VATI RN Maternal Newborn 2019

Encourage client who are prescribed methadone to breastfeed. -The nurse should encourage clients who are prescribed methadone during pregnancy to breastfeed their newborns to help with withdrawal symptoms.

Decreased frequency of contractions. -Terbutaline is a tocolytic medication that is used to halt preterm labor. Terbutaline cause relaxation of smooth muscle, which decrease uterine activity. Therefore, the nurse should identify that a decrease in frequency of contractions is an indication that terbutaline was effective.

Placing a fetal scalp electrode. -A fetal scalp electrode is attached to the presenting part of the fetus in order to provide accurate continuous monitoring of the fetal heart rate. If the client's membranes are intact, the amniotic sac must be artificially ruptured prior to attaching the electrode to enable access to the presenting part.

Heart rate 54/min -The nurse should identify that a heart rate of 54/min is below the expected reference range of 60 to 100/min. During pregnancy, the heart rate increases 10 to 15/min due to increased blood volume and increase tissue demands for oxygen. Bradycardia is a contraindication for the administration of labetalol, an antihypertensive medication. Therefore, the nurse should withhold the medication and notify the provider.

1. Stand posterior to the client. 2. Position arms under the client's axilla and across the client's chest. 3. Place thumb-side of a clenched fist to the client's mid-sternum area. 4. Initiate chest thrust to the client using a backward motion. -If the client becomes unconscious, the nurse should perform CPR and activate emergency medical services.

Maternal blood pressure. -Opioid analgesic can cause hypotension. The nurse should assess the clients blood pressure before and after administering opioids. Pain level. -The nurse should assess the clients baseline pain level prior to administering pain medication and again after administering pain medication to determine the effectiveness of the medication. Opioid analgesic are indicated for the relief of moderate to sever labor pain. Fetal heart rate. -Opioid analgesics can cause fetal bradycardia and changes in variability. The nurse should assess the fetal heart rate prior to administering an opioid analgesic to ensure the rate is within the expedited reference range and to have a baseline for future assessments. The nurse should provide ongoing assessments of fetal heart rate throughout labor according to facility protocol.

Rheumatoid Arthritis. -The presence of a connective tissue disease, such as rheumatoid arthritis or systemic lupus erythematosus, increase a clients risk for developing preeclampsia.

International normalized ratio (INR). -The nurse should monitor the INR of a client who is taking warfarin. Prothrombin time(PT) is also measure to regulate warfarin therapy. However, PT values are more difficult to interpret. INR determined by multiplying the PT by a correction factor based on the specific thromboplastin preparation used for the test, as a way of equalizing laboratory to laboratory variations.

Montevideo units (MVU) of 220 mm Hg. - The nurse should identify that an MVU of 220 mm Hg is within the expected range during the active phase of labor. MVUs generally range between 100 to 250 mm Hg during the first stage of labor and increase to 300 to 400 mm Hg during the second stage of labor. MVUs are calculated by subtracting the baseline uterine pressure from the peak contraction pressure for every contraction that occurs during a 10-min period. The nurse then adds the pressure produced by each contraction during that time to determine the MVUs.

Administer oxygen by nonrebreather face mask. -The first action the nurse should take when using the airway, breathing, circulation approach to client care is to administer oxygen by nonrebreather mask to treat manifestations of respiratory depression due to morphine administration.

Painless vaginal bleeding. -The placenta implants in the lower uterine segment, partially or completely covering the cervix. With cervical changes, the placental blood vessels can tear, which results in bleeding.

Episodes of blurred vision. -Blurred vision is a manifestation of preeclampsia. Arterial vasospasms and decreased perfusion to the retina cause visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.

1. Tachycardia. -Hyperemesis gravidarum typically occurs during the first trimester and results in electrolyte imbalance, excessive weight loss, ketonuria, and nutritional deficiencies. 2. Dry mucous membranes. 3. Poor skin turgor.

BUN 30 mg/dL -Above the expected reference range of 10-20 mg/dL for a client who is pregnant. The BUN typically decreases during pregnancy due to the increase in the glomerular filtration rate. The nurse should identify that an elevated BUN is a manifestation of preeclampsia or HELLP syndrome, potentially serous complications of pregnancy's.

Firmly massage the fundus. -The greatest risk for a postpartum client who is experiencing excessive vaginal bleeding is the development of hypovolemic shock, which can lead to coma and death. Uterine atony is a frequent cause of excessive vaginal bleeding. Therefore, the first action the nurse should take is to massage the clients fundus to encourage muscular contractions, which will decrease bleeding.

Heart rate: 132/min -The nurse should notify the provider of tachycardia greater than 130/min; therefore, this is the priority finding. The client might also report chest discomfort, palpitations and have arrhythmias.

Apply moist heat to the affected breast. -The application of warm compresses prior to feeding or pumping promotes the flow of the breast milk and assists to ensure complete emptying of the breast. This is important to prevent the development of further complications such as the formation of a breast abscess or chronic mastitis.

I will have monthly prenatal visits for the first 28wks of pregnancy. -The initial visit should occur in the first trimester with monthly visits through week 28, and every 2 weeks until week 36, and then every week until the birth of the newborn.

1. You might have to have cultures for sexually transmitted infections prior to placement of the device. -If the provider determines the client is at risk of STI they might require the collection of cultures for STI prior to the placement of the IUD. 2. You might experience irregular spotting the first few months after placement of the device. 3. You will need to sign informed consent prior to the procedure.

Epigastric pain. -This is a manifestation of preeclampsia. Other findings the nurse should report include severe HA, Blurred vision, confusion, N&V, and decrease urinary output.

Initiate and infusion of oxytocin. -The nurse should identify that the client is exhibiting manifestations of hypovolemic shock, which can be caused by uterine atony and is a medical emergency. The nurse should initiate an infusion of 10-20 units of oxytocin, which is an oxytocic medication. This will cause the uterus to contract and decrease bleeding.

Fetal hypoxia -Late decelerations are caused by uteroplacental insufficiency or a decreased blood flow from the uterus to the placenta during contractions. This results in a decreased supply of oxygen to the fetus during the contraction. This pattern can be cause by a wide variety of reasons including uterine tone, maternal hypotension, and disorders that affect the placenta such as maternal diabetes, preeclampsia and post maturity.

The patent should plan to spend individual time with the older sibling. -To enhance and facilitate sibling acceptance of the newborn.

Begin suctioning of mouth and nose. -The nurse should assess the newborns' condition at birth and suction the newborn's mouth and nose with a bulb syringe based on the assessment findings. If the newborns respiratory status is depressed, endotracheal suctions must be done as well to remove any meconium that has entered the newborn's airways.

I will be certain to consume 29 grams of fiber daily. -The client should consume a diet high in fiber and increase fluid intake to help reduce the occurrence of constipation.

Allow the labor to progress naturally. -The absence of late deceleration (a negative results) indicates that the fetus will probably tolerate labor; therefore, the nurse should allow the labor to progress naturally.

1 min is 5.

C is correct. -Immediately after birth, the fundus should be firm, midline with the umbilicus, and approximately 2cm below the level of the umbilicus. At 12hrs postpartum the nurse should palpate the fundus at 1cm (0.4in) above the umbilicus. Every 24hrs the fundus should descend approximately 1-2cm (0.4-0.8in) It should be halfway between the symphysis pubis and the umbilicus by 6 days postpartum.

Wear two pairs of gloves when handling the medication. -Methotrexate is an antineoplastic agent that a pharmacist must prepare in a syringe under a biologic safety cabinet and place in a sealed plastic bag. The nurse should wear two pairs of gloves when removing the syringe from the bag, administering the medication, and disposing of the syringe.

Amenorrhea. -A client can present with amenorrhea for a variety of reasons besides pregnancy.

Administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement. -To prevent hypotension.

Administer IV antibiotic prophylaxis. -To decrease the risk of the neonate contracting a GBS infection, it is recommended that pregnant clients who test positive for GBS receive antibiotics during labor.

Fetal heart rate (FHR) accelerations occur with fetal movement. -A nonstress test measures the response of the FHR to fetal movement. Accelerations of the FHR with fetal movement are a reassuring sign of fetal well being.

Irregular heartbeat. -Cardiac arrhythmia is a potential life-threatening adverse effect of nifedipine. Therefore, the client should report an irregular heartbeat to the provider.

Decrease in blood glucose level. -Maternal metabolism, physical exertion, and delivery of the placenta can lead to a decreased blood glucose level.

Healing. -After 24hrs, yellow exudate usually forms over the glans penis and remains for the next 2-3 days. It sometimes forms a crust, which is expected. The nurse should explain that the yellow film the guardians will see is granulation tissue as the circumcision heals. The guardians should not remove this tissue.

0129 -Begin with the first day of the clients last menstrual period, subtract 3 months, and add 7 days.

Hypotonia -CNS findings of hypoglycemia include lethargy and hypotonia, as well as jitteriness, twitching, poor feeding, temperature instability, apnea, respiratory distress, and seizures.

1. Management of postpartum pain -The nurse should discuss with clients that they will have incisional pain associated with uterine involution. 2. Advantage of early ambulation post-surgical procedure. -Early ambulation following a cesarean birth facilitates circulation in the lower extremities, preventing stasis, and assists with relieving gas pains. 3. The need for an indwelling urinary catheter during delivery. -The nurse should place an indwelling urinary catheter prior to the cesarean birth to keep the client's bladder empty and to avoid interference with the surgical procedure.

Bring your newborn in the bassinet into the bathroom with you. -The client should wheel the newborn in the bassinet into the bathroom with her rather than leave the newborn unattended. The nurse should instruct the client never to leave the newborn unattended.

The most accurate indication of organ perfusion is a clients urine output. -Output greater than 30 mL/hr. is an indication of adequate perfusion and oxygenation.

Depressed fontanels. -Sunken or depressed fontanels are a finding associated with dehydration of the newborn. Additionally, dry oral mucosa, weight loss greater than 10%, and decreased urine output are findings associated with dehydration.

Apply colostrum to the nipples after feeding to help them heal. -Colostrum and breast milk have healing properties and can help reduce soreness.

A newborn who has an axillary temperature of 36C (96.8F). -Cold stress increases the newborn's need for oxygen and can deplete glucose stores. It also can increase the newborn's respiratory rate and cause cyanosis. The expected axillary temperature for the newborn averages 37C (98.6F) and ranges form 36.5C (97.7F) to 37.2C (99F).

I should keep my baby in a rear-facing car seat until he is 2yrs old. -Or until the child reaches the maximum height and weight for the seat.

Cleanse the puncture site with alcohol gauze prior to the procedure. -Or a facility-approved skin cleanser prior to the procedure to minimize the risk of infection.

I will eat small, frequent meals throughout the day. -The client should focus on eating small, frequent meals throughout the day and consuming foods that are appealing.

A client who has an indwelling urinary catheter. -The client's required medical interventions, such as IVs and urinary catheters, increase the risk for falls from tripping over tubing. The nurse should assist the client when getting out of bed and ambulating to prevent an injury from a fall.

Obtain a vaginal culture. -Fever for 2 consecutive days, chills, foul-smelling lochia, and abdominal tenderness are manifestations of endometritis, an infection of the lining of the uterus. The nurse should obtain a vaginal culture using a sterile swab to collect the fluid from the client's vaginal cavity to identify the organism.

Turn the client to a lateral position. -The greatest risk to this client is injury from maternal hypotension and decreased placental perfusion; therefore, the first action the nurse should take is to place the client in a lateral position to relieve the pressure on the vena cava and restore venous return.

Check fetal heart tones. -A variation in fetal heart tones can occur due to a prolapsed umbilical cord. The risk of a prolapsed cord is increased with noncephalic presentations when the membranes are ruptured. Prolapse of the cord compromises circulation to the fetus.

Encourage the support person to apply sacral counterpressure. -Consistent pressure applied by the support person using the heel of the hand or fist against the client's sacral area will lift the fetal head off the spinal nerves and provide relief of the pain in the lower back.

A hematoma -A hematoma is a collection of blood in the connective tissue while the overlying skin or mucous membranes remain intact. Hematomas develop from injury to soft tissue in spontaneous deliveries, as well as forceps-and-vacuum-assisted deliveries. Small hematomas usually reabsorb on their own, but large ones might require incision and ligation of bleeding vessels.

I can breastfeed my baby even though I received this immunization. -According to the CDC, breastfeeding should not delay a client from receiving the rubella immunization.

Generalized petechiae -Are pinpoint round spots that appear on the skin, which can indicate a clotting factor deficiency or infection.

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Monitor intake and output. -The nurse should monitor intake and output because phototherapy can increase the rate of insensible water loss, which contributes to fluid loss and dehydration. The nurse should also monitor the newborns fontanels. Hydration is achieved by breastfeeding or formula feeding the newborn.

Position the client laterally. -Late decelerations occur because of uteroplacental insufficiency. First position the client in a lateral position to improve oxygenation to the fetus.

Respiratory rate 12/min -Respiratory depression is a manifestation of magnesium sulfate toxicity.

Encourage the client to listen to music -The nurse should implement nonpharmacological strategies to encourage relaxation and provide pain relief. There are a wide variety of cutaneous and sensory measures that are simple to implement during this stage of labor, such as music, rocking, breathing techniques, walking and application of hot and cold packs.

We will wash out newborn's face first. -Bathing should proceed from the cleanest part of the body to the most soiled areas. First, from the eyes and face, then to the trunk and extremities, and then to the diaper area to prevent the spread of infection or cross contamination.

I just want to stay in bed all day because nothing interest me anymore. -Feelings of sadness marked by loss of interest in usual activities can indicate depression, which is not a normal adaptation to pregnancy.

Count the radial pulse of the client while auscultating FHTs. -The nurse should count the client's radial pulse while auscultating FHTs to differentiate it from the fetal heart rate.

I will use a rear-facing car seat for my baby for the first 2 years. -Infants should travel in rear-facing car seats until the age of 2 years old or until the child reaches the height or weight requirements that are recommended by the manufacturer of the care seat.

I might notice a change in my skin coloring. -Skin pigmentation deepens during the second trimester of pregnancy due to actions of the melanocyte-stimulating hormone.

Tetanus-diphtheira-acellular pertussis (Tdap) vaccine. -The CDC recommends that clients who are pregnant should receive the Tdap and seasonal inactivated influenza vaccine with each pregnancy. Clients who are pregnant should avoid all live or live attenuated immunizations due to potential for teratogenic effects in the fetus.

History of migraine with aura. -Contain both estrogen and progestin. These hormones can cause an increase in the risk for thrombotic stroke for clients who have migraine w/aura. Safe for client to have migraines without aura to use a COC if they have no other contraindications, such as a history of estrogen-dependent tumors or coronary artery disease.

Position the client using the McRoberts maneuver. -Decreases shoulder dystocia. The nurse should flex the client's thighs sharply against their abdomen, with their legs apart, to straighten the sacral area and rotate the symphysis pubis toward the client's head.

Epigastric pain. -Indication of preeclampsia. Other indications of preeclampsia include abdominal pain, severe HA, HTN, polyuria, and proteinuria.

Change the newborn's position every 2hrs. -Reposition the newborn every 2-3hrs during phototherapy. This will maximize exposure of the skin to the light, enhancing the effectiveness of phototherapy.

Initiate continuous monitoring of the FHR. -Initiate continuous monitoring of the FHR and uterine activity using an external fetal monitor.

A chancre lesion appears within 90 day after infection during the primary stage. -The charge nurse should identify that a chancre is the primary lesion that occurs during a syphilis infection. This lesion appears within 90 days of exposure to the infection and begins as a painless papule, which then erodes into an ulcer.

Place the newborn skin to skin on the mother's chest. -Expected reference range is 36.5-37.5C (97.7-99.5F) for a newborn. This temperature indicates hypothermia. Hypothermia can lead to cold stress, causing tachypnea, decreased pulmonary perfusion, and hypoglycemia.

Urinary output. -Greatest risk for the client is coma and cardiac arrest if adequate perfusion and oxygenation are not achieved. The nurse should identify that a urinary output of at least 30 mL/hr. is the best indication of adequate perfusion and oxygenation. The nurse should insert an indwelling urinary catheter in a client who is experiencing manifestations of hypovolemic shock.

Hct 31% -Below the minimal expected value of greater than 33% during pregnancy. The nurse should report this finding to the provider as it is an indication of anemia.

Increased BUN. -Preeclampsia with severe features to exhibit an increase in BUN, or blood urea nitrogen. The increase is caused by a decreased glomerular filtration rate, secondary to impaired renal perfusion.

Warm the newborn's heel for 10mins prior to the puncture. -Warm heel for 5-10mins prior to puncture. Warming the heel causes vasodilation which enhances blood flow to the puncture site.

Platelet count 99,000/mm3. -A platelet count of 99,000/mm3, or thrombocytopenia, is an indication of HELLP syndrome, a serious complication of gestational HTN.

Glucose 35 mg/dL. -Reference range is 40-45 mg/dL for a newborn who is 24hrs old.

Count the respiratory rate for 60 seconds. -Newborn often have an irregular respiratory rate. Short periods of apnea, and shallow respirations are expected findings for a newborn. The nurse should also assess for symmetry of chest and abdominal movements during inhalation and exhalation.

Ulcerated lesions on the labia. -The nurse should identify that ulcerated lesions on the labia are an expected findings for a client who has genital herpes simplex virus. Other manifestations may include lymphadenopathy, itching, and dysuria.