maternity Flashcards
impaled object
stabilization of the object is the first priority
IV line & fluids
Blood may be drawn
when to activate the
rapid response team
to prevent a client from deterioration into a code/arrest
An acute change in any of the following:
HR <40 or >130/min
SBP <90 mm Hg
RR <8 or >28/min
O2 <90% despite oxygen
Urine output <50 mL/4 hr
LOC
Arterial line
low pressure alarm
hypotension.
check the client for evidence of hypotension and the cause
hemorrhage at connection sites of the tubing and catheter.
verify that these connections are tight on admission of the client to the ICU.
A fast flush of the arterial line system (square wave test) should be performed after the nurse has ruled out a physiological cause of the low pressure alarm. This test helps to verify if the arterial line is functioning correctly.
The transducer should be leveled to the client’s phlebostatic axis
Hypothermia
dysrhythmias
handle gently as spontaneous ventricular fibrillation could develop when moved or touched.
place client on a cardiac monitor ,
anticipate defibrillation
Two large-bore IV catheters
blood draw
Covering the client’s head
Treatment of frostbite
X no massageX
Remove clothing
warm water soaks
analgesia
elevating injured areas
applying loose, nonadherent, sterile dressings
monitoring for compartment syndrome
Breast engorgement
don’t breastfeed or hand express
ice packs to both breasts for 15-20 minutes every 3-4 hours
chilled, fresh cabbage leaves to both breasts
anti-inflammatory analgesic (eg, ibuprofen)
supportive bra, breast binder) until milk flow is diminished
mom has not voided within 6-8 hours after birth
intermittent urinary catheterization may be indicated
Delayed voiding can increase the risk for postpartum hemorrhage
Urinary retention can cause bladder distension, which may be noted by a displaced and/or boggy uterus, or by a palpable bladder
postterm gestation
≥42 weeks
Deep plantar creases over the entire sole of the foot
Dry, cracked, and peeling skin, especially on the hands and feet
Abundant scalp hair and long fingernails
Minimal to absent vernix caseosa
Signs of meconium passage in utero (eg, meconium-stained [yellowish-green] skin or nails)
Cardiac arrest in infants
activate the emergency response system
assess for a pulse by palpating the brachial artery for 5-10 seconds
Chest compressions should be initiated after PPV if the heart rate remains <60/min
weight loss
During the first 3-5 days of life
5%-10% of birth weight is expected due to fluid excretion (eg, urine, stool, respirations)
return to their birth weight after 7-14 days of life.
Weight loss >10% of birth weight warrants further evaluation.
no stool (ie, meconium) is noted within 24-48 hours of birth
nurse should request immediate evaluation
imperforate anus is a congenital malformation of the anorectal opening that prevents normal stool passage
newborn is experiencing a bowel obstruction?
Green vomit
-represents bile from the intestine, which could indicate a bowel obstruction.
Hepatitis B virus infection is a bloodborne illness that poses a significant risk to the newborn
breast feeding is fine
Hepatitis B immunoglobulin and hepatitis B virus vaccine should be administered to the newborn within 12 hours of birth
Average newborn head circumference
13-14 in (33-35 cm)
A smaller or larger head circumference may indicate an abnormal condition (eg, microcephaly, hydrocephalus).
Asymmetric arm movement while testing the Moro reflex
a complication associated with a vacuum-assisted birth
fracture (eg, clavicular, humerus) or brachial plexus injury
Moro reflex (ie, startle reflex)
present until age 3-6 months
a response to sudden loud noises and jarring of the crib
Initially, the newborn extends and raises the arms with fingers fanned out and then curls into the fetal position
Absence of the Moro reflex may indicate an underdeveloped or damaged brain or spinal cord and should be reported to the health care provider
Transient acrocyanosis without central cyanosis during the first day of life
normal
promote warmth by placing the newborn skin-to-skin
normal newborn vitals
BG 2.2-2.5 mmol/L
36.5 C
respirations 60/min
+ periodic pauses lasting <20 seconds
Poorly controlled maternal diabetes
polycythemia (ie, hematocrit >65%).
resp distress
Sustained tachypnea
nasal flaring,
retractions,
grunting
. Respiratory distress may be related to retained amniotic fluid in the lungs, meconium aspiration, or infection
Teaching about newborn home care
Monitor for bulging or indentation of fontanels, which can indicate complications (eg, hydrocephalus, dehydration) because open fontanels are soft spots where the skull bones have not yet fused.
Fold the diaper under the cord to keep the cord dry and prevent irritation and contamination with urine or feces
Expect a loss up to 10% of birth weight in the first few days of life before the newborn begins to gain weight consistently
Feed the newborn every 2-3 hours due to small stomach capacity
oxytocin is initiated at the lowest possible dose and titrated until contractions are of moderate-to-firm intensity and 2-3 minutes apart. The infusion is decreased/discontinued if uterine tachysystole (ie, >5 contractions in 10 minutes) or fetal distress occurs.
oxytocin LOW and SLOW
contractions 2-3 min apart :)
give narcotics. during the PEAK of contractions
(eg, nalbuphine, butorphanol, meperidine)
can help decrease sedation of the fetus and subsequent newborn respiratory depression at birth
Amniotomy = artificial rupture of membranes (AROM)
to augment or induce labor
Monitor the client’s temperature at least every 2 hours
Assess the fetal heart rate before and after
Note the amniotic fluid color, amount, and odor
side-lying or upright position
vaginal birth after cesarean (VBAC)
increased risk for uterine rupture due to previous surgical scarring of the uterus
first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns
sudden cessation of uterine contractions
abnormal fetal heart rate (FHR) patterns
uterine tachysystole (ie, >5 contractions in 10 minutes averaged over 30 minutes)
common adverse effect of oxytocin
late decelerations, fetal tachycardia, bradycardia=
-stop oxytocin immediately
-side-lying position
-oxygen via face mask at 8-10 L/min
-IV fluid bolus
-subcutaneous injection of terbutaline (Brethine) to relax the uterus if other interventions are unsuccessful
Notifying the health care provider
shoulder dystocia
Documenting the exact time of events (eg, birth of fetal head, shoulder dystocia maneuvers)
Verbalizing passing time to guide decision-making by the health care provider (eg, “two minutes have passed”)
Performing maneuvers to relieve shoulder impaction (eg, McRoberts maneuver, suprapubic pressure)
Requesting additional help
forceps or a vacuum extractor
used to shorten the second (pushing) stage of labor
nurse ensures that the client’s bladder is empty, monitors for contractions, and documents the time that forceps or a vacuum extractor was applied.
X never apply fundal pressure X
intrauterine fetal demise (fetal death after 20 weeks gestation)
have an increased risk for DIC due to the release of thromboplastin from the retained fetus, which activates the coagulation cascade
prioritize collecting blood specimens for baseline laboratory tests (eg, coagulation studies, platelet count
apply a tocodynamometer to monitor for uterine contractions and initiate prescribed oxytocin after obtaining a blood specimen for laboratory tests
Color of the amniotic fluid
should be colorless and without a foul odor.
Yellow-green fluid can indicate fetal passage of meconium in utero and lead to respiratory distress in the newborn (ie, meconium aspiration syndrome)
late deceleration
IV fluid bolus
Repositioning the client laterally
Discontinuing the IV oxytocin infusion
recurrent variable decelerations
caused by umbilical cord compression.
Vibroacoustic stimulation is used during nonreactive nonstress testing (ie, no accelerations) to provoke fetal movement. It is never performed during FHR decelerations or fetal bradycardia.
amnioinfusion (ie, instillation of fluid into the uterine cavity) is indicated
A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic, grunting, and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take?
If a client arrives at the hospital in second-stage labor (ie, pushing), the nurse rapidly assesses whether birth is imminent by applying gloves and observing the perineum for bulging or crowning of the presenting fetal part
Normal findings in labor
Fetal heart rate (FHR) baseline of 110-160/min
FHR accelerations (ie, ≥15 beats above baseline for at least 15 seconds)
Moderate FHR variability (ie, fluctuations in baseline of 6-25/min)
Uterine contractions every 2-5 minutes, lasting 40-90 seconds
Progressive cervical dilation, effacement, and fetal descent
Clear amniotic fluid
Bloody show and increased cervical mucus
Oxytocin
via a secondary IV line
frequent maternal/fetal assessment
titrated to achieve an adequate contraction pattern without causing uterine tachysystole or fetal distress.
cervical ripening medications (eg, misoprostol)
X not indicated for induction of labor in a client with a hx of C-section =significantly increases the risk for uterine rupture.
Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the health care provider?
prevent newborn cold stress by promptly drying and placing the newborn on the mother’s abdomen for skin-to-skin contact
interventions that can reduce complications of prematurity for the newborn
magnesium sulfate - seizure prevention
IM corticosteroids (eg, betamethasone - lung development
IV antibiotics for group B Streptococcus (GBS) prophylaxis (eg, penicillin)
right occiput posterior
“that’s my occiput” “that’s my posterior”
apply counterpressure to the client’s sacrum during contractions to help alleviate back pain
Umbilical cord prolapse
knee to chest
client on the hands and knees with the buttocks elevated above the head (ie, knee-chest position
use a sterile, gloved hand to lift the presenting part off the cord
prepare the client for imminent delivery (eg, emergency cesarean birth)
Leopold maneuvers
palpating the pregnant abdomen to identify the fetal presentation.
shoulder dystocia
Suprapubic pressure and the McRoberts maneuver (ie, sharply flexing the thigh onto the maternal abdomen
maximizing fetal oxygenation during pushing efforts:
Pushing while lying down in a lateral position
Using an open-glottis pushing technique (ie, slow exhalation during pushing) -opposite of valsalva
Pushing with every other contraction
late decelerations and minimal variability of the fetal heart rate
dt placental insufficiency
IV fluid bolus
Repositioning the client laterally
Discontinuing IV oxytocin infusion
Placing an internal fetal scalp electrode
Preparing for a potential cesarean birth if interventions do not successfully resolve the abnormal FHR
perinatal asphyxia
Low Apgar scores: An Apgar (ie, Appearance/color, Pulse, Grimace/reaction, Activity/tone, Respiratory effort) score of <7 out of 10 at 5 minutes
Neonatal seizures: Jerking movements that do not go away and ocular manifestations (eg, rapid eye movement, excessive blinking)
low arterial blood pH
Uterine inversion
rare, obstetrical emergency
occurs after birth when the uterine fundus collapses (partially or completely) into the uterine cavity, causing sudden hemorrhage
Successful manual replacement of the inverted uterus through the vaginal canal by the health care provider (HCP) is the first step in resolving the inversion and requires a soft, uncontracted uterus.
Tocolytics (eg, terbutaline) or inhaled anesthetics may be needed to assist with uterine relaxation.
If manual uterine replacement through the vagina is unsuccessful, emergency laparotomy (ie, replacement via abdominal incision) may be necessary
Uterotonic medications (eg, oxytocin, carboprost) must be delayed or discontinued until after the HCP has corrected the inversion (ie, manual uterine replacement)
After uterine replacement, uterotonics are administered to reinforce its location in the pelvis and control further bleeding.
The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precepting nurse to intervene?
-X using nonsterile gloves to examine X
use sterile gloves during vaginal examination in the presence of ruptured membranes to prevent infection
The nurse is caring for a client in active labor who is 8 cm dilated, trembling, and reporting the urge to push. Which of the following actions should the nurse take?
Maternal signs of the transition phase (8-10cm) include nausea/vomiting, trembling, increased pain, fear, irritability, anxiety, and self-doubt in the ability to birth.
The nurse should provide emotional support, encouragement, and coach the client in breathing techniques
second trimester
14 weeks 0 days to 27 weeks 6 days gestation
Quickening (ie, the client’s first perception of light fetal movement), which is expected around 16-20 weeks gestation, depending on parity
Increasing intake of iron-rich foods (eg, meat, dried fruit) and continue taking prenatal vitamins to prevent anemia caused by increased fetal iron requirements after 20 weeks gestation
Expecting an ultrasound around 18-20 weeks gestation to evaluate fetal anatomy and the placenta
Screening for gestational diabetes mellitus (GDM), which occurs between 24-28 weeks gestation (ie, 1-hour glucose challenge test); GDM is a complication of pregnancy caused by hormonally related maternal insulin resistance
Educating on preterm labor warnings (eg, pelvic pressure, low back pain) and signs of preeclampsia, which are reviewed beginning at 20 weeks gestation
Syphilis
Penicillin is the only adequate treatment for syphilis during pregnancy.
If a pregnant client has a penicillin allergy, penicillin desensitization is necessary
diet in preg
avoid consuming
- unpasteurized milk products, -unwashed fruits and vegetables,
-deli meat and hot dogs (unless heated until steaming hot),
- raw fish/meat.
- fish high in mercury (eg, shark, swordfish, king mackerel, tilefish).
preg wt gain
total weight gain of 25-35 lb (11.3-15.9 kg) is appropriate for a client with a prepregnancy BMI of 21 kg/m2
A nurse on the antepartum unit is caring for a client at 30 weeks gestation who was admitted with reports of vaginal bleeding. A diagnosis of placenta previa was confirmed by ultrasound. Which of the following should the nurse tell the client to anticipate?
additional ultrasound is usually performed around 36 weeks gestation to assess placental location
risk of hemorrhage if contractions result in cervical change, a cesarean birth is planned for after 36 weeks gestation and prior to the onset of labor
Active herpes lesions present at the onset of labor
indicate the need for cesarean birth.
Spontaneous abortion (ie, miscarriage)
Avoid sexual intercourse and tampons as prescribed (eg, 2 weeks
Report foul-smelling vaginal discharge, heavy vaginal bleeding, and severe pain
Continue prenatal vitamins with iron to prevent anemia caused by blood loss and use ibuprofen to alleviate cramping
Placenta previa
painless vaginal bleeding after 20 weeks gestation
high risk for hemorrhage.
initiate electronic fetal monitoring
monitor pad counts
initiate large-bore IV access
collect a blood specimen for type and screen.
Digital vaginal examinations are contraindicated.
nitrazine pH test on vaginal secretions
test for rupture of membranes
the presence of blood or semen may result in a false positive, as amniotic fluid is also alkaline
positive: blue
negative: yellow-green
Physiologic changes to blood composition
hemodilution
hemoglobin+ hematocrit =decreased
WBC count=as high as 15,000/mm3
platelet count also may decrease somewhat but should remain within normal range (≥150,000/mm3
The nurse is reinforcing instructions to a client at 34 weeks gestation who is preparing to travel by airplane. Which of the following instructions are appropriate?
Carry an updated copy of the prenatal record in case emergency medical care is necessary during travel
Increase fluid intake
Secure the lap belt under the gravid abdomen and across the hips
Wear compression stockings and unrestrictive clothing
Avoid traveling to Zika- or malaria-prevalent areas and remote areas with poor medical care or lack of sanitation
measuring fundal height
After 20 weeks gestation, the fundal height measurement in centimeters should correlate closely with the number of weeks pregnant (eg, 24 cm = 24 weeks).
should empty the bladder before having fundal height measured
1st trimester
Detection of a fetal heart rate is possible using a Doppler by 10-12 weeks gestation
Quickening, the awareness of fetal movements, occurs around 18-20 weeks gestation in primigravidas and at 14-16 weeks in multigravida
Naegele’s rule for estimating date of delivery
EDB = (LMP − 3 months) + 7 days.
*use first day of last period
The nurse is providing education to a client diagnosed with a molar pregnancy. Which statement by the nurse requires intervention?
avoiding pregnancy during follow-up care to allow the health care provider to monitor for rising hCG levels, which may indicate malignant GTN
The nurse is admitting a client at 39 weeks gestation who is scheduled for induction of labor due to oligohydramnios. When considering the indication for induction, the nurse should anticipate the need for
amnioinfusion (ie, transvaginal infusion of fluids) to help alleviate cord compression by providing extra fluid around the umbilical cord
Placental abruption
abdominal and/or back pain, uterine contractions, uterine rigidity, and dark red vaginal bleeding.
In severe cases, emergency cesarean birth is indicated
Peripheral IV access with a 16- or 18-gauge catheter
A blood specimen should be obtained for type and crossmatch
continuous fetal monitoring
morning sickness
dry, high-carbohydrate foods (eg, toast, crackers) and low-fat proteins
clear, cold, carbonated beverages
with ginger
Eating foods high in vitamin B6 (eg, nuts, seeds, legumes)
Live vaccines are contraindicated in pregnancy
Pregnancy should be avoided for at least 4 weeks after the immunization is given.
nonimmune to rubella should receive the vaccine in the postpartum period
GTPAL
G
Gravidity
The number of times a person has been pregnant, regardless of pregnancy outcome
T
Term
The number of births at 37 weeks 0 days gestation & beyond
P
Preterm
The number of births at 20 weeks 0 days to 36 weeks 6 days gestation
A
Abortions
The number of pregnancies ending before 20 weeks 0 days gestation; these may be spontaneous (miscarriage) or induced abortions
L
Living
The number of currently living children
Preeclampsia
administering antihypertensives (eg, IV labetalol) to reduce blood pressure and IV magnesium sulfate to prevent eclamptic seizures.
prepare the client for delivery of the fetus and placenta
report increased blood pressure, severe symptoms (eg, unrelieved headaches, vision changes, vaginal bleeding), and decreased fetal movement.
Monitor fetal kick counts daily
indirect Coombs test
to screen for Rh sensitization any time hemorrhage secondary to placental abruption is suspected (eg, maternal trauma)
Preconception care
updated vaccinations
folic acid supplementation
avoidance of alcohol, smoking, and illicit substances
regular dental care.
folic acid
Inadequate intake during the first 8 weeks after conception increases the risk for neural tube defects
fortified grain products (eg, cereals, breads, pastas)
green, leafy vegetables (eg, broccoli, asparagus
daily supplement of at least 400 mcg of folic acid in addition to eating foods rich in folic acid.
cooked beans, rice, fortified cereals, and peanut butter
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