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Maternity
| Question | Answer |
|---|---|
| The nurse assesses a pregnant patient and finds that the patient has reduced strength of uterine contractions (UCs). Upon further assessment, the nurse suspects that the patient may have slow progress in labor. Which statement made by the patient indicate | I am worried a lot this time, I had a rough labor the last time |
| After reviewing the urinalysis reports of a pregnant patient, the nurse finds that the patient has preeclampsia. What did the nurse find in the patient's urinalysis report? | Protein |
| A pregnant patient does not allow her partner to touch her and wants to be left alone. What can the nurse suggest to the patient's partner in this situation? | It's a common behavior during pregnancy |
| A pregnant patient does not allow her partner to touch her and wants to be left alone. What can the nurse suggest to the patient's partner in this situation? | Explain the needs, limit the number of invasive examinations, obtain the patient's permission to touch her |
| On interacting with the partner of a pregnant patient, the nurse suggests that the partner soothe the patient's forehead, palms of her hands, and soles of her feet. What patient observation could be the possible reason for such advice to the partner? | Hyperesthesia |
| While caring for a multiparous patient in the second stage of labor, the patient reports the urge to defecate. What is the best nursing intervention? | Assess cervical dilation and station of the patient |
| Upon reviewing the laboratory reports of a pregnant patient, the nurse reports to the primary health care provider (PHP) that the patient has impaired nutrition. Which finding enabled the nurse to conclude this | Presence of ketones in the patient's urine specimen |
| A patient sustained a first-degree laceration during childbirth. What physical finding should the nurse infer from this? The laceration: | Extends to the structures and skin superficial to the muscles |
| The nurse assesses a pregnant patient and finds that the patient has reduced strength of uterine contractions (UCs). Upon further assessment, the nurse suspects that the patient may have slow progress in labor. Which statement made by the patient indicate | I am worried a lot this time, I had a rough labor the last time |
| The primary health care provider (PHP) advised the nurse to assess the maternal temperature and vaginal discharge of a pregnant patient every 2 hours. What is the reason behind this advice? | To assess for potential risk for infection |
| The nurse is caring for a newly admitted nulliparous patient in the ninth month of pregnancy. What should the nurse do to provide effective care? | Explain the various labor stages to the patient |
| Which test is performed to determine if membranes are ruptured? | Fern Test |
| The nurse is caring for a pregnant patient. What interventions should the nurse follow to ensure proper hygiene in the patient? | Clean the perineum of the patient frequently. |
| A patient has been admitted to the labor room. What are the measures to be taken by the nurse to support the partner of the patient? Select all that apply. | Offer snacks and fluids to the partner as required.Demonstrate the performance of the comfort measures.Relieve the person occasionally from the job of supporting the patient. |
| Under which circumstances should a vaginal examination be performed by the nurse? Select all that apply. | An admission to the hospital at the start of laborOn maternal perception of perineal pressure or the urge to bear downWhen membranes rupture |
| After performing Leopold maneuvers, the nurse finds that the fetus of a pregnant patient is in occiput posterior position. Which suitable action should the nurse employ while caring for the patient? | Encourage the patient to sit in hands-and-knees position. |
| The nurse is caring for a Hispanic patient who has given birth to a baby. When does the nurse expect the patient to start breastfeeding? | When the milk comes |
| A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent's class. Which aspect of their birth plan is considered unrealistic and requires further discussion with the nurse? | "We do not want the fetal monitor used during labor because it will interfere with movement and doing effleurage." |
| While caring for a multiparous patient in the second stage of labor, the patient reports the urge to defecate. What is the best nursing intervention? | Assess cervical dilation and station of the patient. |
| The nurse is preparing to perform a nitrazine pH test on a pregnant patient. Arrange the steps that the student nurse would follow while conducting the test. | Inform the patient and the partner about the procedure.Soak the cotton-tipped applicator in the nitrazine dye.Insert the cotton-tipped applicator deep into the vagina. Perform perennial care in the patient as required. Document the test reports of the |
| After reviewing the laboratory reports of a pregnant patient at term, the primary health care provider (PHP) advised the nurse to administer intravenous (I.V.) fluids to the patient. What is the reason for giving such advice? | Dehydration |
| For the labor nurse, care of the expectant mother begins with which situations? Select all that apply. | The onset of progressive, regular contractions The bloody, or pink, show The spontaneous rupture of membranes |
| Which patients are more susceptible to soft-tissue damage with vaginal deliveries? Select all that apply. | Nulliparous patients Patients needing forceps delivery Patients with fetal breech presentation |
| The nurse is caring for a pregnant patient during labor. What should the nurse do immediately after the child's birth? | Dry the infant and place in warm blanket. |
| The nurse is caring for a non-English-speaking pregnant patient. What nursing interventions would help explain the procedure of vaginal examination to the patient? | Call a service for an interpreter. |
| During an assessment, the nurse is instructed to determine the position of the fetal head in a pregnant patient. What should the nurse do to determine whether the fetal head is flexed or extended? | Grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly. |
| The student nurse finds that the patient who is in labor has sweat on the upper lip, is shivering in the extremities, and is vomiting. What would the student nurse interpret from these observations? The patient has symptoms of: | Onset of the second stage of labor. |
| A patient in labor exhibits flushed cheeks. The nurse records the uterine contractions in the patient as being 3 to 5 minutes apart and lasting for about 1 minute. What nursing intervention is most effective to assess the patient's status during this phas | Note patient's appearance and mood every 15 minutes. |
| The nurse assesses a pregnant patient and reports to the primary health care provider (PHP) that the patient is in the second stage of labor. Which of the patient's signs enabled the nurse to give such a report to the PHP? Select all that apply. | Urge to defecate Cervical dilation of 10 cm Premature urge to bear down |
| The nurse finds that the pregnant patient has impaired urinary elimination. Which interventions should be performed by the nurse to relieve the patient's problem? Select all that apply. | Encourage the patient to urinate every 2 hours. Palpate patient's bladder superior to symphysis. Ask the patient to place the hand in running water. |
| The nurse is caring for a Southeast Asian patient who gave birth to a child. What interventions can the nurse perform to promote bonding between the newborn and the family? Select all that apply. | Encouraging the sibling to hold the baby Explaining the molding of the infant's head Explaining the dusky appearance of the infant |
| he nurse observes that a pregnant patient has a blood glucose level of 180 mg/dL in early labor. Which medication order does the nurse expect to receive from the primary health care provider (PHP)? | Ringer's lactate solution to the patient |
| The nurse is assessing a pregnant patient in the last week of gestation. The nurse observes that the patient has flushed cheeks, uterine contractions (UCs) of 65 seconds with a frequency of 4 minutes, and pink to bloody mucus. What stage of labor should t | Active phase |
| The nurse is examining a newly admitted patient who is 39 weeks pregnant and notes that the patient is in the transition phase of labor. Which symptoms does the nurse note to reach this conclusion? | Strong uterine contractions (UCs) |
| The nurse palpates the abdomen of a pregnant patient and reports that the fetus lies in longitudinal position with cephalic presentation. Which observation enabled the nurse to report about the fetal position? | The head feels round, firm, freely movable, and palpable by ballottement |
| The nurse restricts the visitors of a pregnant patient and gives a specific time for the patient to rest and sleep after the labor. What maternal patient experience could be the probable reason for this nursing action? | Severe fatigue during labor |
| The patient reports severe lower back pain during labor. Which position does the nurse plan for the patient during childbirth? | Hands-and-knees position |
| A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: | "It's normal to be anxious about labor. Let's discuss what makes you afraid." |
| The primary health care provider (PHP) advised the nurse to assess the maternal temperature and vaginal discharge of a pregnant patient every 2 hours. What is the reason behind this advice? | To assess for potential risk for infection |
| During an assessment, the nurse is instructed to determine the position of the fetal head in a pregnant patient. What should the nurse do to determine whether the fetal head is flexed or extended? | Grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly. |
| What change in the cervix is most likely to be observed by the nurse if the patient presents with false labor? | Posterior position |
| The nurse is examining a newly admitted patient who is 39 weeks pregnant and notes that the patient is in the active phase of labor. Which symptoms does the nurse note to reach this conclusion? | Strong uterine contractions (UCs) |
| Which characteristic is associated with false labor contractions? | Decrease in intensity with ambulation |
| Which pieces of information are important to obtain when assessing a patient admitted with ruptured membranes? Select all that apply. | Odor of fluid Amount of fluid Time of rupture Color of amniotic fluid |
| Upon reviewing the laboratory reports of a pregnant patient, the nurse reports to the primary health care provider (PHP) that the patient has impaired nutrition. Which finding enabled the nurse to conclude this? | Presence of ketones in the patient's urine specimen |
| The nurse explains that the placenta functions as an endocrine gland, secreting estrogen, progesterone, and: | human chorionic gondotropin |
| An analgesic medication has been administered intramuscularly to a patient in labor. The nurse will evaluate the medication as effective if: | The patient dozes between contractions. |
| Two hours after an epidural infusion has begun, a patient complains of itching on her face and neck. The nurse should: | Recognize that this is a common side effect, and follow protocol for administration of diphenhydramine (Benadryl). |
| Synthetic, version of oxytocin to induce contractions | Pitocin Side effects- water intoxication |
| To treat severe bleeding after childbirth (postpartum) | Hemabate |
| Group B Strep treatment | Penicillin G, if allergic cyndamicin |
| It can treat severe bleeding from the uterus after childbirth | Methergine Contraindicated in HTN patient's |
| What 3 meds babies receive at birth | vitamin K, Erythomicine, Hepatits B vaccine |
| ROM | water breaks, color clear, if more than 18 hrs of rupture baby goes to NICU after delivery. |
| Abbreviation PR | Presentation |
| Abbreviation EFW | Estimated fetal weight |
| 5 million units 1st dose of Pen G, then | 2.5 every 4 hrs until delivery |
| How much fluids does a women get during labor | 125 total fluids |
| PPROM | Preterm premature rupture of membrane |
| IOL | Induction of labor |
| post-op day 1 | POD1 |
| Medicine for preterm labor and preeclampsia , prevents seizures, but does not lower BP. Monitor: may feel groggy, hot; if chest pain let nurse know | Magnesium Toxicity of MG: sob Nurse intervention: reduce medicine Antidote: Calcium Gluconate, keep tongue blade at bedside |
| When does baby lung mature | 37 GA |
| Betamethasone 12 mg, 2 dose every 24 hr: side effect | Elevated blood sugar |
| After shoulder comes out during delivery, what is given IM | Pitocin |
| Labelatol medication is given for | Blood Pressure |
| Medication that settles content of the stomach, given preop | Sodium Citrate, 2 are given, patient cannot have water |
| Ancef/cefazolin medication, given for | infection; on C-section; 30 min before incision |
| Medication given to stop Pre-term contractions | Terbutaline Sulfate Side Effect: Tachycardia |
| Glucose Challenge Test is given at what GA | 50 grams; 25-28 GA; 1hr test |
| GTT 3hr test | 100 grams; fasting |
| When surgeons think bladder has been damaged, what medication is given? | Methylene Blue |
| If a patient has Placenta Previa, What type of labor is expected? | C-Section |
| Umbilical cord has 2 arteries and | one vein |
| What organ becomes the endocrine system | Placenta |
| If patient has tachysystole means they have | uterine rupture; Terbutaline is given nursing intervention: Mom Tachycardia |
| CATEGORY 1; What type of deceleration is observe? | Early Deceleration; head compression Nursing intervention: change positions |
| CATERGORY 2; What type of deceleration is observe? | Variable Deceleration: cord compression |
| CATEGORY 3: What type of deceleration is observed? | Placenta Insufficient; Late Deceleration |
| FETAL SPIRO ELECTRODE monitors | detects actual FHR; greater than 36 GA, ROM, Vertex presentation |
| Monitor postpartum Pt's will be sleepy after MG, can develop help syndrome | hemolysis, elvated liver enzymes,and low platelets |
| Gravida | Number of pregnancies |
| Term | Number of deliveries after 38 weeks |
| Preterm | Number of deliveries after 20 wks but before 38 wks |
| Abortion | Number of deliveries before 20 wks |
| Living | Number of living children |
| True Labor | Cervix dilating 0-10 cm Effacement 0-100% contractions increasing in frequency, duration, intensity station; engaged 0 to +5 bloody show membrane rupture |
| SROM | spontaneous rupture of membrane |
| AROM | Artificial rupture of membrane |
| PROM | Premature rupture of membrane |
| EFM | Externa fetal monitoring |
| FSE | fetal scalp electrode |
| IUPC | intra uterine pressure catheter |
| Amnio Hook | tool to artificially rupture membrane |
| Apgar Score | 1 minute and 5 minute |
| Postpartum is checked head to toe; BUBBLE | Breast; uterus; bladder; bowels (check incision of C-section), Episiotomy (check Perineium), emotional status |
| RhoGam is given at | 72 hrs of delivery for RH negative with infant who is RH Positive |
| Homans sign | calf pain, DVT |
| First stage of labor; from onset of true labor to complete effacement (100%) and dilation (10cm) or cervix; longest stage and includes 3 phases | Latent, Active, Transition phase |
| Form the beginning of labor to 3cm | Latent Phase 1 |
| Cervical dilation form 4-7 cm, effacement (thinning of cervix), is 100% complete. The fetus descends in the pelvis and internal rotation begins, discomfort increases | Active phase 2 |
| Cervix dilates from 8-10 cm. Fetus descends further, bloody show increases. Transition is a short phase with strong contractions. The women may have an urge to push. | Transition phase 3 |
| Expulsion stage, begins with complete 10cm dilation and full effacement of the cervix and ends with the birth of the baby | Second stage of Labor |
| Placental Stage; begins with the birth of the baby and end with the expulsion of the placenta | Third stage of Labor |
| Stage of physical recovery. It begins with the delivery of the placenta through 1-4 hrs after | Fourth stage of Labor |
| Precipitate Birth • A birth that is completed in less than 3 hours • Labor begins abruptly and intensifies quickly • Contractions may be frequent and intense • May have uterine rupture, cervical lacerations, or hematoma | Fetal oxygenation may be compromised • Birth injury may occur from rapid passage through the birth canal • Injuries can include– Intracranial hemorrhage– Nerve damage |
| Nursing Tip after membranes of rupture | Observe for wet under pads and linens after the membranes rupture. Change them as often as needed to keep the woman relatively dry and to reduce the risk for infection or skin breakdown. |
| • Induction (AROM) | is the initiation of labor before it begins naturally |
| is the stimulation of contractions after they have begun naturally | Augmentation |
| Contraindications to Labor Induction • Placenta previa • Umbilical cord prolapse • Abnormal fetal presentation • High station of the fetus | Active herpes infection in the birth canal • Abnormal size or structure of the mother’s pelvis • Previous classic cesarean incision |
| Pharmacological Methods to Stimulate Contractions • Cervical ripening – Prostaglandin in a gel or vaginal insert is applied before labor induction to soften the cervix – Laminaria is an alternative to cervical ripening by swelling inside the cervix | Oxytocin induction and the augmentation of labor – Used to initiate or stimulate contractions – Most commonly used method |
| Benefits of Augmentation | Usually requires less total oxytocin than induction • Uterus is more sensitive to the drug when labor has already begun |
| Non pharmacological Methods to Stimulate Contractions | Walking – Stimulates contractions – Eases pressure of the fetus on the mother’s back – Adds gravity to the downward force of contraction • Nipple stimulation of labor– Causes the pituitary gland to secrete natural oxytocin |
| Complications of Oxytocin Induction and Augmentation of Labor • Most common is related to | – Overstimulation of contractions • Fetal compromise • Uterine rupture • Water intoxication – Inhibits excretion of urine and promotes fluid retention |
| Bishop’s Scoring System | Evaluates the cervical response to induction procedures • A high score (above 6) is predictive of successful labor induction because the cervix has ripened or softened in preparation for labor |
| Version | • A method used to change fetal presentation –Two methods •External •Internal |
| Episiotomy | controlled surgical enlargement of the vaginal opening during birth |
| Laceration | —uncontrolled tear of the tissues that results in a jagged wound |
| Risks and Contraindications of Version • Disproportion between mother’s pelvis and fetal size • Abnormal uterine or pelvic size or shape • Abnormal placental placement • Previous cesarean birth with vertical uterine incision | • Active herpes virus infection • Inadequate amniotic fluid • Poor placental function • Multifetal gestation • Fetus can become entangled in umbilical cord |
| Perineal Lacerations • First degree— | superficial vaginal mucosa or perineal skin |
| Perineal Laceration-Second degree— | involves vaginal mucosa, perineal skin, and deeper tissues of the perineum |
| Perineal Laceration-Third degree- | same as second degree, plus involves anal sphincter |
| Perineal Laceration-Fourth degree | extends through the anal sphincter into the rectal mucosa • Women who have experienced a third- or fourth-degree lacerations are not given anything via the rectum. This includes enemas and suppositories. |
| Perineal massage and stretching exercises before labor may be an alternative to an | Episiotomy |
| Provides traction and rotation of the fetal head when the mother's pushing efforts are insufficient to accomplish a safe delivery in vaginal delivery | Forceps Extraction |
| May also help the physician extract the fetal head through the incision during a C-section birth | Forceps Extraction |
| Forceps or vacuum extraction is used at the end of what stage of labor | Second stage of labor |
| Uses suction applied to the fetal head so the physician can assist the mother's expulsive efforts; used only with occiput presentation | Vacuum Extraction Birth |
| Trauma to maternal or fetal tissues. Laceration or hematoma in vagina. Infant may have bruising, facial, or scalp, lacerations or abrasions, cephalic hematoma, or intracranial hemorrhage. | Risks of Forceps or Vacuum Extraction |
| C-section birth indication:Abnormal labor • Inability of the fetus to pass through the mother’s pelvis • Maternal conditions such as GH or DM • Active maternal herpes virus | Previous surgery on the uterus • Fetal compromise • Placenta previa or abruptio placentae |
| Risks of Cesarean Birth • Mother | – Anesthesia – Respiratory complications – Hemorrhage – Blood clots – Injury to urinary tract – Delayed intestinal peristalsis – Infection |
| Risks of Cesarean Birth Neonate | – Inadvertent preterm birth – Respiratory problems because of delayed absorption of lung fluid – Injury |
| Types of Incisions • Skin – Vertical allows more room for a large fetus – Transverse (a.k.a. Pfannenstiel) and Uterine:– Low transverse: not likely to rupture during another birth; VBAC possible with this type | – Low vertical: minimal blood loss; more likely to rupture during another birth – Classic: rarely used; more blood loss; most likely to rupture during another pregnancy |
| Sequence of Events in Cesarean Birth There is a series of events which will take place during a cesarean section: 1.Administering anesthetic 2. Cleaning and draping the expectant mother 3. Making skin incision | 4. Making uterine incision 5. Rupturing membranes (if not yet completed) 6. Removing the fetal head or buttocks 7. Suctioning the mouth and nose 8. Clamping the cord |
| Nursing Care in the Recovery Room • Vital signs to identify hemorrhage or shock | • IV site and rate of solution flow • Fundus for firmness, height, and midline position • Dressing for drainage • Lochia for quantity, color, and presence of clots • Urine output from the indwelling catheter |
| Emergencies During Childbirth • Prolapsed umbilical cord | – Complete – Palpated – Occult |
| Emergencies During Childbirth Uterine rupture | – Complete – Incomplete – Dehiscence |
| is tearing of the uterus, complete (rupture extends through entire uterine wall and uterine contents spill into the abdominal cavity) | UTERINE RUPTURE Complete |
| incomplete (rupture extends through endometrium and myometrium, but the peritoneum surrounding the uterus remains intact). | UTERINE RUPTURE Incomplete |
| • Uterus turns inside out after delivery of the infant • Most likely to occur – If the uterus is not firmly contracted – During vigorous fundal massage | Uterine Inversion |
| Occurs when amniotic fluid, with its particles such as vernix, fetal hair, and sometimes meconium, enter the woman’s circulation and typically obstructs small blood vessels in her lungs | Amniotic Fluid Embolism: • Characterized by abrupt onset of hypotension, respiratory distress, and coagulation abnormalities |
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