, heartburn, activity, sexuality The nurse is reviewing the postpartum mother's complete blood count (CBC) at 24 hours after delivery and notes a white blood cell (WBC) count of 15,000 mm3. What action should the nurse take? - CORRECT ANSWER-Elevated WBC is an expected finding up to 14 days postpartum - the nurse should document the finding, not assume it to be "normal" and assess for possible source of infection Infant safety is a priority concern for the nurse. What measures can the nurse implement to prevent infant abduction? - CORRECT ANSWER-- each time the newborn is given to a parent, you must verify the ID band on the newborn matches the ID band on the parents; confirm the infants name, sex, date and time of birth and mother's medical record number match. - Only allow medical personal with a photo ID verifying access to the maternal- newborn unit to handle the newborn. - Place alarm band on the infant that will sound if someone attempts to take them off the unit What are expected cardiovascular changes during pregnancy? - CORRECT ANSWER-- Faintness, syncope, varicose veins - Heart size increases and rotates forward toward left - Rate increase by 5 to 10/min - Blood pressure should stay approximately same throughout pregnancy What are indications for amniotomy? Identify one (1) post-procedure intervention. - CORRECT ANSWER-Indications for amniotomy: to initiate or induce labor such as in post term pregnancies 1. Assess fetal heart rate; place scalp electrodes on fetus 2. Assess the amount, color, consistency and odor of the amniotic fluid Fundal Height measurement - CORRECT ANSWER-Should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation What is a priority nursing intervention following the rupture of membranes? - CORRECT ANSWER-Begin FHR monitoring to assess for umbilical cord prolapse Expected findings in a newborn assessment - CORRECT ANSWER-- Acrocyanosis - Positive Babinski - Two visible umbilical cord arteries - Overlapping suture lines (vaginal birth) Expected finding of premature newborn - CORRECT ANSWER-- decreased muscular tone; minimal arm recoil Manifestations of hypoglycemia in newborn - CORRECT ANSWER-- abnormal cry - jitteriness - lethargy - poor feeding - apnea - respiratory distress - seizures Nationally Notifiable Infectious Conditions for pregnancy - CORRECT ANSWER-- HIV