Resource Guide: CKA Test Flashcards
Electronic Fetal Heart Rate Monitoring:
What is the normal BPM?
(Over a 10 minute segment, between contractions)
110-160 BPM
Electronic Fetal Heart Rate Monitoring:
What is the bradycardia BPM?
(Over a 10 minute segment, between contractions)
<110 BPM
Electronic Fetal Heart Rate Monitoring:
What is the tachycardia BPM?
(Over a 10 minute segment, between contractions)
> 160 BPM
What is the most important indicator of fetal well-being? Visually detectable FHR oscillations from the baseline.
Variability
What does variability represent?
Represents intactness of fetal CNS
What are the 4 different levels of variability?
absent, minimal, moderate, or marked variability
Depending on the amplitude of the waves
What are periodic changes?
Changes from the fetal heart rate baseline that are associated with uterine contractions
What are episodic changes?
Changes from the fetal heart rate baseline that are not (or are in between) associated with uterine contractions
What is this describing?
- May be either periodic or episodic
- Are visually apparent abrupt increases in FHR above baseline
- Goal: peak > 15 BPM, duration >15 sec but
Accelerations
What is this describing?
- Are periodic
- Are visually apparent gradual decreases in FHR below baseline. Onset to nadir > 30 sec and coincident with the onset, peak, and ending of contractions
- Does not require additional nursing action
Early decelerations
What are early decelerations caused by?
Fetal head compressions
What is this describing?
- Are periodic
- Visually apparent gradual decrease in FHR below baseline
- Onset to nadir > 30 sec and delayed in timing to peak of contraction
- Requires interventions
Late decelerations
What causes late decelerations?
uteroplacental insufficiency/fetal hypoxia
-requires interventions to enhance fetal oxygenation and placental perfusion
What causes variable decelerations?
What are the interventions?
Caused by cord compression
Interventions aimed at eliminating cord compression, increasing fetal oxygenation
What causes prolonged decelerations?
Many causations: prolapsed cord, tachysystole, rapid decent, abruption, etc
What term is this describing?
Mean FHR rounded to increments of 5 bpm during a 10 minute segment excluding periodic or episodic changes, periods of marked variability and segments of baseline that differ by 25 bpm. Duration must be > 2 minutes
Baseline Rate
What term is this describing?
Fluctuations in the baseline FHR of 2 cycles/min or greater. Visually quantitated as the amplitude of the peak-to-trough in beats per minuute
Variability
What term is this describing?
Amplitude from peak to trough undectable
absent variability
What term is this describing?
Amplitude from peak to trough >undetectable and < 5 bpm
minimal variability
What term is this describing?
Amplitude from peak to trough 6-25 bpm
moderate variability
What term is this describing?
Amplitude from peak to trough > 25 bpm
marked variability
In gestations <32 weeks, peak of 10 bpm and duration of 10 seconds is….
Acceleration, if >32 weeks is 15 bpm and 15 sec
What term is this describing?
Visually apparent abrupt decrease (onset to nadir is < 30 sec) in FHR below baseline. Decrease is >15bpm, duration >15 sec and < 2 min
Variable deceleration
What term is this describing?
Visually apparent abrupt decrease (onset to nadir s < 30 sec) in FHR below baseline. Decrease is > 15 bpm, duration >2min but <10 min
Prolonged deceleration
What are the 3 phases of the first stage of birth?
- Latent phase
- Active phase
- Transition phase
What is the approximate time for the Latent Phase?
6-8 hours
What is the dilation for the latent phase?
0-3cm
What are the contractions frequency, duration and intensity in the Latent Phase?
Every 5-30 minutes
30-40 sec
Mild progress to moderate
25-40 mmHg IUPC
What is the approximate length of time for the Active Phase?
Approx. 3-6 hours
What is the dilation in the Active Phase?
4-7cm
What are the contractions frequency, duration, and intensity in the Active Phase?
Every 3-5 min
40-70 sec
Moderate progress to strong
50-70 mmHg by IUPC
What is the approximate length of time for the Transition Phase?
approx. 20-40 minutes
What is the dilation in the Transition Phase?
8-10 cm
What are the contractions frequency, duration, and intensity in the Transition Phase?
Every 2-3 minutes
45-90 sec
Strong by palpation
70-90 mmHg by IUPC
How long is the second stage? Nullipara and Multipara
Influenced by regional anesthesia
Nullipara: 50 min-2hr
Multipara: 20 min-1hr
What are the 3 types of breathing patterns to comfort for labor and birth?
Slow Breathing Pattern -in through nose, out through mouth -begin when mom has difficulty walking during contractions Light Breathing or Accelerated Breathing -Use when tense -silent inhale, audible exhale -"greet" the contraction w/ cleansing breath -end contraction with another "blow it away" Transition Breathing -pant-pant-blow -he-he-he-blow
What are some techniques to relieve backache during labor and birth?
hands and knees position, pelvic rocking, lunge, walking, stair climbing, slow dancing, birthing ball, changing positions, cold packs, rolling pressure (tennis balls, rolling pins), counter pressure
What are some other effective comfort measures?
Visualization/attention focusing, music and aroma therapy, tub/shower, cold or hot pack, massage techniques, palm massage, effleurage
What are 3 bearing down techniques?
- “Laboring down” or push only with the urge
- Directed pushing or valsalva pushing
- Open-glottis pushing
What are 4 positions for comfort?
Squatting, semi-sitting, hands and knees (easy, help rotate baby, may help the FHR), and dangling (elongates the trunk, relaxes the pelvis)
Postpartum assessment:
How often should you assess lung sounds, RR, cardiac, and neuromuscular (temperature, anesthesia regression, dermatomes, epidural site)?
every 4 hours
Assess BUBBLE HEAVN twice a shift. What does BUBBLE HEAVN stand for?
Breast Uterus Bowel Bladder Lochia Episiotomy/perineum
Homan's sign (bend leg, if pain possible DVT) Emotional bonding and baby Abdomen Vital Signs Nutrition
Assess CHESS once a shift. What does CHESS stand for?
Culture/ethnicity/language Health beliefs Economic/educational Spiritual Beliefs Significant others
Where is the fundus located in the first 24 hours postpartum? Recedes ____/day postpartum.
How do you document?
- Near umbilicus
- Recedes 1cm/day
- U/1= 1cm below umbilicus
- 1/U- 1cm above umbilicus
- Midline or deviation from midline
- Tone: Firm, boggy
Pitocin is never…
Pitocin can cause increase in…
given IV push! always ordered rate
-Pitocin can cause increase in BP
Where will the bladder be if distended? What happens when the bladder is full?
Rise up to the right
It increases vaginal bleeding and it prevents uterine contractions
1st BM is usually… (postpartum mother)
2 days postpartum
-No enema or digital exam if pt has 3rd or 4th degree lacerations!
When should you report Lochia?
if saturation of OB-Pad in 2 hours or less
-You are assessing to precent hemorrhage and shock
Inspect lochia for color, amount, odor, and presence of clots. Color: Days 1-4: \_\_\_\_\_\_ Days 4-10: \_\_\_\_\_ Days 10-3rd to 6th week: \_\_\_\_\_\_ Color shouldn't....
Days 1-4: Rubra
Days 4-10: Serosa (in some women may last 27 days)
Days 10-3rd to 6th week: Alba
Color shouldn’t revert to earlier stage
Lochia: -Slight or scant:\_\_\_\_\_ -Moderate:\_\_\_\_\_\_ -Heavy: \_\_\_\_\_ 1cc=\_\_\_\_\_ Clots? Odor?
Slight or scant: 4 pads/day
-Moderate: 4-8 pads/day
-Heavy: 8 pads
1cc=1gm
Few small clots in first few days is normal but document any clots present.
Earthy, faintly musky; if foul ma indicate infection
What are 3 ways to help prevent thrombophlebitis?
- Early ambulation
- Teach pt stretches and ROM exercises if on bed rest
- Avoid constricting clothing and crossed legs
What are the 3 emotional phases after birth for the mother?
1) Taking in- immediately after birth
- sleeps, depends on others, relives events surrounding birth
2) Taking hold- few days pp
- begins to gain control of body functions, becomes preoccupied with present, is concerned about her health, abby’s health, and ability to care for baby, show independence in self-care and baby care
3) Letting go
- re-establishes relationships with others
What does REEDA stand for? When is it used?
Used to assess C-section incision Redness Edema Ecchymosis Discharge Approximated edges
What baby temperature should you call your instructor or nurse?
below 97.7F (36.5C) OR above 98.9F (37.2C)
What baby RR should you call your instructor or nurse?
below 30 OR above 60
What baby pulse should you call your instructor or nurse?
below 100 or above 160
What baby glucose level should you call your instructor or nurse?
=/<45 mg/dl
OR
above 150 mg/dl
When else should you call your instructor or nurse? (regarding newborn)
- When newborn has not voided or stooled on your shift
- Bilirubin above 10 mg/dl
- Bleeding at circumcision
When should you call your instructor or nurse? (regarding mother) 4 things
- Fundus above the umbilicus or deviated from the midline
- Palpable bladder
- Not voided in past 4 hours
- Saturating a peripad in 2 hours or less (sooner than 2 hours)
How often do you assess and document on the mother?
Every 4 hours, New admission: every 2 hours, first 3 voids (must measure and record)
How often do you assess and document on the newborn?
Every 4 hours
What are the 5 reflexes you check on a newborn? (Upper body)
Grasp reflex, Moro reflex, Rooting reflex, Gag reflex, Blink reflex
Newborn Vital Signs Pulse: \_\_\_bpm -During sleep as low as \_\_\_\_bpm -If crying up to \_\_\_ bpm Apical pulse counted for \_\_\_\_\_
Pulse: 100-160 bpm
-During sleep as low as 80 bpm
-If crying up to 180 bpm
Apical pulse counted for 1 full minute
Newborn Vital Signs
- RR: ____/minute
- Predominantly ___ but synchronous with abdominal movements
- Obligate nose breathers
- Respirations are counted for _____
30-60 respirations/minute
Predominantly diaphragmatic
Respirations are counted for 1 full minute
Newborn Vital Signs
Blood pressure at birth: ___ mmHg
At day 10: _____ mmHg
Birth: 80-60/45-40 mmHg
Day 10: 100/50 mmHg
Newborn Vital Signs Temperature normal range: \_\_C Axillary:\_\_\_C Skin: \_\_C Rectal: \_\_\_C
Normal range: 36.5-37.2C (97.7-98.9F)
Axillary: 36.5-37.2C
Skin: 36-36.5C
Rectal 36.6-37.2C
When should you preform a Neonatal Infant Pain Scale (NIPS)?
(taken with vitals)
immediately before and 30 after painful procedures
What 6 things are you evaluating in the Neonatal Infant Pain Scale?
(0 or 1 for each, except cry is 0-2)
- Facial expression
- Cry (1=whimper, 2=vigorous cry)
- Breathing (relaxed or changed), arms (relaxed or flexed/extended)
- Legs
- State of arousal (sleeping/awake or fussy)
When should you intervene for NIPS score?
Score of 2 or more
What are some interventions for NIPS score?
reposition, swaddle in warm blanket, skin-to-skin, reduce stimulation (dim lights, quiet), hold and rock in vertical position, light massage/stroking, breast or feed, pacifier (if parents have/allow), oral sucrose as ordered
What is a limitation to the NIPS score?
A falsely low score may be seen in an infant who is too ill to respond or who is receiving a paralyzing agent
Bottle Feedings
Do not let the baby sleep longer than _____ if formula fed (during the day) between feedings for the first 6 weeks
4 hours
Bottle Feedings (Frequency and Amount)
- First 48 hrs: ________, _________
- First 2 weeks: _______, ________
- 2-4 weeks: ________, _________
- 1-3 months: _______, __________
- 3-7 months: _________, ________
- First 48 hrs: 6-8 feedings, 10-15 mL/feeding
- First 2 weeks: 6-10 feedings, 60-90mL/feeding
- 2-4 weeks: 6-8 feedings, 90-120mL/feeding
- 1-3 months: 5-6 feedings, 145-175 mL/feeding
- 3-7 months: 4-5 feedings, 175-205 mL/feeding
Breastfeeding
Teach to feed _______. Do NOT go longer than ____ during daytime and or ___ hours at night without attempting to feed for the first 6 weeks.
Teach to feed as often as baby desires.
3 hours
4 hours
Never ____ bottle or ____ a baby for feedings
prop a bottle or leave a baby unattended for feedings
Do not bottle feed a baby in _______
an infant seat (support head well)
After a feeding, always place the baby _________
on its back for sleeping
Breastfed babies do not have to be _________
burped routinely
What 3 positions is burping performed?
1) Over the shoulder
2) Across the lap
3) Sitting with chin supported
If the baby has been _____ it might be necessary to burp the baby before feeding
crying
Burp the baby when sucking ______ or ____ or after ____ for newborns
slows down or stops or after 1/2 to 1 oz for newborns
What are the 4 forms of formula?
1) Concentrated (liquid): must add water
2) Powdered: Must add water
3) Ready to use: Place required amount in bottle
4) Prepackaged Ready to Use: Open and serve
Where should you store all prepared formulas?
in a refridgerator
How should you save formula left in a bottle?
Don’t! You should never save leftover formula. Throw it away.
Change liners or wash bottles in warm soapy water after feedings
How many diapers should a baby go through in days 1-5?
Same number as day of life (Day 1=1 diaper, Day 2=2 diapers, etc)
How many diapers should a baby go through after day 5?
If the baby is getting enough to eat voids are 6-8 times/day
How should you clean diaper area is stool is present?
Use a mild soap and water if present.
If absent, clean with warm water
Stools (What should the baby have) First 2 days: \_\_\_\_\_\_ About day 3:\_\_\_\_\_ (color) End of first week: \_\_\_ (color) -breastfed stools: \_\_\_\_\_ -bottle fed stools:\_\_\_\_\_
First 2 days: Meconium (dark green/back, thick, sticky) About day 3: greenish to yellow green End of first week: yellowish -breastfed: loose, non-smelly -bottle fed: formed with odor *Should have at least one stool per day
What should you tell the mother to do if she has trouble waking her baby up?
call the baby’s doctor
When should the mother call the dr? (in terms of vomiting)
When spitting up a large part or all of a feeding two or more times
When should the mother call the dr? (In terms of diarrhea)
Three or more green, liquid stools (stools have a water ring around them)
When should the mother call the dr? (in terms of feedings)
when the baby refuses to eat 2 feedings in a row
When should the mother call the dr? (in terms of cord)
reddening around the cord area or a bad smell from the cord
When can the baby have a tub bath?
After the cord is dry and falls off, approximately 7-10 days
Cleanse the cord with soap and water only when….
urine or feces gets on the cord
How should you tell the parents to dress the baby?
Like the warmest person in the family dresses. Do not overdress the baby, they can get too hot
Breasts
When/what days is colostrum produced?
first 2-3 days
Breasts
Transitional milk begins by approx. _____days after birth. Continues to change in composition for about _____ days
Transitional- 3-5
continues to change 10 days
When is mature milk established?
approx. 2 weeks
What are 2 reasons why a postpartum mother should wear a bra?
1) Comfort
2) To decrease engorgement and tenderness
Fluid build-up usually ______ days after delivering and____ hours before milk comes in
2-3 days after
24 hours
How should mothers wash their nipples?
With warm water, no soap!
-can use lanolin on breasts and nipples
What are the 2 signs of possible breast infection and 3 actions to treat?
- Pain, warm, hard, redden area
- Fever, feeling ill
- Change baby’s nursing position
- Increase frequency of nursing
- Call provider
Why is the fundus palpated after delivery?
To check for position change from bleeding or full bladder
What are 5 ways to facilitate bladder emptying?
- Squatting or standing to void
- Sound of water running
- Voiding in a sitz bath
- Relaxation techniques
- Pouring water over perineal area
If lactating, increase caloric intake by ____ for a singleton delivery and double this for a twin pregnancy
200-500 calories
What should a postpartum mother do when she voids? (in terms of perineal hygiene)
- Change pad every time she voids
- Use peri-bottle to wash with after each void
- Put on peri-pad from front to back and remove it the same way
Need to report to MD if lochia has ____ or if changes from ______ to _______
foul odor or if changes from whitish to bright red
What are 4 factors that an influence when sexual intercourse can be resumed?
- Degree of perineal tenderness
- Length of time of lochia discharge
- Healing of placental site
- Preference of couple
What are some comfort measures for an episiotomy?
ice packs initially after delivery up to 24 hours, heat later; sitz bath; anesthetic sprays, creams or witch hazel pads (if ordered)
Reassure pts with episiotomy that bowel movement….
will not cause damage to episiotomy
And inform of proper position while at toilet (leaning back with feet elevated on a stool helps to relax anal sphincters)
