Prenatal Priorities
A client at 30 weeks reports painless, bright-red vaginal bleeding. This assessment must be avoided until placental location is confirmed.
What is a digital vaginal examination?
Rationale: Painless, bright-red bleeding suggests placenta previa. A digital vaginal examination can disrupt the placenta and cause life-threatening hemorrhage. Ultrasound should determine placental location first.
The fetal heart rate gradually decreases and returns to baseline at approximately the same time as the contraction. This pattern is present.
What is an early deceleration?
Rationale: Early decelerations mirror uterine contractions and are usually caused by fetal head compression. They are generally benign and do not require corrective intervention.
A client has sudden, painful vaginal bleeding, a rigid tender abdomen, and fetal distress. This complication is most likely.
What is placental abruption?
Rationale: Placental abruption commonly presents with painful bleeding, uterine tenderness or rigidity, frequent contractions, and fetal compromise. Bleeding may be visible or concealed.
One hour after birth, a client has heavy lochia and a boggy fundus displaced above and to the right of the umbilicus. This should be addressed after initial fundal massage.
What is bladder distention?
Rationale: A distended bladder displaces the uterus and interferes with contraction. After massaging the boggy fundus, the nurse should help the client void or catheterize as prescribed.
A term newborn has bluish hands and feet but a pink trunk, regular respirations, and normal vital signs. This finding is present.
What is acrocyanosis?
Rationale: Acrocyanosis is common during the first 24–48 hours as peripheral circulation adapts. Central cyanosis involving the lips, tongue, or trunk is abnormal.
This newborn medication prevents hemorrhagic disease caused by low levels of vitamin K–dependent clotting factors.
What is phytonadione, or vitamin K?
Rationale: Newborns have limited vitamin K stores and immature intestinal flora. Intramuscular phytonadione supports clotting-factor production and reduces bleeding risk.
A pregnant client is Rh-negative and has a negative indirect Coombs test at 28 weeks. This medication should be administered.
What is Rho(D) immune globulin?
Rationale: Rho(D) immune globulin prevents maternal sensitization to Rh-positive fetal blood. It is routinely given around 28 weeks and again within 72 hours after birth if the newborn is Rh-positive.
The fetal heart rate baseline is 140/min with moderate variability and accelerations. No late or variable decelerations are present. This category describes the tracing.
What is Category I?
Rationale: A Category I tracing has a baseline of 110–160/min, moderate variability, and no late or variable decelerations. It indicates normal fetal acid-base status at that time.
After the fetal head is born, it retracts against the perineum. This maneuver is generally performed first.
What is the McRoberts maneuver?
Rationale: Retraction of the fetal head, known as the turtle sign, suggests shoulder dystocia. McRoberts positioning and suprapubic pressure are commonly initiated. Fundal pressure should not be used.
A postpartum client has severe perineal pain and pressure despite analgesics. Her fundus is firm, and lochia is scant. This complication is most likely.
What is a vulvar or vaginal hematoma?
Rationale: Severe localized pain or pressure with a firm uterus and minimal visible bleeding suggests concealed bleeding into the tissues. A rapidly enlarging hematoma requires urgent intervention.
A newborn of a client with diabetes becomes jittery and lethargic 90 minutes after birth. This is the nurse’s priority assessment.
What is checking the newborn’s blood glucose?
Rationale: Infants of diabetic clients are at increased risk for hypoglycemia because of persistent fetal hyperinsulinemia. Jitteriness, lethargy, poor feeding, apnea, and seizures are possible manifestations.
This medication may be administered before a preterm birth to accelerate fetal lung maturity.
What is betamethasone?
Rationale: Antenatal corticosteroids stimulate surfactant production and reduce neonatal respiratory distress syndrome, intraventricular hemorrhage, and other complications of prematurity.
A client at 32 weeks has preeclampsia. She reports persistent epigastric pain and nausea. These findings suggest this serious complication.
What is HELLP syndrome?
Rationale: Epigastric or right-upper-quadrant pain may indicate liver involvement. HELLP stands for hemolysis, elevated liver enzymes, and low platelets and can rapidly threaten maternal and fetal health.
Immediately after rupture of membranes, the fetal heart rate drops to 70/min. A loop of umbilical cord is visible at the vaginal opening. This is the nurse’s priority action.
What is elevating the presenting part off the umbilical cord with a sterile gloved hand?
Rationale: Umbilical cord prolapse causes acute cord compression. The nurse should manually lift the presenting part, call for assistance, position the client to relieve pressure, administer oxygen as indicated, and prepare for emergency birth.
During labor, a client suddenly develops dyspnea, cyanosis, hypotension, and bleeding from IV sites. This rare emergency is suspected.
What is an amniotic fluid embolism or anaphylactoid syndrome of pregnancy?
Rationale: Amniotic fluid entering the maternal circulation may produce abrupt respiratory failure, cardiovascular collapse, and disseminated intravascular coagulation. Immediate resuscitation and multidisciplinary emergency care are required.
A postpartum client has uterine atony and hypertension. This uterotonic medication should generally be avoided.
What is methylergonovine?
Rationale: Methylergonovine causes vasoconstriction and may dangerously increase blood pressure. It is contraindicated in clients with hypertension or preeclampsia.
A newborn receiving phototherapy should receive this nursing intervention to improve treatment effectiveness.
What is exposing as much skin as possible while protecting the eyes and repositioning the newborn regularly?
Rationale: Maximum skin exposure and repositioning improve light absorption. The nurse should also monitor temperature, hydration, stools, bilirubin levels, and eye protection.
Terbutaline is prescribed for uterine tachysystole. This maternal finding would require withholding the medication and notifying the provider.
What is maternal tachycardia, particularly a pulse above the prescribed parameter such as 120/min?
Rationale: Terbutaline is a beta₂-adrenergic agonist that can cause maternal tachycardia, palpitations, hyperglycemia, and pulmonary edema. Maternal and fetal heart rates must be monitored.
A client at 34 weeks reports a severe headache, blurred vision, and decreased fetal movement. Her blood pressure is 168/112 mm Hg. This is the nurse’s priority action.
What is placing the client in a side-lying position and notifying the provider immediately?
Rationale: The client has severe preeclampsia with neurologic symptoms and possible fetal compromise. A side-lying position promotes uteroplacental perfusion while the nurse initiates rapid escalation and prepares for seizure precautions and treatment.
A client receiving oxytocin has six contractions in 10 minutes, each lasting 90 seconds. Recurrent late decelerations are present. This is the first nursing action.
What is discontinuing the oxytocin infusion?
Rationale: The client has uterine tachysystole with fetal intolerance. Stopping oxytocin removes the cause. The nurse should then reposition the client, increase the primary IV fluid as prescribed, notify the provider, and continue fetal assessment.
A client receiving magnesium sulfate has respirations of 9/min, absent patellar reflexes, and a urine output of 20 mL/hr. This medication is the antidote.
What is calcium gluconate?
Rationale: Respiratory depression, absent reflexes, and oliguria suggest magnesium toxicity. Stop the infusion, notify the provider, support respirations, and administer calcium gluconate as prescribed.
Four days after birth, a client reports unilateral calf warmth and swelling. This is the nurse’s priority action.
What is keeping the client in bed and notifying the provider?
Rationale: These findings suggest deep-vein thrombosis. The affected leg should not be massaged because this may dislodge the clot and cause a pulmonary embolism.
A preterm newborn has nasal flaring, expiratory grunting, intercostal retractions, and a respiratory rate of 72/min. This nursing action takes priority.
What is supporting oxygenation and notifying the neonatal team immediately?
Rationale: These are signs of respiratory distress. Airway and breathing take priority. Feeding by mouth should be withheld until respiratory stability is established because tachypnea increases aspiration risk.
Oxytocin 30 units in 500 mL lactated Ringer’s is infusing at 4 milliunits/min. The pump should be set to this rate.
What is 4 mL/hr?
Calculation:
30 units = 30,000 milliunits
30,000 milliunits ÷ 500 mL = 60 milliunits/mL
4 milliunits/min ÷ 60 milliunits/mL = 0.0667 mL/min
0.0667 × 60 = 4 mL/hr
Rationale: Oxytocin is administered by infusion pump and titrated carefully while uterine activity and fetal response are continuously assessed.
A client with type 1 diabetes is 10 weeks pregnant. Her insulin requirements have decreased, and she has experienced several hypoglycemic episodes. This physiologic change best explains the finding.
What is increased insulin sensitivity during the first trimester?
Rationale: Insulin needs may decrease during early pregnancy because of increased insulin sensitivity and fetal glucose use. Requirements usually rise later as placental hormones increase insulin resistance.
A laboring client is 8 cm dilated. The fetal heart rate abruptly decreases from 145 to 85/min and remains there for four minutes. Repositioning does not correct it. This finding requires preparation for this intervention.
What is an emergency operative birth, usually cesarean birth?
Rationale: A fetal heart rate decrease lasting 2–10 minutes is a prolonged deceleration. Persistent bradycardia unresponsive to intrauterine resuscitation may indicate severe fetal compromise and require expedited birth.
During a vaginal birth after cesarean, the client reports sudden tearing abdominal pain. Contractions stop, fetal bradycardia develops, and the presenting part moves upward. This complication is suspected.
What is uterine rupture?
Rationale: Sudden pain, loss of uterine activity, fetal distress, maternal instability, and loss of fetal station are warning signs of uterine rupture. Emergency laparotomy and birth are usually required.
Ten days after birth, a client says, “My baby would be safer without me,” and reports hearing a voice telling her to harm the newborn. This is the nurse’s priority response.
What is ensuring the client and newborn are not left alone and obtaining emergency psychiatric assistance?
Rationale: Hallucinations and thoughts of harm suggest postpartum psychosis, a psychiatric emergency. Immediate safety, direct supervision, and emergency evaluation are required.
Twelve hours after birth, a newborn develops visible jaundice. This finding is interpreted in this way.
What is pathologic jaundice requiring prompt evaluation?
Rationale: Jaundice appearing during the first 24 hours is abnormal and may indicate hemolysis, infection, or another disease process. Physiologic jaundice typically appears after the first 24 hours.
Magnesium sulfate 40 g in 1,000 mL is prescribed at 2 g/hr. The pump should be set to this rate.
What is 50 mL/hr?
Calculation:
40 g ÷ 1,000 mL = 0.04 g/mL
2 g/hr ÷ 0.04 g/mL = 50 mL/hr
Rationale: During magnesium therapy, monitor respiratory rate, deep-tendon reflexes, level of consciousness, urine output, and serum magnesium as ordered. Calcium gluconate should be readily available.