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Flashcards in labor & delivery Deck (7):
1

A mother delivered 5 days ago & who was Dx w/pregnancy induced HTN calls a triage nsg CO having the "worst" HA for the past two days and that everything looks "wavy." What is the NSG's priority & why?

Send ambulance d/t pt being at risk for Sz activity as PIH can progress to preeclampsia or eclampsia prior, during, or 10 days after delivery

2

What is the normal FHR:

120-160 BPM

3

The FHR is 188 BPM. This is an early sign of hypoxia. What are the NSG interventions?

Contact MD, have pt change positions, O2, IVF

4

A mother in her first trimester has just mentioned that she has been taking ACE inhibitors for the past couple of years. What is your priority intervention?

ACE inhibitors are a category X d/t causing teratogenic effects. Pts should be be switched to meds that are not teratogenic

5

A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the mother sits in a nearby chair. The mother states, “This is not my baby, and I do not want it.” After repositioning the child safely, the nurse should respond with which comment?

A: This is a common occurrence after birth, but you will come to accept the baby.

B: “Many women have postpartum blues and need some time to love the baby.”

C: “You seem upset. Tell me what the pregnancy and birth were like for you.”

D: “What a beautiful baby! Her eyes are just like yours and so is her smile.”

C: “You seem upset. Tell me what the pregnancy and birth were like for you.”


A nonjudgmental, open ended response facilitates dialogue between the client and the nurse. The other three options ignore the situation and the needs of the mother. Note that the correct answer is the only client-centered option that is directly associated with the given situation.

6

A nurse, during an assessment of a day-old newborn, notices that the breasts are enlarged bilaterally with a white, thin discharge. What action should the nurse perform next?

A: Obtain fluid to check for glucose by Dextrostix

B: Record the findings while thinking that they are "normal"

C: Ask about medications taken during pregnancy

D: Notify the health care provider within that shift

B: Record the findings as normal

Newborn infants of both sexes may have engorged breasts and may secrete milk during the first few days to weeks after birth.

7

A woman in labor calls a nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse should act based on knowledge that fetal monitoring must now assess for what complication?

A: Variable decels
B: Early decels
C: Periodic accels
D: Late accels

A: Variable decels

When the membranes rupture, there is increased risk initially of cord prolapse if the head is at a minus level. Fetal heart rate patterns may show variable decelerations, which require immediate nursing action to reposition the client, apply oxygen and notify the health care provider.