Professional Documents
Culture Documents
2. Ovulation occurs how many days before the next menstrual period?
- 14 days.
5. Name the major discomforts of the first trimester and one suggestion for
amelioration of each.
- Nausea and vomiting: crackers before rising. Fatigue: teach the need for rest
periods/naps and 7-8 hours sleep at night.
6. If the first day of a woman’s last normal menstrual period was May 28, what is
the estimated delivery date (EDD) using Nagele’s rule?
- Count back 3 months and add 7 days: March 7 (always give February 28 days).
7. At twenty weeks gestation, the fundal height would be ______ , the fetus would
weigh approximately _______ and look like _____ .
- At the umbilicus; 300-400 grams; a baby with hair, lanugo and verniz, but without
subcutaneous fat.
10. State three principles relative to the PATTERN of weight gain in pregnancy.
- Total gain should average 24-30 lbs. Gain should be consistent throughout
pregnancy. An average of 0.9 lb/week should be gained in the 2nd & 3rd trimester.
11. During pregnancy a woman should add ____ calories to her diet, and drink ____
of milk/day.
- 300 calories; 1 quart of milk
12. Fetal heart rate can be auscultated by Doppler at ____ weeks gestation.
- 10-12 weeks
13. Describe the schedule for prenatal visits for a low-risk pregnant woman.
- Once a month until 28 weeks, then once every week until delivery.
4. List 3 necessary nursing actions prior to an ultrasound exam for a woman in the
first trimester of pregnancy.
- Have client fill bladder. Do not allow client to void. Position supine with uterine
wedge.
9. Name the 4 periodic changes of the fetal heart rate, their causes, and one nursing
treatment for each.
- Acceleration: caused by burst of sympathetic activity; they are reassuring and require
no treatment. Early decelerations: caused by head compression, are benign and
caution the nurse to monitor for labor progress and fetal descent. Variable
decelerations: caused by cord compression; change of position should be tried first.
Late decelerations: are caused by UPI (uteroplacental insufficiency) and should be
treated by placing client on her side and administering O2.
10. What is the most important indicator of fetal autonomic nervous system
integrity/health?
- Fetal heart rate variability
12. State the most important action to take when a cord prolapse is determined.
- Examiner should position mother to relieve pressure on the cord with fingers until
emergency delivery is accomplished.
15. Normal fetal scalp pH in labor is ____ and values below ____ indicate true
acidosis.
- 7.25-7.35 normal pH; 7.2 indicates true acidosis.
INTRAPARTUM:
1. List five prodromal signs of labor the nurse might teach the client.
- lightening, braxton-hicks contractions increase, bloody show, loss of mucous plug,
burst of energy, and nesting behaviors.
5. Identify two reasons to withhold anesthesia and analgesia until the mid-active
phase of Stage 1 labor.
- if given too early, can retard labor; if given too late, can cause fetal distress
12. List four nursing actions for the 2nd stage of labor.
- make sure cervix is completely dilated before pushing is allowed. Assess FHR with
each contraction. Teach woman to hold breath for no longer than 5 seconds. Teach
pushing technique.
17. If meconium was passed in utero, what action must the nurse take in the delivery
room?
- arrange for immediate endotracheal tube observation to determine the presence of
meconium below the vocal cords (prevents pneumonitis/meconium aspiration
syndrome)
21. What is the major cause of maternal death when general anesthesia is
administered?
- Aspiration of gastric contents
26. State three actions the nurse should take when hypotension occurs in a laboring
client.
- turn client to left side. Adminsiter O2 by mask at 10L/min. increase speed of
intravenous infusion (if it does not contain medication).
28. What actions can the nurse take to assist in preventing postpartum hemorrhage?
- massage the fundus (gently) and keep the bladder emptied.
29. To promote comfort, what nursing interventions are used for a 3rd degree
episiotomy, which extends into the anal sphincter?
- ice pack, withc hazel compresses, and no rectal manipulation
30. What nursing interventions are used to enhance maternal-infant bonding during
the 4th stage of labor?
- withhold eye prophylaxis up to 2 hours. Perform newborn admission/routine
procedures in room with parents. Encourage early initiation of breastfeeding. Darken
room to encourage newborn to open eyes.
32. List symptoms of a full bladder, which might occur in the 4th stage of labor.
- fundus above umbilicus, dextroverted (to the right side of abdomen), increased
bleeding (uterine atony).
33. What action should the nurse take first when a soft, boggy, uterus is palpated?
- perform fundal massage
35. How often should the nurse check the fundus during the 4th stage of labor?
- q15 minutes X 4 (1 hour), q30 minutes X 2 hours if normal.
NORMAL PUERPERIUM (POSTPARTUM):
1. A nurse discovers a postpartum client with a boggy uterus, displaced above and
to the right of the umbilicus. What nursing action is indicated?
- Perform immediate fundal massage. Ambulate to the bathroom or use bedpan to
empty bladder because cardinal signs of bladder distention are present.
3. Upon admission to the postpartum room, 3 hours after delivery, a client has a
temperature of 99.5F. What nursing actions are indicated?
- Probably elevated due to dehydration and work of labor; force fluids and retake
temperature in an hour; notify physician if above 100.4F.
4. A client feels faint on the way to the bathroom. What nursing assessments
should be made?
- Assess BP sitting and lying, assess Hgb and Hct for anemia.
7. Three days postpartum, a lactating mother has full, warm, taut, tender breasts.
What nursing actions should be taken?
- She is engorged; have newborn suckle frequently; use measures to increase milk
flow; warm water, breast massage and supportive bra.
9. A woman has decided to take birth control pills as her contraceptive method.
What should she do if she misses taking the pill two consecutive days?
- Take two pills for two days and use an alternate form of birth control.
10. A woman asks why she is urinating so much in the postpartum period. The
nurse bases the response on what information.
- Up to 3,000 cc per day can be voided due to the reduction of the 40% plasma volume
increase during pregnancy.
11. A woman’s white blood count returns 17,000; she is afebrile and has no
symptoms of infection. What nursing action is indicated?
- Continue routine assessments; normal leukocytosis occurs during postpartal period
because of placental site healing.
12. What is the most common cause of uterine atony in the first 24 hours
postpartum?
- full bladder
13. What is the purpose of giving docusate sodium (Colace) to the postpartum
client?
- to soften the stool in mother’s with 3rd and 4th degree episiotomies, hemorrhoids, or
Cesarean section delivery.
14. What should the fundal height be at three days postpartum for a woman who
has had a vaginal delivery?
- 3 fingerbreadths/cm below the umbilicus.
2. The nurse anticipates which newborn will be more at risk for problems in the
transitional period. State 3 predisposing factors to respiratory depression in the
newborn.
- Cesarean delivery; magnesium sulfate given to mother in labor; asphyxia/fetal
distress in labor.
3. What is the danger of heat loss to the newborn in the first few hours of life?
- Leads to depletion of glucose (very little glycogen storage in immature liver); begins
to use brown fat for energy producing ketones causing subsequent ketoacidosis and
shock.
6. True or False: the newborn’s head is usually smaller than the chest.
- FALSE: head is usually 2 cm larger unless severe molding occurred.
7. During the physical exam of the newborn, the nurse notes the cry is shrill, high-
pitched, and weak. What are the possible causes?
- CNS anomalies, brain damage, hypoglycemia, drug withdrawal.
8. The nurse notes a swelling over the back part of the newborn head. Is this
normal newborn variation?
- It depends on the exam. If it crosses suture lines and is a caput (edema), it is normal.
If it does not cross suture lines, it is a cephalhematoma with bleeding between the
skull and periosteum. This could cause hyperbilirubinemia. This is an abnormal
variation.
11. Should the normal newborn have a positive or negative Babinski reflex?
- Positive. The transient reflex is present until 12-18 months of age.
13. When suctioning the newborn with a bulb syringe, which should be suctioned
first, the mouth or the nose?
- Mouth; stimulating the nares can initiate inspiration which could cause aspiration of
mucus in oral pharynx.
14. A new mother asks the nurse if circumcision is medically indicated in the
newborn. How should the nurse respond?
- There is controversy concerning this issue, but we do know it causes pain and trauma
to the newborn, and the medical indication may be unfounded.
15. Normal blood glucose in the term neonate is ____. = 40-80 mg/dl.
16. Why does the newborn need vitamin K in the 1st hour after birth?
- Sterile gut at delivery lacks intestinal bacteria necessary for the synthesis of vitamin
K; vitamin K is needed in the clotting cascade to prevent hemorrhagic disorders.
19. A term newborn needs to take in _____ calories per pound per day. After the
initial weight loss is sustained, the newborn should gain _____ per day.
- 50 calories; 1 ouncce or 30 grams.
20. List 5 signs and symptoms new parents should be taught to report immediately
to a doctor or clinic.
- Lethargy; temperature >100F, vomiting, green stools, refusal of 2 feeds in a row.
HIGH-RISK DISORDERS:
1. What instructions should the nurse give the woman with a threatened abortion?
- Maintain strict bedrest for 24-48 hrs. Avoid sexual intercourse for two weeks.
2. Identify the nursing plans and interventions for a woman hospitalized with
hyperemesis gravidarum.
- Weight daily; uring ketone checks 3X daily; progressive diet; check FHR q8h;
monitor for electrolyte imbalances.
6. What specific information should the nurse include when teaching human
papillomavirus detection & treatment?
- Detection of dry; wart-like growths on vulva or rectum. Need for pap smear in the
prenatal period. Treatment with laser ablation (cannot use Podophyllin in
pregnancy). Associated with cervical carcinoma in mother and respiratory
papillomatosis in neonate.
9. All pregnant women should be taught preterm labor recognition. Describe the
warning symptoms of preterm labor.
- More than 5 contractions/hour, cramps, low, dull backache; pelvic pressure; change in
vaginal discharge.
13. What special actions should the nurse take in the intrapartum period if preterm
labor is unable to be arrested?
- Monitor the FHR continuously and limit drugs, which cross placental barriers to
prevent fetal depression or further compromise.
14. A prolonged latent phase for a multipara is ____ and for a nullipara is ____.
Multiparas average cervical dilatation is ____cm/hr in the active phase and
nulliparas average cervical dilatation is ____cm/hr in the active phase.
- >14 hours, >20 hours, 1.5 cm/her; 1.2 cm/hr.
15. What are the major goals of nursing care related to pregnancy-induced
hypertension with preeclampsia?
- Maintenance of uteroplacental perfusion; prevention of seizures; prevention of
complications such as HELLP syndrome, DIC and abruption.
16. Magnesium sulfate is used to treat PIH. A) What is the purpose for
administration of magnesium sulfate? B) What is the main action of magnesium
sulfate? C) The antidote for magnesium sulfate? D) List the 3 main assessment
findings indicating toxic effects of magnesium sulfate.
- A) Prevent seizures by decreasing CNS irritability B) Central nervous system
depression (seizure prevention) C) Calcium Gluconate D) Reduced urinary output,
reduced respiratory rate, and decreased reflexes.
18. What is the priority nursing action after spontaneous or artificial rupture of
membranes?
- Assessment of the fetal heart rate.
20. List the symptoms of water intoxification from the antidiuretic hormone (ADH)
effect of Pitocin (oxytocin).
- Nausea and vomiting, headache, and hypotension.
24. A woman on Orinase (oral hypoglycemic) asks the nurse if she can continue this
medication in pregnancy. How should the nurse respond?
- No, oral hypoglycemic medications are teratogenic to the fetus. Insulin will be used.
26. When should the nurse hold the dose of magnesium sulfate and call the
physician?
- When the client’s respirations are <12/minute, DTRs are absent, or urinary output is
<100cc/4 hours
27. State 3 priority nursing actions in the postdelivery period for the client with
PIH.
- Monitor for signs of blood loss. Continue to assess BP and DTRs q4 hours. Monitor
for uterine atony.
28. When are the 2 most difficult times for control for the pregnant diabetic?
- Late in the 3rd trimester and in the postpartum period when insulin needs to drop
sharply (the diabetogenic effects of pregnancy drop precipitously).
30. List 3 conditions clients with diabetes mellitus are more prone to develop.
- PIH, hydramnios; infection
33. The goal for diabetic management during labor is euglycemia. How is it defined?
- 60-100 mg/dl.
36. What interventions can the nurse implement to maintain cardiac perfusion in a
laboring cardiac client?
- Position client in a semi or high-Fowler’s position. Prevent Valsalva’s maneuvers.
Position client in a supine or R/T for regional anesthesia. Avoid stirrups because of
possible popliteal vein compression and decreased venous return.
38. When may a vaginal birth after Cesarean (VBAC) be considered by a woman
with a previous c-section?
- If a low uterine transverse incision was performed and can be documented AND if the
original complication does not recur, i.e., CPD.
39. Prior to anesthesia for C-section delivery, the mother may be given an antacid or
a gastric antisecretory drug (histamine receptor antagonist). State the reasons
why these drugs are given.
- Antacid buffers alkalize the stomach secretions. If aspiration occurs, less lung
damage ensues. An antisecretory drug reduces gastric acid, reducing the risk of
gastric aspiration.
40. Clients who have had a C-section are prone to what post-op complications?
- Paralytic ileus, infection, thromboembolism, respiratory complications, and impaired
maternal infant bonding.
2. What are the common side effects of antibiotics used to treat puerperal
infection?
- GI adverse reactions: nausea, vomiting, diarrhea, and cramping. Hypersensitivity
reactions: rashes, urticaria, and hives
1. List the major CNS danger signals, which occur in the neonate.
- Lethargy, high-pitched cry, jitteriness, seizures, and bulging fontanels.
2. A baby is delivered blue, limp, and with a heart rate <100. The nurse dries the
infant, suctions the oropharynx and gently stimulates the infant while blowing
O2 over the face. The infant still does not respond. What is the next nursing
action?
- Begin oxygenation by bag and mask at 30-50 breaths/minute. Assist physician in
setting up for intubation procedure.
10. A premature baby is born and develops hypothermia. State the major nursing
interventions to treat hypothermia.
- Place under radiant warmer or in incubator with temperature skin probe over liver.
Warm all items touching the newborn. Place plastic wrap over neonate.
11. Nurses often weigh diapers in order to determine exact urine output in the high-
risk neonate. Explain this procedure.
- Diaper is weighed in grams before applying. Weigh diaper after wetting. Calculate
and record each gram or added weight as one cc of urine.
12. What factors does the nurse look for in determining the newborn’s ability to
take in nourishment by nipple/mouth?
- Good suck, coordinated suck-swallow, takes less than 20 minutes to feed, gaining 20-
30 gm/day.
13. What complications are associated with total parenteral nutrition (TPN)?
- Hyperglycemia, electrolyte imbalance, dehydration, and infection.
14. In order to prevent rickets in the preterm newborn, what supplement is given?
- Calcium and vitamin D.
15. List 4 nursing interventions to enhance family/parent adjustment to a high-risk
newborn.
- Initiate early visitation at ICU. Provide daily information to family. Encourage
participation in support group for parents. Encourage all attempts at care-giving
(enhances bonding).
18. Write one nursing diagnosis generated from the data pertinent to
hyperbilirubinemia.
- Potential for injury related to predisposition of bilirubin for fat cells in brain.
21. Neonates who are “sick” are prone to receive too much stimulation in the form
of invasive procedures and handling too little developmentally-appropriate
stimulation and affection. How might such an infant respond?
- Failure to thrive, lack of crying.
22. How should the nurse determine the length of a tube needed for oral gavage
feeding of a newborn?
- From the bridge of the nose, to the earlobe, to a point halfway between the xiphoid
and the umbilicus.
23. What are the 2 best ways to test for correct placement of the gavage tube in the
infant’s stomach?
- Aspiration of stomach contents with pH testing, and auscultation of air bubble
injected into stomach.
24. What characteristics would the nurse expect to see in a neonate with fetal
alcohol syndrome?
- Microcephaly, growth retardation, short palpebral fissures, and maxillary hypophysia.