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Nursing school level 2 > MTN child test 2 > Flashcards

MTN child test 2 Flashcards

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1
Q

pt has history of HTN, today her BP is 156/102, starts in her eyes, and epigastric pain. what do you want to do first?

A

obtain clean catch urine sample

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2
Q

RhoGAM is given when

A

at 28 weeks and the second is given postpartum

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3
Q

first stage of labor

A

begins with uterine contractions and ends with complete effacement and cervical dilation

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4
Q

phases of first stage of labor

A

latent phase, active phase, and transition phase

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5
Q

latent phase of first stage of labor

A

0-3 cm will be walking around, usually still at home, drinking a lot of water.

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6
Q

active phase of first stage of labor

A

rapid dilation of the cervix. 4-7 cm come to hospital when contractions are 5 minutes apart

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7
Q

transition phase of first stage of labor

A

increased rate of decent of the presenting part. 8 - 10 cm super painful. can’t get an epidural anymore. contractions usually 1-2 minutes apart

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8
Q

lab tests during first stage of labor

A

fern test, CBC, urinalysis, drug screen if no prenatal history, blood type and screen

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9
Q

fern test

A

vaginal swab and look at it under microscope. if there is estrogen it will look like a fern and tells us that the membrane has ruptured

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10
Q

why do we get a CBC

A

H&H baseline

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11
Q

Leopold maneuver

A

feeling where the baby is by pressing on the moms belly

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12
Q

check FHR and UC how often

A

for at least 15 minutes every hour

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13
Q

what should a nurse be doing during the first stage of labor

A

encourage position changes, place wedge under hip to prevent SVC, non pharmacological and pharmacological management, education, and support

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14
Q

SVC

A

superior vena cava syndrome

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15
Q

second stage of labor

A

begins when cervical dilation complete until birth of the baby. women may have burst of energy

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16
Q

latent phase of second stage of labor

A

fetus continues to descend passively through the birth canal and rotates to an anterior position

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17
Q

active phase of second stage of labor

A

strong urge to push as baby pushes on stretch receptors

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18
Q

nursing care during second stage

A

support and monitoring, instruct women to push during contraction, assess fetal response to pushing,

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19
Q

en caul birth

A

infant born inside the amniotic sac

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20
Q

assessment during second stage

A

assess that the peritoneum is flattened and vagina and rectum is bulged. contractions occurring every 2 minutes lasting 60-90 sec

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21
Q

episiotomy

A

surgical cut made at the opening of the vagina to aid in the prevention of tissue rupture

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22
Q

1st degree lacerations

A

perineal skin and vaginal mucosa membrane

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23
Q

2nd degree lacerations

A

skin, mucosa, and fascia of the perineum

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24
Q

3rd degree laceration

A

skin, mucosa, fascia, and muscle of the peritoneal body and extends to rectal sphincter

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25
Q

4th degree laceration

A

extends into the rectum and exposes the lumen of the rectum

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26
Q

third stage of labor

A

separation and expulsion of the placenta and membranes usually occurs 5-30 min after birth

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27
Q

signs to look for during third stage of labor

A

upward rising of the uterus with contractions, sudden gush of blood, lengthening of the umbilical cord

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28
Q

normal blood loss during birth

A

500 mL

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29
Q

babies blood when they are born

A

they are born with 2/3 their blood and the rest comes through the umbilical cord after birth

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30
Q

delayed cord clamping

A

allows for healthy blood volume and full count RBC, stem cells, and immune cells

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31
Q

risk of delayed cord clamping

A

increase risk of jaundice due to higher RBC

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32
Q

nursing care during 3rd stage

A

assess VS every 15 minutes, skin to skin after birth, breast feed within an hour, pain medication

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33
Q

once placenta is delivered what is ordered

A

oxytocin (Pitocin) is ordered for all women to reduce the risk of postpartum hemorrhage

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34
Q

fourth stage of labor

A

recovery and homeostasis beginning to be re-established

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35
Q

nursing goals during forth stage of labor

A

facilitating family bonding, fundal massage, pain meds, ice packs, monitor bladder for distention

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36
Q

first breastfeeding called

A

colostrum - first immunization. contains large numbers of antibodies

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37
Q

where should the uterus be after birth

A

one finger below umbilicus

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38
Q

how do you do a fundal massage and why

A

hold base of uterus and start massaging the top - do it to keep uterus firm so there is no postpartum hemorrhage

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39
Q

FHR should be

A

110-160 bpm

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40
Q

how do we monitor FHR

A

TOCO transducers and ultrasound transducer

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41
Q

best place to find the fetal heart beat

A

in on baby’s back

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42
Q

tocodynamometer (TOCO)

A

uterine external monitoring - measures the frequency and duration of contraction but will not measure the intensity

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43
Q

intrauterine catheter (IUPC)

A

uterine internal monitoring- measures contractions

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44
Q

ultrasound transducer

A

external fetal monitor that is placed over fetal heart

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45
Q

fetal spiral electrode (FSE)

A

internal monitoring of fetal heart rate - spiral catheter placed on presenting part of fetus

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46
Q

early decelerations indicate

A

head compression and nurse doesn’t need to do anything

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47
Q

what happens during late deceleration

A

deceleration starts after contraction and HR doesn’t recover within 30 sec after contraction

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48
Q

late deceleration indicates

A

utter-placental insufficiency - not enough oxygen

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49
Q

late deceleration care

A

don’t need to call doctor right away. turn pt, hydrate and oxygenate. if that doesn’t work turn down Pitocin. if that doesn’t work call doctor

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50
Q

variable decelerations indicate

A

cord is being squeezed/compressed

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51
Q

variable decelerations can happen with or without

A

contractions

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52
Q

what to do during variable decelerations

A

turn pt, if that doesn’t work then amnioinfusion which might cause buoyancy so the cord can float, and if that doesn’t work call the doctor

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53
Q

prolonged decelerations

A

HR drops more than 15 beats and lasts 2-10 minutes

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54
Q

prolonged decelerations indicates

A

fetal distress - baby telling us its not okay

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55
Q

what do you do for prolonged decelerations

A

emergency c section

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56
Q

maternal factors affecting labor

A

uterus stretches, increased estrogen stimulates uterus, progesterone decreases, and oxytocin is released which stimulates UC

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57
Q

fetal factors affecting labor

A

placenta ages and deteriorates triggering contractions, prostaglandins produced by fetus, and fetal cortisol increases and acts on placenta to decrease progesterone

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58
Q

5 Ps

A

powers (contractions), passage (pelvis), passenger (baby), position, psyche

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59
Q

we don’t want contractions to last longer than

A

60-90 seconds

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60
Q

primary powers

A

involuntary - contractions, effacement, dilation, and Ferguson reflux

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61
Q

contractions

A

move downward over the uterus in waves

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62
Q

effacement

A

shortening and thinning of the cervix - 0%-100%

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63
Q

primips

A

first births

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64
Q

multips

A

multiple births

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65
Q

effacement with primips

A

usually happens before dilation

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66
Q

effacement with multips

A

dilate and efface happen together

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67
Q

dilation

A

widening of the cervical opening

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68
Q

Ferguson reflux

A

presenting part of the fetus reaches the stretch receptors and cause release of oxytocin that triggers the maternal urge to bear down

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69
Q

secondary powers

A

voluntary - bearing down efforts aid in getting the fetus out (pushing)

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70
Q

frequency of contraction

A

start of one contraction to the Strat of the next contraction

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71
Q

duration of contraction

A

start of contraction to the end of that same contraction

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72
Q

birth canal is composed of

A

bony pelvis, cervix, pelvic floor muscle, vagina, and introitus

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73
Q

introitus

A

external opening to the vagina

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74
Q

80% of birth canals a

A

gynecoid

75
Q

baby’s fetal station is at 0 when

A

it reaches the ischial spine

76
Q

negative fetal station =

A

higher than the pelvic bone and positive is below

77
Q

+3 fetal station

A

crowning

78
Q

movement of the fetus through the birthing canal is dependent on

A

size of fetal head, fetal presentation, fetal lie, fetal attitude, and fetal position

79
Q

what makes the fetal head flexible

A

sutures and fontanels make skull flexible to accommodate the brain and head during labor

80
Q

fetal lie

A

relation of the spine of the fetus to the spine of the mother

81
Q

fetal lie can be

A

longitudinal, vertical, transverse, or horizontal

82
Q

fetal attitude

A

relation of the fetal body parts on one another

83
Q

fetal position

A

reference of the presenting part to the four quadrants of the mother’s pelvis

84
Q

frank breech presentation

A

feet crossed and up with but presenting

85
Q

complete breech presentation

A

legs crossed and down with feet and butt presenting

86
Q

footling breech presentation

A

feet presenting

87
Q

ROP/LOP cephalic presentation

A

head down and back posterior

88
Q

ROA/LOA cephalic presentation

A

head down and back anterior

89
Q

longitudinal fetal lie

A

baby’s spine is parallel with mom’s spine

90
Q

transverse lie

A

baby’s spine is at a 90 degree angle to moms spine

91
Q

fetal attitude can be

A

vertex, military, brow, or face

92
Q

vertex fetal lie

A

baby cradled up - chin down

93
Q

military fetal lie

A

chin at 90 degree to body

94
Q

brow fetal lie

A

chin up a bit and is the largest circumference of all fetal lies

95
Q

face fetal lie

A

facial features come out first chin raised

96
Q

how many fetal positions are there

A

there are 6 positions

97
Q

first letter in fetal position

A

is the location of the mother - either left or right

98
Q

second letter of fetal position

A

fetal presenting part -

  • O- occiput
  • S- Sacrum
  • M - Mentum
  • A - Shoulder
99
Q

third letter in fetal position

A

relation to mothers pelvis -

  • A=anterior
  • P=posterior
  • T=transverse
100
Q

what position do we want

A

OA

101
Q

sunny side up is what position

A

OP

102
Q

lightening

A

the descent of the presenting part of the fetus into the pelvis

103
Q

lightening in primip vs multips

A

primip- can happen 2-4 weeks before labor begins

multips - can happen in labor

104
Q

Braxton-hicks

A

irregular contractions that don’t cause cervical change

105
Q

bloody show

A

mucous plug will sometimes fall out as cervix ripens (softens) can cause old brown blood and mucus with red blood to mix. can cause 2-4 wks before labor begins

106
Q

spontaneous rupture of membranes

A

can happen before onset of labor or in labor. if it happens before labor doctor has 24 hrs to deliver

107
Q

onset of labor is from

A

an unknown cause

108
Q

can get an epidural up until

A

7 cm

109
Q

cardinal movement of labor

A

engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion

110
Q

engagement

A

when the greatest diameter of the head passes through the pelvic inlet

111
Q

descent

A

movement of the fetus through the birth canal during the 1st and 2nd stage of labor

112
Q

flexion

A

when the chin of the fetus moves toward the fetal chest and happens when the head meets resistance from maternal tissues

113
Q

internal rotation

A

happens in second stage of labor rotation of the fetal head aligns with the long axis of both its own body and maternal pelvis

114
Q

extension

A

the head extends with the resistance of the maternal pelvic floor causing the head to maneuver its way under the pubic bone

115
Q

external rotation

A

sagittal suture moves to a transverse diameter, the shoulders align in the anterior/posterior position to maintain alignment with fetal trunk

116
Q

expulsion

A

shoulders and the remainder of the body deliver

117
Q

gate control theory

A

pleasurable sensations reach brain faster than pain does

118
Q

why should pain management be implemented before pain becomes too severe

A

if pain becomes too severe catecholamines increase and can prolong labor

119
Q

do analgesia opioids cross the placenta?

A

yes and can have effect on the fetus

120
Q

what can opioids do to labor

A

it can prolong it

121
Q

what do you need to check before giving an epidural

A

platelet count

122
Q

what should you give before giving an epidural

A

fluids because epidurals cause hypotension

123
Q

epidurals are contraindicated in

A

hypotension, infection, thrombocytopenia, and cardiac condition

124
Q

spinal anesthesia (block)

A

anesthetic injected into the 3rd, 4th, and 5th interspace into the subarachnoid space

125
Q

side effects of spinal block

A

hypotension, urinary retention, headache, and ineffective breathing patterns

126
Q

nerve block analgesia

A

injecting lidocaine into the skin - local

127
Q

nitrous oxide

A

self administered and helps with pain

128
Q

general anesthesia is used for

A

emergency c section

129
Q

indication for induction of labor

A

pregnancy after 39 weeks, gestational hypertension, preeclampsia, fetal demise, chorioamnionitis, premature rupture on membrane

130
Q

fetal demis

A

baby didn’t make it

131
Q

chorioamnionitis

A

inflammation of fetal membrane due to infection of the amniotic fluid

132
Q

if water breaks baby needs to be out

A

within 24 hours

133
Q

stripping the membranes

A

use the finger to gently separate the sac from the side of the uterus

134
Q

artificial rupture of membranes AROM

A

rupturing the membrane with a tool called an amnihook

135
Q

cervical ripening agents

A

cytotec - makes the cervix softer, causing it to dilate

136
Q

after 4 hours of cytotec you may start

A

Pitocin if labor has not started

137
Q

pitocin is a

A

high risk medication and needs a double RN check

138
Q

Pitocin causes

A

uterine contractions

139
Q

low dose oxytocin administration

A

begin at 2 mu/min and increase by 2 mu/min every 30 minutes until 5 contractions in 10 minutes

140
Q

high dose Pitocin

A

begin at 4 mu/min and increase by 4 mu/min until 5 contractions in 10 minutes

141
Q

max dose of pitocin

A

20 mu/min

142
Q

hypertonic uterine dysfunction

A

uncoordinated uterine activity - contractions are frequent but ineffective in getting cervix to dilate

143
Q

nursing actions in hypertonic uterine dysfunction

A

rest, hydrate, and sedation

144
Q

hypotonic uterine dysfunction

A

pressure of the contraction is insufficient to promote cervical dilation - will have fewer than 2-3 contractions in 10 minutes

145
Q

nursing actions in hypotonic uterine dysfunction

A

walking, artificial rupture of membrane, nipple stimulation, low dose Pitocin

146
Q

precipitous labor

A

labor that lasts less than 3 hours from onset of labor to birth

147
Q

in a precipitous labor the neonate is at risk for

A

hypoxia and CNS damage because rapid birth can cause other not to oxygenate

148
Q

risk factor for precipitous labor

A

multiparous and history of precipitous birth

149
Q

nursing actions during precipitous labor

A

frequent cervical checks, careful inspection of maternal tissue and placenta, and monitoring of post part hemorrhage

150
Q

shoulder dystocia

A

difficulty encountered during delivery in which shoulder cannot pass under the maternal pubic arch

151
Q

most common birth injury

A

broken clavicle

152
Q

prolapsed cord

A

cord lies below presenting part of fetus

153
Q

treatment for prolapsed cord

A

goal is to relieve pressure from the umbilical cord until delivery of the infant - administer O2, tocolytics, and possible emergency c-section

154
Q

meconium stained amniotic fluid

A

fetus has passed first stool before birth

155
Q

what does meconium stained fluid usually show for

A

fetal distress or umbilical compression

156
Q

what does meconium stained fluid put fetus at risk for

A

meconium aspiration syndrome

157
Q

vacuum assisted delivery should be limited to

A

3 pulls in 15 min

158
Q

indications for vacuum assisted delivery

A

fetal distress and maternal exhaustion

159
Q

risk to the fetus using vacuum assisted delivery

A

cephalohematoma, intracranial hemorrhage, bruising and laceration

160
Q

risk to mother using vacuum assisted delivery

A

perineal and vaginal trauma and bladder trauma

161
Q

nursing actions if using the vacuum assisted delivery

A

have mom push well with the vacuum assist

162
Q

baby needs to be at least a _______ to use the vacuum assist

A

+1 - +2

163
Q

risk when using forceps

A

can cause damage to nerves along baby’s face

164
Q

preterm labor

A

uterine contraction occurring between 20-37 weeks but can still make it to full term

165
Q

preterm birth

A

birth that occur before 37 weeks

166
Q

inbetweenies

A

babies born between 34- 37 weeks

167
Q

care for preterm labor

A

administer tocolytic and antenatal coticsoteriods

168
Q

tocolytics

A

suppress uterine activity and given between 20-34 weeks

169
Q

corticosteroids

A

promote fetal lung maturity

170
Q

examples of corticosteroids

A

betamethasone 12 mg IM every 24 hr x 4 doses and dexamethasone 6 mg IM every 12 hours x 4 doses

171
Q

maternal findings with chorioamniontitis

A

maternal fever, fetal tachycardia, uterine tenderness, and foul odor or fluid

172
Q

disseminated intravascular coagulation (DIC)

A

body is breaking down blood clots faster than it can form a clot. body depletes itself from clotting factors leading to bleeding

173
Q

treatment for DIC

A

c-section and intravenous heparin

174
Q

types of c-sections

A

elective (scheduled), unplanned (emergent)- have 30 minutes to get baby out, and emergency cesarean - have 3-6 minutes to get baby out

175
Q

c-section incisions

A

lower segment transverse or vertical. need to cut both the uterus and abdomen

176
Q

vertical incision more associated with

A

higher complications but necessary with preterm breech, anterior placenta previa, and hydrocephalus

177
Q

complications of c-section

A

like any major surgery: bleeding, clotting, infection, UTI, dehiscence of wound

178
Q

preoperative care for C-section birth

A 
CBC and blood type screening 
NPO
VS and FHR
IV with LR
consent signed
hair shaven 
support person in bunny suit
sequential device placed
179
Q

intraoperative care with C-section

A

position wedge, foley, support person at head of bed, documentation, and assist with surgical counts

180
Q

immediate post op care for C-section

A

transfer to PACU, VS every 15 min, oxytocin, pain med, nausea med, and assessment

181
Q

what is important to monitor pt for after c-section

A

may be drowsy and at risk for falling asleep while holding baby

182
Q

is vaginal birth after c-section okay

A

yes there will be a trial if the women has gone through detailed medical history

183
Q

in order to have a vaginal birth after c-section the inaction has to have been

A

a low transverse and reason for c-section can not have been from a maternal factor

Nursing school level 2 (15 decks)

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