OB-Maternity HESI-NCLEX Hints Latest Update 2023

Full bladder is one of the most common reasons for uterine atony or hemorrhage in the first 24 hours after delivery. If the nurse finds the fundus soft, boggy and displaced above and to the right of the umbilicus, what actions should be taken first? First, perform fundal massage; then have the client empty her bladder. Recheck fundus every 15 min for 1 hours, then every 30 min for 2 hours - HESI HINT: 38 Intrapartum Nursing Care If narcotic analgesics are given, raise side rails and place call light within reach. Instruct client not to get out of bed or ambulate without assistance. Caution client about drowsiness as a side effect - HESI HINT: 39 Intrapartum Nursing Care A first-degree tear involves not only the epidermis. A second-degree tear involves dermis, muscle, and fascia. A third degree tear extends into the anal sphincter. A fourth degree tear extends up to the rectal mucosa. Tears cause pain and swelling. Avoid rectal manipulations - HESI HINT: 40 Intrapartum Nursing Care Do not wait until a 1 minute Apgar is assigned to begin resuscitation of the compromised neonate - HESI HINT: 41 Intrapartum Nursing Care Apgar scores of 6 or lower at 5 min require an additional Apgar assessment at 10 minutes - HESI HINT: 42 Intrapartum Nursing Care IV administration of analgesics is preferred to IM administration for a client in labor because the onset and peak occur more quickly and the duration of the drug is shorter. It is important to know the following: IV ADMINISTRATION -Onset: 5 minutes -Peak: 30 minutes -Duration: 1 hour IM ADMINISTRATION -Onset: within 3o minutes -Peak: 1-3 hours after injection -Duration: 4-6 hours - HESI HINT: 43 Intrapartum Nursing Care Tranquilizers (ataractics and phenothiazines) such as Phenergan and Vistaril are used in labor as analgesic-potentiating drugs to decrease the amount of narcotic needed to decrease maternal anxiety - HESI HINT: 44 Intrapartum Nursing Care Agonist narcotid drugs (morphine) produce narcosis and have a higher risk for causing maternal and fetal respiratory depression. Antagonist drugs (Stadol, Nubain) have less respiratory depression but must be used with caution in a mother with preexisting narcotic dependency because withdrawal symptoms occur immediately. - HESI HINT: 45 Intrapartum Nursing Care Pudental block and subarachnoid (saddle) block are used only in the second stage of labor. Peridural and epidural blocks may be used during all stages of labor. - HESI HINT: 46 Intrapartum Nursing Care The first sign of a block's effectiveness is usually warmth and tingling in the ball of the foot or the big toe - HESI HINT: 47 Intrapartum Nursing Care Stop continuous infusion at end of stage I or during transition to increase effectiveness of pushing - HESI HINT: 48 Intrapartum Nursing Care REGIONAL BLOCK ANESTHESIA AND FETAL PRESENTATION: -Internal rotation is harder to achieve when the pelvic floor is relaxed by anesthesia; this results in a persistent occiput-posterior position of fundus -Monitor fetal position. Remember, the mother cannot tell you she has back pain, which is the cardinal sign of persistent posterior fetal position -Regional blocks, especially epidural and caudal blocks, commonly result in assisted (forceps or vaccum) delivery because of the inability to push effectively during the second stage. - HESI HINT: 49 Intrapartum Nursing Care Normal leukocytes of pregnancy averages 12,000-15,000. During the first 10 to 12 days postdelivery, values of 25,000 are common. Elevated WBC and the normal elevated ESR may confuse interpretation of acute postpartal infections. For example, if the nurse assess a clients temp to be 101 on the clients second postpartum day, what assessments should be made before notifying the physician? Assess the fundal height and firmness; assess perineal integrity; check for s/sx of thromboembolism assess pulse, respirations, and BP, assess clients subjective description of sx (burning on urination, pain in leg, excessive tenderness of uterus) - HESI HINT: 50 Normal Postpartum Client and family teaching is a common subject. Remember that when teaching the first step is to assess the clients (parents) level of knowledge and to identify their readiness to learn. Client teaching regarding lochia changes, peripheral care, breastfeeding, and sore nipples are subjects commonly tested on - HESI HINT: 51 Normal Postpartum After the first postpartum day, the most common cause of uterine atony is retained placental fragments. The nurse must check for the presence of fragments of lochial tissue - HESI HINT: 52 Normal Postpartum Women can tolerate blood less, even slightly excessive blood loss, in the postpartal period because of the 40% increase in plasma volume during pregnancy. In the postpartal period, a woman can void up to 3000 mL/day to reduce the volume increase that occurred during pregnancy - HESI HINT: 53 Normal Postpartum Client should void within 4 hours of delivery. Monitor client closely for urine retention. Suspect retention if voiding is frequent and <100 mL per voiding - HESI HINT: 54 Normal Postpartum Women often have a syncopal (fainting) spell on the first amblation after delivery (usually related to vasomotor changes, orthostatic hypotension) The astute nurse will check client's H/H for anemia and BP, sitting and lying downt o ascertain orthostatic hypotension - HESI HINT: 55 Normal Postpartum Kegel exercises increase the integrity of the introitu and improve urine retention. Teach client to alternate contraction and relaxtation of the pubococcygeal muscles. - HESI HINT: 56 Normal Postpartum Assess for thromboembolism: examine legs of postpartum client daily for pain, warmth, and tenderness or a swollen vein that is tender to the touch - HESI HINT: 57 Normal Postpartum Remember RhoGAM is given to an Rh-negative mother who delivers an Rh-positive fetus and has a negative direct Coombs test. If the mother has positive Coombs test, there is no need to give RhoGAM because the mother is already sensitized - HESI HINT: 58 Normal Postpartum Because Rh immune globulins suppress the immune system, the client who receives both RhoGAM and the rubella vaccine should be tested for rubella immunity at 3 months - HESI HINT: 59 Normal Postpartum "Postpartum blues"are usually normal, especially 5 to 7 days after delivery (unexplained tearfulness, feeling down, and having decreased appetite) Encourage use of support persons to help with housework for first 2 postpartum weeks. Refer to community resources. - HESI HINT: 60 Normal Postpartum Continues...