SI EM A Flashcards
Steps of the Leopold Maneuver
Ask the client to empty the bladder before beginning the assessment.
Place the client in the supine position with a pillow under the head, and have both knees slightly flexed.
Place a small, rolled towel under the client’s right or left hip to displace the uterus off the major blood vessels to prevent supine hypotensive syndrome.
STEPS:
1. Identify the fetal part occupying the fundus.
2. Locate and palpate the smooth contour of the fetal back
3. Identifying the descent of the presenting part into the pelvis.
4. Identify the fetal attitude.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps, placing them in the order of performance. Use all the steps.)
A.
Identify the attitude of the head.
B.
Palpate the fundus to identify the fetal part.
C.
Determine the location of the fetal back.
D.
Palpate for the fetal part presenting at the inlet
D,B,C,A
Client education for car seat for a newborn
- Use an approved rear-facing car seat in the back seat, preferably in the middle (away from air bags and side impact), to transport the newborn.
- Keep infants in rear-facing car seats until age 2 or until the child reaches the maximum height and weight for the seat. QS
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
Monitor the rectal temperature every 4 hr.
Cleanse the site with povidone-lodine.
Prepare for surgical closure after 72 hr.
Administer broad-spectrum antibiotics.
Administer broad-spectrum antibiotics.
A nurse is providing teaching about increasing dietary fibre to an antepartum client who reports constipation. Which of the following food selections has the highest fibre content per cup?
Oatmeal.
Cabbage.
Lentils.
Asparagus
Lentils.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase her intake of vitamin B12. Which of the following foods should the nurse recommend?
A.
Fresh citrus fruits.
B.
Brown rice.
C.
Raw carrots.
D.
Fortified soy milk.
D.
Fortified soy milk.
A nurse is assessing a client who is in labor and has received epidural analgesia. Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?
A.
Hypotension.
B.
Polyuria.
C.
Fetal heart rate 152/min.
D.
Maternal temperature of 37.4° C (99.4° F).
A.
Hypotension.
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique.
Which of the following information should the nurse include?
A “Yellow exudate will form at the surgical site in 24 hours.”.
B “Notify the provider if the end of your baby’s penis appears dark red.”.
C “The Plastibell will be removed 4 hours after the procedure.”.
D “Make sure the newborn’s diaper is snug.”.
The correct answer is A. The nurse should include that “yellow exudate will form at the surgical site in 24 hours” as part of the teaching to the parents. This is because the yellow exudate is a normal sign of healing and should not be confused with infection.
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
A.
Place the client in a semi-Fowler’s position for 1 hr after administration.
B.
Instruct the client to avoid urinary elimination until after administration.
C.
Verify that informed consent is obtained prior to administration.
D.
Allow the medication to reach room temperature prior to administration.
C.
Verify that informed consent is obtained prior to administration.
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
A.
Single palmar creases
B.
Rust-stained urine
C.
Subconjunctival hemorrhage
D.
Transient circumoral cyanosis
B.
Rust-stained urine
nurse is admitting a client to the birthing unit who reports contractions started 1 hour ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
A) Postpartum hemorrhage
B) Incompetent cervix
C) Ectopic pregnancy
D) Hyperemesis gravidarum
Postpartum hemorrhage
A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following findings should the nurse expect?
A.
Temperature 37.4°C (99.3°F)
B.
Scant lochia
C.
Uterine tenderness
D.
WBC count 9,000/mm³
C.
Uterine tenderness
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hours old.Term newborn birthed via spontaneous vaginal delivery at 39 weeks of gestation.
Apgar 9/9 at 5-minute score.
Breastfeeding 3 to 4 times per day.
Newborn has voided once since birth and has not passed meconium stool since birth.
Physical Examination.
Fontanels soft and flat.
Head molded with caput succedaneum.
Eyes symmetric, no discharge, sclera yellow.
Mucous membranes dry.
Abdomen soft and rounded, bowel sounds present x 4 quadrants
Vital Signs.
Heart rate 154/min.
Respiratory rate 44/min
Temperature 36.9° C (98.4° F).
Diagnostic Results
Coombs positive (negative. Glucose 50 mg/dL (40 to 60 mg/dL).
Which of the following findings should the nurse report to the provider? Select all that apply.
Glucose level.
Head assessment finding.
Coombs test result.
Sclera color.
Heart rate.
Intake and output.
Mucous membrane assessment.
Sclera color.
Intake and output.
Coombs Results
Mucous membrane assessment.
Staphylococcus Aureus is which precaution
Contact
Expected findings of Neonatal Abstinence Syndrome
CNS: High-pitched, shrill cry; incessant crying; irritability; tremors; hyperactivity with an increased Moro reflex; increased deep-tendon reflexes; increased muscle tone; disturbed sleep pattern; hypertonicity; convulsions
Metabolic, vasomotor, and respiratory findings: Nasal congestion with flaring, frequent yawning, skin mottling, retractions, apnea, tachypnea greater than 60/min, sweating, temperature greater than 37.2° C (99° F)
Gastrointestinal: Poor feeding; regurgitation (projectile vomiting); diarrhea; excessive, uncoordinated, constant sucking
A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?
A.
offer to take pictures of the newborn for the cent
B.
Assure the client that she can have additional children
C.
Avoid talking to the client about the newbornr
D.
Discourage the client from allowing friends to see the newbornn
A.
offer to take pictures of the newborn for the cent
Risk factors for Postpartum Hemorrage
Uterine atony or history of uterine atony
Overdistended uterus
Prolonged labor, oxytocin-induced labor
High parity
Ruptured uterus
Complications during pregnancy (placenta previa, abruptio placentae)
Precipitous delivery
Administration of magnesium sulfate therapy during labor
Lacerations and hematomas
Inversion of uterus
Subinvolution of the uterus
Retained placental fragments
Coagulopathies (DIC)
Oxytocin stimulated contraction contraindications
Contraindications include placenta previa, vasa previa, preterm labor, multiple gestations, previous classic incision from a cesarean birth, and reduced cervical competence.
What is the the description of procedure for tubal ligation?
Procedure: The cutting, burning, or blocking of the fallopian tubes with bands or clips (highly reversible) to prevent the ovum from being fertilized by the sperm.
Advantages, Disadvantages, and Risks for Tubal Ligation
Advantages
Permanent, immediate contraception.
This method can be done within 24 to 48 hr after childbirth.
Sexual function is unaffected.
Disadvantages
A surgical procedure carrying risks related to anesthesia, complications, infection, hemorrhage, trauma
Considered irreversible if a client desires conception
Does not protect against STIs
Risks: Risk of ectopic pregnancy if pregnancy occurs
What is the priority action for bladder distention?
Encourage voiding to prevent bladder distention
Expected findings of trichomoniasis
Expected Findings
Yellow-green, frothy vaginal discharge with foul odor
Dyspareunia and vaginal itching
Dysuria
Physical Examination Findings
Discharge in the vaginal vault during speculum examination, which can be sampled for microscopy
Strawberry spots on the cervix (tiny petechiae)
A cervix that bleeds easily
Nursing actions for a client who has Uterine Atony
Nursing Care
Ensure that the urinary bladder is empty.
Monitor the following.
Fundal height, consistency, and location
Lochia for quantity, color, and consistency
Perform fundal massage if indicated.
If the uterus becomes firm, continue assessing hemodynamic status.
If uterine atony persists, anticipate surgical intervention, such as a hysterectomy.
Express clots that can have accumulated in the uterus, but only after the uterus is firmly contracted. It is critical not to express clots prior to the uterus becoming firmly contracted, because pushing on an uncontracted uterus can invert the uterus and result in extensive hemorrhage. QEBP
Monitor vital signs.
Maintain or initiate IV fluids.
Surgical intervention may be necessary if all other method fail to decrease the bleeding and promote a firm uterus.
*Uterine tamponage is an intrauterine balloon that is placed inside the uterus to treat the postpartum hemorrhage. If this treatment fails, the client will most likely require a hysterectomy.
Client findings that require immediate follow up during a postpartum assessment
A focused postpartum physical assessment should include assessing the client’s BUBBLE (breasts, uterus, bowel, bladder, lochia, episiotomy), vital signs and teaching needs.
Report severe continuous headache, pitting edema of lower extremities, epigastric pain, blurring of vision, flashes of lights or dots before the eyes
Abnormal lochia includes excessive spurting of bright red blood from the vagina, numerous large clots, excessive blood loss, foul odor, persistent heavy lochia beyond day 3, and continued flow of lochia serosa or alba beyond the normal length of time
.Observe for erythema, breast tenderness, cracked nipples, and indications of mastitis in a milk duct of the breast with concurrent flu-like manifestations
Findings in a newborn to report to provider
The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal
infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention.
Expected findings of a newborn who has maternal history of opioid use during pregnancy
For newborns with Opiate withdrawal: Manifestations of neonatal abstinence syndrome or neonatal opioid withdrawal syndrome (NOWS)
Manifestations of neonatal opiod withdrawal syndrome
incidence of seizures, sleep pattern disturbances, stillbirth, SUID, higher birth weights (compared to with heroin exposure)
What findings in placenta previa would require immediate follow up?
vaginal bleeding
A nurse is caring for a patient who is at 32 weeks of gestation and has complete placenta previa. Which of the following assessment findings requires immediate follow-up?”
A.
“Vaginal bleeding.”.
B.
“Fetal heart rate of 174 bpm.”.
C.
“Fundal height of 33 cm.”.
D.
“Abdomen soft on palpation and without tenderness.”.
A.
“Vaginal bleeding.”.
Assessing a client who has Preclampsia:
Severe continuous headache
Nausea
Blurring of vision
Flashes of lights or dots before the eyes
Physical Assessment Findings
Hypertension
Proteinuria
Periorbital, facial, hand, and abdominal edema
Pitting edema of lower extremities
Vomiting
Oliguria
Hyperreflexia
Scotoma
Epigastric pain
Right upper quadrant pain
Dyspnea
Diminished breath sounds
Seizures
Jaundice
Manifestations of progression of hypertensive disease with indications of worsening liver involvement, kidney failure, worsening hypertension, cerebral involvement, and developing coagulopathies
Prevention strategies for postpartum depression
- encourage bounding activities
- community resource
- get plenty of rest and to nap when the newborn sleeps
- remember the important of takin time out for self
- seek counseling and consider social agencies
Interventions for a Newborn who has Neonatal absistence syndrome
Perform ongoing assessment of the newborn using the neonatal abstinence scoring system assessment, as prescribed.
Elicit and assess the newborn’s reflexes.
Monitor the newborn’s ability to feed and digest intake. Offer small frequent feedings.
Swaddle the newborn with legs flexed.
Offer non-nutritive sucking.
Monitor the newborn’s fluids and electrolytes with skin turgor, mucous membranes, fontanels, daily weights, and I&O.
Reduce environmental stimuli (decrease lights, lower noise level).
Patient is post c section and has endometritis. What is the nursing care?
collect vaginal and blood cultures
administer IV antibiotics
administer analgesics
The patient has PostPartum Hemorrhage and received misoprostol. How would you evaluate the effectiveness?
Postpartum hemorrhage is stopped.
Signs of respiratory distress in a newborn
Tachypnea (respiratory rate greater than 60/min)
Nasal flaring
Expiratory grunting
Retractions
Labored breathing with prolonged expiration
Fine crackles on auscultation
Cyanosis
Unresponsiveness, flaccidity, and apnea with decreased breath sounds (manifestations of worsened RDS)
Complications w/ Forceps-Assisted Birth
Facial nerve palsy
Facial bruising
Subdural hematoma
Postop Cesarean: a tender uterus and foul smelling lochia can indicate what
endometritis
Following a cesarean birth, should the client have a lot of bleeding or a little?
If a cesarean section was performed, the amount of bleeding will be decreased because the provider cleans out the uterus after surgery.
A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet.
Which of the following questions should the nurse ask to assess the client’s dietary intake?
A.
“When was the last time you ate meat?”
B.
“Have you considered eating shellfish?”
C.
“How much protein do you eat in a day?”
D.
“Are you taking a Vitamin C supplement?”
C.
“How much protein do you eat in a day?”
What effect can a nonpharmalogival pain management measure have on a patient in labor?
it can reduce anxiety, fear, and tension
Pain management for perineal laceration
Apply ice/cold packs to the perineum for the first 24 hr to reduce edema and provide anesthetic effect. Do not apply directly to the perineum.
Heat therapies (hot packs), moist heat, and sitz baths can be used to increase circulation and promote healing and comfort.
Encourage sitz baths at a hot or cool temperature for 20 min at least twice a day. QEBP
Administer analgesics, such as nonopioids (acetaminophen), nonsteroidal anti-inflammatories (ibuprofen), and opioids (codeine, hydrocodone) for pain and discomfort.
Opioid analgesia can be administered via a patient-controlled analgesia (PCA) pump after cesarean birth. Continuous epidural infusions can also be used for pain control after cesarean birth.
Apply topical anesthetics (benzocaine spray) to the client’s perineal area as needed or witch hazel compresses or hemorrhoidal creams to the rectal area for hemorrhoids.
A nurse is planning care for a client who is 12 hr postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?
A.
Place a witch hazel pad on the client’s perineal pad after each voiding
B.
Apply hydrogel pads to the perineum every 4 hr
C.
Prepare the client for a pudenal nerve block
D.
Encourage the client to apply a warm pack to the perineum for discomfort
B.
Apply hydrogel pads to the perineum every 4 hr
A nurse is providing instructions to a client who has chosen a diaphragm for birth control. Which of the following instructions should the nurse include?
A.
Remove the diaphragm 2 to 4 hr after intercourse.
B.
Insert the diaphragm up to 6 hr before intercourse.
C.
Wash the diaphragm with detergent soap between uses.
D.
Apply a vaginal lubricant to the diaphragm prior to insertion.
B.
Insert the diaphragm up to 6 hr before intercourse.
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make?
A.
“You can bathe and dress your baby if you’d like to.”
B.
“You should name the baby so she can have an identity.”
C.
“I’m sure you will be able to have another baby when you’re ready.”
D.
“If you don’t hold the baby, it will make letting go much harder.”
A.
“You can bathe and dress your baby if you’d like to.”
A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake.
The nurse should instruct the client that which of the following foods has the highest amount of calcium?
A.
1 cup cooked broccoli.
B.
1 large banana.
C.
1/2 cup cubed avocado.
D.
1 medium potato.
A.
1 cup cooked broccoli.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception.
Which of the following instructions should the nurse include?
A.
You should use an oil-based vaginal lubricant when inserting your diaphragm.
B.
You should store your diaphragm in sterile water after each use.
C.
You should keep the diaphragm in place for at least 4 hours after intercourse.
D.
You should have your provider refit you for any diaphragm.
D.
You should have your provider refit you for any diaphragm.
Postterm infant expected findings
Wasted appearance, thin with loose skin, having lost some of the subcutaneous fat
Peeling, cracked, and dry skin; leathery from decreased protection of vernix and amniotic fluid
Long, thin body
Meconium staining of fingernails and umbilical cord
Hair and nails can be long
Alertness similar to a 2-week-old newborn
Difficulty establishing respirations secondary to meconium aspiration
Hypoglycemia due to insufficient stores of glycogen
Clinical findings of cold stress
Neurological manifestations that become apparent with the development of fine motor skills
Macrosomia
