Mark k lecture 11

Question 1

Normal fetal heart rate

Answer 1

120 to 160 beats per minutes

Question 2

Low Fetal HR (heart rate)—HR <110

Answer 2

• This is BAD
• You do “LION”
  o Left side (place mother on the left side)
  o IV
  o Oxygen
  o Notify HCP
• Stop Pitocin (pit) if it was running
  o Implement before “LION”

Question 3

High Fetal HR—HR >160

Answer 3

• Document acceleration of fetal HR
• Take the mother’s temp
• Not a high priority … Baby is WNL

Question 4

Low Baseline Variability

Answer 4

• This is BAD
• Fetal HR stays the same—it doesn’t change
• You do “LION”
  o Left side
  o IV
  o Oxygen
  o Notify HCP
• Stop pit if it is running (first)

Question 5

High Baseline Variability

Answer 5

• Fetal heart rate is always changing—This is GOOD
• Document finding

Question 6

Early Deceleration

Answer 6

• This is normal … No big deal
• Document finding

Question 7

Variable (VERY) Decelerations

Answer 7

• This is very BAD
• This indicates prolapsed cord
• What is the nursing intervention?
  o PUSH and POSITION

Question 8

Late Decelerations

Answer 8

• This is BAD
• You do “LION”
  o Left side
  o IV
  o Oxygen
  o Notify HCP
• Stop pit if it is running

Question 9

VEAL CHOP

Answer 9

Variable declatrions —- Cord compression/prolapse
Early decelations—– Head compression
Accelerations—okay
Late decel—– plemtal insuifferncy

Question 10

The second stage of L&D (labour and delivery) to do’s

Answer 10

1. Deliver head … The mother needs to stop pushing
2. Suction the mouth then the nose … ABC order
   3.Check for nuchal (around the neck) cord
3. Deliver the shoulders, next, the body
4. Make sure baby has ID band on before it leaves the delivery area

Question 11

Third stage of L&D to do’s

Answer 11

• Delivery of the placenta
• What do you check for with the delivery of the placenta?
  o Make sure the placenta is complete and intact
  o Check for 3-vessel cord—2 arteries and 1 vein, AVA

Question 12

Fourth Stage of L&D to do’s

Answer 12

• Recovery
• There are 4 things you do in the 4th stage, 4 times an hour (every 15 minutes)

1. Vital signs: Assessing for shock … Blood pressure goes down, HR goes up … Pt looks
   pale, cold, and clammy
2. Fundus: If it is boggy, massage it … If displaced, catheterize it
   3.Check perineal pads … If there is excessive bleeding, the pad will saturate in 15
   minutes or less
   4.Roll pt over and check for bleeding underneath her

Question 13

Post partum Assessment times

Answer 13

Assess every 4 to 8 hours

Question 14

Post partum Assessment

Answer 14

• Assess for “BUBBLE HEAD”
• Make sure you focus on the 3 designated steps stated as important from BUBBLE HEAD
• Breasts
• Uterine fundus should be firm … Important
  o Massage if fundus is boggy and midline
  o Catheterize pt if fundus is boggy and not midline
• Bladder
• Bowel
• Lochia is vaginal drainage postpartum (Know
  the order) … Important
  o Rubra—red
  o Serosa (if your cheeks are rosy)—pink
  o Alba (albino)—white
  o Moderate amount: 4 to 6 inches on pad in an
  hour
  o Excessive: saturate a pad in 15 minutes
• Episiotomy
• Hemoglobin/hematocrit
• Extremities—Looking for thrombophlebitis … Important
  o What is the best way to determine if a pt has thrombophlebitis?
  The best way is to measure Bilateral calf circumference (Best answer)
  Homan sign is not the best answer
• Affect—emotional
• Discomforts

Question 15

What should the postpartum uterine tone, height, and
location normally be?

Answer 15

• The tone of the fundus should be firm, not boggy
• The height of the fundus after delivery should be at
  the umbilicus (or navel)
  o Fundus involutes about 2 cm every day PP
  (postpartum)
• The location of the uterus should be midline
  o If not midline, the bladder is distended

Question 16

Milia

Answer 16

Milia—White, pinhead-size, distended sebaceous glands on the nose, cheek, chin, and
occasionally on the trunk. Usually disappear after a few week of bathing not a issue

Question 17

Epstein pearls

Answer 17

pearls—Palatal cysts of the newborn, which are small white or yellow cystic
vesicles not a issue

Question 18

Mongolian spot—Bluish

Answer 18

Bluish discoloration in the sacral region of newborn usually seen in
African Americans … Carefully document its presence as such action may prevent child
abuse charges against parents or caregiver not a issue

Question 19

Erythema toxicum neoratorum

Answer 19

Described as flee-bitten lesion … pink rash with firm,
yellow-white papules or pustule on the face, chest, abdomen, back and buttocks of some
newborns. Usually appears 24 to 48 hours after birth and disappear in a few days not a issue

Question 20

Hemangioma

Answer 20

An abnormal accumulation of blood vessels in the skin of the newborn. It is
one of the most common birthmarks associated with childhood and affect 10% of all children not a issue

Question 21

Cephalohematoma

Answer 21

Cephalohematoma—A collection of blood between the periosteum of a skull bone and the
bone itself
o Occurs in one or both sides of the head
o Occasionally forms over the occipital bone
o Develops within the first 24 to 48 hours after birth

Question 22

Caput succedaneum

Answer 22

An edema of the scalp of the neonate during birth from mechanical
trauma of the initial portion of scalp pushing through a narrowed cervix
o The edema crosses the suture lines
o May involve wide areas of the head or it may just be a size of a large egg
o Caput Succedaneum (CS)—Crosses Suture line, and Caput Symmetrical

Question 23

Hyperbilirubinemia in the Newborn

Answer 23

• Physiologic jaundice is normal and appears after 24 hours after birth … Disappears in about
  one week
• Pathologic jaundice is seen in the 1st 24 hours after birth

Question 24

Nevi (Telangiectatic nevi)

Answer 24

Nevi or telangiectatic nevi, a.k.a. “stork bites,” are pink and easily blanched skin lesion that
appear on upper eyelid, nose, upper lip, lower occipital area, and nape of the neck
* No clinical significance
* Disappears by 2 years of age

Question 25

Port wine stain

Answer 25

Port-wine stain or nevus flammeus is seen at birth and is composed of a plexus of newly
formed capillaries in the papillary layer of the corium
* Commonly found on the face and neck
* Red to purple, varies in size, shape and location
* Does not blanch on pressure

Question 26

6 main ob medications

Answer 26

• Terbutaline (Brethine)
• Mag sulfate
• Pitocin
• Methergine
• Bexamethasone
• Surfactant

Question 27

Tocolytics (Stop contractions, stop labor)

Answer 27

• Tocolytics are given to women in premature labor that must be stopped
• Terbutaline (Brethine)
  o S/E: maternal tachycardia (don’t give with cardiac disease)
• Mag sulfate
  o Treatment with Mag sulfate will induce hypermagnesemia, which will cause everything to
  go down
  o HR will go down, BP go down, Reflexes go down, RR go down, LOC go down

Question 28

So, what is the nursing intervention for hypermagnesemia due to mag sulfate treatment?

Answer 28

• Monitor respiration
  o If RR <12, decrease dose of Mag sulfate
• Assess for reflexes
  o Normal reflex is 2+
  o If reflexes are 0 or 1+ … Decrease dose of mag sulfate
  o If reflexes are 3+ or 4+ … Increase dose of mag sulfate

Question 29

Oxytocics (Stimulate and strengthen labor)

Answer 29

Pitocin (Oxytocin)
o S/Es: Uterine hyperstimulation (defined as longer than 90 seconds, closer than 2 minutes)
The nursing intervention is to lower the dose of pitocin in case of uterine
hyperstimulation
* Methergine
o Causes HTN—if it contracts blood vessels it makes sense that this increases BP

Question 30

Fetal/Neonatal Lung Meds

Answer 30

• Betamethasone (steroid)
  o Given to mother IM
  o Can repeat as long baby is in utero
  o S/E: increase glucose (steroid)
• Surfactant (Survanta)
  o Given to baby via transtracheal route
  o Given After birth