NCLEX Review Maternal Newborn Flashcards
What are priority actions with variable late decelerations? What constitutes a deceleration? Cause?
reposition mom on the side or knee to chest
discontinue oxytocin
administer O2 w/nonrebreather mask 8-10L
vaginal exam
assist with amnioinfusion if indicated
FHE slows 15/min below baseline for 15+ seconds
varies in duration, timing and relation to contraction
cord compression
short cord
prolapsed cord
nuchal cord (around neck)
What is a late decel? Causes? Priority nursing actions?
FHR slows after contraction starts and does not return until after contraction is over
placental insufficiency
maternal hypotension, placenta previa, abruptio
uterine tachysystole with oxytocin
preeclampsia
late-term deliver
gestational diabetes or DM
side-lying
increase fluid IV rate
discontinue oxytocin
O2 nonrebreather 8-10L
elevate legs
notify HCP
prepare for vag or cesarean birth
What is proper use of a diaphragm?
properly fitted
replace q2years or w/20% weight fluctuation
empty bladder before insertion
insert w/spermicidal jelly up to 6hrs before coitus
keep in place 6-24 hours post-coitus
use spermicide
wash with soap and water after each use
What are the 2 phases of the 1st stage of labor? What are nursing actions for each stage?
active
transition
active:
client/fetal monitoring
frequent repositioning
void q2h
relaxation, breathing. non-pharm measures
transition:
viod q2h
continue monitoring
rapid pant-pant-blow breathing
discourage pushing until cervix is fully dilated
prepare for birth
observe for crowning
bear down once cervix is fully dilated
What are nusing actions for fibrocytic breast disease?
Reduce salt before menses
wear supportive bra
apple heat/cold to reduce pain
discuss risks of HT
journal effectiveness of treatment plan to find patterns
reinforce does not increase risk for breast cancer
What are some dietary recommendations to maintain during pregnancy?
2nd tri: increase calories 340/day
3rd tri: increase 452/day
increase protein intake
Folic acid: 600 mcg
iron may be cupplemented. Take w/vitC
Calcium: 1000mg/day for both pregannt and nonpregnant
fluid 2-3L
limit caffeine
for nausea: frequent small meals
increase fiber for constipation
What are adverse effects of an enpidural? Nursing actions?
maternal hypotension
fetal bradycardia
fever
itching
inability to feel the urge to void
urinary retention
loss of bearing down reflex
IV bolus to offset hypotension
side-lying after insertion
monitor BP, hypotension and respiratory depression
O2 and suction are available
client safety
assess bladder, catheter
What would be a concerning finding with platelets? Concern? What is HELLP syndrome? HELLP is the risk of what pregnancy condition?
less than 100,000/mm
thrombocytopenia, abnormal bleeding and clotting, DIC
HEMOLYSIS (causes anemia and jaundice)
ELEVATED LIVER enzymes
LOW PLATELETS (bleeding and clotting issues
GH and preeclampsia with hematologic conditions
What are the expected lab values of a early newborn
Hgb: 14-24 g/dL
platelets: 150,000-300,000
Hct: 44-64%
glucose: 40-60 mg/dL
RBC: 4.8-7.1
bilirubin:
24hrs: 2-6
48hrs: 6-7
3-5days: 4-6
WBC: 9,000-30,000
Infant manifestions of hypoglycemia? What consititues hypoglycemia with a heel stick? Priority action
small or large for GA
jitteriness or twitching
weak, abnormal cry
cyanosis
irregular respiratory effort
eye rolling
lethargy
seizure
less than 40 mg/dL
breastfeed or donor breast milk to elevate BG levels, offer oral feedings
What are nursing actions for prolapsed cords?
call for assistance, notify HCP
do not leave client
with gloved finger elevate fetal presentation off cord
reposition client in knee chest, trendelenburg or side-lying
warm, sterile saline soaked towel on presenting cord
FHR monitoring
Administer O2
IV bolus
emergency cesarean likely
