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Maternal ATI Final Exam Study Guide
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What is the fourth stage of labor and when does it start? - Postpartum period- starts after the delivery of the placenta What are the greatest risks during the postpartum period? - Hemorrhage Shock Infection When is RH immune globulin (RhoGAM) administered to post partum women? - Administered 72 hours for women who are Rh-negative and gave birth to infants who are Rh-positive This prevents sensitization to Rh in future pregnancies What is included in the postpartum nursing assessment? - Monitoring vital signs Assessing uterine firmness & location in relation to umbilicus Uterine position in relation to midline (if deviated, assist mom in emptying bladder) Amount of vaginal bleeding (lochia) How often should vitals be monitored after delivery? - Every 15 min for the first hour Every 30 minutes for second hour Every 4-8 hr depending on remaining medication regimen This occurs with contractions of the uterine smooth muscle, whereby the uterus returns to its pre- pregnant state - Involution Defined as blood flow from the uterus during postpartum period - Lochia This type of lochia is bright red in color, bloody consistency, fleshy odor, may contain small clots - Lochia rubra
This type of lochia is pinkish brown in color & serosanguineous consistency - Lochia serosa This type of lochia is yellowish, white creamy color, fleshy odor - Lochia alba When is colostrum present in the new mother's breasts? - During pregnancy and 2-3 days immediately after birth Defined as an infection in a milk duct of the breast with concurrent flulike symptoms - Mastitis What are therapeutic and approved holding positions when breast feeding? - Cradle hold Side-lying hold Football hold What does breast feeding cause the release of? What does this prevent? - Breast feeding causes the release of oxytocin which stimulates uterine contractions (will prevent hemorrhage) What are normal lab values in the post partum period? - Increased Hct & Hgb up to 72 hours Leukocytosis (WBC count up to 20,000-25,000 for the first 10-14 days, without presence of infection) Increased coagulation factors Increased fibrinogen A medical condition during pregnancy defined as excessive nausea and vomiting that is prolonged past 12 weeks of gestation. Results in weight loss & electrolyte imbalance - Hyperemesis gravidarum What are nursing responsibilities when caring for a patient diagnosed with hyperemesis gravidarum? - Monitor client's I&O Assess client's skin turgor/mucous membranes Monitor vital signs Monitor client's weight
This disorder is defined as gestational hypertension with the addition of proteinuria greater than 1+ - Mild preeclampsia This disorder is defined as maternal BP of 160/100 mm Hg or greater, protenuria greater than 3+, oliguria, elevated Cr greater than 1.2mg/dLm visual disturbances, hyperreflexia, pulmonary/cardiac involvement, extensive peripheral edema, hepatic dysfunction & thrombocytopenia - Severe preeclampsia This disorder is defined as severe preeclampsia symptoms along with the onset of seizure activity or coma - Eclampsia This syndrome of pregnancy is a variant of gestational hypertension in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction - HELLP syndrome H- hemolysis (anemia and jaundice) EL- elevated liver enzymes (Elevated ALT/AST, nausea/vomiting) LP- low platelets (thrombocytopenia, DIC) What are antihypertensive medications that are approved to be taken during pregnancy? - Methyldopa (Aldomet) Nifedipine (Adalat, Procardia) Hydralazine (Apresoline, Nesopresol) Labetalol (Normodyne) AVOID ACE INHIBITORS & ARBs What is an anticonvulsant medication used during pregnancy? - Magnesium sulfate What are signs of magnesium sulfate toxicity? - Absence of patellar deep tendon reflexes Urine output less than 30mL/hr Respirations less than 12/min Decreased LOC
Cardiac dysrhythmias If magnesium sulfate toxicity is suspected, what is the priority nursing action? - Discontinue infusion & administer antidote CALCIUM GLUCONATE. Also, prepare to prevent respiratory/cardiac arrest Including what vitamin in the diet will increase absorption of iron supplementation? - Vitamin C This syndrome results from the chronic or periodic intake of alcohol during pregnancy; Alcohol is considered teratogenic - Fetal alcohol syndrome Defined as a serum glucose level of less than 40mg/dL - Hypoglycemia in full term newborn Defined as a serum glucose level of less than 25 mg/dL - Hypoglycemia in pre-term newborn This syndrome is defined as surfactant deficiency in the lungs and is characterized by poor gas exchange and ventilatory failure - Respiratory distress syndrome (RDS) Produced by the body, it is a phospholipid that assists in alveoli expansion & allows gas exchange to occur - Surfactant What are assessment findings of respiratory distress syndrome in a newborn? - Tachypnea (greater than 60/min) Nasal flaring Expiratory grunting Retractions (abdominal) Labored breathing Fine crackles upon auscultation Cyanosis What weeks gestation defines a pre-term newborn? - Between 20-37 weeks gestation
Dehydration Elevated temperature Congenital anomaly where there is failure of the lip or hard/soft palate to fuse - Cleft lip/palate Congenital anomaly defined as failure of the esophagus to connect to the stomach - Tracheoesophageal atresia Congenital anomaly common in newborns with Down syndrome, where first part of bowel has not developed and is not open; Contents of digestion are unable to pass; Requires surgery - Duodenal atresia Congenital anomaly defined as the inability to metabolize the amino acid phenylalanine; Can result in mental retardation if left untreated - Phenylketonuria (PKU) Congenital anomaly defined as instability to metabolize galactose into glucose; Can result in mental retardation if left untreated - Galactosemia Congenital anomaly defined as neural tube defect in which the vertebral arch fails to close; Protrusion of meninges/spinal cord may be present - Spina bifida Congenital anomaly defined as excessive spinal fluid accumulation in ventricles of brain causing the head to enlarge and fontanels to bulge; Sun-setting sign is common - Hydrocephalus (Water on brain) Congenital anomaly defined as a non cyanotic heart defect where the ductus arteriosus connecting the pulmonary artery and the aorta fails to close after birth - Patent ductus arteriosus What is an expected finding for an infant experiencing abstinence syndrome (withdraw from substance after birth)? - Continuous high-pitched cry What are laboratory tests/metabolic screenings done after birth? - Hgb & Hct (if prescribed) Blood glucose
Newborn genetic screening done by heelstick PKU (phenylalanine) testing Hearing screening How does a nurse go about getting a heel stick blood specimen from a newborn? - Warm newborns heel to increase circulation Cleanse area with appropriate antiseptic, allow for drying Spring activated lancet used on outer aspect of heel After puncture, apply pressure with gauze until bleeding stops Cuddle/comfort newborn after completion of procedure to promote feelings of safety How is the newborn identified after birth? - Using two identifiers; Arm band is applied immediately after birth to both mom and father baby to prevent newborn from being given to wrong parents How should newborns be positioned during sleep to prevent SIDS? - Supine "safe sleep" How might stools of breast fed newborns appear? - Yellow and seedy What is mandatory post birth to prevent opthalmia neconatorum? - Erythromycin (Roycin) - Prophylactic eye care What organisms is opthalmia neconatorum caused by? - Neisseria gonorrhoeae or Chlaymdia trachomatis - can cause blindness if left untreated Why is vitamin K administered to newborn within 1 hour after birth? - To prevent hemorrhagic disorders; Because vitamin K into produced in the GI tract of the newborn until day 8, it is administered at birth How should you care an infant while umbilical cord is healing? - Keep clean and dry to prevent infection
Administer o2 at 8-10L/min Insert IV catheter w/tocolytic medication Notify provider Defined as FHR greater than 160 bpm for 10 min or more - Fetal tachycardia What are nursing interventions required when FHR is 160bpm or more? - Administer prescribed antipyretics for maternal fever (if present) Administer o2 by mask at 8-10 L/min Administer IV fluid bolus What nursing intervention is required for early decelerations of FHR? - No intervention required - expected finding Cause: Compression of fetal head resulting from uterine contraction What are late decelerations of FHR caused by? - Uteroplacental insufficiency causing inadequate fetal oxygenation What are nursing interventions required for late decelerations of FHR? - Place client in side-lying position Insert IV catheter and increase fluids Discontinue oxytocin if being infused Administer o2 by mask 8-10 L/min Notify provider Prepare for emergency c-section or assisted vaginal birth What are variable decelerations of FHR caused by? - Umbilical cord compression, prolapsed cord, nuchal cord or oligohydramnios What are nursing interventions required for variable decelerations of FHR? - Reposition client from side to side or into knee-chest
Discontinue oxytocin if being infused Administer o2 by mask 8-10 L/min Perform/assist with vaginal exam Assist with amnioinfusion if prescribed What are some advantages of internal fetal monitoring? - Early detection of abnormal FHR suggesting fetal distress Accurate assessment of FHR variability Accurate assessment of uterine contraction intensity Allows greater maternal freedom What are some disadvantages of internal fetal monitoring? - Membranes must be ruptured- can introduce infection Cervix must be dilated to a minimum of 2-3cm Presenting part must descent to place electrode Specially trained personnel must do procedure A nurse is caring for a client in the third stage of labor. What findings indicate that placental separation has occurred? - Lengthening of the umbilical cord Appearance of dark blood from the vagina Fundus is firm upon palpation (due to uterus contracting) A nurse is caring for a client who is in the transition phase of labor and reports that she needs to have a bowel movement with the peak of contractions. What is the appropriate nursing intervention? - Prepare for an impending delivery- the urge to have a bowel movement indicates fetal descent and complete dilation A nurse is caring for a client who is in the first stage of labor and encourages the client to void every 2 hours. Why is this important? - Distended, full bladder reduces pelvic space needed for birth & impedes fetal descent
What do lower levels of hCG indicate? - Possible misscarriage How do you determine an estimated delivery date using Nagele's rule? - Take the first day of the woman's LMP, subtract 3 months, add 7 days and add 1 year Defined as the number of pregnancies - Gravidity Defined as a woman in her first pregnancy - Primagravida Defined as a woman who has had two or more pregnancies - Multigravida Defined as the number of pregnancies in which the fetus or fetuses reach viability (20 weeks) regardless of whether the fetus is born alive - Parity What does the GTPAL acronym stand for? - Gravidity Term births (38+ weeks) Preterm births Abortions/miscarriages Living children What is supine hypotension syndrome? - Pressure of the uterus on the vena cava, decreasing venous blood flow to the heart What is chloasma? - Pigmentation increases on the face, normal during pregnancy What is line nigra? - Dark line of pigmentation from the umbilicus extending to the pubic area Approximately how long should a mother spend breastfeeding on each breast? - 15-20 minutes per breast & 30-40 minutes total feeding
Before a circumcision is performed, what does a nurse need to assess? - History of bleeding tendencies in family (hemophilia, clotting disorders) Hypospadias/epispadias Ambiguous genitalia (have both male/female characteristics) Illness/infection Post a circumcision, what does a nurse need to assess? - Bleeding q15min for first hour & a1hr for 12 hours Assess for first voiding by newborn post procedure What is recommended exercise type and amount of time during pregnancy? - Exercise during pregnancy yields positive benefits and should consist of 30 minutes moderate exercise (walking/swimming) For the expectant mother experiencing nausea/vomiting, what should the nurse recommend when it comes to eating in the morning? - Eat crackers or plain toast before getting out of bed How is an apgar score made? - Perfect score: 10 5 categories, each worth points each Categories: HR, RR, Muscle tone, Reflex irritability, Color How many veins/arteries should the umbilical cord have? - 1 vein 2 arteries What are expected ranges of physical assessments found in newborn? - Weight- 2500-4000 grams Length- 18-22 in Head circumference- 12.6-14.5 in Chest circumference- 12-13 in What are small white nodules on the roof of the newborns mouth (may or may not be present) - Epstein's pearls
Gross body movements Fetal tone Qualitative amniotic fluid volume This type of stress test consists of a woman brushing her palm across her nipple for 2 minutes, which causes the pituitary to release endogenous oxytocin - Nipple stimulated CST (Contraction stress test) Defined as the aspiration of amniotic fluid for analysis by insertion of a needle transabdnominally into a client's uterus and amniotic sac under direct ultrasound guidance - Amniocentesis High levels of what protein (examined during an amniocentesis) is associated with neural tube defects? - Alpha-fetoprotein (AFP) What are low levels of Alpha-fetoprotein (AFP) associated with? - Down Syndrome What are high levels of Alpha-fetoprotein (AFP) associated with? - Neutal tube defects What are nursing responsibilities following an amniocentesis? - Monitor vital signs, FHR, uterine contractions for 30 minutes following procedure Have client rest for 30 minutes Administer Rh immune globulin (RhoGAM) to the client if she is Rh-negative to protect against Rh isoimmunization (If fetus has different Rh) This type of diagnostic procedure is an assessment of a portion of the developing placenta (chorionic villi) which is aspirated through a thin sterile catheter or syringe through the abdominal wall - Chorionic villi sampling A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis to assess fetal lung maturity. What is the test for fetal lung maturity during an amniocentesis? - Lecithin/sphingomyelin (L/S) ratio
What is an acoustic vibration device & why is it used during a non stress test (NST)? - It is a vibrato device that is used to awaken a fetus from sleeping What are some contraindications for oxytocin therapy during labor? - Sepsis Unripe cervix Genital herpes History of multiple births Uterine surgery What is terbutaline (Brethine) used for? - To stop uterine contractions- causes uterine smooth muscle relaxation Defined as the artificial rupture of membranes (AROM) by provider using an Amnihook or other sharp instrument - Amniotomy Defined as scant amount or absence of amniotic fluid - Oligohydramnios This type of delivery assistance involves using a cup like suction device that is attached to the head - Vacuum-assisted delivery This type of assisted birth is using an instrument with two curved spoon like blades to assist in the delivery of the fetal head - Forceps-assisted birth Defined as an incision made into the perineum to enlarge the vaginal opening to facilitate delivery and minimize soft tissue damage - Episiotomy What are indications for cesarean birth? - Malpresentation (breech) Fetal distress Placental abnormalities High risk pregnancy (HIV+, Hypertensive disorders, diabetes mellitus, active genital herpes lesions) Previous c-section
How can HIV possibly be transmitted to the fetus? - Perinatally through the placenta and postnatally through the breast milk What procedures should be avoided for mom's HIV+? - Amniocentesis and episiotomy- risk of maternal blood exposure to newborn Defined as a bacterial infection that can be passed to the fetus during labor and delivery - Group B Streptococcus, beta hemolytic (GBS) What can a group b strep infection lead to during pregnancy/delivery? - PROM (premature rupture of membranes) Preterm labor and delivery Chorioamniotitis Infections of urinary tract Maternal sepsis Defined as terminated pregnancy before 20 weeks of gestation or fetal weight less than 500 g - Spontaneous abortion What are nursing actions for a client bleeding during pregnancy? - Assess color/amount of bleeding Maintain client on bed rest Avoid vaginal exams Administer meds/blood products as prescribed Defined as the abnormal implantation of a fertilized ovum outside of the uterine cavity, usually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage - Ectopic pregnancy This occurs when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus - Placenta previa Defined as the premature separation of the placenta from the uterus, which can be partial or complete detachment - Abruptio placenta
What are risk factors associated with abrupt placenta? - Maternal HTN Blunt abdominal trauma Cocaine use Cigarette smoking Refers to a thrombus that is associated with inflammation, occurs postpartum - Thrombophlebitis If a client reports leg pain & tenderness, what should the nurse suspect? - Possible DVT What are nursing responsibilities when educating client about preventing thrombophlebitis? - Maintain antiembolism stockings until ambulation established Perform active/passive ROM if on bed rest Avoid prolonged periods of standing, sitting or immobility Have client elevate legs when sitting Maintain adequate fluid intake Tell client to discontinue smoking What are nursing responsibilities when caring for a patient with thrombophlebitis? - Encourage rest Facilitate bed rest DO NOT massage affected area to prevent thrombus from dislodging and becoming an embolus Administer analgesics (NSAIDs) Administer anticoagulants for DVT When administering IV heparin, what lab value should the nurse particularly monitor? - apTT What is the antidote for PO warfarin? - Vitamin K When administering PO warfarin, what lab value should the nurse particularly monitor? - PT and INR
