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NSG222/ NSG 222 Exam 2: (New 2024/ 2025
Update) Family Nursing Review| Questions
and Verified Answers| 100% Correct| A
Grade– Herzing
QUESTION
assessments during first stage of labor** Answer:
- contractions (30- 60 min during latent, 15 - 30 min during active)
- status of membranes
- fetal heart rate
- fetal position and station
- pain level
- encourage breathing techniques
- educate on importance of positioning
QUESTION
labs assessed during first stage of labor (if not already done) Answer:
- urinalysis
- CBC
- syphilis
- HbsAg
- GBS
- HIV
- drug screen
QUESTION
What is the best position for the laboring mother?** Answer:
whatever is most comfortable for the mother, although research shows the upright position is best
QUESTION
transition phase of labor** Answer:
- occurs during last part of active labor when mother is 8- 10 cm dilated
- strong to very strong contractions every 2 - 3 min lasting 45 - 90 seconds
- check FHR every 15 - 30 min
- check mother's vital signs every 15 - 30 min
- check temperature q4h (q2h if ROM)
QUESTION
indications for induction of labor with Oxytocin (Pitocin) Answer:
- large fetus
- gestational age greater than 42 weeks
- maternal hypertension, diabetes, or lung disease
- spontaneous rupture of membranes without start of labor
QUESTION
amniotomy Answer: artificial rupture of membranes
QUESTION
nursing interventions during 4th stage of labor** Answer:
- support
- prevent hemorrhage (fundal massage if needed)
- small void amounts very fre- quently
- uterus displaced to the right
- bladder distention
QUESTION
diastasis recti Answer: separation of the abdominal muscles during pregnancy
QUESTION
contributing factors to postpartum diuresis** Answer:
- large amounts of fluid given during labor
- decreasing Oxytocin levels (antidiuretic)
- retention of extra fluids during pregnancy
- decreasing aldosterone
QUESTION
baby blues** Answer:
- mild postpartum mood disorder (anxiety, irritability, mood swings)
- normal response
- develops 2 - 4 days after birth
- peaks at 4 - 5 days after birth
- resolves by day 10 after birth (with restorative sleep)
QUESTION
phases of maternal adaptation Answer: Phase 1: Taking-In - dependent behavior, 1 - 2 days
Phase 2: Taking-Hold - more independent but accepts help, needs reassurance, lasts several weeks Phase 3: Letting Go - recognizes baby as separate from herself, re-establishes relationships with others
QUESTION
assessment of postpartum woman Answer: B: breasts U: uterus B: bladder B: bowels L: lochia E: episiotomy/perineum E: extremities (signs of DVT or PE) E: emotional status
QUESTION
When are assessments done postpartum?** Answer:
- first hour: every 15 minutes
- second hour: every 30 minutes
- first 24 hours: every 4 hours
- after 24 hours: every 8 hours
QUESTION
normal vital signs postpartum Answer:
- slight elevated temperature up to 100.4 for 24 hours
- 60 - 80 bpm (puerperal bradycardia)
- normal 12 - 20 respirations per minute
- normal BP
- pain level of 0 - 2/
QUESTION
when to call the medical provider after birth Answer:
- soaking a peripad in less than 1 hour
- redness of legs
- edema
- shortness of breath
- dizziness
- elevated temperature
- feelings of harming herself or the baby
QUESTION
Coombs test Answer:
- a test for the presence of anti-Rh factor antibodies in the blood
- given to women who are Rh- to see if they have developed antibodies when baby is Rh+
QUESTION
when to call the pediatrician Answer:
- signs of abdominal obstruction or infection
- temperature <97.5 or >100.
- excessive vomiting
- distended abdomen
- new pustules/blisters
- runny nose
- thrush
QUESTION
What 4 main changes occur for the newborn during the "golden hour?"
Answer:
- circulatory
- respiratory
- thermoregulation
- maintain normal blood sugar
QUESTION
ductus arteriosus** Answer: a blood vessel in a fetus that bypasses pulmonary circu- lation by connecting the pulmonary artery directly to the ascending aorta, closes within a few hours after birth
QUESTION
phases of labor** Answer:
- 1st Stage: 0 - 10cm (latent: 0 - 6cm dilation, active 6 - 10cm dilation)
- 2nd Stage: from 10cm to birth of newborn (up to 3 hours)
- 3rd Stage: separation and delivery of placenta (5-30 minutes)
- 4th Stage: from placental delivery to stabilization of mother (1-4 hours after birth)
QUESTION
What is determined by vaginal examination during labor?** Answer:
- cervical dilation
- cervical effacement (thinning)
- membranes intact/ruptured
- fetal descent
- fetal presentation
QUESTION
Nitrazine swab
QUESTION
fetal bradycardia Answer:
- heartrate < 110 for more than 10 minutes
- caused by epidural, hypoxia, or prolonged cord compression
QUESTION
fetal tachycardia Answer:
- heartrate > 160 for more than 10 minutes
- caused by asphyxia or stimulant use by mother
QUESTION
early decelerations - fetal heart rate Answer:
- lowest point of deceleration mirrors peak of contraction
- caused by compression of the head of the fetus
- no intervention is necessary as this is a normal finding
QUESTION
variable decelerations - fetal heart rate Answer:
- no correlation to contractions
- caused by cord compression
- shaped like u, v, w
- implement LION (left side lying, IV fluids, oxygen & d/c Oxytocin, notify provider)
QUESTION
late decelerations - fetal heart rate** Answer:
- decrease in fetal heartrate after con- traction
- caused by insufficiency of placenta or uterus
- implement LION (left side lying, IV fluids, oxygen & d/c Oxytocin, notify provider)
QUESTION
non-pharmacological interventions for labor** Answer:
- hydrotherapy
- ambulation/position change
- acupuncture
- imagery
- effleurage (superficial stroking of abdomen)
- massage
- controlled breathing
- heat therapy
QUESTION
pharmacological interventions for labor Answer:
- opioids (decreases FHR)**
- ataractics (decreases FHR)
- benzodiazepines (CNS depression)
QUESTION
regional anesthesia during labor Answer:
- epidural (continuous infusion in epidural space of "CAINE" & opioid)
- spinal block (injected into subarachnoid space can be "CAINE" & opioid or just "CAINE")
- patient-controlled epidural
Answer:
- first stool of the newborn
- greenish, black tarry stool
- passed within 1st 12 - 24 hours of birth
QUESTION
physical exam of newborn Answer:
- symmetric features
- patency of nose, ears, rectum
- genitalia normal
- intact back
- skin
QUESTION
newborn reflexes Answer:
- rooting
- sucking
- palmar grasp
- moro reflex (startle)
- Babinski (spread toes when stroking from heel to toes)**
QUESTION
signs of problem with newborn Answer:
- nasal flaring
- grunting
- cyanosis
- abnormal respiratory rate <30 or >60)
- abnormal heart rates (<110 or > 160)
- abnormal size of baby
QUESTION
APGAR**
Answer:
- Appearance (all pink, pink and blue, blue (pale))
- Pulse (>100, <100, absent)
- Grimace (cough, grimace, no response)
- Activity (flexed, flaccid, limp)
- Respirations (strong cry, weak cry, absent)
QUESTION
normal vital signs of newborn Answer:
- temperature: 36.5° to 37.5° C (97.7° to 99.1° F) axillary
- apical pulse: 110 to 160 bpm (100 bpm sleeping, 180 bpm crying)
- respirations: 30 to 60 breaths/min
QUESTION
gestational age Answer:
- preterm: <38 weeks
- term: 38 - 42 weeks
- postterm: >42 weeks
- postmature: >42 weeks with signs of placental aging
QUESTION
skin variations in newborns Answer:
- vernix: thick white coating
- lanugo: fine hair
- Mongolian spots: dark gray/purple spots
QUESTION
bottle feeding recommendations** Answer:
- feed every 3 - 4 hours
- feed for 30 minutes maximum
- frequent burping
- use semi-upright position
- intake should be 1.5- 2 oz/lb of body weight
QUESTION
breast feeding recommendations Answer:
- feed every 2 - 3 hours
- nurse 10 - 20 minutes per side
- milk is good for 4 hours at room temp
- milk is good for 4 days in fridge
- milk is good for 6 months in freezer
QUESTION
true labor** Answer:
- contractions with regular intervals (predictable)
- contractions gradually increase in frequency, duration, and intensity
- nothing mother does stops or controls the contractions
- contractions progress cervical dilation and thinning of cervix
QUESTION
false labor** Answer:
- contractions with irregular intervals
- change of position slows or stops contractions
- contractions soften cervix but DO NOT cause cervical dilation
QUESTION
Factors affecting labor Answer:
- presentation (part of fetus in pelvis first - cephalic, breech, or shoulder)
- position (relationship of presenting part of fetus to the maternal pelvis - LOP, LOA, ROP, ROA)
- station (presenting part of fetus compared to ischial spine - 4 to +4)
QUESTION
5 Ps of labor Answer:
- passageway (birth canal)
- passenger (fetus and placenta)
- powers (contractions)
- position (maternal)
- psychological response
QUESTION
position of fetus (what letters mean) Answer: 1st letter - presenting part of fetus tilted to what side of the maternal pelvis (Right or Left) 2nd letter - presenting part of the fetus (Occiput, Sacrum, Scapula) 3rd letter - location of presenting part of fetus compared to maternal pelvis (Anterior or Posterior)
- most common - LOP, LOA, ROP, ROA
QUESTION
Factors for a positive birth experience Answer:
- provide clear information
