OB Exam 2

Question 1

Appropriate timing for specific prenatal testing

First trimester ultrasound

Answer 1

confirms pregnancy and viability, determines gestational age, rules out ectopic pregnancy, detect multiple gestations, visualization if doing chorionic villi sampling, detect maternal abnormalities such at cysts, fibroids, etc.

Question 2

Appropriate timing for specific prenatal testing

Second trimester ultrasound

Answer 2

establish or confirm dates, detect polyhydramnios and oligohydramnios, detect congenital anomalies, assess placenta function, visualization during amniocentesis

Question 3

Appropriate timing for specific prenatal testing

Third trimester ultrasound

Answer 3

Detect macrosomia, detect congenital anomalies, detect IUGR, determine fetal position, detect placenta previa or abruption, visualization during amniocentesis or external version, amniotic fluid volume assessment, doppler flow studies

Question 4

Nuchal translucency

Answer 4

between 10-14 weeks via ultrasound to check for abnormality that could indicate chromosomal disorder. Greater than 3 mm is considered abnormal

Question 5

Fetal heart activity

Answer 5

by about 6 weeks of gestation via transvaginal ultrasound

Question 6

Placental position and appearance-

Answer 6

18-23 weeks of gestation. Most cases of placenta previa diagnosed during second trimester resolve by term

Question 7

Amniocentesis

Answer 7

possible after 14 weeks of pregnancy

Question 8

Chorionic villi sampling

Answer 8

first trimester- popular technique for genetic studies – between 10-13 weeks

Question 9

Percutaneous umbilical cord sampling

Answer 9

second and third trimesters- used for fetal blood sampling and transfusion

Question 10

Coombs test

Answer 10

screening tool for rh compatibility.

Question 11

Biophysical profile scoring-

Answer 11

Fetal breathing movements:

• score 2- at least one episode of breathing movements of at least 20 seconds
• score 0- absent fetal breathing movements or less than 30 seconds

Fetal movements:

• score 2- at least three trunk/ limb movements in 30 minutes
• score 0- fewer than 3 episodes of movements in 30 minutes

fetal tone:

• score 2- at least one episode of active extension with return to flexion of fetal limb or trunk
• score 0- absence of movement or slow flexion and extension

Question 12

Biophysical profile scoring-

Answer 12

amniotic fluid index:

• score 2- deepest vertical pocket greater than 2 cm
• score 0- deepest vertical pocket less than 2 cm

nonstress test:

• score 2- reactive
• score 0- nonreactive

Question 13

MSAFP/triple marker

Answer 13

analysis of results- performed at 16-18 weeks of gestation, measures the level of three maternal serum makers; MSAFP, hCG and unconjugated estriol.

Question 14

**MSAFP alone can detect neural tube defects. Clients who have abnormal findings should be referred to further screening.

Answer 14

a. ) If a fetus has trisomy 21; the MSAFP and unconjugated levels are low and the hCG will be elevated.
b. ) Low values in all markers is associated with trisomy 18 in the fetus

Question 15

Amniocentesis:

Answer 15

teaching/lung maturity- the aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client’s uterus and amniotic sav under direct ultrasound guidance. **Performed after 14 weeks of gestation.

Question 16

Amniocentesis Teaching:

Answer 16

> explain procedure to patient and obtain informed consent, assist client to supine position and place a wedge under her right hip to display the uterus off the vena cava

> place a drape over the client exposing only her abdomen

> prepare for ultrasound to locate placenta

> cleanse client’s abdomen with an antiseptic solution prior to administration of a local anesthetic

> tell the patient that she will feel slight pressure as the needle is inserted. She should continue breathing because holding her breath will lower her diaphragm

Question 17

Amniocentesis Teaching 2:

Answer 17

monitor vital signs , FHR and uterine contractions throughout and 30 minutes following the procedure. Client should rest for 30 minutes. Tell client to report any fever, chills, leakage of fluid, or bleeding, decreased fetal movement, vaginal bleeding or contractions. Encourage client to drink plenty of liquids and rest for 24 hours post procedure

Question 18

Lung maturity

Answer 18

Amniotic fluid is tested to determine whether the fetal lungs are mature enough to adapt to extrauterine life. L/S ratio- 2:1 indicates lung maturity. Absence of PG is associated with respiratory distress.

Question 19

Diab during preg.

Answer 19

ideal blood sugar during pregnancy should range between 70-110

Question 20

increased risks to fetus-

Answer 20

> spontaneous abortion related to poor glycemic control

> infections related to increased glucose in urine

> decreased resistance because of altered carb metabolism

> hydramnios which can cause overdistention of the uterus

> premature ROM- preterm labor or hemorrhage

> ketoacidosis- untreated hyperglycemia

> hypo/hyperglycemia

Question 21

Hypoglycemia

Answer 21

nervous, headache, weakness, irritability, hunger, blurred vision, tingling of mouth or extremities.

Question 22

Hyperglycemia

Answer 22

polydipsia, polyphagia, polyuria, nausea, abdominal pain, flushed dry skin, fruity breath

Question 23

Lab tests

Answer 23

routine UA with glycosuria

Question 24

Glucola screening/1 hour glucose test

Answer 24

• 50 g oral glucose load followed by blood sugar check 1 hour later. Performed between 24-28 weeks gestation. Positive if BS above 130/140- 3 hour testing is done then

Question 25

Diab interventions

Answer 25

**Women who have gestation diabetes are generally treated with diet and exercise alone. If glucose levels are persistently high, then insulin is begun. Glyburide and metformin may be given for oral hypoglycemics. **

Question 26

Cardiac Decompensation Assessment

Answer 26

• Increased fatigue or difficulty breathing with usual activities
• Feeling of being smothered
• Frequent cough
• Palpitations
• Generalized edema (weight gain)
• Irregular weak rapid pulse
• Crackles at bases of lungs
• Orthopnea
• Rapid respirations
• Most, frequent cough
• Cyanosis of lips and nail beds

Question 27

Preeclampsia

Answer 27

hypertension and proteinuria develop after 20 weeks gestation in a woman who never previously had either condition.

Question 28

S&S of Preeclampsia

Answer 28

• Blood pressure greater than 160/110 mm HG
• Proteinuria greater than 3+
• Elevated serum creatinine greater than 1.1
• Cerebral or visual disturbances (headache and blurred vision)
• Hyperreflexia with possible ankle clonus
• Pulmonary or cardiac involvement
• Peripheral edema that is extensive
• Thrombocytopenia
• Right upper quadrant pain

**daily dose of aspirin to be given in first trimester if patient has a history of preeclampsia

Question 29

Hypertension related disorders teaching

Answer 29

> Take blood pressure as directed, always sit to take it and use your right arm each time for consistent readings

> Report any increase to health care provider

> Dipstick test you clean catch urine to test for protein

> Encourage lateral position

> Perform NST and daily kick counts

> Instruct the client to monitor I&O.

Question 30

HELLP syndrome

Answer 30

a variant of gestational hypertension in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction. HELLP syndrome is diagnosed by lab tests, not clinically. Symptoms tend to worsen at night and improve in the day time. General feeling of malaise, influenza like symptoms.

Question 31

HELLP syndrome acrym

Answer 31

• H: hemolysis; resulting in anemia and jaundice
• EL; elevated liver enzymes- elevated ALT or AST, epigastric pain and n/v
• LP; low platelet- less than 100,000 mm. Resulting in thrombocytopenia, abnormal bleeding and clotting time. Bleeding gums, petechiae, and possibly disseminated intravascular coagulation

** important to remember than many women with HELLP syndrome may not have signs or symptoms of preeclampsia with severe features. Most women will have hypertension but proteinuria may be absent, as a result women are misdiagnosed.

Question 32

Discharge instructions for HELP syndrom

Answer 32

> Maintain bed rest and encourage side lying position

> Promote diversional activities (watch TV, visit with family)

> Avoid foods high in NA and avoid alcohol, caffeine and tobacco

> Drink six to eight 8 oz glasses of water per day

> Maintain a dark quiet environment to avoid stimuli that can precipitate a seizure

> Administer antihypertensives as prescribed

Question 33

Eclampsia

Answer 33

severe preeclampsia manifestations with the onset of seizure activity or coma.

• Preceded by a headache, severe epigastric pain, hyperreflexia, and hemoconcentrations (warning signs for convulsions)

Question 34

Anti-convulsant medication: Magnesium sulfate:

Answer 34

medication of choice for prophylaxis or treatment to depress the CNS and prevent seizures in the client who has eclampsia and severe preeclampsia

Use an infusion control device to maintain regular flow rate

• Inform client that she can initially feel flushed, hot, sedated
• Monitor BP, pulse, respiratory rate, deep tendon reflexes, LOC, urinary output, presence of headache, visual disturbances, epigastric pain, uterine contractions and FHR
• Place client on fluid restriction of 100/125 ml per hour
• Monitor for toxicity: absence of deep tendon reflexes, low urine output, respirations less than 12, decreased LOC, cardiac dysrhythmias

Question 35

Anti-convulsant medication: Magnesium sulfate: suspected

Answer 35

STOP THE INFUSION

Administer calcium gluconate or calcium chloride

Prepare for actions to prevent respiratory or cardiac arrest

Question 36

Hyperemesis: Lab findings

Answer 36

Urinalysis- for ketones and acetones (breakdown of protein and fat) most important initial test- also elevated urine specific gravity

Chemistry profile revealing electrolyte imbalances r/t hyperemesis

• Na, K and Cl reduced from low intake
• Metabolic acidosis because of starvation
• Metabolic alkalosis due to excessive vomiting
• Elevated liver enzymes
• Bilirubin level
• HCT will be elevated due to inability to retain fluid

Question 37

Ectopic Pregnancy S&S

Answer 37

o unilateral stabbing pain and tenderness in the lower abdominal quadrant

o delayed 1-2 weeks lighter than usual menses

o scant, dark red or brown vaginal spotting

o referred shoulder pain due to blood in the peritoneal cavity irritating the diaphragm

o report of indications of shock such as faintness or dizziness

o hemorrhage is the major concern

Question 38

Ectopic Pregnancy Assessment

Answer 38

o transvaginal ultrasound shows an empty uterus

o levels of progesterone and elevated hCG rule out ectopic pregnancy

Question 39

Ectopic Pregnancy Treatment

Answer 39

o replace fluids, and maintain electrolyte balance

o provide client education and psychological support

o prepare patient for surgery and postoperative nursing care

o provide referral for client and partner for pregnancy loss support group

o octain serum hCG and progesterone levels, CBC, type and rH.

Question 40

Spontaneous abortion S&S

Answer 40

o backache and abdominal tenderness

o rupture of the membranes

o dilation of the cervix

o fever

o hemorrhage: hypotension and tachycardia

Question 41

Spontaneous abortion Teaching

Answer 41

o notify the provider of heavy, bright red vaginal bleeding, elevated temperature or foul smelling discharge

o a small amount of discharge is normal for 1 to 2 weeks

o take prescribed antibiotics

o refrain from tub baths, sexual intercourse or placing anything in the vagina for 2 weeks

o avoid becoming pregnant for 2 months

Question 42

Hydatidiform mole S&S

Answer 42

o excessive vomiting due to elevated hcG levels

o rapid uterine growth more than expected

o bleeding is often dark brown resembling prune juice or scant and bright red

o anemia from blood loss

o extremely high hCG level

Question 43

Hydatidiform mole Teachings

Answer 43

o serum hCG analysis following molar pregnancy to be done weekly for 3 weeks, then monthly for 6-12 months

o provide education and emotional support

o instruct the client to use reliable contraception

o increased risk for choriocarcinoma so follow up appointments are important

Question 44

Placenta previ

Answer 44

when the placenta abnormally implants into the lower segment of the uterus near or over the cervix

Question 45

Placenta previ S&S

Answer 45

o painless, bright red vaginal bleeding during second or third trimester

o uterus soft, relaxed and nontender with normal tone

o fundal height greater than usually expected for gestational age

o fetus in a breech, oblique or transverse position

o reassuring FHR

-vital signs within normal limits

o decreasing urinary output

Question 46

Placenta previ Interv.

Answer 46

o assess for bleeding, leakage or contactions

o assess fundal height

o perform leopold maneuvers (fetal position and presentation)

o Refrain from performing vaginal exams

o Administer IV fluids, blood products and medications to promote fetal lung maturation (betamethasone)- c section delivery

o Have oxygen equipment available in case of fetal distress

Question 47

Abruptio placent

Answer 47

the premature separation of the placenta from the uterus occurring after 20 weeks of gestation

Question 48

Abruptio placent S&S

Answer 48

• Sudden onset of intense localized uterine pain with dark red bleeding
• Area of uterine tenderness can be localized or diffuse over uterus
• Contractions with hypertonicity
• Fetal distress
• Clinical findings of hypovolemic shock

Question 49

Abruptio placent Interv.

Answer 49

• Ultrasound is done to check fetal wellbeing and biophysical profile
• Palpate the uterus for tenderness and tone
• Perform monitor of fundal height
• Assess FHR pattern
• IMMEDIATE BIRTH IS THE MANAGEMENT!!!!
• Administer IV fluids, blood products and medications
• Administer oxygen 8-10 L via face mask
• Monitor maternal vital signs, observing for declining hemodynamic status
• Continuous fetal monitoring
• Assess urinary output and monitor fluid balance

Question 50

First stage labor

Latent phase 0-3 cm, active phase 4- 7 cm and transition 8-10 cm. (longest stage and can vary the most in length)

Answer 50

*some dilation and effacement, talkative and eager during latent phase, active phase has some fetal descent, feelings of helplessness and anxiety increases as contractions get stronger. Transition patient becomes tired, restless and irritable, can have n/v, urge to push.

Nursing responsibilities-

• perform leopold maneuvers
• perform vaginal exam
• check for ROM (if membranes rupture FHR is most important assessment)
• perform bladder palpitation on a regular basis to prevent bladder distention
• encourage client to void frequently
• assess temp every 4 hours or every 1-2 if ROM.
• Encourage upright positions but frequent body changes.

Question 51

2nd stage labor -starting after full dilation and ends with the birth

*pushing results in birth of fetus

Answer 51

*pushing results in birth of fetus

Nursing Responsibilities-

• Vitals every 5- 20 minutes
• Assist in partner involvement with pushing
• Promote rest between contractions
• Provide comfort measures such as cold compresses
• Cleanse perineum as needed if fecal material is expelled
• Prepare for care of neonate (check oxygen, preheat warmer, lay out newborn stethoscope and bulb syringe, have CPR equipment ready, check suction)

Question 52

3rd stage labor - following delivery of the neonate to delivery of the placenta

*placental separation and expulsion

Answer 52

*placental separation and expulsion

Nursing Responsibilities-

• instruct client to push once findings of placental separation are present
• administer oxytocic for expulsion of the placenta to occur
• administer analgesics
• gently cleanse the perineal area with warm water and apply an ice pack
• promote baby friend activities between the family and newborn (skin to skin)

Question 53

4th stage labor - after delivery of the placenta to maternal stabilization of vital signs – at least first 2 hours after birth

Answer 53

*lochia scant to moderate rubia, achievement of vital signs homeostasis

Nursing Responsibilities-

• Assess B/P and pulse every 15 min for first 2 hours and temperature every 4 hours for the first 8 hours
• Assess fundus and lochia every 15 minutes for the first hour
• Massage the fundus or administer oxytocics to maintain uterine tone
• Encourage voiding to prevent bladder distention
• Promote an opportunity for parental newborn bonding

Question 54

mother positioning

Answer 54

Positioning- Important to change positions frequently to relieve fatigue, increase comfort and improve circulation.

Nursing Responsibilities- Avoid vaginal examinations if bleeding is present, cervical dilation is the single most important indicator of the progress of labor

Question 55

Significance of fetal presentation, posterior positioning

Answer 55

Presentation- the part of the fetus that enters the pelvis first and leads through the birth canal- cephalic presentation is most common. Complete breech babies need a c section. Posterior positioning can cause severe pain in the women’s sacrum. Mother may need an episiotomy

Question 56

Risk for use of opioids during labor

Answer 56

• Crosses the placental barrier, can cause respiratory depression in newborns if too close to birth of baby
• Reduces gastric emptying; increases the risk for nausea and emesis
• Increases risk for aspiration of food or fluids
• Bladder and bowel elimination can be inhibited
• Sedation
• Altered mental status
• Tachycardia and hypotension
• Allergic reaction

Question 57

Risk for use of general anesthesia

Answer 57

• Respiratory depression- maintain an open airway and cardiopulmonary function
• Administer metoclopramide to increase gastric emptying as prescribed- chance of aspiration of stomach contents
• Risk for clots
• Decrease stomach acid by giving ranitidine
• Chance of hemorrhage- assess client for decreased uterine tone

Question 58

Risks, interventions, contraindications for regional analgesia/anesthesia

Answer 58

Adverse effects- maternal hypotension, fetal bradycardia, inability to feel the urge to void and loss of bearing down reflex. Headache after a spinal

Question 59

regional analgesia/anesthesia Interventions

Answer 59

• Administer a bolus of IV fluids to help offset maternal hypotension (have ephedrine available)
• Do not allow client to ambulate unassisted
• Help position and steady the client into a sitting or side lying position with her back curved
• Coach client in pushing efforts
• Monitor vitals
• Have oxygen and suction available
• Monitor for the return of sensation and motor control in the client’s legs after delivery but prior to standing.
• Assess bladder for distention at frequent intervals and catharize if necessary

Question 60

Interventions for back labor

Answer 60

counter pressure against the lower back

Question 61

EFM

Answer 61

V:
E:
A:
L:

C:
H:
O:
P:

Question 62

Accelerations

Answer 62

visibly apparent, abrupt increase in FHR above the baseline rate. May occur in association with fetal movement or spontaneously. Compression of umbilical vein can be a cause but usually are okay. No interventions required.

Question 63

Decelerations

Answer 63

1. Early decels- gradual decrease in FHR, considered a normal and benign finding. No representation of fetal oxygenation. They are responses to changes in intracranial pressure and cerebral blood flow caused by fetal head compression. No interventions necessary.
2. Late decels- FHR decrease begins after the contraction has started and the lowest point of the deceleration occurs after the peak of the contraction. Cause is a disruption of oxygen transfer from environment to fetus; maternal hypotension, epidural, placental previa or abruptio, hypertensive disorders, postterm gestation, DM, intraamniotic infection.

Question 64

Late decel interv.

Answer 64

• discontinue oxytocin
• assist women to side lying position
• administer oxygen at 10 L by nonrebreathing mask
• correct maternal hypotension by elevating legs
• increase rate of maintenance IV solution
• palpate uterus
• notify physician
• consider internal monitoring, assist with birth if cannot be corrected

Question 65

variable decels

Answer 65

caused bay umbilical cord compression; short cord, knot in cord, prolapsed cord, cord around fetus or neck

• same interventions plus….
• Assist with vagina or speculum exam to assess for cord prolapse
• Assist with amnioinfusion if ordered
• Assist with birth

Question 66

True labor

Answer 66

• contractions occur regularly, become stronger, last longer and occur closer together
• become more intense with walking
• are usually felt in the lower back
• continue despite use of comfort measures
• cervix changes
• fetus becomes engaged

Question 67

False labor

Answer 67

• occurs irregularly or only regularly temporarily
• often stops with position changes
• can be felt in the back or above umbilicus
• can often be stopped through use of comfort measures
• no significant change in cervix
• baby is not present in pelvis

Question 68

Leopolds maneuver

Answer 68

consists of performing external palpations of the maternal uterus through the abdominal wall to determine number of fetuses, presenting part and fetal lie, degree of descent, location of the fetus’s back

1. perform hand hygiene
2. ask women to empty bladder
3. position women supine with one pillow under her head and her knees slightly flexed
4. have a pillow under one of her hips to displace uterus off of major blood vessels
5. using palmar surface of one hand, locate and palpate
6. auscultate FHR post maneuvers

Question 69

Coaching with pushing

Answer 69

to ensure the slow birth of the fetal head, the woman is encouraged to control the urge to bear down by coaching her to take panting breaths or exhale slowly through pursed lips as the baby’s head crowns. At this point the woman needs simple, clear directions from one person. Nurse may have to rouse the woman to get her to cooperate in the bearing down process.

Question 70

Cervical ripening agents: mechanical/chemical:

Answer 70

• administration of a low dose infusion of oxytocin is used for cervical priming
• a balloon catheter is inserted into the intracervical canal to dilate the cervix
• membrane stripping and an amniotomy may be performed
• chemical agents: misoprostol or dinoprostone

Question 71

Csection: priority nursing action in emergency; risks and complications:

Answer 71

• continue to monitor FHR, VS and urinary output
• help support the client because the psychosocial outcomes of unplanned or emergency cesarean birth are usually more pronounced and negative
• complications: aspiratory, amniotic fluid PE, wound infection, DVT, hemorrhage

Question 72

prolapsed cord: priority nursing interventions:

Answer 72

• call for assistance immediately
• notify the provider
• use a sterile gloved hand, insert two fingers into the vagina and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off the cord
• reposition the client in a knee chest, Trendelenburg or a side lying position
• apply a warm, saline soaked towel to the visible cord to prevent drying
• administer oxygen at 8-10 L/min via a face mask
• initiate IV access and administer IV fluid bolus

Question 73

Recognition of uterine rupture:

Answer 73

o client reports sensation of ripping, tearing or sharp pain

o client reports abdominal pain, uterine tenderness

o nonreassuring FHR with indications of distress

o change in uterine shape and fetal parts palpable

o cessation of contractions and loss of fetal station

o manifestations of hypovolemic shock: tachypnea, hypotension, pallor, cool clammy skin

Question 74

Recognition of uterine rupture:

Answer 74

o client reports sensation of ripping, tearing or sharp pain

o client reports abdominal pain, uterine tenderness

o nonreassuring FHR with indications of distress

o change in uterine shape and fetal parts palpable

o cessation of contractions and loss of fetal station

o manifestations of hypovolemic shock: tachypnea, hypotension, pallor, cool clammy skin

Question 75

indications of induction/c section:

Answer 75

• postterm pregnancy (greater than 42 weeks)
• dystocia (prolonged, difficult labor) due to inadequate uterine contractions
• prolonged rupture of membranes
• maternal medical complications
• fetal demise

Question 76

Amniotomy- role of the nurse:

Answer 76

• ensure that the presenting part of the fetus is engaged prior to an amniotomy to prevent cord prolapse
• monitor FHR prior to and immediately following AROM to assess for cord prolapse as evidenced by variable or late decelerations
• Assess and document characteristics of amniotic fluid
• Document time of rupture, temperature every 2 hours and provide comfort measures

Question 77

Breastfeeding: teaching:

Answer 77

• Place client skin to skin as soon as possible following birth and initiate breastfeeding within the first 1-2 hours
• Wear a well fitting, supportive bra
• Emphasize important of hand hygiene prior to breastfeeding
• To relieve engorgement: have client completely empty her breasts at each feeding. Allow infant to nurse on demand. Apply compresses or take a warm shower prior to breastfeeding
• Apply a small amount of breast milk to nipples to help sore nipples and let it air dry

Question 78

Fundus: anticipated placement/ intervention if boggy:

Answer 78

• 1 hour after delivery, the fundus should rise to the level of the umbilicus
• Every 24 hour, the fundus should descend approximately 1-2 cm. It should be between the symphysis pubis and the umbilicus by the sixth postpartum day.
• If fundus is boggy, lightly massage the fundus in a circular motion

Question 79

Assessments: normal/ requiring follow up:

Answer 79

• Monitoring vital signs, uterine firmness and its location in relation to the umbilicus, amount of vaginal bleeding
• Breasts, uterus fundal height and uterine placement and consistency
• Bowel and GI function
• Bladder function
• Lochia (color, odor, consistency and amount)
• Episiotomy (edema, ecchymosis, approximation)
• Vital signs , pain assessment
• Report: numerous large clots and excessive blood loss, foul odor, persistent lochia rubra, redness or swelling and warmth in the calves, redness and tenderness of the breast or fever

Question 80

Postpartum Lab values/vital signs:

Answer 80

o Heart rate increased immediately after birth and blood pressure may too for a few days

o Respiratory function rapidly returns to normal after birth

o Low grade fever is common for the first 24 hours after birth

o Hematocrit level drops moderately for 3-4 days then should go back to normal by 8 weeks.

o WBC count may rise during and after labor

Question 81

Assessment and Intervention for a full bladder:

Answer 81

o Excessive bleeding can occur if the bladder becomes distended

o Overdistended bladder can make the bladder mores susceptible to infection

o Assess client’s ability to void every 2-3 hours

o Assess for distended bladder: fundal height above umbilicus, fundus displaced from the midline, bladder bulges above the symphysis pubis, excessive lochia

o Encourage patient to empty bladder every 2-3 hours

o Measure client’s first few voidings after delivery

o Courage client to increase her oral fluid intake

o Catheterize if necessary for bladder distention if the client is unable to void to completely empty their bladder

Question 82

Discharge teaching: reasons to call your healthcare provider

Answer 82

i. Passing large clots or large amounts of bleeding or an odor
ii. Redness, swelling or warmth to calf
iii. Fever
iv. Redness or warmth to the breasts
v. Postpartum sadness/depression or blues that are not going away

Question 83

Engorgement Teaching: breastfeeding/bottle feeding:

Answer 83

• To relieve engorgement: have client completely empty her breasts at each feeding. Allow infant to nurse on demand. Apply compresses or take a warm shower prior to breastfeeding
• Do not express milk if mother is bottle feeding. A breast binder can be used, ice packs, fresh cabbage leaves, and mild analgesics. Avoid nipple stimulation

Question 84

Reducing post- cesarean complications: abdominal distention, thrombus formation:

Answer 84

o DVT- prevention- maintain sequential compression device until ambulation

o Perform active and passive ROM to promote circulation

o Initiate early ambulation

o Avoid prolonged periods of standing

o Have client elevate legs while sitting and avoid crossing legs

o Maintain fluid intake of 2-3 L

o Discontinue smoking

o DVT treatment-

o Encourage rest and elevate extremity

o Warm moist compresses

o Do not massage affected limb

o Administer anticoagulants

o Give Tylenol for pain

Question 85

Non pharmacological Pain Interventions:

Answer 85

communicate to her health care providers her preferences for relaxation and pain relief measures. No side effects to the baby

• cognitive strategies- childbirth education, Lamaze and patterned breathing exercises, doulas, hypnosis
• gate control theory to promote relaxation and pain relief – aromatherapy, breathing techniques, imagery, music
• effleurage- light gentle circular stroking of the client’s abdomen with the fingertips
• sacral counterpressure- consistent pressure is applied by the support person using the heel of the hand or first
• application of heat or cold
• frequent position changes
• patterned breathing and progressive relaxation exercises

Question 86

Interpretation and nursing intervention for prenatal labs: Rh, rubella:

Answer 86

> Rubella- a subcutaneous injection of rubella is recommended in the postpartum period prior to discharge. Women should not become pregnant for 28 days after injection. Breastfeeding mothers can be vaccinated. Do not give if family is immunocompromised.

> RH- given within 72 hours after birth if newborn is rh positive. Give at 28 weeks of pregnancy for rh negative mothers.