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Maternity Nursing: Prioritizing
Care and Delegation
Maternity and Newborn Nursing
Priority and Delegation
Which client should the postpartum nurse assess first after receiving the a.m. shift report?
The client who is complaining of perineal pain when urinating.
Which newborn infant would warrant immediate intervention by the nursery nurse?
The 6-hour-old newborn whose respirations are 52.
The client in labor is showing late decelerations on the fetal monitor. Which intervention should the nurse implement first?
Place the client in the left lateral position.
The nurse walks into the client's room to check on the mother and her newborn. The client states another nurse just took her baby back to the nursery. Which intervention should the nurse implement first?
Determine whether the infant was returned to the nursery.
The nurse in the labor and delivery department is caring for a client whose abdomen remains hard and rigid between contractions and the fetal heart rate is 100. Which client problem is priority?
Risk for fetal demise.
The nurse working in a women's health clinic is returning telephone calls. Which client should the nurse contact first?
The 16-year-old client who is complaining of severe lower abdominal cramping.
The charge nurse has received laboratory results for clients on the postpartum unit. Which client would warrant intervention by the nurse?
The client whose serum glucose level is 280 mg/dL.
The nurse on the postpartum unit is administering a.m. medications. Which medication should the nurse administer first?
The sliding scale insulin to the client diagnosed with type 1 diabetes.
The labor and delivery nurse is performing a vaginal examination and assesses a prolapsed cord. Which intervention should the nurse implement first?
Place the client in the Trendelenburg position.
Which newborn infant would the nursery nurse assess first?
The 4-hour-old newborn delivered at 42 weeks' gestation.
Which antepartum client should the charge nurse assign to the most experienced nurse?
The 42-week gestation client who has been pushing for 4 hours and has yellow amniotic fluid.
A nurse has been floated from the medical unit to the postpartum unit. Which client should be assigned to this nurse?
The 23-hour postpartum client who is being discharged home this morning.
Which priority intervention should the nurse implement for the 38-week gestation client who is receiving epidural anesthesia?
Pre-hydrate the client with intravenous fluid.
The 28-year-old female client is being scheduled for an emergency appendectomy. Which priority question should the emergency department nurse ask the client?
"Is there any chance you are pregnant?"
Which client should the labor and delivery charge nurse assign to the most experienced nurse?
The client having a vaginal birth who has been pushing for 1 hour.
The female unlicensed assistive personnel (UAP) informs the nurse she has helped the 1-day postpartum client change her peri-pad three times in the last 4 hours. Which action should the nurse implement?
Go to the room and check the client immediately.
Which task should the postpartum nurse not delegate to the unlicensed assistive personnel (UAP)?
Instruct the UAP to administer Rhogam to the client who is Rh- negative.
Which behavior by the unlicensed assistive personnel (UAP) warrants immediate intervention by the postpartum nurse?
The UAP pushes the PCA button for the 8-hour post-op C-section client.
The charge nurse is making assignments on a postpartum unit that has two registered nurses (RNs), two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAPs). Which task/assignment is most appropriate?
Request the LPN to care for the client who is 6 hours postpartum who had eclampsia.
The nurse instructed the unlicensed assistive personnel (UAP) to provide a sitz bath to the postpartum client with hemorrhoids. Which priority intervention should the nurse implement?
Follow-up to ensure the UAP gave the sitz bath.
Which newborn should the charge nurse in the nursery assign to the licensed practical nurse (LPN)?
The 18-hour newborn whose mother was addicted to heroin.
Ethical Principles in Obstetric Care
Autonomy
The client in the obstetric (OB) clinic expresses concern that the judge is requiring her to get a contraceptive implant, stating that she does not think it is right. This requirement violates the ethical principle of autonomy, which is the right of the individual to make their own decisions about their healthcare.
Justice
The client's concern about the judge's requirement to get a contraceptive implant also relates to the ethical principle of justice, which is the fair and equitable treatment of all individuals. The client feels that the judge's decision is unjust and infringes on her right to make decisions about her own reproductive health.
Pregnancy-Induced Hypertension and Preeclampsia
When a client in labor is diagnosed with pregnancy-induced hypertension and preeclampsia, the nurse should implement the following interventions:
Monitor the intravenous (IV) magnesium sulfate. Check the client's telemetry monitor. Assess the client's deep tendon reflexes. Notify the nursery when delivery is imminent or has occurred.
The nurse should not administer furosemide (Lasix) intravenously, as this medication is not typically used in the management of preeclampsia.
Infant Abduction
If a father reports that someone has taken their newborn infant without knowing the code word, the nurse should first implement the action of paging a Code Pink, indicating an infant abduction. This alerts the entire hospital staff to the situation and allows for a coordinated response to locate the missing infant.
Postpartum Hip Pain
When a client who delivered twins 3 days ago calls the women's health clinic with complaints of hip pain that makes it difficult to walk, the nurse's best response is to state that this often occurs a few days after delivery and will go away with time. This acknowledges the client's concern while providing reassurance that the pain is a common postpartum experience.
Stillborn Infant
When a 36-week gestational client has just delivered a stillborn infant, the nurse should notify the hospital chaplain of the fetal demise. This allows the chaplain to provide spiritual support and guidance to the client and their family during this difficult time.
Suspected Abuse
If a nurse notices bruises on the abdomen and back of a client who is 20 weeks' gestation, the most appropriate response is to ask the client, "Do you feel safe in your home?" This open-ended question allows the client to share their experience without making assumptions and demonstrates the nurse's concern for the client's wellbeing.
Intoxicated Visitor
When a boyfriend who is acting erratically and smells of alcohol comes to the postpartum unit demanding his girlfriend's room number, the nurse should contact hospital security to come to the unit. This ensures the safety of the client and staff and allows the security team to address the situation appropriately.
The nurse should not inspect the client's surgical incision or check the client's pupillary response, as these are not relevant to the postpartum assessment.
Cultural Considerations
The nurse's action that warrants intervention by the charge nurse on the postpartum unit is offering the Muslim client a ham sandwich and salad for lunch. This demonstrates a lack of cultural awareness and sensitivity, as pork products are prohibited in the Muslim faith.
Infertility Concerns
When a female client in a free clinic states that she and her husband have been trying to have a baby for 6 years, the nurse's best response is, "You are concerned because you have not been able to get pregnant." This statement acknowledges the client's concern without making assumptions or providing unsolicited advice.
Labor and Delivery Assessment
The labor and delivery nurse should assess the client who is exhibiting early decelerations on the fetal monitor first, as this indicates potential fetal distress and requires immediate intervention.
Prenatal Screening
The pregnant client who warrants intervention by the nurse in the women's health clinic is the client who has 3+ proteins in her urine, as this may be a sign of preeclampsia and requires further evaluation and management.
Postpartum Fundal Assessment
If the nurse notes that the client's fundus is displaced laterally to the right 1 day postpartum, the nursing intervention that should be implemented first is to massage the client's fundus for 2 minutes. This helps to promote uterine involution and prevent postpartum hemorrhage.
Client Confidentiality
If the charge nurse notices that a client's chart has been left on the bedside table, the action they should implement first is to take the client's chart back to the nurse's station. This ensures the client's protected health information is secured and not accessible to unauthorized individuals.
Prenatal Chest X-Ray
When scheduling a 27-year-old female client for a chest x-ray, the nurse should ask the client, "Is there any chance you may be pregnant?" This
question helps to determine if the client is pregnant, as the radiation from the x-ray could potentially harm a developing fetus.
Medication Error Monitoring
If the clinical manager notes that a nurse on the postpartum unit has documented three medication errors in the last 2 months, the action they should implement first is to discuss the errors with the nurse to determine whether there is a medication system problem. This allows the manager to identify any underlying issues that may be contributing to the errors.
Newborn Reflexes
The newborn who would require immediate intervention by the nurse is the newborn whose toes flare out when the lateral heel is stroked, as this may indicate a neurological abnormality.
Disclosure of Paternity
If a postpartum client tells the nurse that her husband is not the father of her baby, the response that best supports the ethical principle of non- maleficence (do no harm) is, "How do you think your husband will feel if he knows he is not the father?" This response considers the potential emotional impact on the husband and avoids directly encouraging the client to disclose the information.
Modular Nursing
Modular nursing is a system of care delivery in which a nurse and a unlicensed assistive personnel (UAP) are assigned a group of postpartum clients. This allows for a more collaborative approach to client care, with the nurse and UAP working together to meet the clients' needs.
Medication Delivery System Transition
The action by the postpartum clinical manager that would be most effective in producing a smooth transition to a new medication delivery system is to have an open-door policy to discuss the change. This allows for open communication and the opportunity for staff to voice their concerns and questions, which can facilitate a more successful implementation of the new system.
Pica During Pregnancy
If a pregnant client at the women's health clinic hesitantly discloses that she is constantly craving and eating dirt, the nurse's first action should be to check the client's hemoglobin and hematocrit (H&H) levels. Pica, the craving and consumption of non-food items, can be a sign of iron deficiency anemia, which requires further evaluation and treatment.
Care for a Stillborn Infant
When a newborn infant dies in utero, the nurse should implement the following interventions:
Allow the mother to hold and cuddle the infant. Encourage the father to talk about his child to the nurse. Recommend to the parents that the child be cremated.
The nurse should avoid discouraging the client from giving the infant a name, as this can be an important part of the grieving process.
Nursing Interventions for Specific Conditions
Premenstrual Syndrome (PMS)
To address a client's concerns about severe PMS, the nurse should implement the following interventions:
Avoid simple sugars such as cakes and candy. Decrease the intake of foods high in salt. Adhere to a regular schedule for sleep.
The nurse should avoid recommending increased intake of colas, coffee, or red wine, as these may exacerbate PMS symptoms.
Vegan Diet during Pregnancy
When a pregnant client follows a vegan diet, the nurse should recommend the following intervention:
Recommend the client eat grains, legumes, and nuts daily.
The nurse should avoid suggesting the client eat eggs or discontinue the vegan diet, as these recommendations may not align with the client's personal preferences and beliefs.
Nursing Assignments and Delegation
Postpartum Unit Assignments
When making assignments on the postpartum unit, the charge nurse should assign the following clients to the medical-surgical nurse:
The patient who delivered 4 hours ago and is complaining of pain. The patient who is being discharged and needs discharge teaching about breastfeeding. The patient who is being treated for HELLP syndrome.
The charge nurse should not assign the patient who is 30 weeks' gestation on a fetal monitor or the patient who is gravida 8 and on a Pitocin drip to the
medical-surgical nurse, as these patients require more specialized postpartum care.
Delegation to Unlicensed Assistive Personnel (UAP)
The postpartum nurse should delegate the following task to the UAP:
Instruct the UAP to take the client whose fundus is not midline to the bathroom.
The nurse should avoid delegating tasks such as taking vital signs for a client with HELLP syndrome, assisting with breastfeeding, or administering Rhogam, as these require the nurse's specialized knowledge and skills.
Nursing Assessments and Interventions
Emergency Department Nurse's Intervention
When the emergency department nurse observes a motor vehicle accident (MVA) involving a pregnant driver, the nurse should implement the following intervention first:
Assess the driver for signs of trauma.
The nurse should prioritize the assessment of the pregnant driver's physical condition and potential injuries before determining the length of gestation or checking for fetal heart tones.
Human Papillomavirus (HPV) Infection in the Mouth
When a client reports an HPV infection in the mouth, the nurse's best response would be:
"This infection is on the rise from oral contact with a person who has the infection."
The nurse should avoid making assumptions about the client's sexual history or suggesting that the infection is only possible through oral sex.
Sexually Transmitted Diseases (STDs) Education
When teaching a health class for 14- to 18-year-old females about STDs, the nurse should include the following information:
The more sexual contacts an individual has both for oral sex and intercourse, the greater the probability that individual has of contracting an STD. The use of a condom during intercourse ensures that a sexually transmitted disease is not passed from one partner to the other.
Rhogam is typically administered to Rh-negative mothers when the infant is Rh-positive to prevent Rh-sensitization, so this medication order may require further clarification.
