It's complicated
A student nurse is caring for a pregnancy client who has experience ROM. Which statement demonstrates understanding of the needs for this client?
A. The baby's defense against infection is gone
B. Labor will start immediately because the barrier is removed
C. The amniotic sac has come out of the uterus
D. The fetus is able to move better now
What is A?
The baby's defense against infection is gone
This assessment finding is the first sign of hypovolemic shock and should be reported in postpartum patients who have experienced excessive blood loss
What is tachycardia?
A pregnant client arrives to the ER stating "My water broke!". Which diagnostic test finding would be consistent with a rupture of membranes?
A. Mucous discharge
B. Amnisure negative
C. Soaked pad or underwear
D. Nitrazine paper turns blue
What is D? Nitrazine paper turns blue
An 18-hour old baby with an elevated bilirubin in placed under phototherapy. Which nursing action should be taken?
A. Give the baby oral rehydration in place of all feedings
B. Rotate the baby from side to back to front every 2 hours
C. Apply restraints to keep the baby under the light source
D. Administer intravenous fluids via pump per doctor orders
What is B? Rotate the baby every 2 hours
Flu-like symptoms accompanied by a reddened, tender area on the breast are typically treated with:
What are antibiotics, fluids, rest, continued emptying of the breast?
Methergine, Hemabate, Pitocin, and Cytotec are medications used to manage this postpartum complication
What is Postpartum Hemorrhage?
Four hours after a difficult labor and birth, a primiparous client refuses to feed her baby, stating the she is just too tired and wants to sleep. The nurse should:
A. Tell the client to feed the baby before resting
B. Recognize this as a behavior of the letting go stage
C. Record the behavior as an ineffective maternal-newborn attachment
D. Take the baby to the nursery and let the client rest.
What is A? Tell the client to feed the baby before resting
Which actions should the nurse take prior to performing a heel stick on an infant?
What is warm the heel?
The neonate experiencing respiratory distress syndrome is displaying tachycardia, grunting, tachypnea, and diminished breath sounds. Which provider orders should the nurse anticipate? Select all that apply
A. Administer formula as needed
B. Administer surfactant
C. Obtain chest x-ray
D. Initiate and maintain IV access
E. Keep infant cooled to assist with breathing
What is B, C, D?
Late decelerations can be caused by _________ and are managed with__________________
What are placental insufficiency (prolonged or excessive contractions, maternal hypotension) and L.I.O.N.S.
Premature rupture of membranes is often caused by:
What is infection?
In this phase of lactogenesis, which starts in pregnancy, the milk is described as liquid gold.
What is lactogenesis I?
These red, blotchy areas with white papules can be found on the baby face, shoulder, back or chest and usually resolve without treatment.
What is erythema toxicum or newborn acne?
Jitteriness, exaggerated moro reflex, high pitched cry, poor feeding, and sneezing are all signs of what condition in the neonate?
What is neonatal abstinence syndrome?
These contraceptive devices used for 3 weeks and removed for 1 week to allow a menstrual period before being reinserted
What are the nuva ring or the patch?
Excessive traction on the umbilical cord during stage 3 of labor leads to this complication
What is inverted uterus?
B.U.B.B.L.E.H.E.E.R. is a pneumonic to help remember the postpartum assessment. What does it mean?
What is: breasts, bladder, bowel, lochia, episiotomy, hematoma/hemorrhoids, emotions, extremities, rhogam/rubella/reflexes?
The nurse should plan to administer vitamin K and Hepatitis B vaccine in this location
What is the vastus lateralis?
Cold stress in the neonate can lead to these complications:
What are: jaundice, hypoglycemia, respiratory distress, mottling, hypoxemia?
What is pant? (and/or turn on her side )
The nurse is caring for a client experiencing dysfunctional labor. Which assessment findings would alert the nurse to fetal compromise?
A. Rupture of membranes
B. Occiput posterior fetal positioning
C. Meconium in the amniotic fluid
D. Early decelerations
What is C? Meconium in the amniotic fluid
The process of the uterus shrinking back to pre-pregnancy size is called
What is involution?
What is a cephalohematoma?
You’re assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 130, pink body and hands with cyanotic feet, weak cry, flexion of the arms and legs, active movement and crying when stimulated. What is your patient’s APGAR score?
What is 8?
The laboring client has had an amniotomy performed in the 1st stage of labor. 10 minutes later the nurse notes variable decelerations on the fetal monitor. What is the likely cause?
What is prolapsed cord?