final exam pt 3

Question 1

what complication is the mother at risk for after the delivery of a macrosomic fetus (>8.8 lb)?

Answer 1

uterine atony

Question 2

what are 4 classic signs of abruptio placentae?

Answer 2

• sudden vaginal bleeding
• abdominal pain
• uterine tenderness
• contractions

Question 3

why can we begin doing amniocentesis around 14 wk of gestation?

Answer 3

that is when amniotic fluid becomes available

Question 4

what type of patients are given Rh immunoglobulin (RhoGAM)?

Answer 4

Rh negative

Question 5

what is the priority nursing action following an amniotomy?

Answer 5

assess fetal HR

Question 6

when is a glucocorticoid injection given to mothers?

Answer 6

premature preterm rupture of membranes

Question 7

what is the focus of care for premature rupture of membranes prior to 32 weeks?

Answer 7

prolonging pregnancy to reduce risk of preterm complications

Question 8

what FHR pattern is suspected with umbilical cord compression?

Answer 8

variable decelerations

Question 9

what should the nurse do if the patient is experiencing hyperstimulation of the uterus due to oxytocin administration?

Answer 9

discontinue oxytocin

Question 10

what order would these events occur in:
- amenorrhea, lightening, Goodells sign and quickening ?

Answer 10

1. amenorrhea
2. Goodells sign
3. quickening
4. lightening

Question 11

what intervention should the nurse take to decrease the likelihood of hypotension caused by epidural anesthesia?

Answer 11

admin IV fluid bolus

Question 12

what complication is the priority of care for a macrosomic newborn whos mother has diabetes mellitus?

Answer 12

hypoglycemia

Question 13

what is the cause of newborn hypoglycemia?

Answer 13

hyperinsulinemia

Question 14

what actions can the nurse take to promote development for the preterm newborn?

Answer 14

• cluster care
• dimming lights
• use both hands to reposition
• prone position (promote flexion)

Question 15

what action should be taken first for late decelerations?

Answer 15

change position

Question 16

what indicates a reactive nonstress test?

Answer 16

2 qualifying accelerations (+15 bpm/15 secs) within 20-mins

Question 17

what is indicates a nonreactive nonstress test?

Answer 17

< 2 accelerations in 20 mins

Question 18

when is the FHR audible by doppler?

Answer 18

8 - 17 weeks

Question 19

what gestational parameter is lanugo an expected finding?

Answer 19

20 - 36 weeks

Question 20

when may quickening begin?

Answer 20

14-16 weeks

Question 21

what are 3 medications that are indicated for preterm labor?

Answer 21

• indomethacin
• magnesium sulfate
• terbutaline

Question 22

what is the priority for the newborn after assuring airway patency?

Answer 22

drying the baby’s skin

Question 23

what action should be taken first after the nurse observes the umbilical cord protruding from the vagina?

Answer 23

insert a gloved hand into the vagina to relieve pressure on the cord

Question 24

what is the priority assessment when admin magnesium sulfate?

Answer 24

resp rate

Question 25

how should fetal station of 0 be interpreted?

Answer 25

lowermost portion of the fetus is at level of the ischial spine

Question 26

what is the priority action for a mother 3 week postpartum who is feeling "down," no energy and wanting to cry?

Answer 26

ask about SI/HI wanting to harm newborn?

Question 27

when should nurse report contractions to the provider?

Answer 27

>90 sec

Question 28

what are some physical traits with postmature newborns?

Answer 28

- positive moro reflex - cracked, peeling skin - long, hard fingernails

Question 29

what education should be provided for the newly pregnant mother?

Answer 29

- expected/unexpected manifestations - postpartum care - newborn care - prenatal visit schedule - when to contact provider

Question 30

what nursing actions should be taken for those with severe preeclampsia?

Answer 30

- bed rest, quiet, nonstimulating - continuous fetal monitoring - daily weight - assess DTR Q1hr

Question 31

what is the priority nursing action following amniotomy?

Answer 31

assess FHR pattern

Question 32

what action should be taken for supine hypotension?

Answer 32

position client with one hip elevated

Question 33

why would a stat ultrasound be ordered for a patient who has reported heavy, red vaginal bleeding?

Answer 33

to determine the location of the placenta

Question 34

what is the priority action for the nurse for the newborn who is SGA?

Answer 34

monitor BG levels

Question 35

what is the priority nursing action for the patient who has saturated a perineal pad within 10 min?

Answer 35

massage the fundus

Question 36

what action should the nurse take to promote the emotional well being of a client who is having an inevitable abortion?

Answer 36

- offer option to view products of conception - possible grief responses - refer support group

Question 37

what is methylergonovine given to prevent?

Answer 37

pph

Question 38

why is ultrasound performed prior to an amniocentesis?

Answer 38

identify location of placenta and fetus

Question 39

what type of abortion is characterized by fetal death, but retained products of conception?

Answer 39

missed miscarriage

Question 40

what characterized an incomplete miscarriage?

Answer 40

passed some, but not all products

Question 41

what type of miscarriage is characterized by heavy bleeding, cervical dilation and often, ROM?

Answer 41

inevitable

Question 42

what type of miscarriage have all products of conception been expelled?

Answer 42

complete

Question 43

what FHR assessment should the nurse obtain prior to administration of spinal epidural anesthesia?

Answer 43

30 min EFM strip

Question 44

how can the nurse elicit a moro reflex?

Answer 44

- sharp clap near infant

Question 45

how should the client be positioned for fetal heart tone assessment?

Answer 45

head supported with pillow

Question 46

how can cold stress be prevented?

Answer 46

place newborn under radiant heat warmer

Question 47

what are expected findings of severe preeclampsia?

Answer 47

- headache - burred vision - photophobia - RUQ pain - +clonus - proteinuria