Uworld Nclex Review Maternal & Child Nursing

UWORLD NCLEX REVIEW MATERNAL & CHILD NURSING Batch 14 12/18/17 Supine hypotensive syndrome occurs when the weight of the abdominal contents compresses the vena cava causing decreased venous return to the heart. This results in low cardiac output (maternal hypotension) and reflex tachycardia. Manifestations include dizziness, pallor, and cold and clammy skin. The client should be immediately repositioned onto the right or left side until the symptoms subside. Prevention of this condition includes using a wedge under the client's hip while in a supine position. (Option 1) Decreased maternal cardiac output can result in decreased placental blood flow and fetal heart rate (FHR) abnormalities. FHR assessment also follows after the client is placed in the right or left lateral position. (Option 2) When supine hypotension is suspected, the client should first be placed in a lateral position. Blood pressure and pulse are checked to confirm the diagnosis. Assessing lung and heart sounds is not a priority. (Option 3) The HCP is notified after placing the client in a lateral position and completing the assessment. Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal occiput rotates and faces the mother's posterior or sacrum. OP fetal position can cause increased back pain or "back labor." Many fetuses in OP position during early labor spontaneously rotate to occiput anterior position (occiput facing the mother's anterior or pubis). The nurse or labor support person can apply counterpressure to the client's sacrum during contractions to help alleviate back pain associated with OP fetal positioning. Firm, continuous pressure is applied with a closed fist, heel of the hand, or other firm object (eg, tennis ball, back massager) (Option 1). (Option 2) Clients should be encouraged to change positions frequently (every 30-60 minutes) during labor to promote fetal rotation/descent and increase maternal comfort. Remaining in bed during early labor increases the risk for persistent fetal malposition and slows labor progression. (Option 3) Left lateral positioning is better for uteroplacental blood flow and fetal oxygenation than supine positioning when the client is resting in bed. However, it may not alleviate the client's back pain. (Option 4) Although epidural anesthesia can provide effective pain relief, it can limit client mobility and contribute to persistent fetal malposition. This client is also still in early labor and has not requested an epidural at this time. Precipitous birth occurs when the newborn is delivered ≤3 hours after the onset of contractions. In the event of precipitous labor, the nurse should be prepared to assist with the birth if the health care provider is unable to arrive in time. Immediately after the birth, the newborn should be dried and placed skin-to-skin on the mother's abdomen at uterine level to promote warmth; this prevents cold stress that can lead to newborn hypoglycemia or respiratory distress (Option 3). If the newborn is stable, the cord can be clamped and cut with sterile scissors after it has stopped pulsating or after the placenta has been expelled. (Option 1) The perineal area can be cleansed if needed once the placenta has been expelled. (Option 2) To avoid uterine inversion or cord avulsion (tearing or snapping), the nurse should not pull on the cord. Once placental separation occurs, signified by cord lengthening, a gush of blood, uterine cramping, and vaginal pressure, the mother can bear down gently to expel the placenta. (Option 4) Fundal massage is performed after expulsion of the placenta to increase uterine tone and decrease bleeding. The enlarging pregnant uterus should be just above the symphysis pubis at approximately 12 weeks gestation (Option 4). At 16 weeks gestation, the fundus is roughly halfway between the symphysis pubis and the umbilicus. It reaches the umbilicus at 20-22 weeks gestation and approaches the xiphoid process around 36 weeks gestation. At 38-40 weeks, the fetus engages into the maternal pelvis and the fundal height drops. After 20 weeks gestation, the fundal height, measured in centimeters from the symphysis pubis to the top of the fundus, correlates closely to the weeks of gestation. (Options 1, 2, and 3) At 12 weeks gestation, the uterine fundus should be just above the symphysis pubis Subjective, objective & positive signs of pregnancy Subjective (presumptive) Objective (probable) Positive (diagnostic)  Amenorrhea  Nausea & vomiting  Urinary frequency  Breast tenderness  Quickening  Excessive fatigue  Uterine & cervical changes o Goodell sign o Chadwick sign o Hegar sign o Uterine enlargement  Braxton Hicks contractions  Ballottement  Fetal outline palpation  Uterine &funicsouffle  Skin pigmentation changes o Chloasma o Linea nigra o Areola darkening  Striaegravidaru  Positive pregnancy tests  Fetal heartbeat heard with Doppler device  Fetal movement palpated by health care provider or visible fetal movements  Visualization of fetus by use of ultrasound Subjective (presumptive) signs of pregnancy are self-reported by a client. This client's symptoms could originate from pathologic causes (eg, urinary tract infection [UTI], sexually transmitted infection), but collectively these symptoms may be indicative of early pregnancy. Any client with possible signs/symptoms of early pregnancy should be asked about menstrual history (Option 3). (Option 1) Regular breast self-exams are an important part of breast self-awareness and may alert the client to early pathologic breast changes. However, breast tenderness is a common sign of early pregnancy, which should be ruled out first. (Option 2) Leukorrhea (ie, whitish, mucoid vaginal discharge) increases during pregnancy in response to rising hormone levels. The client should be questioned about color, odor, and consistency of discharge to rule out infection, but this response from the nurse does not address the larger picture. (Option 4) Increased urinary frequency may result from hyperglycemia, and clients with diabetes are at increased risk for infections (eg, UTI, yeast infection). Reviewing home blood sugar logs would help the nurse assess the client's level of glycemic control over time but would not address the complete picture of the client's acute symptoms. A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk:  Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option 3).  Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft.  Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5).  These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2).  Feeding slowly over 20–30 minutes reduces the risk of aspiration and promotes adequate intake of formula.  Feeding every 3–4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula. (Option 1) Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose. (Option 4) Feeding should take about 20–30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth. Dietary sources of folic acid Excellent sources 100+ mcg/½ cup Good sources 40-100 mcg/½ cup Other sources 40-100 mcg/serving  Asparagus  Turnip/mustard greens  Fortified breakfast cereal  Cooked dried beans  Liver (2 oz cooked)  Broccoli  Spinach  Green peas  Fresh-cooked beets  Fortified spaghetti, pasta  Rice  Tomato juice (3/4 cup)  Orange, 1  Sunflower seeds (1 oz)  Peanut butter ( 2 tbsp)  Enriched bread (1 slice) Folic acid, or folate, is a water-soluble, B-complex vitamin necessary for red blood cell production. Pregnant women and those attempting pregnancy need a minimum of 400 mcg of folic acid per day to decrease the chance of fetal neural tube defects (eg, spina bifida, anencephaly). Most prenatal vitamins contain 400-800 mcg of folic acid; additional folic acid can come from the diet. Leafy green vegetables are the best dietary sources of folic acid. However, other appropriate food choices include cooked beans, rice, fortified cereals, and peanut butter, which provide at least 40 mcg folic acid per serving (Options 1, 2, and 4). (Option 3) Sweet potatoes provide vitamin A, vitamin C, and minerals to the diet but no folic acid. (Option 5) Raw carrots are a dietary source of vitamin A, vitamin C, and minerals, but not of folic acid. During pregnancy, the fetus stores large quantities of glycogen that are used during the transition to extrauterine life. As a result, glucose levels are decreased 1 hour after birth, then rise and stabilize within 2-3 hours. Optimal glucose levels are 70-100 mg/dL (3.9-5.6 mmol/L), but ≥40 mg/dl (2.2 mmol/L) is considered normal (Option 1). A hypoglycemic neonate (40 mg/dl [2.2 mmol/L]) should be fed immediately. Infants of diabetic mothers are at increased risk for hypoglycemia due to excess intrauterine insulin produced in response to high maternal glucose levels. Normal newborn respiratory rate is 30-60 breaths per minute (Option 3). Breathing may be slightly irregular, diaphragmatic, and shallow. Milia (white papules) form due to plugged sebaceous glands and are frequently found on the nose and chin. They resolve without treatment within several weeks (Option 5). (Option 2) A holosystolic murmur (heard during entire systole phase) at the left lower sternal border is a classic sign of a ventricular septal defect (VSD). Although abnormal, most small VSDs close spontaneously within the first 6 months of life. (Option 4) A single transverse crease extending across the palm of the hand is a classic sign of Down syndrome (an extra copy of chromosome 21). Other signs include small and low-set ears, flat nose bridge, protruding tongue, and hypotonia. Supine hypotensive syndrome results from compression of the maternal inferior vena cava by the large gravid uterus in mid to late pregnancy when the client is in the supine position. The venous return is reduced, causing maternal hypotension from reduced cardiac output. The client can also report feeling dizzy and faint. The first step is to rectify the cause by turning the client laterally while still strapped on the backboard. (Option 1) The etiology is not hypovolemia but perfusion. A fluid bolus of isotonic fluids (normal saline or lactated Ringer's) can be administered if the position change does not relieve the symptoms. Mean arterial pressure (MAP) should be 60 mm Hg for effective organ perfusion. Normal MAP is 70-105 mm Hg. (Option 2) The client does not have classic signs of a precipitous or impending delivery. Classic signs or symptoms of the second stage of labor/delivery of the baby include feeling the need to push, an intense urge to bear down, or a sensation of cervical pressure. A pelvic examination can be performed, but it is not the first priority. (Option 3) The etiology is related not to the fetus, but to the maternal circulation. Because the client does not have adequate cardiac output, circulation to the fetus could be compromised. The first priority is to rectify the client's perfusion issue and check the fetus. The best indicators of fetal health are heart rate and movement.