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Exam 2 : PRN 1831/ PRN1831 (NEW 2023/
2024 Update) Principles of Maternal Child
Health Nursing | Review with Questions and
Verified Answers|100% Correct| A Grade -
Rasmussen
QUESTION
How does the bladder impact involution and bleeding Answer: A distended bladder pushes the uterus upward and usually to one side of the abdomen. The fundus may be boggy or firm. If not emptied, a distended bladder can result in uterine atony and hemorrhage because it interferes with the normal contraction of the uterus.
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Postpartum blues, depression Baby blues Answer: resultant from hormonal shift after delivery First few postpartal days peak on the 5th day subside over the next several days.
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Postpartum depression Answer: symptoms are persisting beyond 2 weeks postpartum Get adequate rest Take help from support person Know expected changes (baby blues), & when to report symptoms to provider
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Symptoms of endometritis
Answer: Temperature elevation o Tachycardia o Uterine tenderness, subinvolution o Malaise o Heavy, foul-smelling lochia
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Symptoms of magnesium toxicity Answer: Assess every hour respiratory status/respirations, deep tendon reflexes, and LOC o Antidote: Calcium gluconate
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Symptoms of mastitis Answer: Firm, red, swollen, tender breast w/ fever, myalgias, chills, malaise
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cause of mastitis Answer: common cause is the hemolytic staphylococcus aureus, introduced from the infant's mouth through a fissure in the nipple
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Rubin's phases "taking in" Answer: Dependent First 24-48 hr Focus on meeting personal needs Rely on others for assistance Excited, talkative Need to review birth experience with others
Started 3 months prior to becoming pregnant Spina bifida, anencephaly, myeolomenigocele
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Normal Newborn Vital Signs Answer: HR: 110-160 bpm o R: 30-60 breaths/min o T: 36.5-37.
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Which newborn blood glucose would require immediate intervention? Answer: Normal blood glucose: 40-60 mg/dL o Anything below or above normal range
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What is a code pink? Answer: Infant abduction/missing infant
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What is a code pink preventive measures Answer: ID band should be verified against the client's ID band Photo ID badges Newborn is not given to anyone who does not have a photo Locked maternal-newborn units Sensor device on the ID band or umbilical cord clamp that sounds an alarm
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Recognize newborn rash - Milia Answer: small raised pearly or white spots on the nose, chin, and forehead.
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Recognize newborn rash - Telangiectatic Nevi "Stork Bite" Answer: flat pink or red marks that easily blanch and are found on the back of the neck, nose, upper eyelids, and middle of forehead.
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umbilical cord care Answer:
- keep clean, dry, clean stump with water, watch swelling/redness/purulent d/c
- fold diaper edge down to keep stump dry
- will fall of after 10-14 days
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Newborn Reflexes: Rooting Answer: stroke cheek near corner of mouth (helps infant find nipple) Sucking - infant sucks finger (permits feeding)
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Newborn Reflexes: Moro (Startle) Answer:
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Circumcision care Answer: Keep area clean o Apply diaper loosely o Apply petroleum jelly w/each diaper change for at least 24 hrs after the circumcision to keep the diaper from adhering to the penis o Do not give tub bath *trickle warm water gently over penis o Notify the provider: redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from newborn
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Newborn immunity Answer: Temporary immunity is passed from mom and lasts the first 3 mos of life o Infant gradually produces his/her own immunoglobulin, until adult levels are reached by puberty o IgA is an immunoglobulin produced after the neonatal period (about 1 mos of age) that is contained in breast milk and provides some resistance to respiratory and GI infections
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SIDS & prevention Answer: o Teaching: teach the parent about the importance of the "back-to-sleep" concept to prevent SIDS o Infants should be positioned for sleep on their backs on a firm, flat mattress in a crib, both for their safety
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Newborn Identification and Security Answer:
o Nurse should verify the match each time she brings the baby to mom o Apply matching identification bands on the infant and the mother as well as the father or other designated birth support person. Infants ID band are placed snugly enough so that when the initial weight loss occurs, the ID band does not fall of
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measuring adequacy of feeds for the nursing infant Answer: adequacy of breastfeeds is eval via weight gain and the number of wet diapers: 6/day
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Newborn Output Answer: o Stools: meconium first 24- 48 o Breastfed infants: transition to yellow, liquid, seedy stools o If dry diapers for 8hrs or more notify provider
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newborn vision Answer: intermittent eye crossing is normal
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Ophthalmic Ointment Answer: The application is delayed sometimes to facilitate bonding
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Who gets Rhogam and why? Answer: All Rh-negative clients who have newborns who are Rh-positive (administered IM) o Why: to suppress antibody formation in the mother
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What should you do if a fundus is boggy on assessment? Why? Answer: Have the mom try to empty her bladder/massage o Why: full bladder can impede the uterus ability to stay firmly contracted and result in increased bleeding/hemorrhage
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Identify types of lochia and when to expect them Answer: Lochia rubra: (through day 3) dark red menstrual period like discharge fleshy odor o Lochia serosa: (4-10 days) pinkish brown and serosanguineous consistency o Lochia alba: (10 days - 8 weeks) yellowish white creamy color, fleshy odor
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Bathing and pericare after c/s Answer: Ensure stability during ambulation o Keep stream of water on back away from incision o Keep incision covered with an occlusive dressing o Provide shower chair if needed
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Provide teaching on pericare (understand the rationales Answer: After vaginal: Use warm water in squeeze bottle after every void (front to back) Pat dry, front to back Use optional topical anesthetic (dermaplast) if episiotomy or laceration Apply ice packs (first 24 hrs) Optional: use sitz bath (first 24 hrs)
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Preventing breast engorgement in the bottle feeding mom Answer: Supportive sports bra/ace wrap breasts o Ice packs to the breasts o Apply cabbage leaves to draw out milk
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Dietary sources of calcium Answer:
- milk and milk products
- soy milk
- broccoli
- fortified orange juice
- fish with bones (sardines)
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symptoms of preeclampsia Answer: Headache o Visual disturbances o Epigastric pain o Edema o Proteinuria o Brisk DTRs o Clonus o Seizure (Eclampsia)
(reflex irritability) Floppy - 0 points Minimal response to stimulation - 1 point Prompt response to stimulation - 2 points
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APGAR Scoring: A - Activity Answer: (muscle tone) Absent - 0 points Flexed arms and legs - 1 point Active - 2 points
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APGAR Scoring: R - Respirations Answer: Absent - 0 points Slow & Irregular - 1 point Vigorous Cry - 2 points
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caput succedaneum Answer: diffuse edema of the fetal scalp that crosses the suture lines. reabsorbs within 1 to 3 days
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Cephalohematoma Answer: Swelling caused by bleeding between the osteum and periosteum of the skull. This swelling does not cross suture lines.
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Congenital Hip Dysplasia
Answer: o Assess posterior legs for symmetry of gluteal asymmetry possible dysplasia o Assess bilateral leg length for symmetry asymmetric length possible hip dysplasia o Perform Ortolani and Barlow test positive indicators possible HD
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Immediate actions in the care of the newborn and why Answer: o Dry the infant thoroughly to prevent heat loss/cold stress o Application of ID bands to mom and baby Matching serial numbers that will be verified each time baby is brought to mom to ensure right mom/right baby
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hyperbilirubinemia Answer: Caused by the rapid destruction of excess RBC, which the infant does not need now because he/she is in an atmosphere that contains more oxygen than was available during prenatal life
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hyperbilirubinemia s/s Answer: Appearance: yellow skin and mucous membranes, scleral icteris (yellow discoloration) Testing: indirect and direct bilirubin mainly
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hyperbilirubinemia risks? Answer: If levels too high kernicterus (brain damage)
Answer: Mom will burn an + 500 calories daily above her basal rate while breastfeeding
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Stimulation of the breasts to produce Answer: Frequent stim of breasts via nursing or pumping (at least q 2 hrs) o Alternate breasts
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Avoid combination contraceptives Answer: Estrogen will inhibit milk production
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Breastfeeding Assessment o Education: Answer: Feed on demand Advise mom to alternate breasts when feeding baby Express a small amount of breastmilk/colostrum, apply to the nipple and allow to air dry
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Understand patterns of growth: Answer: Doubles by age 5-6 months and triples by age 1 yr
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patterns of growth: Birth-1 mo Answer: Height/length: 19-21 inches Weight: 7.5lbs Head circumference: 13-14 inches Chest Circumference: 12-13 inches
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patterns of growth: 1-2 mo Answer: Weight: increases 1.5lb per month Height: increases 1 inch per month Head circumference: increases 0.5 in per month
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patterns of growth: 3-6 mo Answer: Weight: double the birth weight by 6 months Height: increases by 1 inch per month
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patterns of growth: 9-12 mo Answer: Weight: triple the birth weight Height: increases 1 inch per month Head & Chest circumference: same at 12 months of age
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Adolescence should increase what? Answer: Increase in caloric intake and rest
developmental stages are assessed to determine if the client is at the expected level of growth and development, to plan care that is age and developmentally appropriate and to modify care as based on the age related characteristics and needs
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What is cephalocaudal development? Answer: Development proceeds from head to toe.
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Cephalocaudal development example Answer: The infant is able to raise his/her head before being able to sit, and he/she gains control of the trunk before walking.
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What is stranger anxiety? When does it occur? Answer: Results from the ability to discriminate between familiar and unfamiliar faces
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When does stranger anxiety occur? Answer: Between 6-8 months, peaks at 8 months.
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appropriate toys according to the developmental stage: birth to 2 months
Answer: Mobiles 8-10in from the face
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appropriate toys according to the developmental stage: 2-4 Months Answer: Rattle and cradle Gym
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appropriate toys according to the developmental stage: 4-6 Months Answer: Bright-colored toys
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appropriate toys according to the developmental stage: 6-9 months Answer: large toys with bright colors w/- movable parts- noise makers
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appropriate toys according to the developmental stage: 9-12 months Answer: Books with large pictures Large push-pull toys Teddy Bears
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appropriate toys according to the developmental stage: Toddlers
