OB-MATERNITY
ANATOMY & PHYSIOLOGY OF REPRODUCTION:
1. State the objective signs that signify ovulation
- abundant, thin, clear cervical mucus; open cervical os; slight drop in BBT and then
0.5-1.0 F rise; ferning under the microscope
2. Ovulation occurs how many days before the next menstrual period?
- 14 days.
3. State three ways to identify the chronological age of a pregnancy (gestation)?
- 10 lunar months, 9 calendar months consisting of 3 trimesters of 3 months each, 40
weeks, 280 days.
4. What maternal position provides optimum fetal maternal/placental perfusion
during pregnancy?
- The knee-chest position, but the ideal position of COMFORT for the mother which
supports fetal/maternal/placental perfusion is the side-lying position off the
abdominal vessels (vena cava, aorta)
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.
8. State the normal psychosocial responses to pregnancy in the 2nd trimester
- Ambivalence wanes and acceptance of pregnancy occurs; pregnancy becomes “real;”
signs of maternal-fetal bonding occur.
9. Hemodilution of pregnancy peaks at ______ weeks and results in a/an ______ in
a women’s Hct.
- 28-32 weeks; increase in Hct
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.
FETAL-MATERNAL ASSESSMENT TECHNIQUES:
1. Name 5 maternal variables associated with diagnosis of a high risk pregnancy
- Age (under 17 years or over 34 years of age), parity (over 5), <3 months between
pregnancies, diagnosis of PIH, diabetes mellitus, or cardiac disease.
2. Is one ultrasound examination useful in determining the presence of intrauterine
growth retardation (IUGR)?
- no, serial measurements are needed to determine IUGR.
3. What does the biophysical profile (BPP) determine?
- Fetal well-being
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.
5. State the advantage of CVS over amniocentesis.
- Can be done between 8-12 weeks gestation with results returned within one week,
which allows for decision about termination while still in 1st trimester.
6. Why are serum or amniotic AFP levels done prenatally?
- To determine if alpha-fetoprotein levels are elevated which may indicate the presence
of neural tube defects; or low levels, which may indicate trisomy 21.
7. What is the most important determinant of fetal maturity for extrauterine
survival?
- L/S ratio (lung maturity, lung surfactant development)
8. Name the 3 most common complications of amniocentesis.
-
Spontaneous abortion, fetal injury, infection.
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
11. Name 4 causes of decreased FHR variability.
- Hypoxia, acidosis, drugs, fetal sleep
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.
13. What is a “reactive” non-stress test?
- FHR acceleration of 15 beats per minute for 15 seconds in response to fetal
movement.
14. What are the dangers of nipple-stimulation stress test?
- The inability to control “oxytocin” dosage and the chance of tetany/hyperstimulation.
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.
2. How is true labor discriminated from false labor?
- true labor: regular, rhythmic contractions that intensify with ambulation, pain in the
abdomen sweeping around from the back, and cervical changes. False labor: irregular
rhythm, abdominal pain (not in back) that decreases with ambulation.
3. State 2 ways to determine if the membranes have truly ruptured (ROM).
-
Nitrazine testing: paper turns dark blue or black. Demonstration of fluid “ferning”
under microscope.
4. Are psychoprophylactic breathing techniques prescribed for use by the stage
and phase of labor?
- No, clients should use these techniques according to their discomfort level and
change techniques when one is no longer working for relaxation.
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
6. Hyperventilation often occurs to the laboring client. What results from
hyperventilation and what actions should the nurse take to relieve the condition?
- Respiratory alkalosis occurs which is caused by blowing off CO2 and is relieved by
breathing into a paper bag or cupped hands.
7. Describe maternal changes that characterize the transition phase of labor.
- irritability, unwillingness to be touched but does not want to be left alone, nausea and
vomiting, and hiccupping.
8. When should a laboring client be examined vaginally?
- Vaginal exams should be done prior to analgesia/anesthesia, to rule out cord prolapse,
to determine labor progress if it is questioned, and to determine when pushing can
begin.
9. Define cervical effacement.
- the taking up of the lower cervical segment into the upper segment; shortening of the
cervix expressed in percent from 0-100% or complete effacement.
10. Where is the fetal heart rate best heard?
- through the fetal back in vertex, OA positions.
11. Normal fetal heart rate in labor is _____ = 110-160 bpm
Normal maternal BP in labor is _____ = <140/90
Normal maternal pulse in labor is _____ = <100 bpm
Normal maternal temperature in labor is _____ = <100.4 F
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.
13. List 3 signs of placental separation.
-
gush of blood; lengthening of cord, and globular shape of uterus
14. When should the postpartum dosage of Pitocin be administered? Why is it
administered?
- give immediately after placenta is delivered to prevent postpartum hemorrhage/atony.
15. State one contraindication to the use of ergot drugs (Methergine).
- Hypertension
16. State 5 symptoms of respiratory distress in the newborn.
- tachypnea, dusky color, flaring nares, retractions, and grunting.
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)
18. What score is considered a good Apgar score?
- 7 to 10
19. What is the purpose of eye prophylaxis for the newborn?
- prevent opthalmia neonatorum, which results from exposure to gonorrhea in vagina.
20. What is the danger associated with regional blocks?
- hypotension resulting from vasodilation below the block, which pools blood in
periphery reducing venous return.
21. What is the major cause of maternal death when general anesthesia is
administered?
- Aspiration of gastric contents
22. Why are PO medications avoided in labor?
- gastric activity stops or slows in labor, decreasing absorption from PO route, may
cause vomiting.
23. State the best way to administer IV drugs in labor.
- at beginning of contraction, push a little medication in while uterine blood vessels are
constricted, thereby reducing dose to fetus.
24. When is it dangerous to administer butorphanol (Stadol), an agonist/antagonist
narcotic?
- when the client is an undiagnosed drug abuser of narcotics, it can cause immediate
withdrawal symptoms.
25. Hypotension often occurs after the laboring client receives a regional block.
What is one of the first signs the nurse might observe?
- Nausea
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).
27. The fourth stage is defined as:
- the first 1 to 4 hours after delivery placenta.
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.
31. List 3 nursing interventions to ease the discomfort of afterpains.
- keep bladder empty. Provide warm blanket to abdomen. Administer analgesics
ordered by doctor.
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
34. What are the symptoms of hypovolemic shock?
- pallor, clammy skin, tachycardia, lightheadedness, and hypotension
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.
2. Which women experience afterpains more than others?
- Breastfeeding women, multiparas, and women who experienced over distention of the
uterus.
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.
5. What factor places the postpartum client at risk for thromboembolism?
- Increased clotting factors.
6. A breastfeeding mother complains of very tender nipples. What nursing actions
should be taken?
- Have her demonstrate infant position on breast (incorrect positioning often causes
tenderness). Leave bra open to air-dry nipples for 15 minutes 3X daily. Remove all
“smothering” creams.
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.
8. What information should be given to a client regarding resumption of sexual
intercourse after delivery?
- Avoid until postpartum exam. Use water soluble jelly. Expect slight discomfort due
to vaginal changes.
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.
15. List 3 signs of positive bonding between parents and newborn?
- Calling infant by name, exploration of newborn head to toe, en face position.
THE NORMAL NEWBORN:
1. The newborn transitional period consists of the first ____ of life.
- 6 to 8 hours of life
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.
4. Normal newborn temperature is ____ = 97.7 – 99.4F
Normal newborn heart rate is ____ = 110-160 bpm
Normal newborn respiratory rate is ____ = 30-60 bpm
Normal blood pressure is ____ = 80/50
5. The nurse records a temperature below 97F on admission of the newborn. What
nursing actions should be taken?
- Place newborn in isolette or under radiant warmer and attach a temperature skin
probe to regulate isolette or radiant warmer temperature. Wrap newborn double if no
isolette or warmer available and put cap on head. Watch for signs of hypothermia
and hypoglycemia.
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, highpitched, 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.
9. What symptoms are common to most newborns with Down Syndrome?
- Low set ears, simian crease on palm, protruding tongue, Brushfield’s spots in iris,
epicanthal folds.
10. Identify 3 ways t determine presence of congenital hip dislocation in the
newborn.
- Hip click determination, asymmetrical gluteal folds, unequal limb lengths.
11. Should the normal newborn have a positive or negative Babinski reflex?
- Positive. The transient reflex is present until 12-18 months of age.
12. A small-for-gestational age newborn is identified as one who ____.
- Has a weight below the 10th percentile for estimated weeks of gestation.
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.
17. Physiologic jaundice in the newborn occurs _____. It is caused by _____.
- Jaundice occurs at 2-3 days of life and is caused by immature liver’s inability to keep
up with bilirubin production of normal RBC destruction.
18. When is the screening test for phenylketonuria done?
- At 2-3 days of life or after enough milk ingestion to determine body’s ability to
metabolize amino acid phenylalanine.
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.
3. Describe discharge counseling for a woman after hydatidiform mole evacuation
by D&C.
- Prevent pregnancy for one year. Return to clinic/MD for monthly hCG levels for 1 yr.
Post-op D&C instructions; call if bright red vaginal bleeding or foul smelling vaginal
discharge occurs, or temperature spike over 100.4F.
4. What condition should the nurse suspect if a woman of childbearing age
presents to an emergency room with bilateral or unilateral abdominal pain with
or without bleeding?
- Ectopic pregnancy
5. List 3 symptoms of abruptio placentae and 3 symptoms of placenta previa.
-
Abruption: fetal distress; rigid, board-like abdomen; pain; dark red or absent bleeding.
Previa: painless, bright red vaginal bleeding; fetal heart rate normal; soft uterus.
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.
7. State 3 principles pertinent to counseling and/or teaching a pregnant adolescent.
- Nurse must establish trust/rapport before counseling/teaching begins. Adolescents do
not respond to an authoritarian approach. Consider the developmental tasks of
identity and social/individual intimacy.
8. What complications are pregnant adolescents more prone to develop?
- PIH, IUGR, CPD, STDs, Anemia.
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.
10. List the predisposing factors to preterm labor.
- Urinary tract infection; over distention of uterus; diabetes; PIH; cardiac disease;
placenta previa, psychosocial factors, i.e., stress
11. When is preterm labor able to be arrested?
- Cervix is <4cm dilated, <50% effacement, and membranes intact and not bulging out
of the cervical os.
12. What is the major side effect of beta-adrenergic (Terbutaline, Ritodrine)
tocolytic drugs?
- Tachycardia
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.
17. What are the major symptoms of pregnancy induced hypertension
(preeclampsia)?
- Increase in BP of 30mmHg systolic and 15 mmHg diastolic over previous baseline;
hyperflexia; proteinuria (albuminuria); CNS disturbances; headache, and visual
disturbances; epigastric pain.
18. What is the priority nursing action after spontaneous or artificial rupture of
membranes?
- Assessment of the fetal heart rate.
19. What is the most common complication of oxytocin augmentation or induction
of labor? List 3 actions the nurse should take if such a complication occurs.
- Tetany. Turn off Pitocin. Turn pregnant woman to side. Administer O2 by face
mask.
20. List the symptoms of water intoxification from the antidiuretic hormone (ADH)
effect of Pitocin (oxytocin).
- Nausea and vomiting, headache, and hypotension.
21. State 3 nursing interventions during FORCEPS delivery.
- Ensure empty bladder. Auscultate FHR before application, during, and between
traction periods. Observe for maternal lacerations and newborn cerebral/facial
trauma.
22. What is the cause of pregnancy induced hypertension?
- The person who determines the exact cause will be our next NOBEL prize winner!
However, the underlying pathophysiology appears to be generalized vasospasm with
increased peripheral resistance and vascular damage. This decreased perfusion
results in damage to numerous organs.
23. What interventions should the nurse implement to prevent further CNS
irritability in the PIH client?
- Darken room, limit visitors, maintain close 1:1 nurse/client ratio, place in private
room, plan nursing interventions all together so client is disturbed as little as possible.
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.
25. Name 3 maternal & 3 fetal complications of gestational diabetes.
- Maternal: hypoglycemia, herperglycemia, ketoacidosis;
Fetal: macrosomia,
hypoglycemia at birth, fetal anomalies
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).
29. Why is regular insulin used in labor?
- It is short-acting, predictable, can be infused intravenously and discontinued quickly
if necessary.
30. List 3 conditions clients with diabetes mellitus are more prone to develop.
- PIH, hydramnios; infection
31. When is cardiac disease in pregnancy most dangerous?
- At peak plasma volume increase, 28-32 weeks gestation and during Stage II labor.
32. Does insulin cross the placental/breast barrier?
- No, therefore insulin-dependent women may breastfeed.
33. The goal for diabetic management during labor is euglycemia. How is it defined?
- 60-100 mg/dl.
34. What contraceptive technique is recommended for diabetic women?
- Diaphragm with spermicide. Avoid birth control pills that contain estrogen and
IUDs, which are an infection risk.
35. List the symptoms of cardiac decompensation in the laboring client with cardiac
disease.
- Tachycardia, tachypnea, dry cough, rales in lung bases, dyspnea, and orthopnea.
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.
37. Gentle counterpressure against the perineum during an emergency delivery
prevents ____ and ____.
- Maternal lacerations, fetal cerebral trauma.
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.
POSTPARTUM HIGH-RISK DISORDERS:
1. May women with a positive HIV antibody test breastfeed?
- No, HIV has been found in breast milk.
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
3. How does the nurse differentiate symptomatology of cystitis from pylonephritis?
- Pyelonephritis has the same symptoms as cystitis (dysuria, frequency, and urgency)
with the addition of flank pain, fever, and pain at costovertebral angle.
4. What are the signs of endometritis?
- Subinvolution (boggy, high uterus), lochia returns to rubra with possible foul smell,
temperature 100.4F or higher, unusual fundal tenderness.
5. What are the nursing actions for endometritis and parametritis?
- Measures to promote lochial drainage; antipyretic measures (acetaminophen, cool
baths); administration of analgesics and antibiotics as ordered; increase fluids with
attention to high protein/high vitamin C diet.
6. State 4 risk factors or predisposing factors t opostpartum infection.
- Operative delivery, intrauterine manipulation , anemia or poor physical health,
traumatic delivery, and hemorrhage.
7. State 4 risk factors or predisposing factors to postpartum hemorrhage.
- Dystocia or prolonged labor, over distention of the uterus, abruptio placentae, and
infection
8. What immediate nursing actions should be taken when a postpartum
hemorrhage is detected?
- Fundal massage. Notify MD if massage does NOT firm fundus. Count pads to
estimate blood loss. Assess/record vital signs. Increase IV fluids and administer
oxytocin infusion as ordered.
9. Must women diagnosed with mastitis stop breastfeeding?
- No, women who abruptly stop breastfeeding may make the situation worse by
increasing congestion/engorgement and providing further media for bacterial growth.
Client may HAVE to discontinue breastfeeding if pus is present or if antibiotics are
contraindicated for neonate.
NEWBORN HIGH-RISK DISORDERS:
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.
3. What does the Silverman-Anderson index measure?
- Respiratory difficulty
4. What are the two major complications of O2 toxicity?
- Retrolental fibroplasias and bronchopulmonary dysplasia.
5. Necrotizing enterocolitis results from ____ and is manifested by ____.
Ischemia/hypoxia results in ____.
- Ischemis hypoxia; abdominal distention, sepsis and a lack of absorption from
intestines. Injury to the intestinal mucosa.
6. Intraventricular hemorrhage is more common in ____ and results in symptoms
of ____.
- Premature neonates and VLBW babies.
7. What conditions make oxygenation of the newborn more difficult?
- Respiratory distress syndrome; alveolar prematurity/lack of surfactant, anemia and
polycythemia.
8. In order to prevent problems with oxygenating the newborn, what parameters
can the nurse observe?
- PO2 50-90, SVO2 60-80 mmHg.
9. What are the cardinal symptoms of sepsis in a newborn?
- Lethargy, temperature instability, difficulty feeding, subtle color changes, subtle
behavioral changes and hyperbilirubinemia.
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 highrisk 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 2030 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).
16. List risk factors for hyperbilirubinemia.
- Rh incompatibility, ABO incompatibility, prematurity, sepsis, perinatal asphyxia.
17. List symptoms of hyperbilirubinemia in the neonate.
- Bilirubin levels rising 5mg/day, jaundice, dark urine, anemia, high reticulocyte (RBC)
count, and dark stools.
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.
19. List 3 nursing interventions for the neonate undergoing phototherapy.
- Apply opaque mask over eyes. Leave diaper loose so stools/urine can be monitored.
Turn every 2 hours. Watch for dehydration.
20. List the symptoms of neonatal narcotic withdrawal.
- Irritability, hyperactivity, high-pitched cry, frantic sucking, coarse flapping tremors,
and poor feeding.
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.