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