ATI Practice Flashcards
Aromatherapy
non-pharmacologic therapy using essential oils, RN doesn’t need special certification to use
% of water in breast milk
87%, which is sufficient for infant’s fluid needs; infant does not need add’l fluids and water should not be substituted for breast milk
Interventions for PP hemorrhage
Fundal massage Assess bladder Admin Oxytocin 20U in IV Admin Methylergonovine (Methergine) 0.2 mg IV --Methergine is ergot alkaloid
50g oral glucose load, followed by plasma glucose measurement 1-hr later; what glucose level is considered a positive screen?
130-140 mg/dl, or anything over 140 mg/dl
If woman has a positive screen for 1-hr test, what is next step?
a 3-hr (100g) oral glucose tolerance test (OGTT). This is administered after an overnight fast and at least 3 days of unrestricted diet (at least 150 g of carbs) and physical activity
When palpating the fundus 1d post delivery it should be firm and midline, 2 finger breadths above umbilicus. If offset to the left, what could be the cause?
a distended bladder. the nurse needs to assist with emptying bladder or she is at risk for subinvolution of uterus
Introspection
Examine emotions of self
Ambivalence
simultaneous occurrence of conflicting feelings; feeling excited and overwhelmed about the upcoming birth of infant
What is the first action the nurse should take when a mother states her “water broke”?
Monitor the fetal heart rate!!! C-O-A-T: Nurse then would assess amniotic fluid (Color, unusual odor, amt, time), perform Nitrazine test to determine pH, and check cervical dilation.
If a newborn is hypoglycemic, what are the s/s?
irregular RR, lethargy, feeding difficulty (latch on), jitteriness, thermal instability
What will happen with the NB abdomen when hypokalemia occurs?
abdominal distention
Why is folic acid intake pertinent for preconception counseling?
Adequate intake is necessary for closure of neural tube during gestation and the best way to ensure availability is for maternal consumption prior to and during pregnancy.
What do late decelerations indicate on fetal monitor?
uteroplacental insufficiency (insufficient blood flow to the placenta)
What is an indication of fetal well-being on HR monitor?
baseline variability
Why is oxytocin given?
Augment labor. If there is cessation of uterine dilation, or want to induce labor it causes the uterus to contract.
What causes bloody show?
effacement and dilation of cervix
At 39 weeks, what is the amount of amniotic fluid?
1L or 1000mL
What is the most likely complication of ruptured membranes? How is it indicated?
Infection. Indicated by maternal tachycardia. Should be reported to Provider. If she is preterm and has premature ROM, nurse should monitor pt temp q2h
Respiratory s/s of NB developing sepsis?
tachypnea, bradycardia, apnea, grunting, nasal flaring, retractions, decr O2 sat, metabolic acidosis,
CV s/s of NB developing sepsis?
decreased CO, tachycardia, hypotension, decreased perfusion
CNS s/s of NB developing sepsis?
temp instability, lethargy, hypotonia, irritability, seizures
GI s/s of NB developing sepsis?
feeding intolerance (decr sucking strength and intake; incr residuals), abdominal distention, vomiting, diarrhea
Skin s/s of NB developing sepsis?
jaundice, pallor, petechiae, mottling
Why is the side-lying position recommended?
b/c it promotes uterine perfusion and feta-placental oxygenation by eliminating pressure on the ascending vena cave and descending aorta, which can lead to supine hypotension
what is the difference b/w a sign and symptom?
a sign can be measured, a symptom is something experienced by the patient
What are s/s of mild preeclampsia?
hypertension ( >140/90), swelling or edema, proteinuria, sudden weight gain (decr urine output, should exceed 30ml/hr). DTR 4+ indicates severe preeclampsia.
What are the results of oxytocin-stimulated contraction test?
Negative, positive, equivocal, suspicious, or unsatisfactory. Negative indicates fetal well-being (repeat in 1 wk). Positive is assoc. w/ intrauterine fetal death, late FHR decelerations in labor, IUGR and meconium-stained amniotic fluid–need to monitor in hospital or deliver). Equivocal, suspicious and unsatisfactory are retested in 24-hr.
If mother has a prolapsed cord, what is the best position?
Knee-chest position (doggy style) b/c it relieves pressure of cord and restores perfusion.
What instruction should a nurse provide initially regarding breathing technique during labor?
Take a cleansing breath. All breathing patterns being with deep relaxing cleansing breath (to greet the contraction and end w/ another deep breath exhaled to “gently blow it away”)
Slow-paced breathing
approx 1/2 of normal breathing rate (3-4 breaths per minute)–this aids in relaxation and optimal O2
modified-paced breathing
shallower and faster than normal rate, not to exceed twice resting RR–allows woman to be more focused and alert
pant-blow breathing
for transition phase when the cervix dilates 8-10 cm. Same rate as modified (shallow, fast, not to exceed twice resting RR)–panting and slow blowing breaths. [pant pant pant blow]
Expected findings with hyperbilirubiemia
brown or gold urine, maculopapular skin rash, yellow mucous membranes.
What does a high-pitched cry indicate when a baby has hyperbilirubinemia and undergoing phototherapy?
acute bilirubin and encephalopathy
What do early decelerations indicate?
fetal head compression, normal with progressing labor and requires no interventions
How long must a car seat face the rear of car?
20lbs and 1 year of age
Priority interventions for pt experiencing variable decelerations.
- chg mom position (side/side, knee chest)
- d/c oxytocin if infusing
- admin O2 8-10L/min by nonrebreather mask
- notify MD
- Assist w/ assess of for cord prolapse
- assist w/ amnioinfusion if ordered.
Priority interventions for pt experiencing late decelerations.
- chg mom position (lateral)
- correct maternal hypotension by elevating legs
- incr rate of main IV soln
- palpate uterus to assess tachysystole
- d/c oxytocin if infusing
- admin O2 8-10Lmin
- Notify MD
- consider internal monitoring
- assist w/ birth
Interventions for maternal hypotension
incr rate of primary IV infusion
Chg to lateral or Trendelenburg position
Admin ephedrine or phenylephrine if other measures are unsuccessful in increasing BP
Interventions for Uterine tachysystole
reduce or d/c the dose of uterine stimulants
admin a uterine relaxant (tocolytic like terbutaline)
Interventions for abnormal FHR tracing in 2nd stage of labor
use open glottis pushing
few pushing efforts during each contraction
make indiv pushing efforts shorter
push w/ every other or every 3rd contraction
push only w/ a perceived urge to push
What complications can prolonged contractions cause?
reduced blood flow to placenta and FHR decelerations, so oxytocin should be d/c if contractions are in normal range of every 60-90 seconds
What is a complication of amniocentesis?
onset of early labor due to leakage of amniotic fluid, should report to provider
What effect does pregnancy have on the gums?
elevated estrogen increases vascularity and proliferation of connective tissue
active phase of labor
cervical dilation of 4-7cm and contractions every 3-5 min lasting 40-70 sec
transition phase of labor
cervical dilation of 8-10cm and contractions every 2-3 min lasting 45-90 seconds, early decelerations are an expected finding on FHR monitor
second stage of labor
from full cervical dilation to birth of baby
third stage
from birth of baby to delivery of placenta
What is assessed on US stethoscope regarding fetal heart tones?
rate, rhythm, location
what is the greatest risk for newborn after delivery?
cold stress. need to dry the baby!!
Nägele’s rule
LMP, subtract 3 calendar months, and add 7 days
What does maternal serum alpha-fetoprotein levels determine?
screening tool for neural tube defects b/w weeks 15-22. MSAFP is low for down syndrome. high results require US and amniocenteisis
Signs of labor
bloody show (blood-tinged d/c)
where are contractions felt during true labor?
lower abdomen and lower back
Non-pharmacologic intervention for lactation suppression?
cabbage leaves–plant sterols and salicylates can help to relieve swelling
what does the biophysical profile assess of the fetus
it includes amniotic fluid volume (AFV), fetal breathing movements (FBM), fetal movements, fetal tone pg. 568
Why should the car seat face the rear?
in the event of frontal crash, the force of impact is distributed over the NB head, neck and back, and back of car seat support the spine
What indicates infection after a circumcision? What are the expected findings?
infection: swelling of penis, redness and discharge. Normal: dark red glans penis, yellow exudate covering penis (occurs about 24h after and remains for 2-3d, should not be removed!!)
Leopold maneuver
assessment of fetal position
how does epidural affect BP
can result in severe hypotension
Upon d/c, highest priority teaching according to ABC is what?
suctioning w/ bulb syringe to maintain an unobstructed airway
What can a nurse do to minimize the pain of a heel stick?
swaddle immediately before puncture
what is an sign of adverse rxn to mag sulfate?
absent DTR
What may a person receiving a tocolytic therapy experience?
hot flashes
where are the fetal heart tones of fetus in LOA heard?
left lower quadrant of mom
