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NCLEX - Maternity

NCLEX Review - Maternity

State the objective signs that signify ovulation. Abundant, thin, clear cervical mucus; spinnbarkeit (egg-white stretchiness) of cervical mucus; open cervical os; slight drop in basal body temperature and then 0.5° to 1° F rise; ferning under the microscope
Ovulation occurs how many days before the next menstrual period? 14 days
State three ways to identify the chronological age of a pregnancy (gestation). 10 lunar months; 9 calendar months consisting of three trimesters of 3 months each; 40 weeks; 280 days
What maternal position provides optimum fetal and placental perfusion during pregnancy? The knee-chest position, but the ideal position of comfort for the mother, which supports fetal, maternal, and placental perfusion, is the side-lying position (removes pressure from the abdominal vessels [vena cava, aorta]).
Name the major discomforts of the first trimester and one suggestion for amelioration of each. Nausea and vomiting: crackers before rising; fatigue: rest periods and naps and 7 to 8 hours of sleep at night
If the first day of a woman’s last normal menstrual period was May 28, what is the EDB using the Nägele rule? Count back 3 months and add 7 days: March 7 (always give February 28 days).
At 20 weeks’ gestation, the fundal height would be _____; the fetus would weigh approximately _____ and would look like _____. At the umbilicus; 300 to 400 g; a baby—with hair, lanugo, and vernix, but without any subcutaneous fat
State the normal psychosocial responses to pregnancy in the second trimester. Ambivalence wanes and acceptance of pregnancy occurs; pregnancy becomes “real”; signs of maternal–fetal bonding occur.
The hemodilution of pregnancy peaks at _____ weeks and results in a(n) _____ in a woman’s Hct. 28 to 32 weeks; decrease
State three principles relative to the pattern of weight gain in pregnancy. Total gain should average 25 to 35 lb. Gain should be consistent throughout pregnancy. An average of 1 lb/week should be gained in the second and third trimesters.
During pregnancy a woman should add _____ calories to her diet and drink _____ of milk per day. 300; 3 cups
FHR can be auscultated by Doppler at _____ weeks’ gestation. 10 to 12
Describe the schedule of prenatal visits for a low-risk pregnant woman. Once every 4 weeks until 28 weeks; every 2 weeks from 28 to 36 weeks; then once a week until delivery
Name five maternal variables associated with diagnosis of a high-risk pregnancy. Age (under 17 or over 34 years of age); parity (over 5); <3 months between pregnancies; diagnosis of preeclampsia, diabetes mellitus, or cardiac disease
Is one ultrasound examination useful in determining the presence of IUGR? No. Serial measurements are needed to determine IUGR.
What does the BPP determine? Fetal well-being
List three necessary nursing actions prior to an ultrasound examination for a woman in the first trimester of pregnancy. Have client fill bladder. Do not allow client to void. Position client supine and with uterine wedge.
State the advantage of CVS over amniocentesis. Can be done between 8 and 12 weeks’ gestation, with results returned within 1 week, which allows for decision about termination while still in first trimester.
Why are serum or amniotic AFP levels done prenatally? To determine whether AFP levels are elevated, which may indicate the presence of neural tube defects; or whether they are low, which may indicate trisomy 21.
What is the most important determinant of fetal maturity for extrauterine survival? L/S ratio (lung maturity, lung surfactant development)
Name the three most common complications of amniocentesis. Spontaneous abortion, fetal injury, infection
Name the four periodic changes of the FHR Accelerations
Accelerations cause and nursing interventions caused by a burst of sympathetic activity; they are reassuring and require no treatment.
Early decelerations cause and nursing interventions caused by head compression; they are benign and alert the nurse to monitor for labor progress and fetal descent.
Variable decelerations cause and nursing interventions caused by cord compression; change of position should be tried first.
Late decelerations cause and nursing interventions caused by UPI and should be treated by placing client on her side and administering oxygen.
What is the most important indicator of fetal autonomic nervous system integrity and health? FHR variability
Name four causes of decreased FHR variability. Hypoxia, acidosis, drugs, fetal sleep
State the most important action to take when a cord prolapse is determined. Examiner should position mother to relieve pressure on the cord or push the presenting part off the cord with fingers until emergency delivery is accomplished.
What is a reactive nonstress test? FHR acceleration of 15 bpm for 15 seconds in response to fetal movement
What are the dangers of the nipple-stimulation stress test? The inability to control oxytocin “dosage” and the chance of tetany/hyperstimulation
Normal fetal scalp pH in labor is _____, and values below _____ indicate true acidosis 7.25 to 7.35; 7.2
List five prodromal signs of labor the nurse might teach the client. Lightening, Braxton Hicks contractions, increased bloody show, loss of mucous plug, burst of energy, and nesting behaviors.
How is true labor discriminated from false labor? True labor: regular, rhythmic contractions that intensify with ambulation, pain in the abdomen sweeping around from the back, and cervical changes; False labor: irregular rhythm, abdominal pain (not in back) that decreases with ambulation
State two ways to determine whether the membranes have truly ruptured. Nitrazine testing: Paper turns dark blue or black; Demonstration of fluid ferning under microscope
Are psychoprophylactic breathing techniques prescribed for use according to the stage and phase of labor? No. Clients should use these techniques according to their discomfort level and should change techniques when one is no longer working for relaxation.
Identify two reasons to withhold anesthesia and analgesia until the midactive phase of stage I labor. If analgesia and anesthesia are given too early, they can retard labor; if given too late, they can cause fetal distress.
Hyperventilation often occurs in the laboring client. What results from hyperventilation, and what actions should the nurse take to relieve the condition? Respiratory alkalosis occurs; it is caused by blowing off CO2 and is relieved by breathing into a paper bag or cupped hands.
Describe the maternal changes that characterize the transition phase of labor. Irritability and unwillingness to be touched, but does not want to be left alone; nausea, vomiting, and hiccupping
When should a laboring client be examined vaginally? Vaginal examinations should be done prior to analgesia and anesthesia to rule out cord prolapse, to determine labor progress if it is questioned, and to determine when pushing can begin.
Define cervical effacement. The taking up of the lower cervical segment into the upper segment; the shortening of the cervix expressed in percentages from 0% to 100%, or complete effacement.
Where is the FHR best heard? Through the fetal back in vertex, OA positions
Normal FHR during labor is _____. 110 to l60 bpm
Normal maternal BP during labor is _____. <140/90
Normal maternal pulse during labor is _____. <100 bpm
Normal maternal temperature during labor is _____. <100.4° F
List four nursing actions for the second stage of labor. Make sure cervix is completely dilated before pushing is allowed. Assess FHR with each contraction. Teach woman to hold breath for no longer than 10 seconds. Teach pushing technique.
List three signs of placental separation. Gush of blood, lengthening of cord, and globular shape of uterus
When should the postpartum dosage of oxytocin (Pitocin) be administered? Why is it administered? Give immediately after placenta is delivered to prevent postpartum hemorrhage and atony.
State one contraindication to the use of ergot drugs (Methergine). Hypertension
State five symptoms of respiratory distress in the newborn. Tachypnea, dusky color, flaring nares, retractions, and grunting
If meconium was passed in utero, what action must the nurse take in the delivery room? Arrange for immediate endotracheal tube observation to determine the presence of meconium below the vocal cords (prevents pneumonitis and meconium aspiration syndrome).
What is considered a good Apgar score? 7 to 10
What is the purpose of eye prophylaxis in the newborn? To prevent ophthalmia neonatorum, which results from exposure to gonorrhea in the vagina
What is the danger associated with regional blocks? Hypotension resulting from vasodilatation below the block, which pools blood in the periphery, reducing venous return
What is the major cause of maternal death when general anesthesia is administered? Aspiration of gastric contents
Why are PO medications avoided in labor? Gastric activity slows or stops in labor, decreasing absorption from PO route; it may cause vomiting.
State the best way to administer IV drugs during labor. At beginning of contraction, push a little medication in while uterine blood vessels are constricted, thereby reducing dose to fetus.
When is it dangerous to administer butorphanol (Stadol), an agonist/antagonist narcotic? When the client is an undiagnosed drug abuser of narcotics, it can cause immediate withdrawal symptoms.
Hypotension commonly occurs after the laboring client receives a regional block. What is one of the first signs the nurse might observe? Nausea
State three actions the nurse should take when hypotension occurs in a laboring client. Turn client to left side. Administer O2 by mask at 10 L/min. Increase speed of intravenous infusion (if it does not contain medication).
How is the fourth stage of labor defined? The first 1 to 4 hours after delivery of placenta
What actions can the nurse take to assist in preventing postpartum hemorrhage? Massage the fundus (gently) and keep the bladder emptied.
To promote comfort, what nursing interventions are used for a third-degree episiotomy that extends into the anal sphincter? Ice pack, witch hazel compresses, and no rectal manipulation
What nursing interventions are used to enhance maternal–infant bonding during the fourth stage of labor? Withhold eye prophylaxis for up to 1 hour. Perform newborn admission and routine procedures in room with parents. Encourage early initiation of breastfeeding. Darken room to encourage newborn to open eyes.
List three nursing interventions to ease the discomfort of afterpains. Keep bladder empty. Provide a warm blanket for abdomen. Administer analgesics prescribed by health care provider.
List the symptoms of a full bladder that might occur in the fourth stage of labor. Fundus above umbilicus, dextroverted (to the right side of abdomen), increased bleeding (uterine atony)
What action should the nurse take first when a soft, boggy uterus is palpated? Perform fundal massage.
What are the symptoms of hypovolemic shock? Pallor, clammy skin, tachycardia, lightheadedness, and hypotension
How often should the nurse check the fundus during the fourth stage of labor? Every l5 minutes for 1 hour; every 30 minutes for 2 hours if normal
A nurse discovers a postpartum client with a boggy uterus that is displaced above and to the right of the umbilicus. What nursing action is indicated? Perform immediate fundal massage. Ambulate to the bathroom or use bedpan to empty bladder because cardinal signs of bladder distention are present.
Which women experience afterpains more than others? Breastfeeding women, multiparas, and women who experienced overdistention of the uterus
Upon admission to the postpartum room, 3 hours after delivery, a client has a temperature of 99.5° F. What nursing actions are indicated? Temperature is probably elevated due to dehydration and work of labor; force fluids and retake temperature in an hour; notify physician if above 100.4° F.
A client feels faint on the way to the bathroom. What nursing assessments should be made? Assess BP sitting and lying; assess Hgb and Hct for anemia
What factor places the postpartum client at risk for thromboembolism? Increased clotting factors
A breastfeeding mother complains of very tender nipples. What nursing actions should be taken? Have her demonstrate infant position on breast (incorrect positioning often causes tenderness). Leave bra open to air-dry nipples for 15 minutes three times daily. Express colostrum and rub on nipples.
Three days postpartum, a lactating mother has full, warm, taut, tender breasts. What nursing actions should be taken? She is engorged; have newborn suckle frequently; take measures to increase milk flow: warm water, breast massage, and supportive bra.
What information should be given to a client regarding resumption of sexual intercourse after delivery? Avoid until postpartum examination. Use water-soluble jelly. Expect slight discomfort due to vaginal changes.
A woman has decided to take birth control pills as her contraceptive method. What should she do if she misses taking the pill for 2 consecutive days? Take two pills for 2 days and use an alternative form of birth control
A woman asks why she is urinating so much in the postpartum period. The nurse bases the response on what information? Up to 3000 mL per day can be voided because of the reduction in the 40% plasma volume increase during pregnancy.
A woman’s white blood count is 17,000; she is afebrile and has no symptoms of infection. What nursing action is indicated? Continue routine assessments; normal leukocytosis occurs during postpartal period because of placental site healing.
What is the most common cause of uterine atony in the first 24 hours postpartum? A full bladder
What is the purpose of giving docusate sodium (Colace) to the postpartum client? To soften the stool in mothers with third- or fourth-degree episiotomies, hemorrhoids, or cesarean section delivery.
What should the fundal height be at 3 days postpartum for a woman who has had a vaginal delivery? Three fingerbreadths/cm below the umbilicus.
List three signs of positive bonding between parents and newborn. Calling infant by name, exploring newborn head to toe, using en face position.
The newborn transitional period consists of the first _____ of life. 6 to 8 hours
The nurse anticipates which newborns will be at greater risk for problems in the transitional period. State three factors that predispose to respiratory depression in the newborn. Cesarean section delivery; magnesium sulfate given to mother in labor; asphyxia or fetal distress during labor
What is the danger to the newborn of heat loss in the first few hours of life? It leads to depletion of glucose (there is very little glycogen storage in immature liver); body begins to use brown fat for energy, producing ketones and causing subsequent ketoacidosis and shock.
Normal newborn temperature is _____. 97.7° to 99.4° F
Normal newborn heart rate is _____. 110 to 160 bpm
Normal newborn respiratory rate is ___. 30 to 60
Normal newborn blood pressure is ____. 80/50
The nurse records a temperature below 97° F on admission of the newborn. What nursing actions should be taken? Place newborn in isolette or under radiant warmer and attach a temperature skin probe to regulate temperature. Double-wrap newborn if no isolette or warmer is available, and put cap on head. Watch for signs of hypothermia and hypoglycemia.
True or False: The newborn’s head is usually smaller than the chest. False: The head is usually 2 cm larger unless severe molding occurred.
During the physical examination of the newborn, the nurse notes the cry is shrill, high-pitched, and weak. What are the possible causes? CNS anomalies, brain damage, hypoglycemia, drug withdrawal
The nurse notes a swelling over the back part of the newborn’s head. Is this a normal newborn variation? It depends. If it crosses suture lines and is a caput (edema), it is normal. If it does not cross suture lines, it is a cephalohematoma with bleeding between the skull and periosteum. This could cause hyperbilirubinemia. This is an abnormal variation.
What symptoms are common to most newborns with Down syndrome? Low-set ears, simian crease on palm, protruding tongue, Brushfield spots in iris, epicanthal folds
Identify three ways to determine the presence of congenital hip dislocation in the newborn. Hip click determination, asymmetric gluteal folds, unequal limb lengths
Should the normal newborn have a positive or negative Babinski reflex? Positive; the transient reflex is present until 12 to 18 months of age.
A small-for-gestational-age newborn is identified as one who _____. Has a weight below the tenth percentile for estimated weeks of gestation.
When suctioning the newborn with a bulb syringe, which should be suctioned first, the mouth or the nose? The mouth; stimulating the nares can initiate inspiration, which could cause aspiration of mucus in oral pharynx.
A new mother asks the nurse whether circumcision is medically indicated in the newborn. How should the nurse respond? There is controversy concerning this issue, but we do know it causes pain and trauma to the newborn, and the medical indications (prevention of penile and cervical cancer) may be unfounded.
Normal blood glucose in the term neonate is _____. 40 to 80 mg/dL
Why does the newborn need vitamin K in the first hour after birth? The sterile gut at delivery lacks intestinal bacteria necessary for the synthesis of vitamin K; vitamin K is needed in the clotting cascade to prevent hemorrhagic disorders.
Physiologic jaundice in the newborn occurs _____. It is caused by _____. Jaundice occurs at 2 to 3 days of life and is caused by immature liver’s inability to keep up with the bilirubin production resulting from normal RBC destruction.
When is the screening test for PKU done? At 2 to 3 days of life, or after enough breast milk or formula, usually after 24 hours, is ingested to allow for determination of body’s ability to metabolize amino acid phenylalanine.
A term newborn needs to take in _____ calories per pound per day. After the initial weight loss is sustained, the newborn should gain _____ per day. 50; 1 oz, or 30 g
List five signs and symptoms new parents should be taught to report immediately to a doctor or clinic. Lethargy, temperature >100° F, vomiting, green stools, refusal of two feeds in a row
What instructions should the nurse give the woman with a threatened abortion? Maintain strict bed rest for 24 to 48 hours. Avoid sexual intercourse for 2 weeks.
Identify the nursing plans and interventions for a woman hospitalized with hyperemesis gravidarum. Weigh daily; check urine ketone three times daily; give progressive diet; check FHR every 8 hours; monitor for electrolyte imbalances.
Describe discharge counseling for a woman after hydatidiform mole evacuation by D&C. Prevent pregnancy for 1 year. Return to clinic or MD for monthly hCG levels for 1 year. Postoperative D&C instructions: Call if bright-red vaginal bleeding or foul-smelling vaginal discharge occurs or temperature spikes over 100.4° F.
What condition should the nurse suspect if a woman of childbearing age presents to an emergency room with bilateral or unilateral abdominal pain, with or without bleeding? Ectopic pregnancy
List three symptoms of abruptio placentae and three symptoms of placenta previa. Abruptio placentae: fetal distress; rigid, boardlike abdomen; pain; dark-red or absent bleeding; Previa: pain-free; bright-red vaginal bleeding; normal FHR; soft uterus
What specific information should the nurse include when teaching about HPV detection and treatment? Detection of dry, wartlike growths on vulva or rectum. Treatment with laser ablation (cannot use podophyllin during pregnancy). Associated with cervical carcinoma in mother and respiratory papillomatosis in neonate.
State three principles pertinent to counseling and teaching a pregnant adolescent. Nurse must establish trust and rapport before counseling and teaching begin. Adolescents do not respond to an authoritarian approach. Consider the developmental tasks of identity and social and individual intimacy.
What complications are pregnant adolescents particularly prone to develop? Preeclampsia, IUGR, CPD, STDs, anemia
All pregnant women should be taught preterm labor recognition. Describe the warning symptoms of preterm labor. More than five contractions per hour; cramps; low, dull backache; pelvic pressure; change in vaginal discharge
List the factors predisposing a woman to preterm labor. Urinary tract infection; overdistention of uterus; diabetes; preeclampsia; cardiac disease; placenta previa, psychosocial factors such as stress
When is preterm labor able to be arrested? Cervix is <4 cm dilated, <50% effacement, and membranes are intact and not bulging out of the cervical os.
What is the major side effect of beta-adrenergic tocolytic drugs (Terbutaline)? Tachycardia
What special actions should the nurse take during the intrapartum period if preterm labor is unable to be arrested? Monitor the FHR continuously and limit drugs that cross placental barriers so as to prevent fetal depression or further compromise.
A prolonged latent phase for a multipara is _____ and for a nullipara is _____. Multiparas’ average cervical dilatation is _____ cm/hr in the active phase, and nulliparas’ average cervical dilatation is _____ cm/hr in the active phase. 14 hours, >20 hours, 1.5, 1.2
What are the major goals of nursing care related to pregnancy-induced hypertension with preeclampsia? Maintenance of uteroplacental perfusion; prevention of seizures; prevention of complications such as HELLP syndrome, DIC, and abruption
What is the purpose of administering magnesium sulfate? To prevent seizures by decreasing CNS irritability
What is the main action of magnesium sulfate? CNS depression (seizure prevention)
What is the antidote for magnesium sulfate? Calcium gluconate
List the three main assessment findings indicating toxic effects of magnesium sulfate. Reduced urinary output, reduced respiratory rate, and decreased reflexes
What are the major symptoms of preeclampsia? Increase in BP of 30 mm Hg systolic and 15 mm Hg diastolic over previous baseline; proteinuria (albuminuria); CNS disturbances
What is the priority nursing action after spontaneous or AROM? Assessment of the FHR
What is the most common complication of oxytocin augmentation or induction of labor? List three actions the nurse should take if such a complication occurs. Tetany. Turn off Pitocin. Turn pregnant woman onto side. Administer O2 by mask.
List the symptoms of water intoxication resulting from the effect of Pitocin (oxytocin) on the antidiuretic hormone (ADH). Nausea and vomiting, headache, and hypotension
State three nursing interventions during forceps delivery. Ensure empty bladder. Auscultate FHR before application, during process, and between traction periods. Observe for maternal lacerations and newborn cerebral or facial trauma.
What is the cause of preeclampsia? the underlying pathophysiology appears to be generalized vasospasm with increased peripheral resistance and vascular damage. This decreased perfusion results in damage to numerous organs.
What interventions should the nurse implement to prevent further CNS irritability in the preeclampsia client? Darken room, limit visitors, maintain close 1:1 nurse-to-client ratio, place in private room, plan nursing interventions all at the same time so client is disturbed as little as possible.
A woman on Orinase (oral hypoglycemic) asks the nurse if she can continue this medication during pregnancy. How should the nurse respond? No. Oral hypoglycemic medications are teratogenic to the fetus. Insulin will be used.
Name three maternal and three fetal complications of gestational diabetes. Maternal: hypoglycemia, hyperglycemia, ketoacidosis; Fetal: macrosomia, hypoglycemia at birth, fetal anomalies
When should the nurse hold the dose of magnesium sulfate and call the physician? When the client’s respirations are <12/min, DTRs are absent, or urinary output is <100 mL/4 hr
State three priority nursing actions in the postdelivery period for the client with preeclampsia. Monitor for signs of blood loss. Continue to assess BP and DTRs every 4 hours. Monitor for uterine atony.
What are the two most difficult times for control in the pregnant diabetic? Late in the third trimester and in the postpartum period, when insulin needs drop sharply (the diabetogenic effects of pregnancy drop precipitously)
Why is regular insulin used in labor? It is short-acting, predictable, can be infused intravenously, and can be discontinued quickly if necessary
List three conditions clients with diabetes mellitus are more prone to develop. Preeclampsia, hydramnios, infection
When is cardiac disease in pregnancy most dangerous? At peak plasma volume increase, between 28 and 32 weeks’ gestation, and during stage II labor
Does insulin cross the placenta-breast barrier? No. Therefore, insulin-dependent women may breastfeed.
The goal for diabetic management during labor is euglycemia. How is it defined? 70 to 90 mg/dL
What contraceptive technique is recommended for diabetic women? Diaphragm with spermicide; clients should avoid birth control pills, which contain estrogen, and IUDs, which are an infection risk.
List the symptoms of cardiac decompensation in a laboring client with cardiac disease. Tachycardia, tachypnea, dry cough, rales in lung bases, dyspnea, and orthopnea
What interventions can the nurse implement to maintain cardiac perfusion in a laboring cardiac client? Position client in a semi- or high Fowler position. Prevent Valsalva maneuvers. Position client in a side-lying position for regional anesthesia. Avoid stirrups because of possible popliteal vein compression and decreased venous return.
Gentle counterpressure against the perineum during an emergency delivery prevents ____ and _____. Maternal lacerations, fetal cerebral trauma
When may a VBAC be considered by a woman with a previous cesarean section? If a low uterine transverse incision was performed and can be documented and if the original complication does not recur, such as CPD
Prior to anesthesia for cesarean section delivery, the mother may be given an antacid or a gastric antisecretory drug (histamine receptor antagonist). State the reasons these drugs are given. Antacid buffers alkalize the stomach secretions. If aspiration occurs, less lung damage ensues. An antisecretory drug reduces gastric acid, reducing the risk for gastric aspiration.
Clients who have had a cesarean section are prone to what postoperative complications? Paralytic ileus, infection, thromboembolism, respiratory complications, and impaired maternal–infant bonding
May women with a positive HIV antibody try to breastfeed? No, HIV has been found in breast milk.
What are the common side effects of antibiotics used to treat puerperal infection? GI adverse reactions: nausea, vomiting, diarrhea, and cramping. Hypersensitivity reactions: rashes, urticaria, and hives
How does the nurse differentiate the symptomatology of cystitis from that of pyelonephritis? Pyelonephritis has the same symptoms as cystitis (dysuria, frequency, and urgency) with the addition of flank pain, fever, and pain at costovertebral angle.
What are the signs of endometritis? Subinvolution (boggy, high uterus); lochia returning to rubra with possible foul smell; temperature 100.4° F or higher; unusual fundal tenderness
What are the nursing actions for endometritis and parametritis? Measures to promote lochial drainage; antipyretic measures (acetaminophen, cool cloths); administration of analgesics and antibiotics as prescribed; increase of fluids, with attention to high-protein and high-vitamin C diet
State four risk factors for or predisposing factors to postpartum infection. Operative delivery, intrauterine manipulation, anemia or poor physical health, traumatic delivery, and hemorrhage
State four risk factors for or predisposing factors to postpartum hemorrhage. Dystocia or prolonged labor, overdistention of the uterus, abruptio placentae, and infection
What immediate nursing actions should be taken when a postpartum hemorrhage is detected? Fundal massage. Notify health care provider if massage does not firm fundus. Count pads to estimate blood loss. Assess and record vital signs. Increase IV fluids and administer oxytocin infusion as prescribed.
Must women diagnosed with mastitis stop breastfeeding? No, women who stop breastfeeding abruptly may make the worse by increasing congestion and engorgement and providing further media for bacterial growth. may have to discontinue breastfeeding if pus is present or antibiotics are contraindicated for neonate.
List the major CNS danger signals that occur in the neonate. Lethargy, high-pitched cry, jitteriness, seizures, and bulging fontanels
A baby is delivered blue, limp, and with a heart rate <100. The nurse dries the infant, suctions the oropharynx and gently stimulates the infant while blowing O2 over the face. The infant still does not respond. What is the next nursing action? Begin oxygenation by bag and mask at 30 to 50 breaths per minute. If heart rate is <60, start cardiac massage at 120 events per minute (30 breaths and 90 compressions). Assist health care provider in setting up for intubation procedure.
What does the Silverman-Anderson index measure? Respiratory difficulty
What are the two major complications of O2 toxicity? RLF and BPD
NEC results from _____ and is manifested by _____. Ischemia/hypoxia results in _____. Ischemic hypoxia, abdominal distention, sepsis, and a lack of absorption from intestines; injury to the intestinal mucosa
IVH is more common in _____ and results in symptoms of _____. Premature neonates and VLBW babies; increased ICP
What conditions make oxygenation of the newborn more difficult? RDS: alveolar prematurity and lack of surfactant; anemia; and polycythemia
In order to prevent problems with oxygenating the newborn, what parameters can the nurse observe? PO2 50 to 90; SvO2 60 to 80 mm Hg
What are the cardinal symptoms of sepsis in a newborn? Lethargy, temperature instability, difficulty feeding, subtle color changes, subtle behavioral changes, and hyperbilirubinemia
A premature baby is born and develops hypothermia. State the major nursing interventions to treat hypothermia. Place under radiant warmer or in incubator with temperature skin probe over liver. Warm all items touching newborn. Place plastic wrap over neonate.
Nurses often weigh diapers in order to determine exact urine output in the high-risk neonate. Explain this procedure. Diaper is weighed in grams before being applied to infant. Diaper is weighed after infant has wet it. Each gram of added weight is calculated and recorded as 1 mL of urine.
What factors does a nurse look for in determining a newborn’s ability to take in nourishment by nipple and mouth? Infant has good suck, has coordinated suck–swallow, takes less than 20 minutes to feed, gains 20 to 30 g/day.
What complications are associated with TPN? Hyperglycemia, electrolyte imbalance, dehydration, and infection
In order to prevent rickets in the preterm newborn, what supplements are given? Calcium and vitamin D
List four nursing interventions to enhance family and parent adjustment to a high-risk newborn. Initiate early visitation at ICU. Provide daily information to family. Encourage participation in support group for parents. Encourage all attempts at caregiving (enhances bonding).
List the risk factors for hyperbilirubinemia. Rh incompatibility, ABO incompatibility, prematurity, sepsis, perinatal asphyxia
List the symptoms of hyperbilirubinemia in the neonate. Bilirubin levels rising 5 mg/day, jaundice, dark urine, anemia, high reticulocyte (RBC) count, and dark stools
Write one nursing diagnosis generated from the data pertinent to hyperbilirubinemia. Risk for injury related to predisposition of bilirubin for fat cells in brain
List three nursing interventions for the neonate undergoing phototherapy. Apply opaque mask over eyes. Leave diaper loose so stools and urine can be monitored but cover genitalia. Turn every 2 hours. Watch for dehydration.
List the symptoms of neonatal narcotic withdrawal. Irritability, hyperactivity, high-pitched cry, frantic sucking, coarse flapping tremors, and poor feeding
Neonates who are “sick” are prone to receive too much stimulation in the form of invasive procedures and handling and too little developmentally appropriate stimulation and affection. How might such an infant respond? Failure to thrive, absence of crying
How should a nurse determine the length of a tube needed for the oral gavage feeding of a newborn? Measure from the bridge of the nose to the earlobe and then to a point halfway between the xiphoid and the umbilicus.
What are the two best ways to test for correct placement of the gavage tube in the infant’s stomach? Aspiration of stomach contents and pH testing; auscultation of an air bubble injected into the stomach
What characteristics would the nurse expect to see in a neonate with fetal alcohol syndrome? Microcephaly, strabismus, growth retardation, short palpebral fissures, maxillary hypoplasia, abnormal palmar creases, irregular hair, whorls, poor suck, cleft lip, cleft palate, small teeth
Created by: CocoDiva
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