SWIFTRIVER MATERNITY COMPREHENSIVE
QUESTIONS AND ANSWERS SURE A+
✔✔Maria Sanchez, 20-year-old female, G1 P1 L1, 39 weeks gestation. Pregnancy
uncomplicated. O+, Rubella immune, Group B Strep negative. NKDA. 12-hour 1st
stage, 1 hour 2nd stage, 10 minute 3rd stage. Spontaneous vaginal delivery with 1st
degree perineal laceration one hour ago. Vital signs stable; fundus firm, midline, at
umbilicus; Lochia rubra moderate, no clots; Up to bathroom x1- 500 mL, no dysuria,
instructed on peri-care; Legs still a little "tingly" but able to bear weight with assist X2.
Pain level 3/10- ice to perineum with relief. Neonate male- Juan- 3500 g; Apgar 8 & 9; T
36.8 C, 98.2 F; AP 156 beats/minute, regular; R 52 breaths/minute, irregular. Skin-to-
skin with mother for first hour. Beginning to show hunger cues. Their plan is do both
breast and bottle feeding; "las dos cosas." Maria's husband Raul is a quiet presence.
Her mother, grandmother, and older sister were Maria's support persons in labor. Mar -
✔✔Safety:
Fall Risk- True
Injury, risk for maternal- True
Physiological:
Acute Pain- True
Chronic Pain-False
Ineffective breastfeeding, risk for- True
Infection, risk for-True
Love and Belonging:
Anxiety- False
Deficient Knowledge- True
Readiness for Enhanced Parenting- True
✔✔Clara Guidry, Scenerio 1 - ✔✔1. Assist mother to unlatch infant from breast and
place infant in crib or hand to the husband.
2.Massage uterine fundus. Massaging the fundus until firm and tightly contracted closes
off blood vessels at the placental site and stops bleeding
, 3.Call for help using emergency call system.
4.Set oxytocin rate to Bolus on IV pump as ordered by healthcare provider.
5. Assess bladder status and need to perform straight catheter.
✔✔Clara Guidry, Scenario 2 - ✔✔1. Educate patient regarding indwelling urinary
catheter placement, Wash hands.
2 .Insert indwelling urinary catheter and connect to collection bag, secure to patient's
thigh.
3. Measure urine return in collection bag; Reassess uterine tone, response to massage,
level in relation to umbilicus, and position in abdomen.
4. Reassess vaginal bleeding and presence for clots; change under pads as needed.
5. Wash hands, document findings and completion of procedure.
✔✔Clara Guidry Scenario 3 - ✔✔1. Reassess vital signs.
2. Set plain Lactated Ringers to Bolus rate on IV pump.
3. Administer Methergine 0.2 mg IM per healthcare provider order.
4. Assist healthcare provider with exam to assess for cervical or vaginal
lacerations/hematoma or retained placental pieces.
5. Anticipate laboratory studies: CBC, blood typing and crossmatch, coagulation
studies.
✔✔Clara Guidry Scenario 4 - ✔✔1. Administer Oxygen via nonrebreather face mask at
10-12L/min
2.Assist healthcare provider with administration of misoprostol (Cytotec) 1000 mcg
rectally
3. Establish an additional IV line and anticipate additional crystalloids (Lactated
Ringer's), colloids (albumin), blood and blood products
4. Continue to closely monitor vital signs, uterine fundus tone/level and vaginal bleeding
5. Anticipate healthcare provider insertion of postpartum balloon and/or return to
operating room
✔✔Clara Guidry Scenario 5 - ✔✔1. Use therapeutic communication/active listening to
assess patient's concerns and interest in pumping for colostrum
2. Consult Lactation Consultant or provide education to patient and assist with pumping.
3. Discuss with patient's partner for willingness/interest to feed baby colostrum.
4. Assist partner in feeding pumped colostrum and partner skin-to-skin contact.
5. Assess patient's ability to hold infant and assist patient with holding baby skin-to-skin
after feeding for maternal-infant bonding.
✔✔Jenny Theriot, Scenario 1. You enter the patient's room. After washing and gloving
your hands, you identify yourself and the patient, Mrs. Jenny Theriot. You assist her to
change into a gown and place her on a triage stretcher in semi-Fowler's position.
SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY
SHOULD BE IMPLEMENTED: - ✔✔1. Establish therapeutic communication
2.Assess Vital Signs
3. Perform Leopold's
QUESTIONS AND ANSWERS SURE A+
✔✔Maria Sanchez, 20-year-old female, G1 P1 L1, 39 weeks gestation. Pregnancy
uncomplicated. O+, Rubella immune, Group B Strep negative. NKDA. 12-hour 1st
stage, 1 hour 2nd stage, 10 minute 3rd stage. Spontaneous vaginal delivery with 1st
degree perineal laceration one hour ago. Vital signs stable; fundus firm, midline, at
umbilicus; Lochia rubra moderate, no clots; Up to bathroom x1- 500 mL, no dysuria,
instructed on peri-care; Legs still a little "tingly" but able to bear weight with assist X2.
Pain level 3/10- ice to perineum with relief. Neonate male- Juan- 3500 g; Apgar 8 & 9; T
36.8 C, 98.2 F; AP 156 beats/minute, regular; R 52 breaths/minute, irregular. Skin-to-
skin with mother for first hour. Beginning to show hunger cues. Their plan is do both
breast and bottle feeding; "las dos cosas." Maria's husband Raul is a quiet presence.
Her mother, grandmother, and older sister were Maria's support persons in labor. Mar -
✔✔Safety:
Fall Risk- True
Injury, risk for maternal- True
Physiological:
Acute Pain- True
Chronic Pain-False
Ineffective breastfeeding, risk for- True
Infection, risk for-True
Love and Belonging:
Anxiety- False
Deficient Knowledge- True
Readiness for Enhanced Parenting- True
✔✔Clara Guidry, Scenerio 1 - ✔✔1. Assist mother to unlatch infant from breast and
place infant in crib or hand to the husband.
2.Massage uterine fundus. Massaging the fundus until firm and tightly contracted closes
off blood vessels at the placental site and stops bleeding
, 3.Call for help using emergency call system.
4.Set oxytocin rate to Bolus on IV pump as ordered by healthcare provider.
5. Assess bladder status and need to perform straight catheter.
✔✔Clara Guidry, Scenario 2 - ✔✔1. Educate patient regarding indwelling urinary
catheter placement, Wash hands.
2 .Insert indwelling urinary catheter and connect to collection bag, secure to patient's
thigh.
3. Measure urine return in collection bag; Reassess uterine tone, response to massage,
level in relation to umbilicus, and position in abdomen.
4. Reassess vaginal bleeding and presence for clots; change under pads as needed.
5. Wash hands, document findings and completion of procedure.
✔✔Clara Guidry Scenario 3 - ✔✔1. Reassess vital signs.
2. Set plain Lactated Ringers to Bolus rate on IV pump.
3. Administer Methergine 0.2 mg IM per healthcare provider order.
4. Assist healthcare provider with exam to assess for cervical or vaginal
lacerations/hematoma or retained placental pieces.
5. Anticipate laboratory studies: CBC, blood typing and crossmatch, coagulation
studies.
✔✔Clara Guidry Scenario 4 - ✔✔1. Administer Oxygen via nonrebreather face mask at
10-12L/min
2.Assist healthcare provider with administration of misoprostol (Cytotec) 1000 mcg
rectally
3. Establish an additional IV line and anticipate additional crystalloids (Lactated
Ringer's), colloids (albumin), blood and blood products
4. Continue to closely monitor vital signs, uterine fundus tone/level and vaginal bleeding
5. Anticipate healthcare provider insertion of postpartum balloon and/or return to
operating room
✔✔Clara Guidry Scenario 5 - ✔✔1. Use therapeutic communication/active listening to
assess patient's concerns and interest in pumping for colostrum
2. Consult Lactation Consultant or provide education to patient and assist with pumping.
3. Discuss with patient's partner for willingness/interest to feed baby colostrum.
4. Assist partner in feeding pumped colostrum and partner skin-to-skin contact.
5. Assess patient's ability to hold infant and assist patient with holding baby skin-to-skin
after feeding for maternal-infant bonding.
✔✔Jenny Theriot, Scenario 1. You enter the patient's room. After washing and gloving
your hands, you identify yourself and the patient, Mrs. Jenny Theriot. You assist her to
change into a gown and place her on a triage stretcher in semi-Fowler's position.
SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY
SHOULD BE IMPLEMENTED: - ✔✔1. Establish therapeutic communication
2.Assess Vital Signs
3. Perform Leopold's
