bstrandable NCLEX OB/Peds 1 of 3

A 52-year-old client states, “My husband is upset because I don’t enjoy sex as much as I used to.” Which priority client data should a nurse initially collect?

A. History of hysterectomy
B. Date of last menstrual cycle
C. Use of birth control methods
D. History of thought disorder

ANS: B
The nurse should assess the client’s last menstrual cycle to determine if the client is experiencing the onset of menopause. Menopause usually occurs around the age of 50. The decrease in estrogen can result in multiple symptoms including a decrease in biological drives and sexual activity.
In the course of an assessment interview, a female client reveals a history of bisexual orientation. Which action should the nurse initially implement when working with this client?

A. Self-assess personal attitudes toward homosexuality.
B. Review client’s possible childhood sexual abuse history.
C. Encourage discussion of aversion to heterosexual relationships.
D. Explore client’s family history of homosexuality.

ANS: A
The nurse should initially self-assess personal attitudes toward homosexuality. The nurse must be able to recognize the potential for negative feelings compromising client care. Unconditional acceptance of each individual is an essential component of compassionate nursing.
A recently widowed client reports a fear of intimacy due to an inability to achieve and sustain an erection. He has become isolative, has difficulty sleeping, and has recently lost weight. Which correctly written nursing diagnosis should be prioritized for this client?

A. Risk for situational low self-esteem AEB inability to achieve an erection
B. Sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm
C. Social isolation R/T low self-esteem AEB refusing to engage in dating activities
D. Disturbed body image R/T penile flaccidity AEB client statements

ANS: B
Based on the client’s symptoms, the nurse should prioritize the nursing diagnosis of sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm. The nurse should assess the client’s mood and level of energy because depression and fatigue can decrease desire for participation in sexual activity.
A nurse is assessing a client diagnosed with pedophilia. What would differentiate this sexual disorder from a sexual dysfunction?

A. Symptoms of sexual dysfunction include inappropriate sexual behaviors, whereas symptoms of a sexual disorder include impairment in normal sexual response.
B. Symptoms of a sexual disorder include inappropriate sexual behaviors, whereas symptoms of sexual dysfunction include impairment in normal sexual response.
C. Sexual dysfunction can be caused by increased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual disorders.
D. Sexual disorders can be caused by decreased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual dysfunction.

ANS: B
The nurse should identify that pedophilia is a sexual disorder in which individuals partake in inappropriate sexual behaviors. Sexual dysfunction involves impairment in normal sexual response. Pedophilia involves having sexual urges, behaviors, or sexually arousing fantasies involving sexual activity with a prepubescent child.
A female client on an inpatient unit enters the day area for visiting hours dressed in a see-through blouse and wearing no undergarments. Which intervention should be a nurse’s first priority?

A. Discuss with the client the inappropriateness of her attire.
B. Avoid addressing her attention-seeking behavior.
C. Lead the client back to her room and assist her to choose appropriate clothing.
D. Restrict client to room until visiting hours are over.

ANS: C
The most appropriate intervention by the nurse is to lead the client back to her room and assist her to choose appropriate clothing. The client could be exhibiting signs of exhibitionism which is characterized by urges to expose oneself to unsuspecting strangers.
A nurse is working with a client diagnosed with pedophilia. Which client outcome is appropriate for the nurse to expect during the first week of hospitalization?

A. The client will verbalize an understanding of the importance of follow-up care.
B. The client will implement several relapse-prevention strategies.
C. The client will identify triggers that lead to inappropriate behaviors.
D. The client will attend aversion therapy groups.

ANS: C
During the first week of hospitalization, identifying triggers that lead to inappropriate behaviors is an appropriate outcome for a client diagnosed with pedophilia. Pedophilia involves intense sexual urges, behaviors, or fantasies involving sexual activity with a prepubescent child.
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When planning care for a client diagnosed with female sexual arousal disorder, what should a nurse document as an expected outcome of senate focus exercises?

A. To initiate immediate orgasm
B. To reduce anxiety by eliminating physical touch
C. To focus on touching breasts and genitals
D. To reduce goal-oriented demands of intercourse

ANS: D
The expected outcome of senate focus exercises is to reduce goal-oriented demands of intercourse. Senate focus exercises consist of touching and being touched by another with attention focused on the physical sensations encountered. Erotic contact is gradually increased, leading to the possibility of sexual intercourse. The reduction in demands reduces performance pressures and anxiety associated with possible failure.
A newly married woman comes to a gynecology clinic reporting anorexia, insomnia, and extreme dyspareunia that have affected her intimate relationship. What initial intervention should the nurse expect a physician to implement?

A. A thorough physical to include gynecological examination
B. Referral to a sex therapist
C. Assessment of sexual history and previous satisfaction with sexual relationships
D. Referral to the recreational therapist for relaxation therapy

ANS: A
The nurse should expect the physician to implement a thorough physical to include a gynecological examination to assess for any physiological causes of the client’s symptoms. Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse.
A client is diagnosed with sexual aversion disorder. Which symptom of this disorder should the nurse correctly pair with an appropriate therapeutic intervention?

A. Avoidance of all genital sexual contact treated by systematic desensitization
B. Avoidance of all genital sexual contact treated by medicating with tadalafil (Cialis)
C. Anorgasmia treated by vardenafil (Levitra)
D. Anorgasmia treated by sensate focus exercises

ANS: A
The nurse should recognize that this sexual aversion disorder is characterized by an avoidance of genital sexual contact. Sexual aversion implies anxiety, fear, or disgust in sexual situations. Sexual aversion can be treated by systematic desensitization.
A psychiatric nursing instructor is teaching about the psychological effects of the diagnosis of a sexually transmitted disease (STD). Which student statement indicates that further instruction is needed?

A. “STDs carry strong connotations of illicit sex and considerable social stigma.”
B. “STDs can cause insanity.”
C. “The diagnosis of HIV can generate hopelessness and helplessness.”
D. “Antibiotics administered in the early stages can cure all STDs.”

ANS: D
The instructor should identify the need for further instruction if a student states that antibiotics can cure all STDs. STDs refer to infections that are contracted primarily through sexual activities or intimate contact. An example of an incurable STD is HIV. STDs are at epidemic levels in the United States.
A client is diagnosed with female sexual aversion disorder. In addition to systematic desensitization techniques, which medication therapy could accompany this intervention?

A. Quetiapine (Seroquel)
B. Phenelzine (Nardil)
C. Amoxapine (Asendin)
D. Carbamazepine (Tegretol)

ANS: C
The nurse should identify that medication therapy of amoxapine could complement systematic desensitization techniques. Amoxapine is a heterocyclic antidepressant that can assist in reduction of anxiety.
A nurse is counseling a client diagnosed with transgenderism. Which characteristic would differentiate this disorder from transvestic fetishism?

A. Clients diagnosed with transvestic fetishism are dissatisfied with their gender, whereas clients diagnosed with transgenderism are not.
B. Clients diagnosed with transgenderism are dissatisfied with their gender, whereas clients diagnosed with transvestic fetishism are not.
C. Clients diagnosed with transgenderism never engage in cross-dressing, whereas clients diagnosed with transvestic fetishism do.
D. Clients diagnosed with transvestic fetishism never engage in cross-dressing, whereas clients diagnosed with transgenderism do.

ANS: B
The nurse should identify that clients diagnosed with transgenderism are dissatisfied with their gender, whereas clients diagnosed with transvestic fetishism are not. Both clients diagnosed with transgenderism and transvestic fetishism may participate in cross-dressing.
Which of the following characteristics should a nurse identify as “normal” in the development of human sexuality for an 11-year-old child? (Select all that apply.)

A. The child experiments with masturbation.
B. The child may experience homosexual play.
C. The child shows little interest in the opposite sex.
D. The child shows little concern about physical attractiveness.
E. The child is unlikely to want to undress in front of others.

ANS: A, B, E
The nurse should identify that experimenting with masturbation and homosexual play and not wanting to undress in front of others are characteristics that are normal in the development of human sexuality in an 11-year-old child. Interest in the opposite sex usually increases during this age, and children often become self-conscious about their bodies.
A nursing instructor is teaching about the various categories of paraphilia. Which of the following categories are correctly matched with expected behaviors? (Select all that apply.)

A. Exhibitionism: Mary models lingerie for a company that specializes in home parties.
B. Voyeurism: John is arrested for peering in a neighbor’s bathroom window.
C. Frotteurism: Peter enjoys subway rush-hour female contact that results in arousal.
D. Pedophilia: George can experience an orgasm by holding and feeling shoes.
E. Fetishism: Henry masturbates into his wife’s silk panties.

ANS: B, C, E
Categories of paraphilia include voyeurism (observing unsuspecting people who are naked, dressing, or engaged in sexual activity), frotteurism (touching or rubbing against a nonconsenting person), fetishism (using nonliving objects in sexual ways), and pedophilia (recurrent sexual urges involving sexual activity with a prepubescent child). Exhibitionism is a paraphilia but involves the urge to show one’s genitals to unsuspecting strangers.
An adolescent in her first trimester of pregnancy continues to smoke cigarettes. The client tells the nurse that she’d like to quit but she doesn’t want to gain any more weight. What should the nurse do for this client?
1. Review the hazards of smoking with the client and suggest a smoking-cessation class.
The labor and delivery unit has 10 clients in varying stages of labor. Staffing for the upcoming shift consists of four registered nurses (RNs) and one licensed practical nurse (LPN). Which client care assignment is best?
The stable clients in the early stages of labor should be assigned to the LPN.
“Which of the following nutritional instructions should the nurse provide to a 32-year-old primigravida?
” 1. Caloric intake should be increased 300 cal/day. 2. Protein intake should be increased by more than 30 g/day. 5. Intake of all minerals, especially iron, should be increased. “
The nurse is reviewing a pregnant client’s nutritional status. To determine whether she has an adequate intake of vitamin A, the nurse should check her diet for consumption of:
4. dairy products”
A pregnant client in her second trimester reveals that she feels very anxious because of a lack of knowledge about giving birth. Which intervention by the nurse is most appropriate for this client?
provide her with the information and teach her the skills she’ll need to understand and cope during
A pregnant client tells the nurse that she dreads coming for her prenatal examinations. She states, “When I see the physician, he constantly reminds me that so many women keep weight on after having children; it really depresses me.” How should the nurse respond?
2. “Have you asked the physician why he feels it’s important for him to say that to you?”
A client, 8 weeks pregnant, has a history of lactose intolerance. To prevent a nutritional deficiency as a result of lactose intolerance, the nurse teaches her about lactase replacement. Which teaching point is appropriate?
3. Add lactase replacement drops to milk at least 24 hours before drinking it.
A client in her second trimester of pregnancy has been diagnosed with gestational diabetes. While instructing the client about home glucose monitoring the client states, “Why should I use this if the diabetes is going to resolve after I have my baby anyway?” Which response by the nurse is best?
4. “The monitor helps you see how your blood sugar is being controlled during your pregnancy to help prevent complications.”
A client who’s 12 weeks pregnant attends a class on fetal development as part of a childbirth education program. The nurse says that at 16 weeks’ gestation, the client’s fetus will likely:
3. have audible heart sounds.
A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take?
1. Place the client on her left side and start supplemental oxygen, as ordered, to maximize fetal oxygenation
“During a prenatal screening of a client with diabetes, the nurse should keep in mind that the client is at increased risk for which complications?
1. Still birth 3. Pregnancy-induced hypertension 5. Spontaneous abortion
The nurse uses nitrazine paper to determine whether a pregnant client’s membranes have ruptured. If the membranes have ruptured, the paper will turn which color?
2. Blue
A pregnant client asks the nurse about the percentage of congenital anomalies caused by drug exposure. How should the nurse respond?
1. 1%
When teaching a group of pregnant adolescents about reproduction and conception, the nurse is correct when stating that fertilization occurs:
4. in the first third of the fallopian tube.
Which of the following would the nurse expect to find as presumptive signs of pregnancy?
1. Amenorrhea and quickening
A client is admitted for an amniocentesis. Initial data collection findings include the following: 16 weeks pregnant, vital signs within normal limits, hemoglobin 12.2 gm, hematocrit 35%, and type O-negative blood. Which action would be most important to include in the client’s plan of care after the amniocentesis has been completed?
1. Administer RhoGAM.
Infertility in a 25-year-old couple is defined as:
3. the couple’s inability to conceive after 1 year of unprotected attempts
Which of the following functions would the nurse expect to be unrelated to the placenta?
4. Production of maternal antibodies
A client with hyperemesis gravidarum is on a clear liquid diet. Which foods would be appropriate for the nurse to serve?
“3. Tea and gelatin 4. Ginger ale and apple juice 5. Cranberry juice and chicken broth “
A woman who’s 10 weeks pregnant tells the nurse that she’s worried about her fatigue and frequent urination. The nurse should:
1. recognize these as normal early pregnancy signs and symptoms.
A client has just expelled a hydatidiform mole. She’s visibly upset over the loss and wants to know when she can try to become pregnant again. Which of the following would be the nurse’s best response?
2. “”I can see that you’re upset; however, you must wait at least 1 year before becoming pregnant again.””
A client has come to the clinic for her first prenatal visit. The nurse should include which statement about using drugs safely during pregnancy in her teaching?
4. “”Consult with your health care provider before taking any medications.””
During her first prenatal visit, a pregnant client admits to the nurse that she uses cocaine at least once per day. Which nursing diagnosis is most appropriate for this client?
“3. Imbalanced nutrition: Less than body requirements related to limited food intake
When questioned, a pregnant client admits she sometimes has several glasses of wine with dinner. Her alcohol consumption puts her fetus at risk for which condition?
4. Learning disability
The caloric requirements for a client of normal weight increase by how much during pregnancy?
1. 300 kcal
A client who’s 4 weeks pregnant comes to the clinic for her first prenatal visit. When obtaining her health history, the nurse explores her use of drugs, alcohol, and cigarettes. Which client behavior identifies a safe level of alcohol intake for this client?
4. The client consumes no alcohol.
When collecting data on a client during her first prenatal visit, the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breast-feeding success?
2. “”I support your commitment; however, you may have to supplement each feeding with formula.
A nurse is obtaining a medication history from a client who suspects she’s pregnant. At which week of gestation does placental transport of substances to and from the fetus begin?
3. Fifth week
The nurse is assisting in planning care for a 16-year-old client in the prenatal clinic. Adolescents are prone to which complication during pregnancy?
1. Iron deficiency anemia
After receiving large doses of an ovulatory stimulant such as menotropins (Pergonal), a client comes in for her office visit. Data collection reveals the following findings: Weight gain of 6 lb (3 kg), ascites, and pedal edema. These findings indicate that the client is:
2. demonstrating signs of hyperstimulation syndrome.
At 15 weeks’ gestation, a client is scheduled for a serum alpha-fetoprotein (AFP) test. Which maternal history finding would indicate a need for this test?
“1. Family history of spina bifida in a sister
The nurse is providing care for a pregnant 16-year-old client. The client says that she’s concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying:
3. “”Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems.””
A client is in the last trimester of pregnancy. The nurse should instruct her to notify her obstetrician immediately if she notices:
“1. blurred vision.
During each prenatal checkup, the nurse obtains the client’s weight and blood pressure and measures fundal height. What is another essential part of each prenatal checkup?
1. Evaluating the client for edema
A pregnant client is prescribed an iron supplement. Which point should the nurse include when teaching the client about taking the supplement?
3. Eat a diet rich in vitamin C to promote iron absorption.
A pregnant client is brought to the emergency department after being an unrestrained driver in a motor vehicle accident. When questioned about seatbelt use, the client states that she thought a seatbelt would harm her baby. Which response by the nurse is best?
3. “”The only way to safely secure yourself in a car is to use a seatbelt.””
A client is expecting her second child in 6 months. During the psychosocial assessment, she says, “I’ve been through this before. Why are you asking me these questions?” What is an appropriate response by the nurse?
“Each pregnancy has a unique psychosocial meaning.”
A client with pregnancy-induced hypertension (PIH) probably exhibits which of the following symptoms?
3. Proteinuria, headaches, and double vision
“The nurse is caring for a 16-year-old pregnant client who is taking an iron supplement. Which instruction should the nurse include when teaching the adolescent about ferrous sulfate?
” 3. Avoid taking the supplement with milk. 4. Avoid taking the supplement with antacids. 5. Avoid chewing the extended-release form of the drug”
A client makes a routine visit to the prenatal clinic. Although she believes that she is 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. The physician diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal:
“2. grapelike clusters.
During a home-care visit with a pregnant client, the nurse notices extension cords crossing between rooms. How should the nurse intervene?
1. Explain that extension cords can pose a danger to the client when she’s walking.
Which findings would be considered positive signs of pregnancy?
“3. Fetal heartbeat and fetal movement on palpation
The nurse has a client at 30 weeks’ gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her baby?
4. Discourage breast-feeding because HIV can be transmitted through breast milk.
A famous pregnant client comes to the physician’s office for a routine prenatal examination. While the client is in the office, the media arrives asking for information about the client. What should the nurse do?
2. Inform the media that you can’t comment about whether the person is being seen in the office
A client who’s 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping her cope with these cramps?
“3. Teaching her to dorsiflex her foot during the cramp
A client in the first trimester of pregnancy comes to the facility for a routine prenatal visit. She tells the nurse she doesn’t know whether she’s ready to have a baby, even though this was a planned pregnancy. Which response should the nurse offer?
2. “”You’re feeling ambivalent, which is normal during the first trimester.””
After developing severe hydramnios, a primigravid client exhibits dyspnea, along with edema of the legs and vulva. Which procedure should the nurse expect her to undergo and why?
“2. Amniocentesis to temporarily relieve discomfort
During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which client statement indicates an accurate understanding of the nurse’s instructions?
“3. “”I’ll increase my intake of unrefined grains.””
The nurse observes many cuts and bruises on the back, arms, and legs of a pregnant client. The client tells the nurse, “I was cleaning and a box of supplies fell on me.” Which response by the nurse is most appropriate?
3. “”It’s our responsibility to maintain client confidentiality and to make sure our clients are safe. I’d be glad to listen if there’s anything you want to talk about.””
The nurse is providing instruction to a woman who is 18 weeks pregnant. Which findings are expected at this time?
1. Fundal height of approximately 18 cm 2. Quickening “
A client is in the 8th month of pregnancy. To enhance cardiac output and renal function, the nurse should advise her to use which body position?
“2. Left lateral
During a physical examination, a client who’s 32 weeks pregnant becomes pale, dizzy, and light-headed while supine. Which action should the nurse immediately take
1. Turn the client on her left side
A client comes to her prenatal examination complaining of increasing episodes of leg cramping. Which intervention by the nurse is most appropriate?
2. Instructing the client to gently stretch her legs to relieve the cramping
During the sixth month of pregnancy, a client reports intermittent earaches and a constant feeling of fullness in the ears. What is the likely cause of these symptoms?
2. Eustachian tube vascularization
What key psychosocial tasks must a woman accomplish during the third trimester?
“4. Overcoming fears she may have about the unknown, loss of control, and death
An adolescent who’s 14 weeks pregnant comes to the clinic for a prenatal examination. During the examination, the client says to the nurse, “I’m still not sure whether I want to keep my baby.” Which response by the nurse is best?
. “Have you and your physician discussed your options?”
A client is at her ideal weight when she conceives. During a prenatal visit 2 months later, she asks the nurse how much weight she should gain during pregnancy. What is the nurse’s best response?
4. “”You should gain 24 to 32 lb.””
After undergoing prenatal blood testing, a client learns that she tested positive for human immunodeficiency virus (HIV). What should the nurse do with this information?
4. Follow facility policy for documenting and communicating HIV status
A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. She tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from:
3. an unknown cause.
“A client who is 14 weeks pregnant mentions that she has been having difficulty moving her bowels since she became pregnant. Which hormones are responsible for this common discomfort during pregnancy?
“1. Progesterone
The nurse is providing dietary teaching to a pregnant client. To help meet the client’s iron needs, the nurse should advise her to eat:
4. spinach and beef.
A client is receiving terbutaline (Brethine) to stop preterm labor. The physician plans to discharge the client in the morning with a terbutaline infusion pump. Which instruction should the nurse include when teaching the client about the drug?
“3. “”Assess the insertion site for signs of infection.””
The nurse is discussing posture with a client who’s 18 weeks pregnant. Why should the nurse caution her to avoid the supine position?
1. This position impedes blood flow to the fetus.
A newly pregnant woman tells the nurse that she hasn’t been taking her prenatal vitamins because they make her nauseous. In addition to telling the client how important taking the vitamins are, the nurse should advise her to:
“2. take the vitamin on a full stomach.
A client, 2 months pregnant, has hyperemesis gravidarum. Which expected outcome is most appropriate for her?
“4. The client will exhibit uterine growth within the expected norms for gestational age.
Which drug will the physician probably order to treat a pregnant client who is experiencing morning sickness?
“4. Phosphorated carbohydrate solution (Emetrol)
During her fourth clinic visit, a client who’s 5 months pregnant tells the nurse she was exposed to rubella during the past week and asks whether she can be immunized now. How should the nurse respond?
. “No, because the live viral vaccine is contraindicated during pregnancy.”
“A client is scheduled for amniocentesis. What should the nurse do to prepare the client for the procedure?
” 1. Ask the client to void. 4. Assess fetal heart rate. 6. Monitor maternal vital signs. “
A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client:
“3. tea and gelatin dessert.
A client who’s 30 weeks pregnant has a corrected atrial septal defect and minor functional limitations. Which pregnancy-related physiologic change places her at greatest risk for more severe cardiac problems?
2. Increased plasma volume
The nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate?
2. They’re usually felt in the abdomen.
A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should complete which of the following tasks?
1. Ask her to void.
A client with pregnancy-induced hypertension (PIH) receives magnesium sulfate, 4 g in 50% solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client?
2. To prevent seizures
A client comes to the clinic for a routine prenatal examination. The nurse notices that the client is disheveled and unkempt. The client explains, “I have no energy to take care of myself and I really don’t care.” How should the nurse intervene?
2. Offer to assist the client with basic care needs while waiting for the physician.
A client who’s 37 weeks pregnant comes to the clinic for a prenatal checkup. To evaluate the client’s preparation for parenting, the nurse might ask which question?
“What changes have you made at home to get ready for the baby?”
The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which findings?
3. Breast sensitivity
A low-risk client who’s 6 weeks pregnant comes to the clinic for her first prenatal visit. At this time, the nurse should assign highest priority to:
“1. establishing a schedule of prenatal visits.
The nurse is teaching a client who’s 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling this client’s blood glucose levels, so she has started insulin therapy. The nurse should consider the teaching effective when the client says:
2. “”I need to use insulin each day.””
“A client admitted with preterm labor is prescribed magnesium sulfate to halt contractions. The nurse should monitor the client for which adverse reactions to the drug?
” 3. Respiratory rate less than 12 breaths/minute 4. Extreme muscle weakness Palpitations 6. Hot flashes”
A pregnant client concerned about gaining weight during pregnancy questions the nurse about dietary intake. Which response by the nurse is best?
“4. “”I’ll ask the dietitian to speak with you about normal weight gain during pregnancy.””
A pregnant client who’s diabetic is at risk for having a large-for-gestational-age infant because of which of the following?
2. Insulin acting as a growth hormone on the fetus
A client is 8 weeks pregnant. Which teaching topic is most appropriate at this time?
2. Common discomforts of pregnancy
The nurse is caring for a client after evacuation of a hydatidiform mole. The nurse should tell the client to:
4. use birth control for at least 1 year.
A client in the first trimester of pregnancy joins a childbirth education class. During this trimester, the class is most likely to cover which physiologic aspect of pregnancy?
3. Warning signs of complications
A client is admitted to the facility in preterm labor. To halt her uterine contractions, the nurse expects the physician to prescribe:
“4. terbutaline (Brethine).
During her first prenatal visit, a client expresses concern about gaining weight. Which of the following actions should be the nurse’s next step?
1. Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet.
A pregnant client asks questions about labor and delivery. During the nurse’s explanations, the client states, “Is it true that a lot of other people are going to be in the room while I’m giving birth? I was expecting privacy.” Which response would be appropriate for the nurse to make to this client?
“2. “”What did the physician tell you about the delivery room?””
The nurse is caring for a client who’s on ritodrine (Yutopar) therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy?
2. Crackles
“The nurse is teaching a pregnant client about exercises that may be helpful during pregnancy. Which points should the nurse include in her instruction?
“1. Pelvic rocking may help relieve lower back pain. 2. Abdominal breathing lifts the abdominal wall off of the uterus. 3. Kegel exercises help improve vaginal contractility and bladder control.
A 30-year-old primiparous client at 34 weeks’ gestation comes to the prenatal facility concerned about the reddish streaks she has increasingly developed on her breasts and abdomen. She asks what these skin changes are and whether they’re permanent. What should the nurse tell her?
3. “”These streaks are called striae gravidarum, or stretch marks; they’ll grow lighter after delivery.””
During a routine prenatal visit, a pregnant client reports heartburn. To minimize her discomfort, the nurse should include which suggestion in the plan of care
1. Eat small, frequent meals
When determining maternal and fetal well-being, which of the following data collection findings is most important?
2. Fetal heart rate and activity
A client at 28 weeks’ gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to:
4. promote fetal lung maturity.
When evaluating a client’s knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her?
. “If I have blurred or double vision, I should call the clinic immediately.”
A client who’s pregnant with her second child comes to the clinic complaining of a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she’s apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing
1. Braxton Hicks contractions
A client who’s 5 weeks pregnant reports nausea and vomiting. The nurse reassures the client that these symptoms probably will subside by:
2. 9 to 12 weeks’ gestation.
The nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client indicates an understanding of the nurse’s teaching?
3. “”I can lie in any comfortable position, but I should stay off my back.””
Which statement accurately describes estrogen and progesterone levels during the 16th week of pregnancy?
1. Both estrogen and progesterone levels are rising.
A client’s membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client’s temperature at 101.8° F (38.8° C). After initiating prescribed antibiotic therapy, the nurse should prepare the client for:
2. delivery.
The nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning?
“4. On admission to the facility
A pregnant client in her second trimester visits the health care practitioner for a regular prenatal checkup. The nurse weighs the client. She then compares the client’s current and previous weights. During the second trimester, how much weight should the client gain per week?
2. 1 lb (0.45 kg)
A client with type 1 diabetes mellitus has just learned she’s pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide?
3. “”Insulin requirements usually decrease during the first trimester.””
The nurse checks a client for signs and symptoms of ectopic pregnancy. What is the most common finding associated with this antepartum complication?
“4. Abdominal pain
During a prenatal visit, the nurse measures a client’s fundal height at 19 cm. This measurement indicates that the fetus has reached approximately which gestational age?
2. 19 weeks
When collecting data on a pregnant client with diabetes mellitus, the nurse stays alert for signs and symptoms of a vaginal or urinary tract infection (UTI). Which condition makes this client more susceptible to such infections?
“4. Glycosuria
When providing health teaching to a primigravid client, the nurse tells the client that she’s likely to first experience Braxton Hicks contractions. When do these contractions typically begin?
2. Between 23 and 27 weeks’ gestation
At 32 weeks’ gestation, a client is admitted to the facility with a diagnosis of pregnancy-induced hypertension (PIH). Based on this diagnosis, the nurse expects assessment to reveal:
1. edema.
The nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When collecting data on this client, the nurse’s highest priority is to evaluate:
2. maternal vital signs and fetal heart rate (FHR).
A client who’s 2 months pregnant complains of urinary frequency and says she gets up several times at night to go to the bathroom. She doesn’t have other urinary symptoms. How should the nurse intervene?
“4. Explain that urinary frequency is expected during the first trimester.
A client in her first trimester of pregnancy complains that she’s always tired. Which response by the nurse is best?
“1. “”Needs for rest and sleep typically increase during the first trimester of pregnancy.””
The nurse prepares a client who’s 28 weeks pregnant for a nonstress test (NST). Which intervention is likely to stimulate fetal movements during this test?
“1. Having the client drink orange juice
During a routine assessment, a pregnant client tells the nurse that she hasn’t had a bowel movement for “close to a week.” What should the nurse do to help this client
3. Discuss the client’s diet, focusing on her fiber and water intake
The nurse is developing a plan of care for a client in her 34th week of gestation who’s experiencing preterm labor. What nonpharmacologic intervention should the plan include to halt premature labor?
3. Promoting adequate hydration
At what gestational age would a primigravida expect to feel quickening?
3. 18 to 22 weeks
The nurse is caring for a 16-year-old pregnant client. The client is taking an iron supplement. What should this client drink to increase the absorption of iron?
4. A glass of orange juice
A pregnant client arrives in the emergency department and states, “My baby is coming.” The nurse sees a portion of the umbilical cord protruding from the vagina. Why should the nurse apply manual pressure to the baby’s head?
3. To relieve pressure on the umbilical cord
The nurse is collecting data on a client who is believed to be pregnant. Which signs or symptoms indicate a hydatidiform mole?
2. Abnormally high human chorionic gonadotropin (hCG) levels
A pregnant client asks how she can best prepare her 3-year-old son for the upcoming birth of a sibling. The nurse should make which suggestion?
4. “”Involve your son in planning and preparing for a sibling.””
When should a client who’s Rh(D)-negative and D-negative and who hasn’t already formed Rh antibodies receive Rh(D) human immunoglobulin (RhIg) to prevent isoimmunization?
3. At about 28 weeks’ gestation and again within 72 hours after delivery
A client, now 37 weeks pregnant, calls the clinic because she’s concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action?
“2. Explain that these are expected problems for the latter stages of pregnancy.
A client, 7 months pregnant, is receiving the tocolytic agent terbutaline (Bricanyl), 17.5 mcg/minute I.V., to halt uterine contractions. She also takes prednisone (Orasone), 5 mg by mouth twice per day, to control asthma. To detect an adverse interaction between these drugs, the nurse should monitor the client for:
2. pulmonary edema.
The nurse is reviewing a client’s prenatal history. Which finding indicates a genetic risk factor?
“2. The client has a child with cystic fibrosis.
The nurse determines that a client is in false labor. After obtaining discharge orders from the nurse-midwife, the nurse provides discharge teaching to the client. Which instruction is appropriate at this time?
4. “”Return to the facility if your contractions become more intense.””
The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that:
1. the delivery may need to be induced early.
On her second visit to the prenatal facility, a client states, “I guess I really am pregnant. I’ve missed two periods now.” Based on this statement, the nurse determines that the client has accomplished which psychological task of pregnancy?
4. Accepting the biological fact of pregnancy
During routine preconception counseling, a client asks how early a pregnancy can be diagnosed. What is the nurse’s best response?
1. “”8 days after conception””
A client who’s 24 weeks pregnant has sickle cell anemia. When preparing the plan of care, the nurse should identify which factor as a potential trigger for a sickle cell crisis during pregnancy?
“2. Dehydration
A client is in the 38th week of her first pregnancy. She calls the prenatal facility to report occasional tightening sensations in the lower abdomen and pressure on the bladder from the fetus, which she says seems lower than usual. The nurse should take which action?
1. Review premonitory signs of labor with the client.
During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise her to:
“4. divide daily food intake into five or six meals.
After an amniotomy, which client goal should take the highest priority?
2. The client will maintain adequate fetal tissue perfusion
A pregnant client tells the nurse that she doesn’t like milk and can’t possibly drink three to four glasses per day as recommended by her physician. Which intervention by the nurse is best?
2. Explaining that other dairy products, such as cheese and yogurt, may be substituted for milk
A client who’s 7 weeks pregnant comes to the clinic for her first prenatal visit. She reports smoking 20 to 25 cigarettes per day. When planning the client’s care, the nurse anticipates informing her that if she doesn’t stop smoking, her fetus will develop:
3. intrauterine growth retardation.
During a health-teaching session, a pregnant client asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. Which answer should the nurse supply?
1. 7 days after fertilization
Which medication is considered safe during pregnancy?
3. Insulin
The nurse is developing a teaching plan for a client who’s 2 months pregnant. The nurse should tell the client that she can expect to feel the fetus move at which time?
2. Between 16 and 22 weeks’ gestation
A nurse in a prenatal clinic is assessing a 28-year-old who’s 24 weeks pregnant. Which findings would lead this nurse to suspect that the client has mild preeclampsia?
4. Hypertension, edema, proteinuria
After determining that a pregnant client is Rh-negative, the physician orders an indirect Coombs’ test. What is the purpose of performing this test in a pregnant client?
4. To detect maternal antibodies against fetal Rh-positive factor
A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention?
4. Ketones in urine
Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy?
“1. Abdominal pain, vaginal bleeding, and a positive pregnancy test
The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to:
4. be taught about diet.
A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond?
“No, it can initiate premature uterine contractions.”
A 20-year-old female’s pregnancy is confirmed at a clinic. She says her husband will be excited, but she is concerned because she herself isn’t excited. She fears this may mean she’ll be a bad mother. The nurse should respond by:
“2. telling her such feelings are normal in the beginning of pregnancy.
Approximately how much time is required for the blastocyst to reach the uterus for implantation?
2. 7 days
A client who’s 4 months pregnant asks the nurse how much and what type of exercise she should get during pregnancy. How should the nurse counsel her?
3. “”Walk briskly for 10 to 15 minutes daily, and gradually increase this time.””
A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic?
2. Danger signs during pregnancy
A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this client?
2. Deficient fluid volume
A client asks how long she and her husband can safely continue sexual activity during pregnancy. How should the nurse respond?
“4. “”As long as you wish, if the pregnancy is normal””
A client calls to schedule a pregnancy test. The nurse knows that most pregnancy tests measure which hormone?
“1. Human chorionic gonadotropin (hCG)
A client who’s planning a pregnancy asks the nurse about ways to promote a healthy pregnancy. Which of the following would be the nurse’s best response?
4. “”Folic acid supplements improve pregnancy outcomes by preventing certain complications.””
While caring for pregnant adolescents, the nurse should develop a plan of care that incorporates which health concern?
4. Level of emotional maturity
A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client’s health history for risk factors for this abnormal condition, the nurse expects to find:
1. a history of pelvic inflammatory disease.
When evaluating a pregnant client’s fundal height, the nurse should measure in which way?
4. From the symphysis pubis notch to the highest level of the fundus
A client who’s 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. She’s admitted for treatment of an ectopic pregnancy. Of the following nursing diagnoses, the nurse should give the highest priority to:
1. Risk for deficient fluid volume.
A client treated with terbutaline (Brethine) for preterm labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?
“1. Report a heart rate greater than 120 beats/minute to the physician.
A client who’s 32 weeks pregnant is hospitalized with preterm labor. After preterm labor is arrested, she’s discharged with a prescription for oral terbutaline (Brethine). Which instruction should the nurse provide during discharge teaching?
“2. “”Abstain from sexual intercourse unless you use a condom.””
As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy?
4. Reduced intestinal motility
The nurse is checking the legs of a client who’s 36 weeks pregnant. Which finding should the nurse expect?
2. Bilateral dependent edema
A pregnant client’s last menstrual period began on October 12. The nurse calculates the estimated date of delivery (EDD) as:
4. July 19
The nurse obtains the antepartum history of a client who’s 6 weeks pregnant. Which finding should the nurse discuss with the client first
2. Her consumption of six to eight cans of beer on weekends
A pregnant client in her third trimester asks why she needs to urinate frequently, as she did during the first trimester. What should the nurse tell her?
3. This symptom is normal and results from the fetus exerting pressure on the bladder.
The nurse is providing care for a pregnant woman. The woman asks the nurse how she can effectively deal with her fatigue. The nurse should instruct her to:
2. try to get more rest by going to bed earlier.
An 18-year-old pregnant woman tells the nurse that she’s concerned that she may not be able to take care of herself during her pregnancy. She states that prenatal care is expensive and her job doesn’t provide insurance. The nurse should recognize that the client:
4. should be referred to community resources available for pregnant women
During the first 3 months, which hormone is responsible for maintaining pregnancy?
“1. Human chorionic gonadotropin (hCG)
A pregnant client comes to the clinic after missing several scheduled prenatal appointments. During the initial assessment, the client states, “I haven’t been coming to some of my appointments because I go to a homeopathic specialist who takes great care of me.” Which response by the nurse is best?
2. “You should mention the homeopathic specialist to your physician so he can help devise the best care plan for you.”
What is the primary nursing diagnosis for a client with a ruptured ectopic pregnancy?
3. Deficient fluid volume
A client who’s 24 weeks pregnant and diagnosed with preeclampsia is sent home with orders for bed rest and a referral for home health visits by a community health nurse. Which comment made by the client should indicate to the nurse that the client understands the purpose of home health visits?
3. “”The community health nurse will check me and my baby and talk with my physician.””
The nurse is collecting data on a pregnant woman in the clinic. In the course of the data collection, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to:
“1. assess the client’s readiness to stop.
A client is 2 months pregnant. Which factor should the nurse anticipate as most likely to affect her psychosocial transition during pregnancy?
1. Support from her partner
The nurse is obtaining a prenatal history from a client who’s 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask:
2. “”Do you have any cats at home?””
A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate?
3. The fetus isn’t in distress at this time.
What discomforts are common during the 1st trimester of pregnancy?
Morning sickness, fatigue, and urinary frequency.
What discomforts are common during the 2nd trimester of pregnancy?
Heartburn and constipation (no laxatives!)
What discomforts are common during the 3rd trimester of pregnancy?
Urinary frequency (end of 3rd), heartburn, constipation, backache, insomnia, supine hypotensive syndrome (left side lying), and leg cramps.
If a woman during her 1st trimester is experiencing back pain what should be done?
Investigate further bc back pain during the 1st trimester isn’t normal and she may be experiencing an ectopic pregnancy. Other symptoms associated with ectopic pregnancy include increased heart rate and pulse from hemorrhage.
If a woman in her 3rd trimester of pregnancy is experiencing leg cramps what should be done?
Nothing bc leg cramps in this trimester are normal. (NOT DVT)
What is ALPHA-FETOPROTEIN SCREENING?
Alpha-fetoprotein is the predominant protein in fetal plasma. It is excreted into the amniotic fluid thru fetal urine. Some cross into maternal circulation so AFP CAN BE MEASURED IN BOTH THE MATERNAL SERUM AND IN THE AMNIOTIC FLUID. Abnormal concentrations are associated with fetal anomalies. It is optimally done during 15 and 18 weeks of gestation. If abnormal ultrasound follows and if still unexplained amniocentesis is next.
What is beneficial about maternal serum AFP evaluation?
It is a simple blood test and is least invasive.
What can elevated levels of AFP indicate?
OPEN NEURAL TUBE DEFECTS, ABDOMINAL WALL DEFECTS (OMPHALOCELE, GASTROSCHISIS).
What can low levels of AFP indicate?
CHROMOSOMAL TRISOMIES (DOWNS SYNDROME).
What is TRIPLE MARKER SCREENING?
It is when two other markers, human chorionic gonadotropin (hCG) and unconjugated estriol have been added to an AFP evaluation. This triple marker screening has been found to increase the detection of trisomy 18 and 21. Maternal serum samples are taken between 15 and 22 weeks gestation. If all three markers are low= positive result (amniocentesis would follow).
What is CHORIONIC VILLI SAMPLING?
The villi are made up of cells that reflect the genetic makeup of the fetus. The samples are used to diagnose abnormalities (it doesn’t assess for neural tube defects bc those require amniotic fluid). It is recommended only for women who are at risk for fetal anomalies. Use is restricted bc of reported complications (spotting, bleeding, uterine cramping, and fetal loss). Essentially taking a piece of the baby so try to avoid if possible.
Why is an amniocentesis done during the 2nd trimester? During the 3rd?
It is done during the 2nd (before 30 wks) to identify chromosomal abnormalities. It is done during the 3rd (after 30 wks) to determine fetal lung maturity to diagnose fetal hemolytic disease (Rh incompatible).
What is the best test for determining fetal lung maturity?
The lecithin/sphingomyelin (L/S) ratio is best known for estimating fetal lung maturity.
What L/S ratio indicates adequate maturity?
At 30 weeks the sphingomyelin plateaus but the lecithin continues to rise. A ratio greater than 2:1 generally indicates that surfactant is adequate and the lungs are mature.
What drug can be used to stimulate fetal lung maturity in a fetus? Considerations?
Betamethasone. It takes 24 hours to start working and may increase mom’s blood sugar.
What is a biophysical profile?
It is a prenatal ultrasound of fetal well being often done with a non-stress test. SINCE IT IS AN ULTRASOUND A FULL BLADDER IS REQUIRED.
What are the three types of antepartum fetal surveillance?
Nonstress test, contraction stress test, and the biophysical profile. The goal is to prevent perinatal morbidity and mortality, determine fetal health, and guide interventions.
What hormone do home pregnancy tests look for indicating pregnancy?
HcG human chorionic gonadatropin
What should an umbilical cord contain?
AVA (two arteries and a vein) if patient doesn’t have AVA then they are priority.
What is Nagel’s rule?
It is used to determine an estimate of the due date. It says to count back 3 months and add 7 days from your last menstrual period. Watch for a post due date question (it may ask about post not the actual estimated due date).
If a womens last menstrual period is 5/21 when is her estimated due date?
February 28th!
What is Leopolds maneuver?
It is used to determine the baby’s position and know where to place the stethescope.
Left occiput anterior =
Easy labor
Left occiput posterior=
Difficult/painful labor
What is the purpose of a nonstress test?
To observe the RESPONSE of the fetal heart rate to the stress of activity.
What does a nonreactive nonstress test indicate?
Nonreactive, nonstress, not good. It means that the baby probably can’t handle a vaginal birth (ex: cord around baby’s neck=variable decelerations and emergency c-section).
What does a reactive nonstress test indicate?
Reactive Response is Real good. Heart rate is elevated in response to stress of activity. Baby can handle vaginal delivery.
What is considered tachycardia for a fetus? Indicative of what?
>160 bpm, indicative of maternal or fetal infection or fetal hypoxia (an ominous sign).
What is considered fetal bradycardia? Indicative of? Intervention?
<120 bpm, indicative of fetal hypoxia or stress and maternal hypotension after epidural initiation (place client on left side, increase fluids, and stop pitocin).
WHAT IS AN EARLY DECELERATION?
HR SLOWS BEFORE PEAK OF CONTRACTION AND RECOVERS BY END OF CONTRACTION. (BEING EARLY IS GOOD)
WHAT ARE EARLY DECELERATIONS INDICATIVE OF?
HEAD COMPRESSION (NOT OMINOUS=NO INTERVENTION REQUIRED).
WHAT ARE LATE DECELERATIONS?
HR DECREASES AFTER PEAK OF CONTRACTION AND RECOVERS AFTER CONTRACTION ENDS. (BEING LATE IS BAD).
WHAT ARE LATE DECELERATIONS INDICATIVE OF? INTERVENTIONS?
FETAL STRESS AND HYPOXIA OR DEFICIENT PLACENTAL PERFUSION (CHANGE MATERNAL POSITION AND DISCONTINUE OXYTOCIN (PITOCIN)).
WHAT ARE VARIABLE DECELERATIONS?
TRANSIENT DECREASE IN HR ANY TIME DURING CONTRACTION.
WHAT ARE VARIABLE DECELERATIONS INDICATIVE OF? INTERVENTIONS?
CORD COMPRESSION (CHANGE MATERNAL POSITION-KNEE CHEST/ASS IN AIR). IF CORD IS PROTRUDING NEVER TOUCH.
What is decreased variability?
A smooth baseline. The baseline should vary by 10 to 15 beats every minute. The loss of short term variability can be ominous where as long term loss (20 to 40 mins) is probably not significant and can indicate a sleep cycle.
What is decreased variability indicative of?
Fetal sleep cycle, depressant drugs, hypoxia, or CNS anomalies.
What is an acme?
A peak of something
What are the three different ratings for APGAR CRITERIA?
0 (POOR), 1, and 2 (BETTER). LOWEST SCORE IS A 0 AND HIGHEST IS 10.
What are the different criteria for APGAR SCORING?
COLOR, HR, REFLEX IRRITABILITY, MUSCLE TONE, RESPIRATORY EFFORT.
WHAT KIND OF STOOL IS PASSED WITHIN 36 HOURS OF BIRTH?
MECONIUM (THICK, BLACK/GREEN, TENACIOUS).
What can meconium after 36 hours indicate?
Megacolon with absence of peristalsis.
What kind of stool follows meconium and when?
Within 48 hours after birth transitional stool is passed (meconium combined with greenish/brown milk stools).
What kind of stool occurs 4-5 days after birth?
Milk stools (yellow, green-yellow).
What pregnancy complications are of concern in the 1st trimester?
Ectopic pregnancy, abortion, incompetent cervix, and hyperemesis gravidarum)
What pregnancy complications are of concern in the 3rd trimester?
Placenta previa, abruptio placenta, and hypertensive disorders.
What treatment should be done for ectopic pregnancy?
Surgical treatment and IV FLUID
What is a characteristic sign of placenta previa?
painless bleeding around the 7th month
What is characteristic of abruptio placentae?
Tender abdomen c pain/bleeding
What classifies as eclampsia?
Pregnancy induced hypertension after a seizure.
What preventative measures are taken for hypertensive disorders during pregnancy?
No sodium intake, I&O, and elevate extremities.
What type of pregnancy complication patient could be assigned to a non-OB nurse?
Hyperemesis Gravidarum
What is done for an incompetent cervix?
Purse string procedure
What is done for GDM patients during any trimester?
Since they experience polyuria, polydypsia, and polyphagia ICE CHIPS would be good and frequent blood sugar checks.
What is the triad of symptoms in hypertensive disorders?
Edema, increased BP, and Proteinuria
What is a hydatidiform mole? Treatment?
It is a rare mass or growth that forms inside the uterus at the beginning of pregnancy. It is a presumptive sign of pregnancy. A D&C will be performed and HcG levels will be taken every month for a year to determine the tissue is gone. The patient shouldn’t get pregnant again for another year and they are at increased risk for Ca. (Chemo is given for HcG levels that indicate choriocarcinoma).
What should be watched with hydramnios?
“Too much amniotic fluid”. There is an increased risk for hemorrhage.
When is Rhogam received?
1st trimester or 72 hours after childbirth
What is the treatment for pregnancy induced HTN (PIH)?
Bed Rest, increased protein diet, BP meds, monitor for seizures, and MgS04 if needed.
When does preeclampsia usually occur?
Third trimester
What are the symptoms of mild preeclampsia?
Hypertension (sys increase of 30 and diastolic of 15), Edema (generalized & periorbital, gain 1lb/wk in 3rd T), and Proteinuria (1gm/24 hrs, 1+ protein).
What are the S&S of severe preeclampsia?
Hypertension, Edema, Proteinuria, Midepigastic pain d/t liver edema, increased ICP (cerebral), visual changes, vomiting, and oliguria.
What causes preeclampsia to become eclampsia?
The presence of seizures.
What is given to prevent or treat PIH seizures?
Magnesium sulfate
What will lab tests show with severe preeclampsia?
HELLP= Hemolysis, Elevated Liver function tests, and Low Platelet count.
What needs to be available when a patient with preeclampsia delivers and why?
Blood (ABO) bc the patient will lose an increased amount of blood during delivery.
Why is MAGNESIUM SULFATE given to pregnant women?
To prevent seizures with the complication of pregnancy induced hypertension (PIH).
What will a woman on MgS04 feel like?
Sleepy bc it is a nervous system depressant.
What is the antidote for MgS04?
Calcium gluconate
What are the S&S of MgS04 toxicity? Treatment?
BURP= Blood pressure decreased, urine output decreased (<30), respirations <12, and patella reflex absent. D/C mag sulfate if see these signs.
What is pitocin used for?
To induce labor.
What are the side effects of pitocin?
PITOCIN= pressure elevated, intake and output bc holding fluid, TETANIC CONTRACTIONS, oxygen decrease in fetus, cardiac arrhythmia, irregularity in fetal heart rate, and N&V. Imagine Pitty Pitocin in a row boat looking into a PIT watching the Tetanic sink into the ocean (ocin).
What should be done when pitocin is being administered?
Document contractions: counting from beginning of contraction to beginning of the next and add to the rest of the period.
What should be done if contractions are lasting 1 1/2 mins or if side effects are presenting?
STOP THE PITOCIN. If contractions are lasting that long then the baby isn’t getting oxygen during that time.
What are the three types of Pharmacologic intrapartum pain management methods?
Epidural block, subarachnoid block, and general anesthesia.
What are important considerations when an epidural block is being administered?
ASSESS for hypotension at least every 5 mins after block is started, YOU MUST HAVE AN IV, AND IF HYPOTENSION OR SIGNS OF IMPAIRED PLACENTAL PERFUSION OCCUR= INCREASE THE RATE OF IV FLUID/ TURN WOMAN ON HER LEFT SIDE/ AND ADMINISTER O2 VIA FACE MASK (8-10 L).
When are pain drugs given during pregnancy?
ACTIVE phase only. If given during transitional phase they can effect the baby.
Can a quadriplegic deliver vaginally?
Yes!
What is an important consideration when a subarachnoid block is being administered?
MUST HAVE AN IV and care for hypotension or signs of impaired placental perfusion. (a subarachnoid block is done just before birth so it doesn’t provide pain relief for labor).AND IF HYPOTENSION OR SIGNS OF IMPAIRED PLACENTAL PERFUSION OCCUR= INCREASE THE RATE OF IV FLUID/ TURN WOMAN ON HER LEFT SIDE/ AND ADMINISTER O2 VIA FACE MASK (8-10 L).
What interventions should be completed with antepartal pain management?
Prehydration, displace uterus to left, observe BP and fetal HR, and observe for bladder distension.
What are characteristics of TRUE LABOR?
Contractions (increase in frequency, duration, and intensity), cervix is dilated and effaced, the presenting part is descending into the birth canal, a mucous plug is present, when walking pain intensifies, and membranes may rupture.
What are the 4 stages of labor?
First (stage of cervical dilation), second (stage of expulsion), third (placental stage), and fourth (maternal homeostatic stabilization).
What are the three parts of the first stage of labor?
Latent (<4cm, if give drugs at this time will stop the labor), Active (Give drugs), and Transitional (>8cm)
What does the 1st stage of labor (cervical dilation stage) begin and end with?
Begins with onset of regular contractions and ends with complete dilation.
What would be needed if mom is given demerol and ends up delivering the baby an hour later?
Narcan for the baby bc will show effects of drug.
What does the 2nd stage of labor (expulsion stage) begin and end with?
Begins with complete cervical dilation and ends with delivery of the fetus.
What does the 3rd stage of labor (placental stage) begin and end with?
Begins immediately after fetus is born and ends when the placenta is delivered.
What does the 4th stage of labor (maternal homeopathic stabilization stage) begin and end with?
Begins after the delivery of the placenta and continues for one hour after delivery.
Who is most likely to die from hemorrhage during labor, a women having an 11 lb. baby or a woman delivering sextuplets?
The woman with the 11 lb. baby.
What should a pregnant woman who is constipated be told to eat?
Legumes
What is a normal weight gain during pregnancy? By trimester? Calorie increase?
25-35 lbs. is normal for entire pregnancy. Gain 3 lbs. during 1st trimester, 0.7 lb/week or half of expected wt gain during 2nd trimester, and 1 lb/wk during the 3rd trimester. Calories should be increased by 300/day while pregnant and 500 while nursing.
What is the correct position for using a bulb syringe on an infant?
Head slightly lower than the rest of the body (trendelenburg=dependent)
What are the correct steps for using a bulb syringe?
Position head slightly lower than rest of the body, compress bulb before inserting into mouth, insert into side of mouth, release slowly, empty, then suction the nose AFTER the mouth
What are the steps of a postpartum assessment?
BUBBLE HE= BREAST (mastitis), UTERUS (fundus should be firm and midline several fingers above umbilicus about the size of a GRAPEFRUIT), BLADDER (distension, diuresis during 1st 2 days post), BOWEL (laxative need 3rd day should be normal), LOCHIA (no odor & appropriate type), EPIOSIOTOMY (infection & healing), HOMANS SIGN (thrombophlebitis), AND EMOTIONAL (Support).
What are the 3 types of lochia and when do they occur?
Rubra (dark red, 1st 3 days), Serosa (pinkish, sero-sanguinous, 3-10 days), and alba (creamy or yellowish after the 10th day and may last a week or two).
What should be taught to pregnant women who want to avoid an episiotomy?
Squatting or pelvic rocking
What S&S will a pregnant women who had a forceps assisted birth present with?
Tight and itchy=(hematoma)
What should be told to a woman who asks about intercourse one day after giving birth?
Intercourse must stop after discharge and should not be reinstated for 6 weeks.
Can a woman use tampons after birth for lochia?
NO!!!! bc they are at risk for toxic shock syndrome
What should be done if a woman is cramping after being given methergine?
Nothing it is an expected outcome and means that the drug is working.
How is methergine used after birth?
It is used to control bleeding by promoting increased contractions and stiffening of the uterus muscles.
What should be taught to a woman with mastitis?
Continue to breast feed on both breasts.
What should a pregnant woman be taught to do to toughen nipples?
Expose to air after a feeding
What should a woman who is having trouble producing milk do?
Apply heating pads to the breasts
What should a woman do if not breast feeding their baby to prevent engorgement?
Apply ice pack to breasts and wear a tight bra
What sign will the baby show that they are correctly latched to the breast?
Their lips will flange
What is the proper way to help the baby release suction on the breast?
Put finger in the corner of the mouth to break suction. DON’T pull or can cause trauma to breast.
What are the 4 types of heat loss in an infant?
Evaporation (moisture on skin), CONDUCTION (CONTACT WITH COLD OBJECTS-SCALE OR COLD HANDS), Convection (drafts from open doors or air conditioning), and Radiation (by cold surfaces, so from baby to crib and out window).
What might cause babies to not shiver when cold?
Increased brown fat present
What are risk factors for hypoglycemia in a newborn?
Post maturity, cold stress, and maternal diabetes.
What are signs of hypoglycemia in a newborn?
(40-60 mg/dL =normal in infant) Jitteriness, low temperature, and lethargy.
If you see signs of hypoglycemia in a newborn what should you do?
Check sugar and give glucose h20 (don’t need anymore evidence)
What are the treatments for a baby with elevated bilirubin?
Bili-light or fiber optic blanket, monitor skin temp, check for dehydration, and increased formula or breast feeding to increase excretion of bilirubin in stool.
Should a baby’s eyes be covered for both the bili-light and the fiber optic blanket?
NO. The bili-light requires the eyes to be covered but the fiber optic blanket does not.
A cold or dehydrated baby=
A dead baby
If the power goes out and a baby is under a bili-light are they a priority patient?
YES!!!! Bc they may get cool rapidly without the light. Cold baby=dead baby
What should a baby undergoing bili light therapy be wearing?
As little clothes as possible (diaper) and eye coverings.
What is a baby at risk for if bilirubin levels become too elevated?
Kernicterus (brain damage)
What should you do in the case of an imminent (right now) vaginal birth?
Place sheets or newspapers under mother, don gloves, WITH ONE HAND PRESS A CLEAN CLOTH AGAINST THE PERINEUM FOR SUPPORT AND INSTRUCT HER TO PANT. AS THE BABY’S HEAD EMERGES, PLACE THE OTHER HAND ON IT GENTLY BUT FIRMLY TO PREVENT AN EXPLOSIVE DELIVERY (CAN CAUSE TEARING AND RAPID PRESSURE CHANGES IN BABYS SKULL) AND SUPPORT THE CHILD!!!!!!. Check umbilical cord, place hands on either side of head and deliver body, after delivered and the baby is crying dry him/her thoroughly, including head, and wrap him in towel or blanket (heat loss is dangerous). If she can start breast feeding immediately it will stimulate oxytocin release and uterine contractions to help deliver the placenta and reduce bleeding.
What will a woman with abruptio placentae present with?
Sharp abdominal pains and vaginal spotting (or large amounts of vaginal bleeding), tender and rigid abdomen, pale, anxiousness, diaphoretic, tachycardia, increased respirations, and increased temperature.
What should be done 1st?
Place in left side lying position and administer 4 L nasal cannula.
What are the risks of abruptio placentae?
Fetal anoxia or death, and maternal shock, hemorrhage, or death. (an emergency c-section is usually indicated).
What should be done in preparation for an emergency c-section as a result of an abruptio placentae?
Keep her NPO for surgery, administer supplemental oxygen, and start a large bore IV line.
What are causes of abruptio placentae?
HTN, trauma, diabetes, cocaine use, alcohol abuse, cigarette smoking, PROM, or an abnormally short umbilical cord.
What are the S&S of a ruptured ectopic pregnancy?
Sick to stomach, cramps, pallor, slight fever, bright red vaginal bleeding, excruciating shooting pain in right shoulder which worsens with inhaling, tachycardia, and hypotension. (if states last menstrual period 8 weeks ago with spotting can suspect)
What should be done immediately for a women with a ruptured ectopic pregnancy?
Notify MD, insert a large bore IV, infuse NaCl at 150/hr, ask about food incase surgery, blood and urine tests, vital signs, morphine, and surgery prep.
What needs to be taught to new parents about cord care?
Keep area clean and dry, diaper below cord to prevent irritation, cleanse with alcohol, signs of infection are redness, drainage, swelling, and odor.
What needs to be taught to new parents about circumcision care?
Observe for bleeding with FIRST URINATION, Change the dressing with vaseline gauze only, NO ICE on penis, and apply diaper loosely to prevent irritation.
What needs to be taught to new parents about preterm bonding?
Encourage parents to hold/sing to their infant, promote skin to skin contact, feedings promote bonding, and make sure focused when bonding (ex: NO TV while breast feeding.
What will happen to a preterm (before 37 weeks) infants ear if folded forward?
It will open slowly or stay folded in very premature infants.
How will a premature (before 37 weeks) infants male genitalia vary from normal?
Fewer shallow rugae on the scrotum
How will a premature (before 37 weeks) infants heel creases vary from normal?
Soles are smoother, creases extend less than 2/3 of the way from the toes to the heel.
What differences will a post term baby have?
They are old so wrinkly with sugar problems.
What is a condition needed before introduction of solid foods is allowed?
Extrusion reflex has disappeared (4-5 months). Babies don’t chew!
What is the child’s concept of death over time?
Infant/toddler (0-2 yrs)= loss of caretaker (bottle/milk), early childhood (2-7 yrs)= reversible/temporary “sleeping”, Middle childhood/school age (7-12)= irreversible but doesn’t apply to them, and Adolescence (12+)= understand death is inevitable and irreversible but seems like a distant event.
What should be taught to a family preparing to take their infant home on a home apnea monitor?
All caregivers should learn how to use the home apnea monitor and CPR!!! That the alarm is set for apnea >20 seconds, and that EXTENSION CORDS/ ADAPTERS/ CHEATER PLUGS ARE NOT TO BE USED WITH THE MONITOR (or any medical equipment).
What are S&S of menopause?
Hot flashes, night sweats, sensitive and moody, increase in vaginal bleeding during menstrual period times, and anemia.
What has to be existent for it to be considered sterile?
Absence of periods for 12 months in a row. If both ovaries are removed=instant menopause.
What things can be done to reduce hot flashes?
Wear cotton clothes, wear natural fibers, dress in layers, herb: black cohosh (helps decrease), avoiding dairy product and meat (they increase HFs).
What things place someone at risk for developing osteoporosis?
Woman, thin, white or Asian, family Hx, menopause b4 age 45, smoking, drink more than 2 drinks per day, not getting enough exercise, excess coffee and carbonated beverages, and lack of calcium and vitamin D.
How is osteoporosis treated?
With diet (calcium and vitamin D), exercise, and medication if needed.
What should be avoided if you have osteoporosis?
Carbonated beverages, excess salt, red meat, excess caffeine, and excess alcohol bc can slow body’s calcium absorption.
What are some common osteoporosis medications?
Alendronate (FOSAMAX), Ibandronate (Boniva), Risedronate (Actonel), Teriparatide (Forteo), and Raloxifene (Evista)
What should be looked out for when taking Fosamax, Actonel, or Boniva (bisphosphates)?
Trouble swallowing, chest pain, or severe/worsening of heart burn.
What should be looked out for when taking Evista (selective estrogen receptor modulator)?
Pain, redness, swelling in the legs, unexplained uterine bleeding, or breast abnormalities.
What should be looked out for when taking Forteo (a parathyroid hormone)?
Sit or lie down if the drug causes a fast heartbeat, lightheadedness, or dizziness.
What vaccines should adults be getting?
Tetanus (q 10 yrs), Influenza (q yr @50), Pneumonia (1x @65), Shingles (1x @60), MMR (2 doses between 19 & 49), and Varicella (2 doses between 19 & 49 if no immunity).
What are the two back alterations that osteoporosis can cause?
Dorsal Kyphosis (hump back) and cervical lordosis (Lower L-shaped curve to back)
What activities should people with osteoporosis avoid?
High impact sports. Water aerobic and swimming is great!!!
What are the most common osteoporosis associated injuries?
Crush fractures especially at T8 and below. Hip and Colles’ (distal fracture of radius in forearm) fractures are MOST COMMON.
What is a common med regimen for a person with osteoporosis?
Calcium supplement, Fosomax or Actonel, and Estrogen.
How/When should Fosamax be taken?
To prevent GI side effects take with 8 ounces of water first thing in the morning. Stay sitting up and NPO for at least half an hour before eating or taking other drugs.
What general safety precautions should be implemented with infants?
Car seats should always be in the center of the backseat of the car, always keep on hand on baby during a bath, never shake or jiggle your baby vigorously or throw him/her in the air, always store medications and household products out of reach, and never leave your baby unattended on surfaces above the floor such as changing tables (SAFEST PLACE FOR BABY IS UNDER LEGS WHILE COOKING BC CAN’T ROLL OFF OF ANYTHING), no chains/crosses around babies neck (Hispanics-tape cross to HOB or chart but not wear), and NO METAL TOYS.
What reflexes is a baby born with?
Moro, palmar grasp, plantar grasp (babinski), sucking, rooting, stepping/walking, placing, tonic neck (fencing), and swimming.
What is the plantar grasp (Babinski) reflex?
When foot is touched toes spread out and foot twists inward. Gone by 9-12 months.
What is the palmar grasp used to check for?
Hypothyroidism (cretinism) will sleep 23 hours.
What is a cremateric reflex?
Touch the inner thigh of a boy and his scrotum will elevate (+ for life).
What is the red reflex?
Red pupils when picture is taken.
Trunk-curve reflex?
Fingers down babies spine should curve like a cat.
In what babies is the moro/startle reflex exaggerated?
Crack/drug babies
What types of smells/tastes do babies prefer?
Sweet smells and tastes is prefered
When will a baby show a preference for mothers voice and turn head in the direction of sound?
By third month
What change in hearing will a baby develop by 7 months?
Locates sound accurately
When is vision in a baby fully developed?
At seven months
For how long should a baby face the back in a car seat?
<1 yr
How long should a child remain seated in the backseat?
12 yrs
PHYSIOLOGICAL MATERNAL CHANGES
Cardiovascular system
1. Circulating blood volume increases
2. Heart is elevated upward and to L because of displacement of diaphragm as uterus enlarges.
3. Pulse may increase about 10 beats per minute; blood pressure may slightly decline during 2nd trimester
4. Increase in body’s demand for iron; physiological anemia may occur.
5. Sodium and water retention may occur, which can lead to weight gain.
Respiratory system
1. Oxygen consumption increases as a result of an increase in metabolic rate and tissue mass.
2. Diaphragm is elevated as result of inlarged uterus.
3. Respiratory rate remains unchanged.
4. Shortness of breath may be experienced.
Gastrointestinal (GI) System
1. Nausea and vomiting may occur as result of secretion of human chorionic gonadotropin (hCG), which subsides by the 3rd month.
2. Increase in body’s nutritional requirements (vitamins, minerals, calores, protein, and iron)
3. Constipation as a result of decreased GI motility or pressure of the uterus.
4. Chages in appetite, flatulence, and heartburn as result of decreased GI motility and slow emtying of stomach.
5. Alteration in taste and smell may occur.
6. Hemorrhoids as a result of increased venous pressure.
7. Altered gallbladder function that can lead to gallstone formation caused by an increase in progesterone.
Renal System
1. Frequency of urination occurs during the first and third trimesters as a result of pressure of enlarging uterus on bladder, which causes decreased bladder capacity.
2. Decreased bladder tone is caused by hormonal changes.
3. Renal function increases
4. Renal threshold for glucose may be reduce.
Endocrine system.
Basal metablic rate rises.
Reproductive system
1. Uterus
a. Enlarges from 60 to 1000g.
b. Irregular contractions occur.
2. Cervix
a. Becomes shorter, more elastic, and larger in diameter.
b. Endocervical glands secrete a thick mucus plug, which is expelled from the canal when dilation begins
c. Increased vascularization causes a softening and a violet discoloration (Chadwick’s sign)
3. Ovaries: Cease ovum production
4. Vagina
a. Hypertrophy and thickening of muscle occurs.
b. Increase in vaginal secretions occurs; secretions are usually thick, white, and acidic.
5. Breasts
a. Breast size increases
b. Increase in blood flow to the breasts; swelling, tingling, and tenderness are common.
c. Nipples ecome more pronounced and the areolae become darder, with an increase in ductal growth.
d. Colostrum may leak from breasts.
Skin
1. Dark streak down midline of abdomen may appear (linea nigra)
2. Cholasma (mask of pregnancy), which is a blotchy, brownish hyperpigmentation, may occur over forehead, cheeks, and nose.
3. Reddish-purple stretch marks (striae) may occur on abdomen, breasts, thighs, and upper arms.
Musulosketetal system
1. Postural changes occur as increased weight of uterus causes a forward pull of bony pelvis.
2. Ligament laxity and softening of connective tissue are seen throughout body as a result of an increase in estrogen and relaxin.
PSYCHOLOGICAL MATERNAL CHANGES
Ambivalence
1. May occur even when the pregnancy is planned.
2. Mother may experience a dependence-independene conflict and ambivalence related to role changes, changes in body image, and fear of unknown.
3. Partner may experience ambivalence related to assuming new role, increased financial responsibilities, mother’s physical changes, and having to share attention with child.

Acceptance
1. Factors that may be related to acceptance of pregnancy are woman’s readiness for experience and her identification w/the motherhood role.
2. Commonly occurs at 20 weeks, when quickening is likely to occur.

Emotional lability
1. Frequency in change of emotional states or extremes in emotional states caused by hormone changes.
2. These emotional changes are common, but the mother may believe that these changes are abnormal.

Body image changes: perception of her image during pregnancy occurs gradually and may be either positive or negative; often influenced by her partner.

Relationship w/fetus.
1. Woman may daydream to prepare for motherhood and think about maternal qualities she would like to possess.
2. Woman first accepts biological fact that she is pregnant.
3. Woman next accepts growing fetus as distinct from herself and as a person to nurture.
4. Finally, woman prepares realistically for birth and parenting of child.

DISCOMFORTS OF PREGNANCY
Nausea and vomiting
1. Occur during first trimester
2. Caused by elevated hCG levels and changes in carbohydrate metabolism.
3. Interventions
a. Eating dry crackers before arising
b. Avoiding brushing teeth immediately after arising.
c. Eating small, frequent, low-fat meals during the day.
d. Drinking liquids between meals rather than at meals.
e. Avoiding fried foods and spicy foods.
f. Acupressure (some types may require a prescription)
g. Herbal remedies, only if approved by a physician or nurse-midwife.

Syncope
1. Usually occurs during 1st trimester; supine hypotension occurs, particularly during the 2nd and 3rd trimesters.
2. May be hormonally triggered or caused by increased blood volume, anemia, fatigue, sudden position changes, or lying supine.
3. Interventions
a. Sitting w/feet elevated
b. Changing positions slowly
c. Changing to lateral recumbent position to relieve pressure of uterus on inferior vena cava.
d. Increasing fluid intake

Urinary urgency and frequency
1. Usually occurs during 1st and 3rd trimesters.
2. Caused by pressure of uterus on bladder.
3. Interventions
a. Drinking 2 quarts of fluid during day
b. Limiting fluid intake during evening.
c. Voiding at regular intrvals.
d. Sleeping on side at night.
e. Wearing perineal pads, if necessary.
f. Performing Kegel excercises

Breast tenderness and tingling
1. Can occur from 1st through 3rd trimesters.
2. Caused by increased levels of estrogen and progesterone.
3. Interventions
a. Encouraging use of a supportive bra w/nonelastic straps
b. Avoiding use of soap on nipples and areolae to prevent drying.

Increased vaginal discharge
1. Can occur from 1st – 3rd rimesters
2. Caused by hyperplasia of vaginal mucosa and increased mucus production.
3. Interventions
a. Wearing cotton underwear
b. Avoiding douching
c. Using proper cleansing and hygiene techniques.
d. Advising client to consult physician or nurse-midwife if infection is suspected.

Nasal stuffiness or nosebleeds
1. Occurs during 1st-3rd trimesters
2. Occurs as result of increased estrogen that causes swelling of nasal tissues and dryness
3. Interventions
a. Encouraging use of humidifier.
b. Avoiding use of nasal sprays or antihistamines.

Fatigue
1. Occurs usually during 1st-3rd trimesters
2. Is usually result of hormonal changes
3. Interventions.
a. Arranging frequent rest periods throughout day.
b. Using correct body mechanics
c. Engaging in regular exercise
d. Performing muscle relaxation and strengthening exercises for legs and hip joints.
e. Avoiding eating and drinking foods that contain stimulants throughtout pregnancy.

Heartburn
1. Occurs during 2-3rd trimesters.
2. Results from increased progesterone levels,decreased GI motility, esophageal reflux, and the displacement of the stomach by enlarging uterus.
3. Interventions
a. Eating small, frequent meals and avoiding fatty and spicy food
b. Sitting upright for 30 min. after a meal.
c. Drinking milk between meals.
d. Performing tailor-sitting exercises (sitting cross-legged)
e. Taking antacids only if recommended by the physician or nurse-midwife.

Ankle edema
1. Usually occurs during 2-3rd trimesters
2. Occurs as a result of vasodilation, venous stasis, and increased venous pressure below the uterus.
3. Interventions
a. Elevating legs during day
b. Sleeping on left side
c. Wearing supportive stockings
d. Avoiding sitting or standing in one position for long periods.

Varicose veins
1. Usually occur during 2-3rd trimesters
2. Occur because of weakening walls of veins or valves and venous congestion.
3. Interventions
a. Wearing support hose
b. Elevating feet when sitting
c. Lying w/feet and hips elevated.
d. Avoiding long periods of standing or sitting
e. Moving about while standing to improve circulation
f. Avoiding leg crossing
g. Avoiding constricting articles of clothing

Headaches
1. Usually occur during 2-3rd trimesters.
2. Occur as a result of changes in blood volume and vascular tone.
3. Interventions
a. Changing position slowly.
b. Applying a cool cloth to forehead
c. Eating a small snack
d. Using acetaminophen (Tylenol) only if prescribed by the physician or nurse-midwife.

Hemorrhoids
1. Usually occur during 2-3rd trimester
2. Occur as a result of increased venous pressure and/or contstipation.
3. Interventions
a. Soaking in a warm sitz bath
b. Sitting on a soft pillow
c. Eating high-fiber foods and avoiding constipation
d. Drinking sufficient fluids
e. Increasing exercise, such as walking
f. Applying ointments, suppositories,s or compresses as prescribed by the physician or nurse-midwife.

Constipation
1. Usually occurs during 2-3rd trimesters.
2. Occurs as result of decreased intestinal motility, displacement of intestines, and taking iron supplements.
3. Interventions
a. Eating high-fiber foods
b. Drinking sufficient fluids
c. Exercising regularly
d. Avoiding laxatives and enemas unless their use is approved by the physician or nurse-midwife.

Backache
1. 2-3rd trimester
2. Occurs as a result of exaggerated lumbosacral curve, which is cause by enlarged uterus.
3. Interventions
a. Encouraging rest
b. Using correct body mechanics and improving posture.
c. Wearing low-heeled shoes
d. Performing pelvic rocking and abdominal breathing exercises
e. Sleeping ona firm mattress

Leg cramps
1. Usually occur during 2-3 trimester
2. Occur as result of an altered calcium-phosphorus balance, pressure of the uterus on nerves, or fatigue
3. Interventions
a. Getting regular exercise, especially walking
b. Dorsiflexing foot of affected leg
c. Increasing calcium intake

Shortness of breath
1. 2-3rd trimester
2. Occurs as reult of pressure on diaphragm
3. Interventions
a. Allowing frequent rest periods and avoiding overexertion
b. Sleeping w/head elevated or on side
c. Performing tailor-sitting exercises.

LABORATORY TESTS
A. Blood type and Rh factor
1. ABO typing is performed to determine woman’s blood type.
2. Rh typing done to determine presence or absence of Rh antigen (Rh positive or Rh negative)
3. If client if Rh- and has a negative antibody screen, client will need repeat antibody screens and should receive Rh immune globulin at 28 weeks’ gestation.

B. Rubella titer
1. If client has negative titer, indicates susceptibility to rubella virus; client should receive appropriate immunization postpartum.
2. Client must be using effective birth contol at time of immunization, she must be counseled to not become pregnant for 1 to 3 months after immunization (as specified by health care provider) and to avoid contact w/anyone who is immunocompromised.
3. If rubella vaccine is administered at same time as Rh immune globulin, may not be effective.

C. Hemoglobin and hematocrit levels
1. Hemoglbin and hematocrit levels will drop during gestation as result of increased plasma volume.
2. A decrease in hemoglobin level below 10g/dL or a decrease in hematocrit level below 30g/dL indicates anemia.

D. Papanicolaou (Pap) smear: Done during initial prenatal examination to screen for cervical neoplasia.

E. Sexually transmitted infections
Gonorrhea
Syphilis
Herpes virus
Chlamydia

F. Sickle cell screening
1. Indicated for clients who are at risk for sickle cell disease.
2. A + test result may indicate a need for further screening.

G. Tuberculin skin test
1. Health care provider may prefer to perform this skin test after delivery.
2. A + skin test indicates need for a chest radiograph (using abdominal lead shield) to rule out active disease; in a pregnant client, a chest radiograph will not be performed until after 20 weeks’ gestation (after fetal organs are formed)
3. Those who convert to positive may be referred for treatment w/medication after delivery.

H. Hepatitis B surface antigen
1. Recommended for all women because of prevalence of sidease in general population
2. Vaccination for hepatitis B antigen may be specifically indicated for following:
a. Health care workers
b. Clients born in Asia, Africa, Haiti, or Pacific islands
c. Clients w/previously undiagnosed jaundice or chromic liver disease
d. IV drug abuses
e. Clients w/tattos
f. Clients w/histories of blood transfusions
g. Clients w/histories of multiple episodes of sexually transmitted infections
h. Clients who have been previousl rejected as blood donors
i. Clients w/histories of dialysis or renal transplantation
j. Clients from households having hepatitis B-infected members or hemodialysis clients.

I. Urinalysis and urine culture
1. A urine specimen for glucose and protein determinations s/b obtained at every prenatal visit.
2. Glycosuria is a common result of decreased renal threshold that occurs during pregnancy
3. If glycosuria persists, this may indicate infection
4. White blood cells in the urine may indicate infection
5. Ketonuria may result from insufficient food intake or vomiting
6. Protein levels of 2+ to 4+ in urine may indicate infection or gestatinal hypertension.

PRENATAL VISITS
*Every 4 wks for first 28-32 weeks’ gestation
*Every 2 wks from 32 to 36 weeks’ gestation
*Every wk for 36 to 40 weeks
DIAGNOSTIC TESTS
Ultrasonography
1. Outlines and identifies fetal and maternal structures
2. Helps confirm gestational age and estimated date of delivery.
3. May be done abdominally or transvaginally during pregnancy.
4. Interventions
a. If an abdominal ultrasound is being performed, the woman may need to drink water to fill bladder before procedure to obtain a better image of the fetus
b. If a transvaginal ultrasound is being perfromed, a lubricated probe is inserted into the vagina.
c. Inform client that the test presents no known risks to client or fetus..
Alpha-fetoprotein (AFP) screening
1. Assesss quantity of fetal serum proteins; if AFP level is elevated, it is associated w/open neural tube and abdominal wall defects.
2. Can detect spina bifida and Down syndrome
3. Interventions
a. Explain AFP level is determined by a single maternal blood sample drawn at 15-18 weeks’ gestation.
b. If level is elevated an gestation is less than 18 wks, 2nd sample drawn
c. Ultrasonography performed if AFP level is elevated to rule out fetal abnormalities and multiple gestations.
Chorionic villus sampling (CVS)
1. Physician aspirates small sample of chorionic villus tissue at 8 to 12 weeks
2. CVS performed to detect genetic abnormalities
3. Interventions
a. Obtain informed consent
b. Instruct client to drink water to fill bladder before procedure to aid in positioning uterus for catheter insertion
c. Instruct client to report bleeding, infection, or leakage of fluid at insertion site after procedure.
d. Rh – woman may be given Rho(D) immune globulin (RhoGAM),
because CVS increases risk of Rh sensitization.
Kick counts (fetal movement counting)
1. Mother sits quietly or lies down on her L side and counts fetal kicks for a period o time, as instructed.
2. Instruct client to notify physician if fewer than 10 kicks in a 12 hr. period or as instructed by doc.
Amniocentesis
1. Aspiration of amniotic fluid done at 16 weeks or thereafter.
2. May reveal genetic disorders, metabolic defects, lung maturity , and sex
3. Risks
a. Maternal hemorrhage
b. Infection
c. Rh isoimmunization
d. Abruptio placentai
e. Amniotic fluid emboli
f. Premature rupture of membranes
4. Interventions
a. Obtain informed consent
b. If less than 20 wks, woman must have full bladder to support uterus; if more than 20 wks, woman must have empty bladder to minimize chance of puncture.
c. Prepare client for ultrasonography, which is performed to locate placenta and avoid puncture.
d. Obtain baseline vital signs and fetal heart rate; monitor q 15 min.
e. Position client supine during exam and on left side after
f. Instruct client that if chills, fever, leakage of fluid at needle-insertion site, decreased fetal movement, uterine contractions, or cramping occur, she is to notify doc.
Fern test
1. A microscopic slide test to determine the presence of amniotic fluid leakage.
2. With use of sterile technique, a specimen is obtained rom the external os of cervix and vaginal pool and examined on a slide under a microscope.
3 A fernlike pattern that results from the salts of amniotic fluid indicates the presence of amniotic flid
4. Interventions
a. Place client in dorsal lithotomy position.
b. Instruct client to cough; this causes fluid to leak from uterus if membranes are ruptured.
Nitrazine test
1. A Nitrazine test strip is used to detect presence of amniotic fluid in vaginal secretions.
2. Vaginal secretions have a pH of 4.5 to 5.5; they do not affect yellow color of Nitrazine strip or swab
3. Amniotic fluid has a pH of 7.0 to 7.5 and turn yellow Nitrazine strip or swab a blue color.
4. Interventions
a. Place client in dorsal lithotomy position
b. Touch test tape to fluid
c. Asses test tape for a blue-green, blue-gray, or deep blue color, which indicates that membranes are probably ruptured.
Nonstress test
*Performed to assess placental function and oxygenation
*Determines fetal well-being
*Evaluates fetal heart rate (FHR) in response to fetal movement

Interventions:
*An external ultrasound transducer and tocodynamometer are applied to the mother, and a tracing of at least 20 minutes’ duration is obtained so that FHR and uterine activity can be observed.
*Obtain a baseline BP reading, and monitor BP frequently.
*Position mother in L lateral position to avoid vena cava compression.
*Mother may be asked to press a button every time she feels fetal movement. Monitor records a mark at each point of fetal movement, and this is used as a reference point to assess FHR response.

Results
*Reactive Nonstress Test (normal, negative)
*”Reactive” indicates a health fetus.
*The result requires 2 or more FHR accelerations of at least 15 beats per minute and lasting at least 15 seconds from beginning of acceleration to end, in association w/fetal movement, during a 20 min. period.

*Nonreactive Nonstress Test (Abnormal)
*No accelerations or accelerations of less than 15 beats per minute or lasting less than 15 seconds in duration during a 40-minute observation.

*Unsatisfactory
*Cannot be interpreted because of poor quality of FHR tracing

Contraction stress test
Description
*Assess placental oxygenation and function
*Determines fetal ability to tolerate labor
*Determies fetal well-being
*Fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions
*Performed if nonstress test is abnormal

Interventions
*The external fetal monitor is applied to the mother, and a 20-30 min baseline strip is recorded.
*The uterus is stimulated to contract, either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation, until 3 palpable contractions w/duration of 40 sec. or more during a 10 min. period have been achieved.
*Frequent maternal blood pressure reading are obtained, and the mother is monitored closely while increasing doses of oxytocin are given.

Results
*Negative Contraction Stress Test
*Represented by no late decelerations of the FHR

*Positive Contraction Stress Test (Abnormal )
*Represented by late decelerations of FHR w/50% or more of contractions in absence of hyperstimulation of the uterus.

Equivocal
*Contains decelerations but w/less than 50% of contractions, or uterine activity shows a hyperstimulated uterus.

Unsatisfactory
*Adequate uterine contractions cannot be achieved or FHR tracing is not sufficient quality for adequate interpretation.

Nutrition
*Average expected weight gain – 25 to 35 lbs.
*Increase of 300 calories per day during pregnancy.
*Calories needs greater in last 2 trimesters
*Increase of 500 calores per day during lactation.
*Diet rich in folic acid – prevents neural tube defects.
*no alcohol
Vegan
Refrains from eating animal products.

Protein – from whole grains, legumes, seeds, nuts, and vegetables to provide essential amino acids.

Lactose intolerance
* if consumed – abdominal distention, discomfort, nausea, vomiting, cramps, loose stools
* need to consume calcium other than diary
*Cheese, yogurt; cooked forms-custards, fermented dairy products
*Lactaste may be prescribed before ingesting milk products.
Danger Signs of Pregnancy
Severe vomiting
Chills
Fever
Burning on urination
Diarrhea
Abdominal cramping or vaginal bleeding
Sudden discharge of fluid from Vagina before 37 wks.
Severe backache or flank pain
Change in fetal movements
Visual disturbances
Swelling of face or fingers or over sacrum
Headaches
Epigastric or abdominal pain
Muscular irritability or seizures
Glycosuria or other signs of diabetes mellitus
ABORTION
Elective
Spontaneous-vaginal bleeding w/passage of clots and tissue thru vagina.
Low uterine cramping and contractions
Hemmorrhage and shock
Interventions: Bedrest, vital signs, monitor cramping and bleeding,
count perineal pads to evaluate blood loss (save expelled tissues and clots); maintain IV fluids, monitor for shock; prepare client for D & C; Rh immune globulin given to appropriate Rh- women.
AIDS
HIV causitive factor for AIDS
A.. Description
AZT (Zidovudine) for prevention of maternal-fetal HIV transmission; administered orally after 14 wks gestation, IV during labor, Syrup to neonate after birth for 6 weeks.
B. Transmission – genital secretions from infected person; perinatal exposure of infant to infected maternal secretion thru birth process or breast-feeding
C. Mother managed as high risk – vulnerable to infections
D. Diagnosis
1. Tests to determine – ELISA (enzyme-linked immunosorbent assay); WB (Western blot) and IFA (indirect fluorescent antibody)
2. Two ELISA test w/same blood sample; if reactive follow-up test of WB or IFA
3. + WB or IFA – confirmatory for HIV
4. + ELISA that fails to be confirmed by WB or IFA not considered negative; repeat in 3 to 6 months.
E. Interventions
1. Prenatal period-Prevent opportunistic infections; avoid amniocentesis and fetal scalp sampling (perinatal transmission)
2. Intrapartum period-a. If fetus not exposed to HIV in utero – highest risk during DELIVERY thru birth canal. b. avoid use of scalp electrodes c. avoid episiotomy (maternal blood) d. avoid admin of oxytocin (vaginal tears-blood) e. Place heavy absorbent pads under mother’s hips-absorb amniotic fluid and maternal blood f. promptly remove neonate from mother’s blood after delivery g. Suction infant promptly. h. Admin AZT IV to mother during labor and delivery
3. Postpartum period-a. Monitor for sings of infection b. Mother in protective isolation if immunosuppressed c. Restrict breast-feeding D. Instruct mother to monitor for signs of infection, report any sign if they occur
(SELECT ALL THAT APPLY) The nurse must administer erythromycin ophthalmic ointment 0.5% to a neonate born 30 minutes ago. How should the nurse proceed?
(1) Clean the eyes before administration (2) Put on gloves.(4) Open the eyes by putting a thumb and finger at the corner of each lid and gently pressing on the periorbital ridges. (5) Spread the ointment from the inner canthus of the eye to the outer canthus. (6) Wipe excess ointment from the eyes after waiting 1 minute.
A new mother is concerned because her breast-feeding neonate wants to “nurse all the time.” Which of the following responses is most appropriate to address the mother’s concerns regarding her neonate’s breast-feeding behavior?
“Breast milk is ideal for your baby, so his stomach will digest it quickly, which requires more feedings.”
A postpartum client plans to breast-feed her first child, a full-term neonate. She asks the nurse, “How will I know if my baby is getting enough to eat?” The nurse informs her that nutritional intake is adequate if the neonate:
exhibits a steady weight gain.
The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:
lethargy
An appropriate-for-gestational-age neonate should weigh:
between the 10th and the 99th percentiles for age.
A client plans to breast-feed her healthy, full-term neonate. The nurse encourages her to start breast-feeding within 30 minutes of the neonate’s birth because:
the neonate will be responsive and eager to suck at this time.
Which of the following describes how the nurse interprets a neonate’s Apgar score of 8 at 5 minutes?
A neonate who’s in good condition
It’s difficult to awaken a neonate 3 hours after birth. The nurse recognizes that this behavior indicates:
normal progression into the sleep cycle.
Which finding in a neonate suggests hypothermia?
Bradycardia
A client is concerned that her 2-day-old, breast-feeding neonate isn’t gaining weight. The nurse should teach the client that breast-feeding is effective if:
the neonate latches onto the areola and swallows audibly.
At birth, a neonate weighs 7 lb, 3 oz. When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should expect which nursing diagnosis to be added to the plan of care?
Risk for injury related to hyperbilirubinemia
Which of the following measurements reflects normal calorie intake for a neonate?
110 to 130 calories per kg
The nurse is assessing a neonate. Health history findings indicate that the mother drank 3 oz (89 ml) or more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find in the neonate?
Upturned nose
Which neonate is at greatest risk for the nursing diagnosis Imbalanced nutrition: Less than body requirements related to poor sucking?
A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day
While discharging a neonate, the nurse notices that the parents have placed the infant in a child car seat. Which action takes priority?
Pointing out that an infant car seat is safest and arranging for them to rent one
Which of the following explanations describes the rationale for administering vitamin K to every neonate?
The neonate lacks intestinal flora to make the vitamin.
Which sign indicates respiratory distress in a neonate?
Nasal flaring
A client’s gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and delivers a baby boy. Which priority intervention should be included in the plan of care for the baby during his first 24 hours?
Provide frequent early feedings with formula.
A neonate’s pulse rate drops below 60 beats/minute. How should the nurse intervene? Rank in chronological order. Use all the options.
2. Gently shake the neonates shoulders, 3. Call for Help, 1. Place the neonate on a firm, flat surface, 4. Us the hand-tilt-chin-lift method, 5. Assess breathing, and then give 2 slow breaths 6. Give compressions
Which of the following describes a preterm neonate?
A neonate born at less than 37 weeks’ gestation regardless of weight
A client gives birth to a neonate prematurely, at 28 weeks’ gestation. To obtain the neonate’s Apgar score, the nurse assesses the neonate’s:
respiration.
While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which of the following?
This is a normal adverse effect of phototherapy.
When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F (35.3° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which nursing diagnosis takes highest priority at this time?
Hypothermia related to heat loss
The nurse prepares to administer an I.M. injection of prophylactic vitamin K to a normal, full-term neonate. Which needle should the nurse use?
25G, 5/8″ needle
During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis?
Support the neonate’s head and back with the forearm.
When assessing a male neonate, the nurse notices that the urinary meatus is located on the ventral surface of the penis. How should the nurse report this finding?
She should report the finding as hypospadias.
The nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate’s parents?
Deficient knowledge related to apneic episodes
(SELECT ALL THAT APPLY) Which of the following instructions should the nurse provide on discharge from the facility to the parents of a neonate who has been circumcised?
1. The neonate must void before being discharged home. 2. Apply petroleum jelly to the glans of the penis with each diaper change. 5 The circumcision requires care for 2 to 4 days after discharge.
The night before discharge, a client expresses guilt that she’ll have to return to work in 3 weeks and leave her infant with a nanny. The client asks the nurse for an opinion about using a nanny. What should the nurse say first?
“It’s difficult to be a working parent, but having a nanny will provide your baby with a consistent caregiver while you’re gone.”
The nurse is assigned to care for two mothers and their infants. One mother tested positive for group B streptococcus infection and her infant has been running a low temperature of 97.4° F (36.3° C). Which precaution should the nurse take while waiting for the physician to evaluate the infant?
Observe standard precautions and place the infant of the infected mother in a warmer inside the mother’s room.
Just after delivery, the nurse measures a neonate’s axillary temperature at 94.1° F (34.5° C). What should the nurse do?
Rewarm the neonate gradually.
When assessing the neonate of a client who used heroin during her pregnancy, the nurse expects to find:
irritability and poor sucking.
How does the nurse assess the rooting reflex of a neonate?
Stroking the neonate’s cheek
A mother is concerned that her neonate, who was delivered without complications at 38 weeks, isn’t eating enough and will lose too much weight. The mother states, “He only breast-feeds for about 3 minutes on one side.” Which instruction should the nurse provide to this mother?
“I understand your concern, but he has stored nutrients before birth just for this reason.”
The nurse assesses a 1-day-old neonate. Which finding indicates that the neonate is experiencing respiratory distress?
Nasal flaring
The nurse is about to give a full-term neonate his first bath. How should the nurse proceed?
Bathe the neonate only after his vital signs have stabilized.
An unmarried, unemployed young mother is being discharged with her infant, accompanied by a friend. After referrals to social services and home health care, which assessment is most important to make?
Determining whether the temperature in the client’s home is kept around 70° F (21.1° C) during the day
A full-term neonate is diagnosed with hydrocephalus. Data collection is likely to reveal:
wide or bulging fontanels.
To minimize the amount of a drug received by an infant through breast-feeding, the nurse should tell the mother to:
take the medication immediately after breast-feeding.
(SELECT ALL THAT APPLY) The nurse is demonstrating cord care to a mother of a neonate. Which actions should the nurse teach the mother to perform?
1. Keep the diaper below the cord. 4 Only sponge-bathe the neonate until the cord falls off. 5 Clean the length of the cord with alcohol several times daily.
The nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward:
preventing infection.
A client confides that she’s estranged from the abusive father of her infant. Which nursing intervention would ensure client confidentiality?
Discussing with the client whether she’d like to use another name while hospitalized
As part of the respiratory assessment, the nurse observes the neonate’s nares for patency and mucus. The information obtained from this assessment is important because:
neonates are obligate nose breathers.
The licensed practical nurse is delegating responsibilities to a certified nurse’s aide on a busy postpartum unit. Which task can be appropriately delegated to the nurse’s aide?
Bottle-feeding a 24-hour-old neonate
A girl neonate is admitted to the nursery following a long and difficult labor. Admission vital signs are temperature 96.5° F (35.8° C), heart rate 168 beats/minute, and respiratory rate 64 breaths/minute. After placing the neonate under the radiant heater, the nurse’s next action should be to:
check the neonate’s blood glucose level.
What is a common adverse effect of phototherapy?
Watery stools
Meconium aspiration syndrome is suspected in a neonate. What’s the most accurate diagnostic tool used to confirm the diagnosis?
Vocal cord examination using a laryngoscope
A neonate receives an Apgar score at 1 and 5 minutes of age. The 1-minute Apgar score is a good indication of:
how well the neonate tolerated labor.
(SELECT ALL THAT APPLY) The nurse is performing a neurologic assessment on a 1-day-old neonate. Which of the following findings would indicate possible asphyxia in utero?
3. The neonate’s toes don’t curl downward when his soles are stroked. 4. The neonate doesn’t respond when the nurse claps her hands above him. 6. The neonate displays weak, ineffective sucking.
The nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering the eyes and gonads for protection. The nurse knows that the goal of phototherapy is to:
decrease the serum unconjugated bilirubin level.
A client just had twins. Twin “A” weighs 2,500 g (5 lb, 8 oz), and Twin “B” weighs only 1,900 (4 lb, 3 oz). In addition to routine nursing care, the physician has ordered that Twin “B” be kept in an isolette to help maintain his temperature. The nurse might suggest which of the following interventions instead of using an isolette to maintain the baby’s temperature?
Placing the twins in the same crib so the larger baby can keep the smaller baby warm
Which of the following options is a contributory factor to thermoregulation in a preterm neonate?
Immature central nervous system (CNS)
Which intervention should the nurse perform as soon as possible when caring for a 21-week-old anencephalic neonate?
Dry and dress the neonate in clothing with a hat, and swaddle him snuggly in blankets.
Which finding is considered normal in the neonate during the first few days after birth?
Weight loss, then return to birth weight
A neonate begins to gag and turns a dusky color. What should the nurse do first?
Aspirate the neonate’s nose and mouth with a bulb syringe.
A client with human immunodeficiency virus (HIV) infection gives birth to an HIV-positive neonate. When assessing the neonate, the nurse is likely to detect:
hepatosplenomegaly.
The nurse is recording an Apgar score for a neonate. The nurse should assess:
heart rate, respiratory effort, reflex irritability, and color.
(SELECT ALL THAT APPLY) The nurse is planning to administer an injection of Vitamin K (AquaMEPHYTON) to a neonate. After administering the drug, the nurse should monitor the neonate for which adverse effects?
1. Jaundice 2. Edema. 3. Erythema 4. Pain at the injection site
The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity:
results from exposure of an antigen through immunization or disease contact.
The nurse wraps an infant in two blankets and places a hat on his head. His axillary temperature is 97.2° F (36.2° C). After 30 minutes, his axillary temperature is 97.4° F (36.3° C). How should the licensed practical nurse (LPN) intervene?
Place the infant under a warmer and notify the registered nurse.
A parent asks the nurse about the practice of adding rice cereal at age 3 months to a bedtime bottle to “help the baby sleep through the night.” Which response accurately addresses the parent’s concern?
“Nighttime feedings provide the infant with adequate fluid, and are typically needed until at least age 4 months.”
To ensure that the breast-feeding neonate’s weight loss remains within the expected parameter of 5% to 10%, the nurse should initially establish which of the following types of feeding schedules?
Provide feeding on demand.
Six hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss?
Cool isolette walls
The nurse has been teaching a new mother how to feed her infant son who was born with a cleft lip and palate. Which action by the mother would indicate that the teaching has been successful?
Burping the baby frequently
Which intervention takes priority when caring for a neonate immediately after birth?
Covering the neonate’s head with a cap
Which of the following is the primary reason for putting breast-feeding neonates to the breast immediately after delivery?
Most neonates are alert immediately following birth and are ready to nurse.
The nurse is assessing a 1-day-old neonate whose mother smoked 1 pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy?
Small size for gestational age
The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it’s an expected finding of physiologic jaundice and is caused by which of the following?
Large, immature liver
A baby born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat due to evaporation?
Drying him thoroughly after a bath
A nurse is preparing to perform phenylketonuria (PKU) testing. Which baby is ready for the nurse to test?
A 2-day-old baby who has been breast-fed
One minute after birth, a neonate has an Apgar score of 7. What should the nurse do?
Stimulate breathing by rubbing the neonate’s back.
Which of the following data collection findings would the nurse interpret as abnormal for a term male neonate who’s 1 hour old?
Slight yellowish hue to the skin
A client tells the nurse that she doesn’t want to sign the hepatitis B vaccination consent form because she heard that, “vaccinations can cause autism.” What’s the most appropriate nursing interaction?
Discussing the purpose of the vaccine and providing the client with written information
During neonatal resuscitation immediately after delivery, chest compressions should be initiated when the heart rate falls below how many beats per minute?
60
When caring for a neonate, what is the most important step the nurse can take to prevent and control infection?
Practicing meticulous hand washing
Moments after birth, a neonate of 32 weeks’ gestation develops asphyxia. As the neonatal team starts resuscitation, the nurse must:
keep the neonate’s head in the “sniff” position.
The nurse is collecting data on a baby boy born 3 hours ago. Which finding would make the nurse suspect a congenital hip dislocation?
Unequal gluteal folds
When using a Pavlik harness on a neonate with developmental dysplasia of the hip, the nurse should ensure that the affected hip is in which position?
Flexed and abducted
A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation?
By positioning the neonate so that the head remains still
After delivering an 8 lb (3.6 kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of:
sterile water.
A female neonate born by elective cesarean section to a 25-year-old mother weighs 3,265 g (7 lb, 3 oz). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which of the following?
Respiratory distress due to lack of contractions
Parents of a neonate born with severe congenital anomalies have requested that the staff institute a do-not-resituate (DNR) order. While working with this family, the nurse applies the ethical principle of autonomy by:
making sure the parents are well informed about their infant’s condition and that they’ve made an informed decision.
The nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate?
Enlarged breast tissue
A neonate born 30 hours after rupture of membranes has an axillary temperature of 100.8° F (38.2° C). Which intervention should the nurse employ?
Instruct the family to keep the infant in the mother’s room until culture results are available.
A client who admits she uses heroin gives birth to a neonate at 32 weeks’ gestation. Which neonatal assessment is most important for the nurse to perform?
Evaluation for signs of drug withdrawal
A primigravid client gives birth to a full-term girl. When teaching the client and her husband how to change their neonate’s diaper, the nurse should instruct them to:
clean and dry the neonate’s perineal area from front to back.
A postpartum client is receiving anticoagulant therapy for deep vein thrombophlebitis. Discharge teaching should include which instruction?
Avoid over-the-counter preparations containing aspirin.
A client plans to bottle-feed her full-term neonate. What is the normal feeding pattern for a full-term neonate during the 24 hours after delivery?
40 to 60 ml of formula every 2 to 4 hours
A client in transition complains to the nurse that the physician was verbally abusive and “rough during a vaginal exam.” Just then, the physician reappears and asks the nurse for a sterile glove for another vaginal check. The nurse’s first priority should be to:
ask the physician to step out of the room and then discuss with him the need to transfer care to another physician.
The mother of a 3-day-old, breast-fed infant expresses concern that her infant has had two recent diapers that contained a lot of loose, yellowish stool. Which explanation by the nurse is best?
“It’s normal for breast-fed infants to pass three or more loose, yellow stools per day.”
The nurse is assigned to care for four neonates. Which neonate should she assess first?
A 4-hour-old, 10-lb, 7-oz (4,734 g) boy delivered vaginally
While caring for a healthy female neonate, the nurse notices red stains on the diaper after the baby voids. Which of the following should the nurse do next?
Do nothing because this is normal.
anticonvulsant.
A woman with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is:
Delivery of the fetus
What is the only known cure for preeclampsia?
Glycosuria
Which clinical sign is not included in the classic symptoms of preeclampsia?
Absence of deep tendon reflexes
Which assessment finding would convince the nurse to “hold” the next dose of magnesium sulfate?
Abdominal palpation
Which intrapartal assessment should be avoided when caring for the woman with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome?
+3 edema
The nurse is explaining how to assess edema to the nursing students working on the antepartum unit. Which score indicates edema of lower extremities, face, hands, and sacral area?
Hydatidiform mole
A woman is admitted with vaginal bleeding at approximately 10 weeks of gestation. Her fundal height is 13 cm. What potential problem should be investigated?
Total placenta previa
Which maternal condition always necessitates delivery by cesarean section?
the pregnancy is less than 20 weeks.
Spontaneous termination of a pregnancy is considered to be an abortion if:
missed abortion.
An abortion in which the fetus dies but is retained in the uterus is called:
marginal
A placenta previa in which the placental edge just reaches the internal os is called:
Hard, boardlike abdomen
What condition would indicate concealed hemorrhage in an abruptio placentae?
assess fetal heart rate (FHR) and maternal vital signs.
The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode is to:
she should be assessed for signs of dehydration and starvation.
A 28-year-old primigravida is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on the knowledge that:
assess weight gain, location of edema, and urine for protein.
A 17-year-old primigravida has gained 4 lb since her last prenatal visit. Her blood pressure is 140/92 mm Hg. The most important nursing action is to:
worsening disease and impending convulsion.
A client with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate:
fetus is Rh positive.
Rh incompatibility can occur if the woman is Rh negative and her:
Incomplete abortion at 10 weeks
In what situation would a dilation and curettage (D&C) be indicated?
Bed rest
What order should the nurse expect for a client admitted with a threatened abortion?
Recurrent pelvic infections
What data on a client’s health history would place her at risk for an ectopic pregnancy?
Fundal height measurement of 18 cm
What finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?
Determining cervical dilation and effacement
What routine nursing assessment is contraindicated in the client admitted with suspected placenta previa?
presence of abdominal pain.
The primary symptom present in abruptio placentae that distinguishes it from placenta previa is:
decreased fibrinogen.
The nurse understands that a laboratory finding indicative of DIC is:
administer calcium gluconate.
A woman taking magnesium sulfate has respiratory rate of 10 breaths/min. In addition to discontinuing the medication, the nurse should:
hemorrhage is the major concern.
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that:
Degree of glycemic control before and during the pregnancy
Which factor is most important in diminishing maternal/fetal/neonatal complications in the pregnant woman with diabetes?
Hypoglycemia
Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?
Previous birth of large infant
Which factor is known to increase the risk of gestational diabetes mellitus?
placental hormones are antagonistic to insulin, resulting in insulin resistance.
Glucose metabolism is profoundly affected during pregnancy because:
eating her meals and snacks on a fixed schedule.
To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant diabetic will need to alter her diet by:
eat 6 saltine crackers.
When the pregnant diabetic experiences hypoglycemia while hospitalized, the nurse should have the client:
varies depending on the stage of gestation.
Nursing intervention for the pregnant diabetic is based on the knowledge that the need for insulin:
Mitral valve prolapse
What form of heart disease in women of childbearing years usually has a benign effect on pregnancy?
instruct her to avoid strenuous activity.
When teaching the pregnant woman with class II heart disease, the nurse should:
She must report any chest discomfort or productive cough.
Which instructions are most important to include in a teaching plan for a client in early pregnancy who has class I heart disease?
bacterial endocarditis.
Antiinfective prophylaxis is indicated for the pregnant woman with a history of mitral valve stenosis related to rheumatic heart disease because the woman is at risk of developing:
Rubella
For which of the infectious diseases can a woman be immunized?
The woman must make arrangements to stay somewhere other than her home until the children are no longer contagious.
A woman who delivered her third child yesterday has just learned that her two school-age children have contracted chickenpox. What should the nurse tell her?
Plan for retesting during the third trimester.
A woman has a history of drug use and is screened for hepatitis B during the first trimester. What is an appropriate action?
“Even though my test is positive, my baby might not be affected.”
A woman has tested human immunodeficiency virus (HIV) positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?
pelvic pain, abdominal pain, vaginal spotting or light bleeding, missed period.
Throughout the world the rate of ectopic pregnancy has increased dramatically over the past 20 years. This is believed to be due primarily to scarring of the fallopian tubes as a result of pelvic infection, inflammation, or surgery. The nurse who suspects that a client has early signs of ectopic pregnancy should be observing her for symptoms such as:
Gynecoid
Which pelvic shape is most conducive to vaginal labor and delivery?
Keep underpads and linens as dry as possible
What actions of the nurse prevent infections in the labor and delivery area?
Cloudy amniotic fluid with strong odor
A pregnant woman with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicate a potential infection?
Terbutaline
A woman in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will probably be prescribed for at-home continuation of the tocolytic effect?
Lie supine and relax.
Which technique is least effective for the woman with persistent occiput posterior position?
cesarean delivery.
Birth for the nulliparous woman with a fetus in a breech presentation is usually by:
eclampsia.
Methergine (an oxytocic drug) increases the blood pressure. The nurse should question the order to administer Methergine to the woman with a history of:
A multiparous woman at 39 weeks of gestation who is expecting twins
Which client situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor?
Incomplete uterine relaxation
Which factor is most likely to result in fetal hypoxia during a dysfunctional labor?
palpate the infant’s clavicles.
After a birth complicated by a shoulder dystocia, the infant’s Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should:palpate the infant’s clavicles.
“I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps.”
A laboring client in the latent phase is experiencing uncoordinated, irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain?
Dehydration stimulates secretion from the posterior pituitary.
Why is adequate hydration important when uterine activity occurs before pregnancy is at term?
Any activity could increase the risk of recurrence of labor contractions.
What activity guidelines should be included when teaching a client about home care for preterm labor?
Reposition the mother with her hips higher than her head.
Which nursing action must be initiated first when evidence of prolapsed cord is found?
notify the physician promptly.
A woman who had two previous cesarean births is in active labor, when she suddenly complains of pain between her scapulae. The nurse’s priority action should be to:
Restore circulating blood volume by increasing the intravenous infusion rate.
What action should be initiated to limit hypovolemic shock when uterine inversion occurs?
Presenting part at a station of -3
What factor found in maternal history should alert the nurse to the potential for a prolapsed umbilical cord?
compression of the umbilical cord is more likely.
The fetus in a breech presentation is often born by cesarean delivery because:
encouraging urination about every 1 to 2 hours.
An important independent nursing action to promote normal progress in labor is:
“You should come into the office and let the doctor check you.”
A woman who is 32 weeks pregnant telephones the nurse at her obstetrician’s office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is:
Fetal heart rate, maternal pulse, and blood pressure
“You should come into the office and let the doctor check you.”
contractions abruptly stop during labor.
The nurse should suspect uterine rupture if:
false, This is often referred to as the “turtle sign” and is an indication of shoulder dystocia.
The nurse has been caring for a primiparous client who is suspected of carrying a macrosomic infant. Pushing appears to have been effective so far; however, as soon as the head is born, it retracts against the perineum much like a turtle’s head drawing into its shell. In evaluating the labor progress so far, the nurse is aware that this is normal with large infants and extra pushing efforts by the mother may be necessary.
“I’ll put my support stockings on every morning before rising.”
Which statement by a postpartal woman indicates that further teaching is not needed regarding thrombus formation?
inspect the placenta after delivery.
The nurse knows that a measure for preventing late postpartum hemorrhage is to:
Postpartum blues
Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth?
notify the physician.
A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000 g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. The nurse should:
500 mL in the first 24 hours after vaginal delivery.
Early postpartum hemorrhage is defined as a blood loss greater than:
Assess the fundus for firmness.
A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she “feels all wet underneath.” You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action?
lacerations of the genital tract.
A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests:
6.5-lb infant after a 2-hour labor.
A postpartum client would be at increased risk for postpartum hemorrhage if she delivered a:
Notify the physician of any increase in the amount of lochia or a return to bright red bleeding.
What instructions should be included in the discharge teaching plan to assist the client in recognizing early signs of complications?
oral methylergonovine maleate (Methergine) for 48 hours.
The nurse should expect medical intervention for subinvolution to include:
D&C
If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is appropriate to correct the cause of this condition?
Local tenderness, heat, and swelling
The mother-baby nurse must be able to recognize what sign of thrombophlebitis?
Assist the client in performing leg exercises every 2 hours.
Which nursing measure would be appropriate to prevent thrombophlebitis in the recovery period after a cesarean birth?
100.8° F on the second and third postpartum days
Which temperature indicates the presence of postpartum infection?
possible infection.
A white blood cell (WBC) count of 28,000 cells/mm3 on the morning of the first postpartum day indicates:
facilitates drainage of lochia.
The client who is being treated for endometritis is placed in Fowler’s position because it:facilitates drainage of lochia.
forcing fluids to at least 3000 mL/day.
Nursing measures that help prevent postpartum urinary tract infection include:
Initiating early and frequent feedings
Which measure may prevent mastitis in the breastfeeding mother?
the organisms that cause mastitis are not passed to the milk.
A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that:
odor of the lochia.
If the nurse suspects a uterine infection in the postpartum client, she should assess the:
hematoma
The nurse is in the process of assessing the comfort level of her postpartum client. Excess bleeding is not obvious; however, the new mother complains of deep, severe pelvic pain. The registered nurse (RN) has noted both skin and vital sign changes. This client may have formed a ____________________.
False, On the contrary, the unusual activity of the hospital staff may make the mother and her family very anxious.
Should a postpartum complication such as hemorrhage occur, the nursing staff will spring into action to ensure that client safety needs are met. This level of activity is very reassuring to both the new mother and her family members as they can see that the client is receiving the best of care.
anemia, exhaustion, failure to attach to her infant, postpartum infection.
The visiting nurse must be aware that women who have had a postpartum hemorrhage are subject to a variety of complications after discharge from the hospital. These include:
Adequate prenatal care
What is most helpful in preventing premature birth?
greater surface area in proportion to weight.
In comparison with the term infant, the preterm infant has:
keeps the alveoli open during expiration.
Decreased surfactant production in the preterm lung is a problem because surfactant:
encourage the parents to touch her.
An infant girl is preterm and on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time. It is important for the nurse to:
it could make respiratory distress syndrome worse.
The most important reason to protect the preterm infant from cold stress is that:
is unable to coordinate sucking and swallowing.
The preterm infant who should receive gavage feedings instead of a bottle is the one who:
Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.
Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem?
Lack of subcutaneous fat
What is a characteristic of the postterm infant who weighs 7 lb, 12 oz?
Retinopathy of prematurity (ROP)
In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level?
blood glucose of 25 mg/dL.
In caring for the postterm infant, thermoregulation can be a concern, especially in the infant who also has a:
They are below the 10th percentile on gestational growth charts.
hich is true about newborns classified as small for gestational age (SGA)?
Prevent hypoglycemia by early and frequent feedings.
What nursing action is especially important for the SGA newborn?
The head seems large compared with the rest of the body.
What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction?
Three successive temperature measurements were 97° F, 96° F, and 97° F.
What data would alert the nurse caring for an SGA infant that additional calories may be needed?
They are prone to hypoglycemia, polycythemia, and birth injuries.
Which statement is true about large for gestational age (LGA) infants?
Grunting
Of all the signs seen in infants with respiratory distress syndrome, which sign is especially indicative of the syndrome?
hypoxia in utero.
While caring for the postterm infant, the nurse recognizes that the elevated hematocrit level most likely results from:
Cracked, peeling skin
What data would alert the nurse that the neonate is postmature?
Risk for infection
Because of the premature infant’s decreased immune functioning, what nursing diagnosis would the nurse include in a plan of care for a premature infant?
put an undershirt on the infant in the incubator.
To maintain optimal thermoregulation for the premature infant, the nurse should:
nurture both the infant and the parents to optimize neonatal outcomes.
The neonatal intensive care unit (NICU) environment should:
problems with thermoregulation, hyperbilirubinemia, sepsis
Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for:
pain
The NICU nurse begins her shift by assessing one of the preterm infants assigned to her care. The infant’s color is pale, his O2 saturation has decreased, and he is grimacing. This infant is displaying common signs of ____________________.
Naegeles rule
rule for EDB first day of last menstrual period subtract 3 months and add 7 days
McDonalds method
method use uterine size to indicate gestaional age by measuring cm distane from symphysis pubis to top of uterine fundus. fundal hieght
quickening
the feeling of fetal movement by mother occurs between 16-18 weeks, is less accurate EDB
FHR auscultated
this can occur as early as 8 weeks gestation using doppler but normally heard 10-12 weeks
gravida
number of times woman is pregnant
para
number of births after 20 weeks gestation
multiple count as one pregnancy
if mother has twins she is gravida 1 para 2
37 weeks
what is considered a term birth
20-36 weeks
what is considered pre-term birth
aborted
if pregnancy end in spontaneous or therapeutic __ prior to 20 weeks
subjective and objective signs
what signs may or may not be associated with pregnancy.
diagnostic
what signs can only be associated with pregnancy
120-160 bpm
normal fetal heart rate beginning at 8 weeks with doppler
fetoscope
FHR assessed by this equipment starting at 16 weeks
presumptive signs
subjective signs may not be associated with pregnancy – amenorrhea, NV, fatigue, urinary requency, breast change and quickening
probable signs
objective signs may not be associated with pregnancy – hegar’s sign, mcdonalds sign, enlarged abdomen, pigmentation, striae, ballottement, positive pregnancy test, palpation of fetal outline
positive signs
diagnostic sign of pregnancy fetal heartbeat, fetal movement felt by examiner, fetus on ultrasound
gestational age
fundal height is a measure from symphysis pubis to top of uterine fundus shows this age
maternal physical exam
vital signs, HW, thyroid, heart and breath sounds, reproductive organs, uterus size, pelvis exam are part of these
H&H, blood type, Rh, irregular antibody, rubella, TB, renal function, UA, STI, Pap, offer HIV
what type of tests are given to pregnant female
erythroblastosis or hyperbilirubinemia
what two complications may be identified from a blood type and Rh stats during first prenatal visit
4.2-5.4
RBC norm
12-16 g/dL
normal hemoglobin
37-47%
normal hematocrit
5,000 to 10,000
WBC norm
150,000 to 400,000
platelet counts
RBC increases
what happens to RBC during pregnancy
H&H drop a little
what happens to H&H levels during pregnancy
WBC increase slightly
what happens to WBC during pregnancy
mid-stream clean catch specimen
what kind of urinalysis specimen is collected for pregnancy
pH decreases with ketones and glucose
what happens to urine during pregnancy
preeclampsia
this may be indicated if protein is found in urine of +1
WBC or nitrates
these may be found in urine to show UTI may show risk of pre-term labor
ketones
this product found in urine may indicate diabetes mellitus and hyperglycemia
toxoplasmosis
infection in mother assoc. with consuming undercooked meat or poor handwashing after handling cat liter and may pass it to fetus through placenta causing flu symptoms
serologic test
how is toxoplasmosis identified in pregnant female
miscarriage, hydrocephaly, CNS lesions
what can happen to fetus with toxoplasmosis
Hep A
infection spread by droplets associated with poor handwashing after defecation
Hep B
most common fetus infection from blood and genital secretions during labor and delivery.
preterm birth, hepititis intrauterine death
hep A and B effects the fetus with these risks
rubella
droplet infection that may affect child with miscarriage, congential anomalies and death
cytomegalovirus CMV
respiratory droplet infection transmitted from day care, mentally handicapped are at high risk may cause fetal death, jaundice, hydrocephaly, deafness
Herpes
STI from vescular lesions on genitalia fetus is at high risk from primary infection of mother if lesion in birth canal, may need a cesarean delivery
HPV human papillmavirus
STI genital warts fetus can acquire during birth process
gardasil vaccine
what is the prevention for HPV
gonorrhea
what is the STI that if not treated to neonate with eye drops the infant could be blind
every 4 weeks during first 28 weeks gestation
when are prenatal visits wo be done in first 28 weeks gestation
every 2 weeks
when are prenatal visist be done between 28-36 weeks
every week until delivery
when are prenatal visits done after 36 weeks
colostrum
milk production in breasts
quickening, colostrum production physical changes and danger signs
what is instructed to mother concerning physical changes of pregnancy
acceptance, vitals, weight, nutrition, glucose or protein in urine
what do you assess for during collaborative management during pregnancy
premature labor or abruptio placentae
what are two ppossible causes of abdominal pain during pregnancy
hyperemesis gravidarum
persistent vomiting during pregnancy that may cause dehydration
visual disturbance, edema hands and face, severe HA
what are three danger signs of HTN or preeclampsia
epigastric pain
besides visual disturbance, edema, or HA what els is a danger sign to preeclampsia
abruptio placentae, placentae previa, bloody show
what are three possible causes of vaginal bleeding during pregnancy
glucose
what is found in urine to diagnose diabetes mellitus during prego
protien
what is found in urine to diagnose preeclamspia in pregnancy
nitrates and leukocytes
what is found in urine to diagnose UTI
Hgb
what is tested for iron-deficiency anemia
fundal height, movment and FHR
what are three assessment findings for fetus
24-28 weeks
when do you check mother glucose for gestational diabetes
AFP alpha-fetoprotein
test measured at 16-18 weeks gestation if serum increased indicates neural tube defects.
glucose tolerance test GTT
50 g oral glucose load is given after one hour levels found greater than 130-140 mg/dL then followed by a 3 hour 100 g to diagnose gestational diabetes
oral glucose tolerance test OGTT
test procedure of high carb diet for 3 days then 8 hour fasting with glucose levels assessed then 100 g oral glucose and checked again at 1,2,3 hours for gestational diabetes
first trimester and obese
when is transvaginal ultrasound completed
greater than 95
what is an abnormal BS after fasting for 8 hours
bladder is full
when is it best to have an abdominal ultrasound
biparietal diameter and femur length
how will the ultrasound help assess health care provider of growth rate
kitzenger
birthing method of sensory memory Stanislavsky method to teach relaxation
bradley
birthing method husband to coach relaxation through abdominal breathing and exercise
lamaze
birthing method to educate about developing fetus and exercises to decrease fear and pain
avoid strong odors, avoid drinking while eating, avoid spicy or greasy foods,
to manage NV during early pregnancy – drink carbonated beveraes, eat crackers or toast before getting out of bed, small frequent meals but avoid –
well-fitting supportive bra
how to manage breast tenderness during early pregnancy
increase daytime fluid intake, decrease night time fluid intake
how to avoid urinary frequency during early pregnancy
plan nap during day and early bedtime
how to avoid fatigue during early pregnancy
cool air vaporizer
how to manage nasal stuffiness and nasal bleeding during early prego
eat small frequent meals, avoid spicy/greasy foods, dont lie down after eating use low sodium antacids
how to manage heartburn during late prego
increase fluid and fiber, exercise, stool softeners
how to manage constipation during late prego
avoid constipation, apply topical anesthetics, ointments or ice paks, sitz bath or warm soak, reinsert into rectum
how to manage hemorrhoids during late prego
elevate legs, wear hose, avoid crossing legs, avoid restrictive clothing and standing for long
manage varicose veins in late prego
arise slowly, avoid standing for long and check H&H
manage faintness during late prego
goodells sign
estrogen causes softening of cervix is this sign during pregnancy
chadwicks sign
estrogen causes bluish color of cervix during pregnancy
estrogen and progesterone
what hormones cause breasts to increase in size and number of glands
Cardiac output increases 30-40%
what does the cardia output levels do with an increased pulse of 10-15 bpm during prego
BP drops
what does the BP do in the first and second trimester
pregnant uterus press on pelvic and femoral vessels
postural hypotension during prego occurs due to limiting blood return to heart because
pallor, dizzy, clammy skin
what are s/s of postural hypotension
position on left side
how do you correct postural hypotension
lordosis
curvature of lumbar spine increases to complensate for weight of gravid uterus
diastasis recti
separation of abdominal muscle after uterus enlarges
increased hCG (human chrionic gonadotropin)
during the first trimester this hormone increases and can cause NV
relax smooth muscles
progesterone levels do this causing decreased peristalsis causing bloating, reflux, constipation and worsens when gravid uterus presses on intestines
hemorrhoids
constipation and increase pressure on blood vessel in rectum can lead to this
first trimester and third trimester
gravid uterus presses on bladder causing urniary frequency in this trimester
GFR increases 50%
during second trimester this function increasesand remains elevated until delivery in renal function
estrogen
what hormone causes increased pigmentation during prego
chloasma, linea negra and striae gravidarum
what three integumentary systems are affected during prego
water retention
increased sex hormones and decreased serum protein causes this in prego
hCG
hormones stimulates progesterone and estrogen production and cause NV in first trimester
estrogen
hormone stimulates uterine development to support fetal grwoth and ducts in breasts for lacatation`
progesterone
maintains endometrium , decreases uterin contractility, breast ancini, relaxes smooth muscles
relaxin
hormone made by corpus luteum decreases uterine contractility softens cervix
prostaglandins
lipids found in female reproductive system, contribute to onset of labor
more or less calories
nutritional status of underweight or over weight will need this nutrient respectivley
adolescent mother
these mothers need increased caloric intake for both the meternal and fetal growth
additional 300 calories a day
a healthy pregnant woman will need an additional – calories per day
folic acid
B6 vitamin that reduce risk of birth defects
protein, folate, prenatal vitamin, minerals
what is added to the diet for prego
10-13 lbs
how much of the 25-35 total pounds gained in first 20 weeks
about one pound per week
how much weight gain per week after week 20
NV, epigastric discomfort, abd cramping, abd distention, loose stools
s/s of lactos intolerance from insufficient lactase enzyme
lactase
this may be added to milk or chewed before ingesting milk to help breakdown lactose
cheese or yogurt
if lactose intolerated these two dairy products may be better tolerated
whole grain foods and legumes, or nuts and legumes, or whole grain and nuts
strict vegetarians need combinations of proteins for adequate amounts
B12
all vegetarian prego need this vitamin
Describe the exploratory phase?
holding toys, ages 0-7 yr
Describe toys as adults tools phase?
imitation, age 1-7 yr
Describe games and hobbies phase?
ages 8-12
Describe solitary play
plays alone, but enjoys presence of others, interest centered on own activity

occurs during infancy

Describe parallel play
plays alongside, not with, another; characteristic of TODDLERS, but can occur in other age groups
Describe associative play
no group goal; often follows a leader
PRESCHOOL age (4 year)
Describe cooperative play
organized, rules, leader/follower relationship est

SCHOOL-AGE

What is the Denver II test?
screen kids from birth to 6 yr in 4 skill areas:

1. personal-social
2. fine motor
3. language
4. gross motor

How does muscular coordination and control happen?
proceeds head-to-toe (cephalocaudal), trunk-to-periphery (proximosdistal), gross-to-fine
How to introduce foods?
only introduce one food at a time for each 2 week period

start with least allergenic foods from 6 mo (iron-fortified rice cereal) progressing to more allergic foods (egg, orange juice)

cereal –> fruit –>vegetables –> potatoes –> meat –> egg –> orange juice

When does separation anxiety happen?
8 mo
Describe phases of separation anxiety.
Protest- cries/screams for parents; inconsolable by others

Despair- crying ends; less active; disinterested in food/play; clutches security obj if available

Denial- appears adjusted; evidences interest in environment; ignores paraent when he/she returns; resigned, not contented

G&D at 1 month
head sags, early crawling movement, “floppy”
G&D 2 month
posterior fontanell closes
diminished tonic neck and Moro reflex (gone by 3 mo)
able to turn from back to side
eyes begin to follow moving obj
social smile first appears
2-3 months posterior fontanell closure
able to lift head 45 degrees
G&D 3 months
can bring obj to mouth at will; head held erect, steady; smiles w/mother’s presence; audibly laughs
G&D 4 months
ABSENT tonic neck reflex; drooling; Moro reflex gone

4-5 mo start solid foods

G&D 5 months
BIRTH WEIGHT doubles
takes obj presented to him/her
G&D 6 months
avg weight gain 4 oz per week; teething may begin; can turn from back –> stomach; early ability to distinguish and recognize strangers [DON’T leave infant alone]; can sit up with support
G&D 7 months
sits for short periods using hands for support; grasps toys w/hand; abrupt mood shifts
G&D 8 months
stranger anxiety and reverts to phases
G&D 9 months
can SIT ALONE, responds to parental anger, PINCHER GRASP; responds to verbal commands like “no-no”; count 2 cubes
G&D 10 months
crawls well; pulls self to standing position w/spt (think crib safety), brings one hand together, vocalizes 1-2 words
G&D 11 months
erect standing posture w/spt
G&D 12 months
tripled birth weight; needs help w/walking;eats w/fingers; can say two words in addition to mama and dada

can build 2 block tower

shows interest in pleasing parents like hugging mom when asked

When does a child respond to his/her own name?
6-8 months
When does a child take deliberate steps?
9-10 months
What are appropriate toys for birth – 2 months
mobiles 8-10 in from face
What are approps toys for 2-4 mo?
rattle, cradle gym
What are approps toys for 4-6 mo?
brightly colored toys (sm enough to grasp, large enough for safety)
What are approps toys for 6-9 mo?
Large toys with bright colors, movable parts, and noisemakers
What are approps toys for 9-12 mo?
books w/large pics, large push-pull toys, teddy bears
What is the major cause of death in infants?
aspiration— watch out for hot dogs, candy

also falls, car seats and bursn

What is expected for a 15 month old?
walks alone, builds 2 block tower, throws obj, grasps spoor, names commonplace obj
Whats common for an 18 month old?
anterior fontanelle usually closed

walks backwards, climbs stairs

scribbles

builds 3 block tower

thumb sucking

temper tantrum

Whats typical for a 24 month old?
early efforts at jumping, builds 5-6 block tower; 300 word vocabulary; obeys easy commands
Whats typical for a 30 month old?
walks on tiptoe, builds 7-8 block tower, stands on one foot, has sphincter control for toilet training
What are age-approp toys for toddlers, 12-36 mo?
push-pull toys, low rocking horses, dolls, stuffed animals

like toys that move b/c they are big explorers

What are the #1 cause of death for toddlers?
MVA, scalding and posioning
What is expected of a 3 yr old?
copies a circle, builds a bridge w/3 cubes, less negative/dec temper tantrums, learns from experience, rides tricycle, walks backwards & downstairs, undresses without help, 900 word vocab USES SENTENCES, may invent an imaginary friend
What is typical of a 4 yr old?
climbs and jumps well, laces shoes, brushes teeth, 1500 word vocab, skips and hops on one foot, throws overhead
What is typical of a 5 year old?
runs well, jumps rope, 2100 word vocab, begins cooperative play, gender specific paly (dress up, imitation), skips on alterante feet
What are age approps toys for preschoolers aged 3-5?
child imiative of adult patterns and roles.

offer playground materials, housekeeping toys (play kitchen), coloring books, tricycles w/helmet

Whats typical of a 6 yr old?
self-centered, show off, rude; extreme sensitivity to criticism, begins losing temp teeth, perm teeth start to come in, ties knots
Whats typical of a 7 year old?
team games/sports/organizations, develops concept of time, prefers playing with same sex
Whats typical of an 8 yr old?
actively seeks out friends, eye development complete, writing replaces printing
Whats typical of a 9 yr old
Skillful manual work possible, conflict btw adult authorities and peer group
Whats typical for a 10-12 yr old?
uses telephone, develops interest for opposite sex, loves conversation, raises pets
What are age approp toys for school-age kids 6-12?
construction toys, sewing tools, table games, sports, repair building, chores, mechanical activities
What are potential probs for school age kids?
enuresis, encopresis, head lice
strength of the urinary stream.
To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH) the nurse will ask the patient about _________________
Teach that ED is not a common complication following a TURP.
A patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because he is afraid it might affect his ability to have intercourse. Which action should the nurse take?
his interest in sexual activity may decrease while he is taking the medication.
The health care provider prescribes finasteride (Proscar) for a 56-year-old patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that ____________
transrectal ultrasonography (TRUS).
A patient has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level. The nurse will anticipate that the patient will need teaching about ______________
Bladder irrigation prevents obstruction of the catheter after surgery.
When teaching a patient who is scheduled for a transurethral resection of the prostate (TURP) about continuous bladder irrigation, which information will the nurse include?
how to care for an indwelling urinary catheter.
A patient with symptomatic benign prostatic hyperplasia (BPH) is scheduled for photovaporization of the prostate (PVP) at an outpatient surgical center. The nurse will plan to teach the patient ______________
prostate specific antigen (PSA) testing.
A 51-year-old man is scheduled for an annual physical exam at the outpatient clinic. The nurse will plan to teach the patient about the purpose of _______________________
possible fecal contamination of the surgical wound.
A 64-year-old has a perineal radical prostatectomy for prostatic cancer. In the immediate postoperative period, the nurse establishes the nursing diagnosis of risk for infection related to _______________
pelvic floor muscle exercises.
Following a radical retropubic prostatectomy for prostate cancer, the patient is incontinent of urine. The nurse will plan to teach the patient _______________
“I should call the doctor if I have any incontinence at home.”
Following discharge teaching for a patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH), the nurse determines that additional instruction is needed when the patient says, _______________
hot flashes.
Leuprolide (Lupron) is prescribed for a patient with cancer of the prostate. In teaching the patient about this drug, the nurse informs the patient that side effects may include
Sexual intercourse and masturbation will help relieve symptoms.
Which information will the nurse include when teaching a patient who has a diagnosis of chronic prostatitis?
varicocele.
A couple is seen at the infertility clinic because they have not been able to conceive. When performing a focused examination to determine any possible causes for infertility, the nurse will check the man for the presence of __________________
Testicular self-examination should be done in a warm area.
Which information will the nurse plan to include when teaching a 19-year-old to perform testicular self-examination?
Ask the patient if he has any questions or concerns about the diagnosis and treatment.
A 32-year-old man who is being admitted for a unilateral orchiectomy for testicular cancer does not talk to his wife and speaks to the nurse only to answer the admission questions. Which action is best for the nurse to take?
he should continue to use other methods of birth control for 6 weeks.
When performing discharge teaching for a patient who has undergone a vasectomy in the health care provider’s office, the nurse instructs the patient that ______________
ineffective role performance related to effects of ED.
A 46-year-old man who has erectile dysfunction (ED) tells the nurse that he decided to seek treatment because his wife “is losing patience with the situation.” The most appropriate nursing diagnosis for the patient is ___________
“Have you been taking any over-the-counter (OTC) medications recently?”
A patient with benign prostatic hyperplasia (BPH) with mild obstruction tells the nurse, “My symptoms have gotten a lot worse this week.” Which response by the nurse is most appropriate?
undescended testicles.
When obtaining a focused health history for a patient with possible testicular cancer, the nurse will ask the patient about any history of ________________
pain management.
When caring for a patient who has been diagnosed with orchitis, the nurse will plan to provide teaching about __________________
Insert a urinary retention catheter.
A patient with benign prostatic hyperplasia (BPH) is admitted to the hospital with urinary retention and new onset elevations in the blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first?
A 48-year-old whose father died of metastatic prostate cancer
When reviewing patient laboratory results, the nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the following four patients. Which patient’s PSA result is most important to report to the health care provider?
Manually instill and then withdraw 50 mL of saline into the catheter.
After a transurethral resection of the prostate (TURP), a patient with continuous bladder irrigation complains of painful bladder spasms. The nurse observes a decrease in urine output and clots in the urine. Which action should the nurse take first?
“Are you using any recreational drugs or drinking a lot of alcohol?”
A 22-year-old man tells the nurse at the health clinic that he has recently had some problems with erectile dysfunction. When assessing for possible etiologic factors, which question should the nurse ask first?
Ask the patient about any prescription drugs he is taking.
A 53-year-old man tells the nurse he has been having increasing problems with erectile dysfunction (ED) for several years but is now interested in using Viagra (sildenafil). Which action should the nurse take first?
A 66-year-old man who has a painful erection that has lasted over 7 hours
The nurse working in a health clinic receives calls from all these patients. Which patient should be seen by the health care provider first?
The patient has had a gradual decrease in the force of his urinary stream.
Which assessment information about a 62-year-old man is most important for the nurse to report to the health care provider when the patient is asking for a prescription for testosterone replacement therapy?
What are the four “t’s” in terms of cyanotic defects in pediatrics?
T =Tetralogy of fallot
T =Truncus arteriosus
T =Transportation of the great vessels
T =Tricuspid atresia
What is Truncus arteriosus?
rare type of heart disease that occurs at birth (congenital heart disease), in which a single blood vessel (truncus arteriosus) comes out of the right and left ventricles, instead of the normal two vessels
What is enuresis?
Definition: intentional or involuntary passage of urine in a child who is beyond age when bladder control should be normally controlled (occurs twice a week for 3 months in child older than 5)
What are some findings associated with acute glomerulonephritis?
oliguria
edema (periorbital and peripheral)
hematuria (“smoky” or “tea-colored” urine)
mild hypertension
lethargy
moderate proteinuria
loss of appetite
Does GFR increase or decrease in cases of AGN?
decreases, the patient retains fluids and thus should eat a diet of low protein, salt, and K
What characterizes the presentation of nephrotic syndrome?
Definition: massive proteinuria, hypoalbuminemia, hyperlipemia and edema
What kind of diet should patients with nephrotic syndrome be on?
no added salt but high in potassium and protein
How should you position a child to reduce the periorbital edema associated with nephrotic syndrome?
Fowlers or high fowlers
What is Wilms tumor?
rare type of kidney cancer; a nephroblastoma
What is hemolytic uremic syndrome?
an acute disorder shows the following “triad”:
1 hemolytic anemia
2 thrombocytopenia
3 acute renal failure
What are some common findings among infants with increased ICP?
full or bulging fontanelles, macrocephaly (large head), poor feeding, vomiting, and irritability.
What causes respiratory distress in infants?
Not enough surfactant in the lungs
Define apnea
Apnea is an unexplained episode of cessation of breathing for 20 seconds or longer, hypotonia, and cyanosis or pallor.
What usually causes the croup, and how do we treat it?
The most common form of croup is acute laryngotracheobronchitis or viral croup, which is an infection of both the upper and lower respiratory tracts. The classic “barky” harsh cough, stridor, and fever are treated with antipyretics and cool air/mist.
What do the secretions produced by an infant with a transesophogeal fistula look like?
Resemble copious amounts of fine white frothy bubbles of mucus in the mouth and nose. Neonates with TEF develop these secretions, which recur despite suctioning. They may also develop rattling respiration and episodes of coughing, choking, and cyanosis.
What is Hirschprung’s disease???
A disorder of the abdomen that occurs when all or part of the large intestine has no nerves and therefore cannot function. The affected segment of the colon cannot contract and therefore pass stool through the colon, creating an obstruction.
What would the findings in a newborn with Hirschprung’s disease be?
Findings in newborns include failure to take liquids, constipation, and bile-stained vomitus.
How do a child’s bones compare to those of an adults?
Children’s bones are more flexible and porous than those of adults; in fact, fractures are very rare before age 1.
Should you attempt visualization of the epiglottis for a child with croup?
Never attempt to directly visualize epiglottis with tongue depressor on child with any of the croup syndromes (laryngitis, tracheitis, epiglottitis) because it can trigger laryngospasm.
How do you know how much a baby is peeing, and how much should they be peeing?
One gram of diaper weight equals one milliliter of urine.
Children with urine output less than one milliliter/kilogram/hour should be closely monitored for possible renal failure.
If a newborn coughs, chokes, and turns blue with feeding, what should the nurse suspect?
tracheoesophageal fistula (note the 3 C’s – cough, choke, and cyanosis).
What is the difference in terms of recovery breaths for an adult vs. an infant?
adult: give 1 breath every 5 to 6 seconds (approximately 10 to 12 breaths/minute) and recheck pulse every 2 minutes

child and infant: give 1 breath every 3 to 5 seconds (approximately 12 to 20 breaths/minute) and recheck pulse every 2 minutes

In what situation do you give a ratio (between chest compressions and ventilation) of 15:2 vs. 30:2?
ONLY for an infant or child when two rescuers are present to participate in CPR. All other situations are 30:2!
What defines an “infant”?
1 year or less. 1 year->puberty=child
Can you use the pediatric pads on an adult for a defibrillator?
NO. however, you can use adult pads on a child.
If a person is choking and becomes unresponsive, describe the sequence of the rescuers actions.
1. activate the EMS system
2. lower the client to the ground
3. begin with compressions (don’t check for a pulse)
*if you were not certain the person was choking, you would just immediately begin CPR
4. Open the victim’s mouth wide and look for the object before giving breaths; remove object only if able to remove without further pushing down airway
What does the acronym “CHANS” refer to?
Types of shock are classified according to etiology: CHANS
C ardiogenic – caused by inability of the heart to pump blood effectively (due to heart attack or heart failure)
H ypovolemic – caused by inadequate blood volume (due to bleeding or dehydration)
A naphylactic – caused by allergic reaction
N eurogenic – caused by damage to nervous system (due to extreme emotional upset due to personal tragedy or disaster)
S eptic – caused by systemic infection
What is cryoprecipitate?
a blood product; given for blood transfusions for those lacking clotting factors
How should your patient that you suspect is going into (or is in) shock be positioned?
Do not elevate or lower head: maintain complete bed rest in flat position or with legs slightly raised to increase venous return (modified trendelenburg)
What is a Myringotomy?
Surgical procedure in which a small incision is created in the eardrum to relieve pressure caused by excessive build-up of fluid or to drain pul from the middle ear.
Naegeles rule
rule for EDB first day of last menstrual period subtract 3 months and add 7 days
McDonalds method
method use uterine size to indicate gestaional age by measuring cm distane from symphysis pubis to top of uterine fundus. fundal hieght
quickening
the feeling of fetal movement by mother occurs between 16-18 weeks, is less accurate EDB
FHR auscultated
this can occur as early as 8 weeks gestation using doppler but normally heard 10-12 weeks
gravida
number of times woman is pregnant
para
number of births after 20 weeks gestation
multiple count as one pregnancy
if mother has twins she is gravida 1 para 2
37 weeks
what is considered a term birth
20-36 weeks
what is considered pre-term birth
aborted
if pregnancy end in spontaneous or therapeutic __ prior to 20 weeks
subjective and objective signs
what signs may or may not be associated with pregnancy.
diagnostic
what signs can only be associated with pregnancy
120-160 bpm
normal fetal heart rate beginning at 8 weeks with doppler
fetoscope
FHR assessed by this equipment starting at 16 weeks
presumptive signs
subjective signs may not be associated with pregnancy – amenorrhea, NV, fatigue, urinary requency, breast change and quickening
probable signs
objective signs may not be associated with pregnancy – hegar’s sign, mcdonalds sign, enlarged abdomen, pigmentation, striae, ballottement, positive pregnancy test, palpation of fetal outline
positive signs
diagnostic sign of pregnancy fetal heartbeat, fetal movement felt by examiner, fetus on ultrasound
gestational age
fundal height is a measure from symphysis pubis to top of uterine fundus shows this age
maternal physical exam
vital signs, HW, thyroid, heart and breath sounds, reproductive organs, uterus size, pelvis exam are part of these
H&H, blood type, Rh, irregular antibody, rubella, TB, renal function, UA, STI, Pap, offer HIV
what type of tests are given to pregnant female
erythroblastosis or hyperbilirubinemia
what two complications may be identified from a blood type and Rh stats during first prenatal visit
4.2-5.4
RBC norm
12-16 g/dL
normal hemoglobin
37-47%
normal hematocrit
5,000 to 10,000
WBC norm
150,000 to 400,000
platelet counts
RBC increases
what happens to RBC during pregnancy
H&H drop a little
what happens to H&H levels during pregnancy
WBC increase slightly
what happens to WBC during pregnancy
mid-stream clean catch specimen
what kind of urinalysis specimen is collected for pregnancy
pH decreases with ketones and glucose
what happens to urine during pregnancy
preeclampsia
this may be indicated if protein is found in urine of +1
WBC or nitrates
these may be found in urine to show UTI may show risk of pre-term labor
ketones
this product found in urine may indicate diabetes mellitus and hyperglycemia
toxoplasmosis
infection in mother assoc. with consuming undercooked meat or poor handwashing after handling cat liter and may pass it to fetus through placenta causing flu symptoms
serologic test
how is toxoplasmosis identified in pregnant female
miscarriage, hydrocephaly, CNS lesions
what can happen to fetus with toxoplasmosis
Hep A
infection spread by droplets associated with poor handwashing after defecation
Hep B
most common fetus infection from blood and genital secretions during labor and delivery.
preterm birth, hepititis intrauterine death
hep A and B effects the fetus with these risks
rubella
droplet infection that may affect child with miscarriage, congential anomalies and death
cytomegalovirus CMV
respiratory droplet infection transmitted from day care, mentally handicapped are at high risk may cause fetal death, jaundice, hydrocephaly, deafness
Herpes
STI from vescular lesions on genitalia fetus is at high risk from primary infection of mother if lesion in birth canal, may need a cesarean delivery
HPV human papillmavirus
STI genital warts fetus can acquire during birth process
gardasil vaccine
what is the prevention for HPV
gonorrhea
what is the STI that if not treated to neonate with eye drops the infant could be blind
every 4 weeks during first 28 weeks gestation
when are prenatal visits wo be done in first 28 weeks gestation
every 2 weeks
when are prenatal visist be done between 28-36 weeks
every week until delivery
when are prenatal visits done after 36 weeks
colostrum
milk production in breasts
quickening, colostrum production physical changes and danger signs
what is instructed to mother concerning physical changes of pregnancy
acceptance, vitals, weight, nutrition, glucose or protein in urine
what do you assess for during collaborative management during pregnancy
premature labor or abruptio placentae
what are two ppossible causes of abdominal pain during pregnancy
hyperemesis gravidarum
persistent vomiting during pregnancy that may cause dehydration
visual disturbance, edema hands and face, severe HA
what are three danger signs of HTN or preeclampsia
epigastric pain
besides visual disturbance, edema, or HA what els is a danger sign to preeclampsia
abruptio placentae, placentae previa, bloody show
what are three possible causes of vaginal bleeding during pregnancy
glucose
what is found in urine to diagnose diabetes mellitus during prego
protien
what is found in urine to diagnose preeclamspia in pregnancy
nitrates and leukocytes
what is found in urine to diagnose UTI
Hgb
what is tested for iron-deficiency anemia
fundal height, movment and FHR
what are three assessment findings for fetus
24-28 weeks
when do you check mother glucose for gestational diabetes
AFP alpha-fetoprotein
test measured at 16-18 weeks gestation if serum increased indicates neural tube defects.
glucose tolerance test GTT
50 g oral glucose load is given after one hour levels found greater than 130-140 mg/dL then followed by a 3 hour 100 g to diagnose gestational diabetes
oral glucose tolerance test OGTT
test procedure of high carb diet for 3 days then 8 hour fasting with glucose levels assessed then 100 g oral glucose and checked again at 1,2,3 hours for gestational diabetes
first trimester and obese
when is transvaginal ultrasound completed
greater than 95
what is an abnormal BS after fasting for 8 hours
bladder is full
when is it best to have an abdominal ultrasound
biparietal diameter and femur length
how will the ultrasound help assess health care provider of growth rate
kitzenger
birthing method of sensory memory Stanislavsky method to teach relaxation
bradley
birthing method husband to coach relaxation through abdominal breathing and exercise
lamaze
birthing method to educate about developing fetus and exercises to decrease fear and pain
avoid strong odors, avoid drinking while eating, avoid spicy or greasy foods,
to manage NV during early pregnancy – drink carbonated beveraes, eat crackers or toast before getting out of bed, small frequent meals but avoid –
well-fitting supportive bra
how to manage breast tenderness during early pregnancy
increase daytime fluid intake, decrease night time fluid intake
how to avoid urinary frequency during early pregnancy
plan nap during day and early bedtime
how to avoid fatigue during early pregnancy
cool air vaporizer
how to manage nasal stuffiness and nasal bleeding during early prego
eat small frequent meals, avoid spicy/greasy foods, dont lie down after eating use low sodium antacids
how to manage heartburn during late prego
increase fluid and fiber, exercise, stool softeners
how to manage constipation during late prego
avoid constipation, apply topical anesthetics, ointments or ice paks, sitz bath or warm soak, reinsert into rectum
how to manage hemorrhoids during late prego
elevate legs, wear hose, avoid crossing legs, avoid restrictive clothing and standing for long
manage varicose veins in late prego
arise slowly, avoid standing for long and check H&H
manage faintness during late prego
goodells sign
estrogen causes softening of cervix is this sign during pregnancy
chadwicks sign
estrogen causes bluish color of cervix during pregnancy
estrogen and progesterone
what hormones cause breasts to increase in size and number of glands
Cardiac output increases 30-40%
what does the cardia output levels do with an increased pulse of 10-15 bpm during prego
BP drops
what does the BP do in the first and second trimester
pregnant uterus press on pelvic and femoral vessels
postural hypotension during prego occurs due to limiting blood return to heart because
pallor, dizzy, clammy skin
what are s/s of postural hypotension
position on left side
how do you correct postural hypotension
lordosis
curvature of lumbar spine increases to complensate for weight of gravid uterus
diastasis recti
separation of abdominal muscle after uterus enlarges
increased hCG (human chrionic gonadotropin)
during the first trimester this hormone increases and can cause NV
relax smooth muscles
progesterone levels do this causing decreased peristalsis causing bloating, reflux, constipation and worsens when gravid uterus presses on intestines
hemorrhoids
constipation and increase pressure on blood vessel in rectum can lead to this
first trimester and third trimester
gravid uterus presses on bladder causing urniary frequency in this trimester
GFR increases 50%
during second trimester this function increasesand remains elevated until delivery in renal function
estrogen
what hormone causes increased pigmentation during prego
chloasma, linea negra and striae gravidarum
what three integumentary systems are affected during prego
water retention
increased sex hormones and decreased serum protein causes this in prego
hCG
hormones stimulates progesterone and estrogen production and cause NV in first trimester
estrogen
hormone stimulates uterine development to support fetal grwoth and ducts in breasts for lacatation`
progesterone
maintains endometrium , decreases uterin contractility, breast ancini, relaxes smooth muscles
relaxin
hormone made by corpus luteum decreases uterine contractility softens cervix
prostaglandins
lipids found in female reproductive system, contribute to onset of labor
more or less calories
nutritional status of underweight or over weight will need this nutrient respectivley
adolescent mother
these mothers need increased caloric intake for both the meternal and fetal growth
additional 300 calories a day
a healthy pregnant woman will need an additional – calories per day
folic acid
B6 vitamin that reduce risk of birth defects
protein, folate, prenatal vitamin, minerals
what is added to the diet for prego
10-13 lbs
how much of the 25-35 total pounds gained in first 20 weeks
about one pound per week
how much weight gain per week after week 20
NV, epigastric discomfort, abd cramping, abd distention, loose stools
s/s of lactos intolerance from insufficient lactase enzyme
lactase
this may be added to milk or chewed before ingesting milk to help breakdown lactose
cheese or yogurt
if lactose intolerated these two dairy products may be better tolerated
whole grain foods and legumes, or nuts and legumes, or whole grain and nuts
strict vegetarians need combinations of proteins for adequate amounts
B12
all vegetarian prego need this vitamin
An appropriate intervention for a child with bronchiolitis is
increased fluids
What is the best liquid for the nurse to give to a child who has had a tonsillectomy?
Apple Juice
The nurse determines a parent understands diet teaching for a child with cystic fibrosis when she states the child should eat which type of diet
High calorie, high protein
The nurse places a child with croup in and environment of high humidity for which effect?
Decreased mucosal swelling
An appropriate nursing action when a child is suspected of having epiglottistis is to
avoid examination of the pharynx
The nurse observes a child who had a tonsillectomy a few hours earlier is swallowing frequently. What is the appropriate action for the nurse to take?
Notify the dr
What info would be included in a teaching plan for a child with asthma
Identify early signs of an asthma attack
the nurse would expect the parent of an infant with croup to describe the infant’s cough as
barking
Which med is not useful when a child is experiencing an asthma attack
cromolyn sodium
A 3 yr old boy was seen in the clinic by the pediatrician and diagnosed with pneumonia. Amoxicillin for 10 days was prescribed, with a followup visit in 2 weeks. What need to be taught to the patient
importance of taking all of the prescribed amoxicillin
What is the most common congenital heart defect occurring in children
ventricular septal defect
What is the best method of feeding an infant in congestive heart failure from a large ventricular septal defect
feed smaller amounts more frequently
Digoxin(Lanoxin) is withheld if the pulse of a newborn is below ____ bpm
100
When an infant is receiving digoxin (Lanoxin), the nurse would be alert to which finding as a sign of toxicity?
nausea and vomiting
A nurse’s responsibility when a child is receiving diuretics is to
monitor serum electrolyte levels
Hypertension is identified in a 10yr old child during routine screening, the nurse should expect which plan of care to be implemented initially?
a blood pressure measurement is scheduled in 4 weeks
An infant with tetralogy of Fallot becomes hypercyanotic. the nurse would place the infant in the ________________ position.
Knee-chest
An infant with a congenital heart abnormality would most likely experience
difficult feeding
A congenital heart defect that results in decreased pulmonary blood flow is
tetralogy of Fallot
The nurse measuring an infants blood pressure finds it is higher in the arms than the legs. The finding is associated with which congenital heart defect
Coarctation of the aorta
By what age do children realize that death is final and permanent
10
It is recommended that iron fortified formula be given to infants through the age of
12months
Which of the following presents the greatest risk to the risk to the child with hemophilia
Intracranial bleeding
Signs and symptoms that might indicate that a child has idiopathic thrombocytopenic purpura include
petechiae and purpura
The diagnostic test that confirms a diagnosis of leukemia is
bone marrow aspiration
When caring for a child on steriod therapy, it is important to seek immediate medical attention if the child
develops a fever
Children with Hodgkin’s disease usually present with
painless cervical neck lump
children with hemophilia should aviod
salicylates
Children with sickle cell trait
Will no develop the disease
An appropriate nursing intervention for the child admitted to the hospital in sickle cell crisis would be to
monitor the childs response to analgesics
Immediate nursing care of a child with hemophilia who has hemarthrois includes
immobilization of the area of pain
The greatest concern of a nurse caring for a child with ITP is
injuries that might initiate bleeding
Anxiety can be decreased in both the family and the child who has cancer by
explaining all procedures before they are done
A common childhood disease that can have devastating effect on an immunosuppressed child
chickenpox
Nursing care of an adolescent with cancer who is refusing to cooperate with treatment should include
allowing the adolescent to make some choices
What would be the initial nursing action when a child receiving a transfusion of packed red blood cells complains of chills and back pain
discontinue the transfusion
Which diagnostic test permits visualization of the upper GI tract
Endoscopy
Children with failure to thrive fall below the ___ percentile in weight and height on growth charts
3rd
Which approach might best support maternal attachment when caring for a child with failure to thrive
encourage the mother to participate in the child’s care
Which signs and symptoms are characteristic of pinworms
itching, irritability, and restlessness
Children with intussusception may have bowel movements containing blood and mucus and no feces
currant jelly stools
a newborns total body weight is about _______water
77%
Which action should the nurse take before adding potassium to a child’s IV
establish that child is voiding
The nurse taking a history form parents of an infant with pyloric stenosis would expect them to report the infant experienced which sign
Projectile vomiting
When a child has pinworms, the nurse should know that
andy family member with symptoms should be treated
Which info would the nurse give to parents of an infant with gastroesophageal reflex disease
Place prone with the head elevated after feeding
The nurse doing a newborn assessment knows the earliest sign of Hirschsprung’s disease is
failure to pass meconium
The organ damaged by acetaminophen poising is the
liver
The nurse would explain to parents that infants are more susceptible to accidental ingestion of foreign bodies because they are
likely to put everything in their mouths
The nurse was giving a newborn her first feeding when the baby started coughing and choking. This is indicative of which condition
Tracheoesophageal atresia
A child appears apathetic and weak. His growth is below normal normal for his age. There is a white streak in the child’s hair. The nurse recognizes these signs as characteristic of
kwashiorkor
A childs arterial blood gas results are pH 7.30, PaCO2-36,HCO3-21. The nurse determines the child is experiencing which acid-base imbalance
metabolic acidosis
Safety and security
A young child is being admitted to an acute care setting. He has never been hospitalized before. As the nurse enters the room, the child begins to cry and cling to his mother. According to Maslow’s hierarchy of needs, the child is exhibiting the need for:
Sit face to face with the patient, conversing slowly and clearly.
As a nurse caring for an older adult, you know that being hospitalized can be confusing and upsetting. Which intervention would be most appropriate when caring for this patient?
Assist with the plan of care and recommend revisions as necessary.
As an LPN, you know that your role in the nursing process when a patient is admitted is to:
During hospitalization
Effective discharge requires careful planning and continuing assessment of a patient’s needs:
Physical therapy
During discharge planning, which of the following disciplines of the health care team assists in rehabilitating and restoring a patient’s musculoskeletal function to its highest potential?
AMA (against medical advice)
You notice that your patient has his call light on. As you enter the room, the patient is fully dressed and ready to leave. He begins yelling at you to take his IV out because he is going home. When a patient leaves the hospital without a physician’s order, it is considered to be leaving:
“Hello, Ms. Green, my name is ?”
You are assisting the RN with a newly admitted female patient. What is the most appropriate way to address the patient?
Contact with blood; Contact with skin disease; Improper care of the body; Lack of sleep
As nurses today, we have to care for patients from many different cultures and backgrounds. Select all of the following ideas/beliefs from the Japanese culture about how illness is caused.
Have the patient sign a Consent for Treatment
A patient is being admitted to the surgical floor. Before the patient goes to surgery, the Admissions department will:
Call the admitting nurse at the facility and give a brief summary of the patient’s medical diagnosis, treatment care plan, and medications.
Your patient is being transferred to a long-term care facility for rehabilitation. As the nurse, what will you need to do in order to provide continuity of care for this patient?
ensuring the patient has an allergy band.
During the registration process, the admission clerk is responsible for:
introduce self and roommates.
A 36-year-old schoolteacher is admitted for observation and various diagnostic tests. The initial nursing action in her admission process is to:
never appropriate.
A 90-year-old great-grandfather has been hospitalized with pneumonia. It is necessary to reorient him to his surroundings periodically. The nurse assisting him with his morning care remembers that to call an older male patient “Gramps” is:
intraagency transfer.
A patient has been transferred out of the ICU to a medical unit. A nurse has been assigned to complete the transfer. This type of transfer is called a:
the patient is a human being deserving dignity, courtesy, and respect.
A 52-year-old patient is being transferred to the recovery room from the surgical unit following extensive surgery as the result of trauma from an automobile accident. The nurse assigned to complete his care remembers that when admitting, transferring, or discharging a patient:
ensure continuity of care.
A 45-year-old patient has been recently diagnosed and hospitalized for type 1 diabetes mellitus. The multidisciplinary health care team has been preparing for her dismissal. The purpose of discharge planning is to:
on his admission to the hospital.
An 84-year-old patient has been hospitalized for 6 days with a diagnosis of a stroke. The nurse knows planning for the patient’s dismissal should begin:
explain the risks of leaving and request that the patient sign a paper accepting responsibility for problems that may occur.
A patient is determined to leave the hospital. His physician is not aware of his intent, nor is it in his best interests to be discharged at this time. When a patient chooses to leave a health care facility without a physician’s written order, the nurse should:
greet the patient by name.
The nurse is admitting a patient to the nursing unit. The nurse’s first action is to:
wish the patient well.
The patient is being discharged. The nurse should:
have the patient sign consent for treatment.
A patient is being admitted to the hospital for stabilization of her heart condition. Before arriving on the nursing unit, the admissions department will:
obtaining vital signs.
When a patient arrives on the nursing unit, the LPN is probably responsible for:
method of discharge.
Nursing documentation at discharge should include a:
continuity of care from hospital to home.
The services of a transition specialist for patient discharge often leads to an increase in:
The Preschool age child is in which age range?
3-5 years
The average weight gain for the preschooler is ________ per year.
5 lbs
The average height increase for the preschooler is _______ per year which is mostly due to an elongation of the __________.
2-3 inches; legs (rather than the trunk)
Physically, the preschooler is built more like a(n) (toddler/adult) and is usually _________ and_______.
adult; slender; agile
At what age are the following appropriate milestones: pedal a tricycle, jump in place, broad jump, balance on one foot, walk up and down steps using alternating feet, build a tower of 9-10 cubes, copy a circle, put facial features on a circle, and feed and dress himself?
3 years
At what age are the following appropriate milestones: balance on one foot for 5 seconds, walk heel to toe, catch a ball, throw a ball overhand, skip and hop on one foot, use scissors, lace shoes, copy a square, and add three parts to a stick figure?
4 years
At what age are the following appropriate milestones: skip and hop on alternate feet, throw and catch a ball, jump rope, jump from a height of 12 inches, balance on alternate feet with eyes closed, tie shoelaces, use scissors, begin to print a few letters or numbers, copy a diamond and triangle, and draw a stick figure with seven to nine parts?
5 years
At what age are the following appropriate milestones: have a vocabulary of about 900 words and can use complete sentences of 3-4 words, asks many questions, and begins to sing songs?
3 years
At what age are the following appropriate milestones: understands time in relation to daily events, prizes independence, takes pride in his accomplishments, enjoys entertaining others, shares family secrets with outsiders, and commonly has an imaginary friend, is egocentric (unable to envision situations from perspectives other than his own)?
4 years
At what age are the following appropriate milestones: have a vocabulary of approximately 2,100 words and can use sentences with 6-8 words, asks the meaning of words, has many questions, can name the days of the week and the months of the year, enjoys group play with similar or identical activities but without organization or rules (associative play)?
5 years