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Maternal Newborn Nursing Exam
Tubal Ligation
Understanding Tubal Ligation
Tubal ligation, also known as having your tubes tied or tubal sterilization, is a type of permanent birth control. During the procedure, the fallopian tubes are cut, tied, or blocked to permanently prevent pregnancy. Tubal ligation prevents an egg from traveling from the ovaries through the fallopian tubes and blocks sperm from traveling up the fallopian tubes to the egg. The procedure does not affect the menstrual cycle; it just prevents fertilization.
Client Understanding
A client who understands the teaching on tubal ligation would correctly state that "Ovulation will remain the same." This indicates that the client understands the procedure does not affect the normal ovulation process.
The other statements are incorrect: - "Premenstrual tension will no longer be present" is incorrect, as tubal ligation does not affect premenstrual symptoms. - "Hormone replacements will be needed following this procedure" is incorrect, as tubal ligation does not require hormone replacement therapy. - "My monthly menstrual period will be shorter" is incorrect, as tubal ligation does not affect the duration of the menstrual period.
Complications of Forceps-Assisted Birth
Facial Palsy
Difficult delivery, with or without the use of forceps, may lead to facial palsy (facial paralysis) in the newborn. Facial paralysis, especially noticeable when the infant cries, is typically observed 15 minutes after a forceps-assisted birth. This is an important complication of the birth method that the nurse should identify.
The other options are not direct complications of forceps-assisted birth: - Hypoglycemia is a metabolic complication, not specifically related to the birth method. - Polycythemia is an increase in red blood cells, which can occur in various situations, not just forceps-assisted birth. - Bronchopulmonary dysplasia is a chronic lung condition, not a direct complication of forceps-assisted birth.
Terbutaline for Preterm Labor
Side Effects of Terbutaline
Terbutaline (Brethine) is a beta-adrenergic agent used to treat preterm labor. These medications are associated with various side effects, including tachycardia, irregular pulse, myocardial ischemia, and pulmonary edema. Therefore, they should not be used in women with known or suspected heart disease.
Client Understanding
A client who understands the teaching on terbutaline would correctly state that "This medication could cause me to experience heart palpitations."
The other statements are incorrect: - "This medication could cause me to experience blurred vision" is not a common side effect of terbutaline. - "This medication could cause me to experience ringing in my ears" is not a common side effect of terbutaline. - "This medication could cause me to experience frequent urination" is not a common side effect of terbutaline.
Nonpharmacological Pain Management in
Labor
Promoting Client Comfort
Applying fundal pressure by pushing on the mother's abdomen in the direction of the birth canal can assist spontaneous vaginal birth, shorten the length of the second stage, and reduce the need for instrumental birth or cesarean section.
The other nursing actions are not as effective in promoting client comfort during labor: - Assisting the client into a squatting position may be helpful, but is not the most effective action mentioned. - Having the client lie in a supine position is not recommended, as it can reduce blood flow to the fetus.
- Encouraging the client to void every 6 hours is important, but does not directly promote comfort during contractions.
Trichomoniasis in Pregnancy
Symptoms of Trichomoniasis
Trichomoniasis is a sexually transmitted infection that can occur during pregnancy. Common symptoms include a characteristically yellowish-to-greenish, frothy, mucopurulent, copious, malodorous vaginal discharge.
The other adverse effects are not commonly associated with clomiphene citrate: - Tinnitus (ringing in the ears) is not a typical side effect. - Urinary frequency is not a common side effect. - Chills are not a common side effect.
Newborn Physical Assessment Findings
Chest Circumference
The nurse should expect the chest circumference of a newborn to be 2-3 cm (0.8-1.2 in) smaller than the head circumference. The average chest circumference is 30-33 cm (11.8-13 in), with a chest circumference less than or equal to 30 cm being a concern.
The other findings are not typical newborn physical assessment findings: - Bulging fontanels are not expected in a normal newborn. - Nasal flaring is not a normal newborn physical characteristic. - A length from head to heel of 40 cm (15.7 in) is longer than the average newborn length.
Care for Neonatal Abstinence Syndrome
Soothing Interventions
For a newborn with neonatal abstinence syndrome, the nurse should include swaddling the newborn in a flexed position with hands midline against the chest and legs loosely swaddled in lumbar flexion to decrease sensory stimulation. Other interventions to minimize environmental and physical stimulation include low lighting, low noise levels, and avoiding abrupt changes in the infant's environment. Gentle handling and holding the infant close to the body can increase the sense of security.
The other interventions are not appropriate for a newborn with neonatal abstinence syndrome: - Increasing visual stimulation can be overstimulating.
- Weighing the newborn every other day is not a recommended intervention.
- Discouraging parental interaction is not recommended, as parental involvement is important.
Management of Neonatal Hypoglycemia
Appropriate Nursing Actions
When a newborn of a mother with type 2 diabetes mellitus has a blood glucose level of 65 mg/dL at 6 hours of age, the nurse should reassess the blood glucose level prior to the next feeding. Obtaining a serum glucose level and feeding the newborn immediately are appropriate actions, but the nurse should first reassess the blood glucose level.
Administering 50 mL of dextrose solution IV is not the appropriate initial action, as the newborn is not severely hypoglycemic.
Exercise Safety During Pregnancy
Recommended Practices
The client statements that indicate an understanding of the teaching on exercise safety during pregnancy are: - "I should consume three 8-ounce glasses of water after I exercise." - "I will check my heart rate every 15 minutes during exercise sessions." - "I should rest by lying on my side for 10 minutes following exercise."
The other statements are not recommended: - Limiting hot tub use to 30 minutes after exercise is not necessary. - Limiting exercise sessions to 30 minutes in humid weather is not a recommended guideline.
Fetal Monitoring During Labor
Abnormal Contraction Duration
The charge nurse should instruct the staff to report contraction durations exceeding 90 seconds, as this is outside the normal range of 45-80 seconds. Contraction durations of 95 to 100 seconds are considered abnormal and should be reported to the provider.
The other findings are within the normal range and do not require reporting:
- Contraction frequency of 2 to 3 minutes apart is normal. - Absent early deceleration of the fetal heart rate is not necessarily a concerning finding. - A fetal heart rate of 140 beats per minute is within the normal range.
Risk Factors for Pelvic Inflammatory Disease
Sexually Transmitted Infection
The nurse should identify a history of chlamydia infection as a risk factor for developing pelvic inflammatory disease (PID). Pelvic inflammatory disease is often caused by sexually transmitted infections, such as chlamydia and gonorrhea.
The other findings are not direct risk factors for PID: - Recurrent cystitis is not a risk factor for PID. - Frequent alcohol use is not a risk factor for PID. - Use of oral contraceptives is not a risk factor for PID.
Urinary Tract Infection in Pregnancy
Immediate Intervention
A client's statement of "It burns when I urinate" at 37 weeks of gestation requires immediate intervention by the nurse. Burning or painful urination can be a symptom of a urinary tract infection, which is more common during pregnancy and requires prompt treatment.
The other client statements do not require immediate intervention: - Swollen feet can be a normal pregnancy symptom. - Missing a meal is not an urgent concern. - Seeing spots may or may not require immediate intervention, depending on the severity and other symptoms.
Car Seat Safety
Proper Car Seat Positioning
The parent's statement indicating an understanding of car seat safety is "I should position my baby's car seat at a 45-degree angle in the car." Positioning the car seat at a 45-degree angle helps support the baby's head and neck.
The other statements are not correct: - The car seat should be rear-facing until the baby is at least 12 months old and 20 pounds. - The harness should be snug in a slot at or below the baby's shoulders. - The retainer clip should be positioned at the baby's armpit level, not the abdomen.
Hemolytic Diseases in Newborns (HDN)
Genetic Causes of HDN
The most common genetic cause of HDN is when the mother is Rh-negative, and the father is Rh-positive. In this scenario, the baby's Rh factor can be positive, like the father's, which can lead to problems if the baby's red blood cells cross over to the Rh-negative mother. This usually happens at delivery when the placenta detaches.
Hyponatremia in Pregnancy
As a consequence of the physiological adaptation during pregnancy, there is a reduction in serum sodium of 3-6 mmol/L and a reduction in serum osmolality of 10 mOsm/kg. Hyponatremia is diagnosed if serum sodium is less than 135 mmol/L in non-pregnant individuals, but less than 130 mmol/L in pregnant women.
Respiratory Distress in Newborns
Sternal retraction is a common clinical sign of respiratory distress in premature infants. Frontal chest radiographs show increased, ill-defined central radiolucency over the lower chest, which correlates well with a curvilinear indentation seen on lateral views.
Magnesium Sulfate Toxicity
Symptoms of magnesium sulfate toxicity are seen with the following maternal serum concentrations: - Loss of deep tendon reflexes (9.6-12 mg/ dL) (> 7 mEq/L) - Respiratory depression (12-18 mg/dL) (> 10 mEq/L) - Cardiac arrest (24-30mg/dL) (> 25mEq/L)
Acyclovir for Genital Herpes
Acyclovir is used to treat infections caused by certain types of viruses, including cold sores around the mouth (caused by herpes simplex), shingles (caused by herpes zoster), and chickenpox. This medication is also used to treat outbreaks of genital herpes.
Amniocentesis Complications
Complications associated with amniocentesis include fetomaternal hemorrhage from a pierced placenta, amnionitis, preterm labor, and leakage of amniotic fluid.
Oxytocin Infusion for Labor Induction
Traditional protocols for oxytocin infusion regimens recommend increases of the infusion rate at 15-20 minute intervals. However, recent clinical studies agree that prolonged intervals of 30-40 or even 60 minutes are superior to shorter dosage intervals in terms of safety and efficacy.
Hemolytic Uremic Syndrome
E. coli can cause a severe complication called hemolytic uremic syndrome, which occurs most commonly in young children (age 5 and younger). This condition destroys platelets and red blood cells and leads to kidney failure.
Management of Late Decelerations During Labor
If a client experiences late decelerations of the fetal heart rate during labor, the nurse should place the client in the left lateral recumbent position. Increasing the rate of infusion of the maintenance IV solution is an appropriate action, and oxygen should be administered at a rate of 8 to 10 L/ min. The nurse should also discontinue the oxytocin infusion immediately.
Preeclampsia Management at Home
The client with mild preeclampsia should be instructed to check her urine for protein daily, as any amount of protein in the urine over 300 mg in one day may indicate preeclampsia.
Newborn Assessment Priorities
Based on the ABC rule, the nurse should assess the newborn with nasal flaring first, as this is a sign of potential breathing difficulty or respiratory distress.
Risk Factors for Postpartum Infection
A midline episiotomy places the client at risk for infection.
Management of Hypovolemic Shock
The nurse should insert an indwelling urinary catheter to monitor perfusion of the kidneys in a client experiencing hypovolemic shock.
Maternal Newborn Care
Intravenous Fluid Management
Provide additional or maintain existing IV infusion of lactated Ringer's solution or normal saline solution to restore circulatory volume. The woman should have two patent IV lines; insert a second IV infusion using a 16- to 18-gauge IV catheter. Give oxygen by nonrebreather face mask or nasal prongs at 8 to 10 L/ min.
Immunizations for Newborns
The nurse should inform the client that the newborn will receive the Hepatitis B immunization at birth, 1 to 2 months, and between 6 to 18 months. It is injected intramuscularly soon after birth.
Newborn Laboratory Findings
The nurse should report an abnormal WBC count (32,000/mm3) to the provider, as it often indicates the newborn's body is fighting an infection. The blood culture will determine if any bacteria can be grown in the blood.
Newborn Vital Signs and Interventions
If a newborn has a respiratory rate of 50/min, a heart rate of 130/min, and an axillary temperature of 36.1°C (97°F), the nurse should apply a cap to the newborn's head to decrease heat loss.
Phototherapy for Newborns
The nurse should ensure the newborn's eyes are closed beneath the shield during phototherapy to prevent damage to the retinas and corneas.
Care for Fetal Demise
The nurse should offer the parents the choice of holding the infant in their arms, as it can make the grieving process easier.
Misoprostol Administration
The nurse should instruct the client to stay in a side-lying position for 30 to 40 minutes after each dose of misoprostol. Oxytocin for induction of labor should be initiated no sooner than 4 hours after the last dose of misoprostol, following agency protocol.
Postterm Newborn Characteristics
The nurse should expect to find overgrown nails, abundant scalp hair, visible creases on palms and soles of feet, and minimal fat deposits in a postterm newborn.
Breastfeeding Education
The nurse should inform the client that freshly expressed or pumped breast milk can be stored in a deep freezer for up to 12 months.
Rh Immunization
The nurse should administer Rho(D) immune globulin to an Rh-negative mother who has an Rh-positive infant to prevent antibodies from forming.
Neonatal Abstinence Syndrome
The nurse should initiate seizure precautions for an infant showing signs of neonatal abstinence syndrome, such as irritability, seizures, hyperactivity, and exaggerated Moro reflex.
False Labor
The nurse should include that contractions during false labor become temporally regular, unlike true labor.
Epidural Analgesia Adverse Effects
The nurse should monitor for bilateral crackles as a potential adverse effect of epidural block with opioid analgesia.
Prenatal Laboratory Tests
The nurse should plan to conduct a 1-hour glucose tolerance test between 24 and 28 weeks of pregnancy to screen for gestational diabetes.
Bacterial Vaginosis Treatment
The nurse should expect to administer metronidazole (Flagyl) to treat bacterial vaginosis.
Breastfeeding Nipple Care
The nurse should ensure the newborn's mouth is wide open before latching to the breast to help decrease nipple discomfort.
Preterm Newborn Assessment
Lanugo
A preterm newborn at 32 weeks of gestation is expected to have sparse (thin) lanugo, which is the fine hair covering much of the body. This is in contrast to the minimal arm recoil, popliteal angle of less than 90 degrees, and creases over the entire sole, which are not expected findings in a preterm newborn at this gestational age.
Hypnosis for Labor Pain Control
Enhancing Relaxation and Diminishing Fear
Hypnosis techniques used for labor and birth place an emphasis on enhancing relaxation and diminishing fear, anxiety, and the perception of pain. Women using this technique report a greater sense of control over painful contractions and a higher level of satisfaction with their childbirth experience.
Focusing on Controlling Body Functions
The nurse should include information about focusing on controlling body functions as part of the teaching for a client who plans to use hypnosis to control labor pain. This is in contrast to the information about synchronized breathing, which is not required during hypnosis, and the statement that hypnosis does not work for controlling pain associated with labor, which is incorrect.
Maternal Hypotension and Fetal Heart Rate
Variability
Turning the Client to Her Side
If a nurse caring for a client in active labor observes a maternal blood pressure of 98/58 mmHg and minimal fetal heart rate variability on the fetal monitor following epidural placement, the appropriate action is to turn the client to her side before calling the healthcare provider. This action helps to improve maternal blood pressure and fetal well-being.
