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NCLEX: Prioritization, Delegation, And Assignment 5th Edition > Pregnancy > Flashcards

Pregnancy Flashcards

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1
Q

Type 1 diabetes. Priority educación

  1. Insulin requirements will raise during 2 & 3 trimestre
  2. Infants of DM mothers can be Macrosoic, higher cesarean rate
  3. Breast feeding recommended, insulin use not a Contradictions
  4. Achievements of optimal glycemic control is the utmost importance in preventing congenital anomal
A
  1. Achievements of optimal glycemic control is the utmost importance in preventing congenital anomal

Macorsomic (birth weight of more than 4,000 grams (8 lb 13 oz) or 4,500 grams (9 lb 15 oz), or greater than 90% for gestational age.)

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2
Q

First & Second to access

  1. 17 (G1P0) 40 Weeks contractions q6min, patient is crying loudly
  2. 22 (G3P2) 38 wks contractions q3min requesting to use the bathroom
  3. 32 (G4P3) 27 wks noted bleeding after intercourse
  4. 27 (G2P1) 37 wks exp. spontaneous rupture of membranes 30 minutos ago but feels no contractions
A
  1. 22 (G3P2) 38 wks contractions q3min requesting to use the bathroom

Then

  1. 32 (G4P3) 27 wks noted bleeding after intercourse
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3
Q

Magnesium Sulfate Prophylaxis in Pre-eclampsia. Priority assessment

  1. Check Deep Tendon Reflexes
  2. Observe vaginal bleeding
  3. RR
  4. Note urine output
  5. Monitor for calf pain
A
  1. Check Deep Tendon Reflexes (Disappear at Toxic Levels)
  2. RR (Magnesium Sulfate Toxicity)
  3. Note urine output (Excreted through kidneys)

Not
2. Observe vaginal bleeding
5. Monitor for calf pain

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4
Q

Active labor 39 wks. Which must be addressed at this time.

  1. Hemoglobin 11 at 28 wks
  2. Positive Strep B at 36 wks
  3. UTI E. Coli at 20 wks
A
  1. Positive Strep B at 36 wks

Notify HCP and antibiotics Prophylaxis will be delivered to reduce risk of mother to child infection

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5
Q

Active labor. Late fetal heart decelerations & decreased variability in fetal heart rate. HCP says that it is acceptable. What do you do?

A

Go up chain of command and communicate assessment of fetal heart rate to next appropriate HCP

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6
Q

Normal fetal HR

A

110 - 160

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7
Q

Fetal HR acceleration is atleast 15 BMP for 15 seconds.

What level of concern is this?

A

Not a concern.

It is a good finding

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8
Q

Early fetal decelerations in response to a contraction.

Mirror image of mother’s contractions

Level of concern for Early (mirror image) of fetal decelerations?

A

Early fetal decelerations- Fine (no concern) - Cause: Head compression

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9
Q

Variability of 6 - 25 BPM in fetal HR is a good finding.

What does it demonstrate

A

Healthy nervous system

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10
Q

Fetal Bradycardia is a HR <_____ for 10 minutes

A

110

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11
Q

Fetal Bradycardia <110

Interventions

A

Side laying posistion

Oxygen, fluids

Notify HCP

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12
Q

Fetal tachycardia >160 for 10 minutes

Causes: Maternal Fever, Fetal Hypoxia, Maternal Hyperthyroidism, cocaine use.

Interventions:

Fetal tachycardia & decreased variability =

Interventions

A

Treat causes: Antipyretic

Fetal tachycardia & decreased variability = Severe Fetal Distress

Deliver baby

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13
Q

Late Decelerations.

Describe the HR in response to the mother’s contractions

Cause:

Interventions:

A

Not mirror image.
The Lowest point comes after the Highest point in the contraction.

Cause: Placental Defeciney- lack of blood

Interventions:

Left lying posistion
IV fluid
Oxygen / Discontinue Oxytocin
Notify HCP

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14
Q

Variable Decelerations: Sharp “V” shape in fetal heart monitor

Cause:

Interventions

A

Umbilical Cord compression. Increases BP & decreases HR

Interventions: Trendelenburg posistion / Knee chest posistion

Oxygen / Discontinue Oxytocin

Notify HCP

Amniotic Fluid infusion

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15
Q

Causes

Variable Decelerations

Early Decelerations

Accelerations

Late Decelerations

A

VEAL CHOP

Variable Decelerations = Cord compression

Early Decelerations = Head compression

Acceleration = OK

Late Decelerations = Placental Insufficiency

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16
Q

Which fetal HR would you put mom in Trendelenburg or knee chest posistion

A

Variable Decelerations

17
Q

What is the cause of late decelerations

A

Uteroplacental insufficiency

18
Q

First action for active labor and mild variable fetal HR decelerations

A

Change posistion. Left side laying

19
Q

Pregant vegetarian at 12 weeks. What is the first appropriate nursing action

  1. Recommend B¹² & iron supplements
  2. Recommend protien drinks daily
  3. Obtain 24 hr diet recall history
  4. Determine reason for her vegetarian ways.
A
  1. 24 hr diet recall history

Use this to determine if deficiency exist

20
Q

During delivery complicated by shoulder dystocia. What intervention would require immediate intervention.

  1. Applying fundal pressure
  2. Applying suprapubic pressure
  3. Requesting immediate presence of the neonatologist
  4. Flexing the Maternal legs back across the Maternal abdomen
A

Applying fundal pressure

Shoulder dystocia (After head comes out shoulder get caught on pubic bone. Baby can “turtle” and go back inside)

21
Q

Which statements indicate that additional discharge teachings are needed for a family who had 1st baby 24 hrs ago

  1. The crib is ready with lots of stuffed animals & quilts
  2. My wife wants the flu shot before she goes home
  3. Will bring baby to pediatrician in 3 weeks
  4. I will give formula at night & wife will breast feeding during the days.
  5. Always put baby in face up laying posistion
A

More teaching needed.
1. The crib is ready with lots of stuffed animals & quilts (Firm mattress & minimal blankets)
3. Will bring baby to pediatrician in 3 weeks ( newborn discharged <72 hrs need to see RN OR HCP in 3 days)
4. I will give formula at night & wife will breast feeding during the days.
( Breastfeeding women should breast feed at all feedings)

Correct statements - no teaching needed
2. My wife wants the flu shot before she goes hom
5. Always put baby in face up laying posistion

22
Q

Recieved epidural anesthetic. Cervix 6 cm dilated. BP 60/38. Appropriate nursing actions SATA

  1. high fowler posistion
  2. Turn to a lateral posistion
  3. Notify anesthesiologist
  4. Prepare emergency C section
  5. Decrease IV fluid
A
  1. Turn to a lateral posistion
    (May relieve pressure on vena cava)
  2. Notify anesthesiologist
    (May need ephedrine to correct hypotension)
    Patient may be experiencing “supine hypotension “ cause pressure on vena cava from uterus & epidural medication.

Not correct
4. Prepare emergency C section
1. Hihh fowler
5. Decreased fluids

23
Q

Natural birth with a Doula. Which nursing action can help patient achieve goal of unmedicated delivery.

  1. Encourage patient to stay in bed
  2. Allow patients support team to provide labor support with minimal nursing presence
  3. Assess effectiveness of support team and offer suggestions as indicated.
  4. Offer pain meds on a regular bas
A
  1. Assess effectiveness of support team and offer suggestions as indicated.

Even with a support team in place the RN needs to observe & assess patients comfort & safety during labor.

24
Q

32 weeks Painless vaginal bleeding. Which statement requires immediate intervention.

  1. I’m going to check your vitals
  2. I’m going to apply a fetal monitor
  3. I’m going to perform a vaginal examination to see if your cervix is dilated
  4. I’m going to feel your abdomen to check the posistion of the baby
A
  1. I’m going to perform a vaginal examination to see if your cervix is dilated

Digital vaginal exam is Contradicted & can cause worse bleeding

Placenta previa

Painless vaginal bleeding can be a symptom of placenta previa

When the placenta covers the opening in the mother’s cervix.

Placenta previa risk factors include a previous delivery,
>35
Previous surgeries: (C-section) or uterine fibroid removal.

Main symptom is bright red vaginal bleeding without pain during the second half of pregnancy.

The condition can also cause severe bleeding before or during delivery.

25
Q

Placenta previa

When the placenta covers the opening in the mother’s cervix.

Placenta previa risk factors include a previous delivery
>35
Previous surgeries: (C-section) or uterine fibroid removal.

Main symptom…

The condition can also cause severe bleeding before or during delivery.

C section is usually performed with this.

A

bright red vaginal bleeding without pain during the second half of pregnancy.

26
Q

22 yr 6 wks postpartum. Admits to crying daily, feeling overwhelmed, and sometimes thinks she might hurt the baby. Priory action

  1. Advise patient of community resources, parents groups, and depression hot lines
  2. Counsel that baby blues are common and assess nutrition, rest, and availability of help at home.
  3. Contact HCP to evaluate her prior to leaving the clinic
  4. Advise not to use Antidepressants when breast feeding
A

Contact HCP to evaluate her prior to leaving the clinic

RN must have her evaluated before leaving.

Baby blues are milder and during 1st & 2nd week

27
Q

3 day old. Which is an abnormal finding.

  1. Urinated 3 times yesterday
  2. Bowel movement was dark at first now it is yellow-green
  3. Baby cried 2 hrs last night
  4. Baby ate 4 times in past 24 hours
A
  1. Baby ate 4 times in past 24 hours

New born should feed 8 / 12 times daily

Void 6 - 8 times daily After 4th day.

28
Q

Full term new born. 4 days old. Birth weight 7lbs. Which assessment is most significant

  1. Today weights 6 lbs 9 oz
  2. Skin is peeling
  3. Infants breast is swollen
  4. Yellow discharge from right eye
A

Yellow discharge from right eye

Possible conjunctivitis.

Weight loss of 5 - 10% normal first day of life

29
Q

Phototherapy on 36 hr old. Which are appropriate interventions.

  1. Cover eyes with mask
  2. Monitor temp closely
  3. NPO
  4. Apply ointment to skin
  5. Offer sterlie water during treatment
A
  1. Cover eyes with mask
  2. Monitor temp closely

Breast feeding continue to avoid dehydration

30
Q

Patient in labor positive QuantiFERON-TB gold tuberculosis (TB) test. Chest x ray showed no active TB. How should the nurse care for this patient.

  1. Isolate mother, initiate droplet precautions, seperate mother and baby don’t allow breasr feeding
  2. Mother & child can room together in isolation
  3. No isolation needed and encouraged to breast feed. Encourage to follow up postpartum for initation of medication FOR latent TB
  4. Face mask on mother outside room. Isolate from baby but encourage to pump breast milk for feedings.
A
  1. No isolation needed
    X ray showed no active TB, Not contagious.

Treatment of latent TB is Appropriate

31
Q

Can a mother with Varicella breast feed her infant?

Why?

A

Yes, because the baby has a vaccination against it.

32
Q

Prenatal client doesn’t want flu vaccine best response.

  1. Respect preferences and give information on how to avoid getting the flu, handwashing, nutrition, rest
  2. Inform that changes to heart,lung, and immune system in pregnancy put her at higher risk. Also, flu in pregnancy can have complications (premature delivery)
  3. Inform it is acceptable to defer until postpartum if they are worried about vaccines affects on pregant
  4. Explain vaccine is mandatory in pregnancy
A
  1. Inform that changes to heart,lung, and immune system in pregnancy put her at higher risk. Also, flu in pregnancy can have complications
  2. Factually explains real risk associated with the disease in pregnancy
33
Q

Order of seriousness

  1. 32 G1P1 day 2 after normal vag dev, tearful because the baby has been up all night crying and not nursing well
  2. 22 G3P3 6 hrs post norm vag delivery. Wants to speak with social workers about giving up baby
  3. 16 yr 1 day post partum BP 160/ 90 complain of headache
  4. 26 yr G2P2 1 day post C section temp 100.5
A
  1. 16 yr 1 day post partum BP 160/ 90 complain of headache (Pre-eclampsia Fatal
  2. 32 G1P1 day 2 after normal vag dev, tearful because the baby has been up all night crying and not nursing well
  3. 22 G3P3 6 hrs post norm vag delivery. Wants to speak with social workers about giving up baby (This is a rough time when the nurse can help the patient with breast feeding tips to continue)
  4. 26 yr G2P2 1 day post C section temp 100.5
34
Q

Which of the following nurse statements are incorrect regarding influenza & droplet precautions SATA

  1. I will be wearing gown, gloves & mask to care for you today.
  2. I will put on a mask before I care for you today.
  3. Any visitors to the room will be offered a mask to wear
  4. I will be moving you to a negative pressure room.
  5. You must wear a mask when your outside your room.
  6. Droplets of your breast milk will be infectious you will need to pump and dump your milk
A
  1. I will be wearing gown, gloves & mask to care for you today.
    (Droplet protection = mask)
  2. I will be moving you to a negative pressure room. (Negative pressure = Airborn)
  3. Droplets of your breast milk will be infectious you will need to pump and dump your milk (No flu virus inside milk, however, flu antibodies are which will help the baby)

True statements
2. I will put on a mask before I care for you today.
3. Any visitors to the room will be offered a mask to wear
5. You must wear a mask when your outside your room

NCLEX: Prioritization, Delegation, And Assignment 5th Edition (26 decks)

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