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NCLEX > Maternity > Flashcards

Maternity Flashcards

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1
Q

true vs false labor

A

true:

  • regular timing of contractions
  • radiating contracting pain
  • unable to relieve contraction pain with activity
  • exam changes present

false:

  • fails to have any changes to the cervix and baby posittion
  • contraction goes away with activity
  • contractions felt above belly button and dont radiate from back to abdomen
  • irregular timing of contractions
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2
Q

tests to evaluate during first trimester

A

transvaginal probe placed inside vagina
- can help diagnose extopic pregnancy or abnormal vaginal bleeding

ultrasound
- used between 6 and 8 weeks
- determines the sex of the baby
- encourage NOT to void immediately before the test
because full bladder will enhance visualization

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3
Q

tests to evaluate during second trimester

A

urinalysis to monitor for presence of protein and glucose
AFP screening
- performed at 16-18 weeks

diabetes screening
- performed at 24-48 weeks

oral glucose tolerance testing
Hep B, HIV screening
TB test

amniocentesis
- performed at 15-18 weeks
Rh-factor incompatability screening

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4
Q

maternal changes in second trimester

A

heartburn

  • avoid greasy, and fried foods
  • eat smaller portions

bleeding gums
leg cramps
constipation
colostrum can be produced

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5
Q

fetal assessment in second trimester

A

ask about date of quickening (kickig)
- 18-20 weeks

dopplet ultrasound to measure fetal heart rate
- 12-14 weeks

heigh of fundus in cm

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6
Q

tests to evaluate during third trimester

A

encourage client to talk to partner about:

  • pregnancy affecting sexually
  • preparation for support
  • preparation any other children about new siblings

should perform fetal movement count daily

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7
Q

maternal changes in third trimester

A

urinary incontinent
- perform kegel exercises

hemorrhoids
low back pain
insomnia

varicosities

  • change positions frequently
  • don’t cross legs

dyspnea or shortness of breth
leaking of colostrum

around wk 28, the nurse should:
- explain the purpose of and how to count kicks

call HCP if:

  • vaginal bleeding
  • abdominal pain, especially sudden and epigastric pain
  • uterine contractions
  • PROM
  • decreased or absent fetal movements
  • increased temp greater than 101 and is persistent
  • persistent headache or visual disturbances
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8
Q

first stage of labor

A

latent stage:
irregular contractions become progressively coordinated
may be more than 10 minutes apart and last about 30 seconds
cervix effaces and dilates to 4 cm

lasts approx 8 hours

active phase:
lasts approx 4 hours for primipara, and 2 hours for multipara
cervix becomes fully dilated
contrctions will increase in frequency and duration
- they will become more regular
- about 3-5 min apart, lasting 45 seconds

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9
Q

second stage of labor

A

birth of the child
assist with positioning the mother for delivery
- supine with knees bent (dorsal lithotomy position)
- sims position
- partial sitting or squatting
- on her hands and knees

remind mother not to hold her breath while pushing

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10
Q

third stage of labor

A

placental separation

3 classic signs of pacental seapration:

  • uterus contracts and rises
  • umbilical cord suddenly lengthens
  • gush of blood occurs
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11
Q

fourth stage of labor

A

take vital signs every 15 min

  • rise in temp may be due to dehydration or epidural
  • if the rise in temp lasts for 24 hours then it is infection

assess bladder for distention
encourage first void within one hour postpartum, then every 2 hours, 3 hours

fundus should be the size of a grapefruit

breasts should be soft with colostrum present
- warm compress or warm shower to stimulate milk flow

check calves for pain, tenderness or redness

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12
Q

newborn lab tests and screening

A

metabolic screening for metabolic diseases, genetic disorder , anemia

bilirubin levels should be less than 10
PKU screening after 24-48 hours

growth and gestational assessment
pain and hearing

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13
Q

newborn immunizations

A

Vitamin K

HEp B vaccine

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14
Q

newborn cord care and care of circumcision

A

umbilical cord clamp usually be removed in the first 24-48 hours

folding the diaper down to expose the cord to air may speed up the drying process
- cord will fall on its own with little to no bleeding

circumcision:
gently washing the penis with warm water after each diaper change

apply petroleum jelly on circumcised area
make sure diapers are fastened loosely
- with will have less pressure on penis while it heals

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15
Q

newborn feeding and burping

A

should eat every 3-4 hours if formula fed newborn

should every 2-3 hours if breastfed

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16
Q

naegeles rule

A

First day of last menstrual period + 9 months + 7 days

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17
Q

preeclampsia

A

hypertensive disorder that occurs after 20 weeks gestation

18
Q

preeclampsia risk factors

A 
history of preeclampsia or family hisotyr
1 st pregnancy
diabetes, lupus, high BP 
kidney disease
obese BMI >30
more than one baby
age
- young <18 or advanced >35
19
Q

preeclampsia signs and symptoms

A

hypertension
proteinuria
- uric acid and creatnine levels icnrease
- urinary output decrease

edema
upper abdominal pain 
increase in liver enzymes
decreased platelets lead to:
- DIV, hemolysis which can lead to HELLP syndrome
20
Q

severe preeclampsia condition can lead to

A

HELLP

  • hemolysis
  • elevated liver enzymes
  • low platelets

eclampsia: seizures
placental abruption
restrict fetal growth or death

21
Q

preeclampsia management

A

check urine

  • > 1+ dipstick test
  • 24 hours urine: >300 mg
  • > 0.3 mg creatinine to protei ration

hyperactive deep tendon reflexes
monitor BP and edema
- weight gain of 2 pounds in a week

left side lying position
assess for seiure activity

mag sulfate - monitor for txocitiy
calcium gulconate - antidotes

protein rich diet
- watch salt intake
watch for HELLP, eclampsia, placental abruption and restricted fetal grwoth and death

administer antihypertensives

  • labetalol
  • hydralazine
22
Q

gravidity and parity

A

gravidity: # of times a woman has been pregnant whether abortion or not
parity: # of times a woman has BIRTHED or COMPLETED pregnancy at 20 weeks gestation

23
Q

GTPAL

A

g: gravidiity
T: term
-number born (alive or stillbonr) at 37 weeks onward
- if they are twins or triplets its still 1, because you are counting the number of pregnancies

Preterm: number born 20-37 weeks
- whether alive or stillborn

a: aboriton
l: living

24
Q

APGAR

A

appearance:

0: pale/bleu all over
1: acrocyaosis
2: pink

pulse:

0: absent
1: <100 bpm
2: >100 bpm

grimace:

0: no response
1: grimace (no cry)
2: cry, active movement

activity:

0: none, flaccid
1: some
2: arms, leg flexed

respiration:

0: absent
1: weak/irregular cry
2: strong, vigorous cry

performed at 1 min and 5 min after birth
may be reassessed at 10 min after birth so, 5 min later, if score is 6 or less

25
Q

Rh incompatability

A

occurs when Rh positive father and Rh negative mother have an Rh positive baby

Rh negative and Rh negative can get blood, but because the baby is Rh positive, the mom’s blood will start attacking the baby’s RBCs

Prevention is key
- done by getting a Rhogam shot if Rh negative at 28 weeks and then within 72 hours AFTER delivery of baby is baby is Rh positive

rhoGAM stops the immune system from creating antibodies against the baby’s Rh positive blood

if mom already has antibodies created, then RhoGAM won’t be effective

26
Q

hyperemesis gravidarum

A

excessive nausea, and vomiting leading to weight loss, electrolyte imbalances, nutritional deficiencies and ketonuria

27
Q

hyperemesis gravidarum interventions

A

antiemetics
IV hydrations
correction of electrolyte imbalances

28
Q

ectopic pregnancy

A

ovum implants outside of the uterus

not a viable pregnancy and will rupture if not caught in time

29
Q

ectopc pregnancy symptoms

A

abdominal pain
delayed menses
abdnormal vaginal bleeding

30
Q

ectopic pregnancy interventions

A

teaching for clients receiving medical therapy like methotrexate
perioperative care for clients receiving surgical treatment

31
Q

gestational hypertension

A

elevated BP >140/90 after the 20th week of pregnancy on more than one occasion and absence of proteinuria

32
Q

gestational hypertension interventions

A 
accurate and regular BP monitoring
urinanalysis 24 hour urine collection
lab tests:
- creatinine
- platelet count
- liver enzymes

fetal movement counts
non-stress testing
low sodium diet

moderate to low actvity
client teaching

bedrest is no longer recommended for those with gestational hypertension

33
Q

proplapsed cord

A

most common after the membranes rupture and cord is “washed” by escaping fluid

when fetus presses on the cord, blood flow to and from the fetus is reduced or completely blocked leading fetal hypoxia

34
Q

prolapsed cord care

A

remain with the client and request emergency help

insert 2 gloved fingers into the vagina and hold the presenting part of the cord
sims position, knee to chest or trendelenburg

cover protruding cord with sterile, saline soaked gauze or twoel

administer high flow oxygen
C-section

35
Q

placenta previa

A

painless bright red vaginal bleeding

goal: prevent hemorrhage during delivery
will require C-section

36
Q

abruption placentae risk factors

A

gestational hypertension
cocaine use
smoking
blunt external abdominal trauma

37
Q

abruption placentae manifestation

A

vaginal bleeding
abdominal pain
contractions

38
Q

abruption placentae interventions

A

immediate birth is treatment of choice

should be suspected in pregnant clients who experience a sudden onset of severe, localized uterine pain with or without vaginal bleeding

39
Q

preterm labor and birth interventions

A

primary goal is prevention

give prophylactic progesterone
activity restrictions, including bedrest
restriction of sexual activity to provide “pelvis rest”

hospitalization
administration of tocolytics
- indomethacin
- terbutraline
- mag sulfate
- CCB

mag sulfate
- closely monitor resp status, deep tendon reflexes and LOC

40
Q

dystocia

A

lack of progress in labor for any resons

41
Q

dystocia causes

A

ineffective uterine contractions
abnormalities in fetal presentation
maternal pelvic structure

42
Q

dystocia interventions

A

version
- turning of the fetus

cervical ripening with miso
administration of oxytocin
amniotomy-artificial rupturing of membranes

NCLEX (21 decks)

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