lOMoARcPSD|46354221
NR 327 Exam 2 Review - NR 327 exam 2 study guide
Maternal-Child Nursing (Chamberlain University)
, lOMoARcPSD|46354221
NR 327
Exam 2 Content Review Sheet
Textbook Chapters: 14, 17, 19, 20, 21, 22
ATI Chapters: 17, 18, 19, 22, 23, 24, 25, 26
****Not all inclusive****
Fetal Heart Monitor (distress, interventions) & FHM Strips
Normal FHR: 110-160
Accelerations:
o Temporary increase
o Reassuring no interventions
Early deceleration: mirror mom’s contractions
o Cause: compression of baby’s head on pelvis/soft tissue
o Normal – no interventions, expected finding
Late deceleration: responds after contraction
o Cause: uteroplacental insufficiency
o Non-reassuring needs intervention
o Nursing interventions: side-lying position, IV fluids, discontinue oxytocin,
administer O2, palpate uterus for tachysystole (more frequent intense
contractions), notify provider
Variable deceleration: not uniform look for Vs
o Cause: cord compression
o Requires intervention
o Nursing interventions: knee-chest position or side-side repositioning, discontinue
oxytocin, administer O2, notify provider
REMEMBER VEAL CHOP MINE
V – variable C – cord compression M – move side left
E – early decels H – head compression I – identify labor progression
A – acceleration O – OK N – no intervention
L – late decels P – placental insufficiency E – execute immediately STOP = stop
Pitocin, turn patient on side, O2 via face mask, plain IV fluid increased
Fetal bradycardia: FHR drops below 110 for at least 10 minutes
o Causes: uteroplacental insufficiency, umbilical cord prolapses, maternal
hypotension, anesthetic meds mom received
o Interventions: stop oxytocin, left side position, O2, notify provider
Fetal tachycardia: FHR increases above 160 for over 10 minutes
o Causes: infection, cocaine use, dehydration
, lOMoARcPSD|46354221
o Interventions: antipyretics, oxygen, IV fluid bolus
The contractions:
o Increment: beginning, building of pressure
o Acme: most intense part of the contraction
o Decrement: diminishing of the contraction
o Rest: period of time between contractions
BUBBLE HER
Breasts:
o Inspect for size, contour, asymmetry, engorgement, or erythema
o Check the nipples for cracks, redness, fissures, or bleeding
Note if they are erect, flat, or inverted
Uterus:
o Assess the fundus to determine the degree of uterine involution
Have the woman empty her bladder first before assessing the fundus
o Fundus should be midline and should not feel boggy or relaxed
o 1-2 hours after birth, the fundus is between the umbilicus & the symphysis pubis
o 6-12 hours birth, the fundus is usually at the level of the umbilicus
o The fundus progresses downward at a rate of 1 fingerbreadth or 1 cm per day after
childbirth
o On the first postpartum day, the top of the fundus is located 1 cm below the
umbilicus and is recorded as U/1
o If the fundus is NOT firm, then gently massage the uterus using a circular motion
until it becomes firm
Bladder:
o Assess the bladder for distention & adequate emptying after efforts to void
NR 327 Exam 2 Review - NR 327 exam 2 study guide
Maternal-Child Nursing (Chamberlain University)
, lOMoARcPSD|46354221
NR 327
Exam 2 Content Review Sheet
Textbook Chapters: 14, 17, 19, 20, 21, 22
ATI Chapters: 17, 18, 19, 22, 23, 24, 25, 26
****Not all inclusive****
Fetal Heart Monitor (distress, interventions) & FHM Strips
Normal FHR: 110-160
Accelerations:
o Temporary increase
o Reassuring no interventions
Early deceleration: mirror mom’s contractions
o Cause: compression of baby’s head on pelvis/soft tissue
o Normal – no interventions, expected finding
Late deceleration: responds after contraction
o Cause: uteroplacental insufficiency
o Non-reassuring needs intervention
o Nursing interventions: side-lying position, IV fluids, discontinue oxytocin,
administer O2, palpate uterus for tachysystole (more frequent intense
contractions), notify provider
Variable deceleration: not uniform look for Vs
o Cause: cord compression
o Requires intervention
o Nursing interventions: knee-chest position or side-side repositioning, discontinue
oxytocin, administer O2, notify provider
REMEMBER VEAL CHOP MINE
V – variable C – cord compression M – move side left
E – early decels H – head compression I – identify labor progression
A – acceleration O – OK N – no intervention
L – late decels P – placental insufficiency E – execute immediately STOP = stop
Pitocin, turn patient on side, O2 via face mask, plain IV fluid increased
Fetal bradycardia: FHR drops below 110 for at least 10 minutes
o Causes: uteroplacental insufficiency, umbilical cord prolapses, maternal
hypotension, anesthetic meds mom received
o Interventions: stop oxytocin, left side position, O2, notify provider
Fetal tachycardia: FHR increases above 160 for over 10 minutes
o Causes: infection, cocaine use, dehydration
, lOMoARcPSD|46354221
o Interventions: antipyretics, oxygen, IV fluid bolus
The contractions:
o Increment: beginning, building of pressure
o Acme: most intense part of the contraction
o Decrement: diminishing of the contraction
o Rest: period of time between contractions
BUBBLE HER
Breasts:
o Inspect for size, contour, asymmetry, engorgement, or erythema
o Check the nipples for cracks, redness, fissures, or bleeding
Note if they are erect, flat, or inverted
Uterus:
o Assess the fundus to determine the degree of uterine involution
Have the woman empty her bladder first before assessing the fundus
o Fundus should be midline and should not feel boggy or relaxed
o 1-2 hours after birth, the fundus is between the umbilicus & the symphysis pubis
o 6-12 hours birth, the fundus is usually at the level of the umbilicus
o The fundus progresses downward at a rate of 1 fingerbreadth or 1 cm per day after
childbirth
o On the first postpartum day, the top of the fundus is located 1 cm below the
umbilicus and is recorded as U/1
o If the fundus is NOT firm, then gently massage the uterus using a circular motion
until it becomes firm
Bladder:
o Assess the bladder for distention & adequate emptying after efforts to void
