Mother Baby exam 3 with verified
answers rated A+
A nurse is assessing a 2 1/2 yr old toddler at a well-child visit. Which finding should the nurse
report to the provider? - CORRECT ANSWER ✔✔The head circumference exceeds the chest
A nurse is providing education about developmental milestones of a toddler with a newly
licensed nurse. Sort milestones according to child's age: 12 or 24 months? - CORRECT ANSWER
✔✔12 months: build a tower of two blocks, drink from lidless cup, and place a block in a
container
24 months: run, kick a ball, walk up a couple of stairs, and eat with a spoon
A nurse is performing a developmental screening on an 18-month old. Which of the following
skills should the nurse expect the toddler to be able to perform? - CORRECT ANSWER ✔✔- A
nurse should expect a toddler who is 18 months can attempt to use a spoon and walk
independently
A nurse is providing teaching about growth and development characteristics with the guardian
of a toddler who is 2 years of age. Which statement by the guardian should the nurse identify
indicates an understanding? - CORRECT ANSWER ✔✔- "my child should be able to kick a ball"
Fetal Heart Tone guidelines - CORRECT ANSWER ✔✔- initial 10-20 min cont. FHR assessment on
entry into labor area
- complete prenatal and labor risk assessment on all clients
- intermittent auscultation every 30 mins during active for low risk and every 15 for high risk
- during 2nd stage of labor intermittent auscultation every 15 mins for low risk and 5 for high
risk
,Fetal heart tone - CORRECT ANSWER ✔✔Breech - FHR heart high in abdomen
Cephalic - heard lower
External monitoring - CORRECT ANSWER ✔✔- electronic fetal monitoring
- measures movement then calculates heart beat
- TOCO: measures contractions, placed on fundus (very top of uterus) doesn't tell us the
strength & pressure
- to measure strength, palpate, then use "mild, moderate, or strong" contractions
Primary objective for fetal heart tones - CORRECT ANSWER ✔✔Fetal oxygenation (decrease in
fetal heart tones)
Internal monitor criteria - CORRECT ANSWER ✔✔- ruptured membranes need to happen before
hand
- cervical dilation of at least 2 cm
- fetal present part low enough to allow placement of scalp electrode
- skilled practitioner available to insert spiral electrode
- IUPC, internal fetal scalp electrode through cervix, lives in amniotic fluid, gives pressure for
contractions, tells EXACTLY how strong they are
- use maybe if they've had a previous C section
Physiologic responses to labor : FETAL - CORRECT ANSWER ✔✔- FHR accelerations,
decelerations
- decrease in circulation or perfusion
- increase in arterial carbon dioxide pressure
- blood flow
- sinusoidal pattern could mean fetal ANEMIA, emergency C section
, Category patterns to determine fetal heart tones - CORRECT ANSWER ✔✔Category 1 - normal,
baseline, no late or variable declarations
Category 2 - require Eval, cont. surveillance, any fetal tachy or Brady sustained for at least 10
mins, Brady not accompanied by absent variability, minimal or marked variability (see if maybe
a change in position would help)
Category 3: abnormal , fetal bradycardia, recurrent late deceleration , recurrent variable
deceleration, declined or absent variability, sinusoidal pattern
Interventions for a category 3 pattern on fetal heart tones - CORRECT ANSWER ✔✔- notify
provider
- stop pitocin to decrease contractions & promote relaxation to help with blood flow to fetus
- turn or reposition on left or right or knee chest position (cord may be in the way)
- oxygen, if maternal oxygen sat is low, 10 L/min on a non breather, try to do this intervention
last because it causes more stress to mom (anxiety)
- increase IV fluid rate, get IV fluid bolus
- look for any underlying cause like fever, post term, pain meds, epidural?
- provide reassurance, if this doesn't work we may have to do a C section , let mom know
- modify pushing in the 2nd stage to improve fetal oxygenation
- document intervention and changes in FHR
- prepare for an expeditious surgical birth, let mom and other nurses in NICU know
Intrauterine resuscitation category 3 & we need to execute interventions? - CORRECT ANSWER
✔✔- reposition mother
- fluid bolus
- oxygen 10L/min on non rebreather mask
answers rated A+
A nurse is assessing a 2 1/2 yr old toddler at a well-child visit. Which finding should the nurse
report to the provider? - CORRECT ANSWER ✔✔The head circumference exceeds the chest
A nurse is providing education about developmental milestones of a toddler with a newly
licensed nurse. Sort milestones according to child's age: 12 or 24 months? - CORRECT ANSWER
✔✔12 months: build a tower of two blocks, drink from lidless cup, and place a block in a
container
24 months: run, kick a ball, walk up a couple of stairs, and eat with a spoon
A nurse is performing a developmental screening on an 18-month old. Which of the following
skills should the nurse expect the toddler to be able to perform? - CORRECT ANSWER ✔✔- A
nurse should expect a toddler who is 18 months can attempt to use a spoon and walk
independently
A nurse is providing teaching about growth and development characteristics with the guardian
of a toddler who is 2 years of age. Which statement by the guardian should the nurse identify
indicates an understanding? - CORRECT ANSWER ✔✔- "my child should be able to kick a ball"
Fetal Heart Tone guidelines - CORRECT ANSWER ✔✔- initial 10-20 min cont. FHR assessment on
entry into labor area
- complete prenatal and labor risk assessment on all clients
- intermittent auscultation every 30 mins during active for low risk and every 15 for high risk
- during 2nd stage of labor intermittent auscultation every 15 mins for low risk and 5 for high
risk
,Fetal heart tone - CORRECT ANSWER ✔✔Breech - FHR heart high in abdomen
Cephalic - heard lower
External monitoring - CORRECT ANSWER ✔✔- electronic fetal monitoring
- measures movement then calculates heart beat
- TOCO: measures contractions, placed on fundus (very top of uterus) doesn't tell us the
strength & pressure
- to measure strength, palpate, then use "mild, moderate, or strong" contractions
Primary objective for fetal heart tones - CORRECT ANSWER ✔✔Fetal oxygenation (decrease in
fetal heart tones)
Internal monitor criteria - CORRECT ANSWER ✔✔- ruptured membranes need to happen before
hand
- cervical dilation of at least 2 cm
- fetal present part low enough to allow placement of scalp electrode
- skilled practitioner available to insert spiral electrode
- IUPC, internal fetal scalp electrode through cervix, lives in amniotic fluid, gives pressure for
contractions, tells EXACTLY how strong they are
- use maybe if they've had a previous C section
Physiologic responses to labor : FETAL - CORRECT ANSWER ✔✔- FHR accelerations,
decelerations
- decrease in circulation or perfusion
- increase in arterial carbon dioxide pressure
- blood flow
- sinusoidal pattern could mean fetal ANEMIA, emergency C section
, Category patterns to determine fetal heart tones - CORRECT ANSWER ✔✔Category 1 - normal,
baseline, no late or variable declarations
Category 2 - require Eval, cont. surveillance, any fetal tachy or Brady sustained for at least 10
mins, Brady not accompanied by absent variability, minimal or marked variability (see if maybe
a change in position would help)
Category 3: abnormal , fetal bradycardia, recurrent late deceleration , recurrent variable
deceleration, declined or absent variability, sinusoidal pattern
Interventions for a category 3 pattern on fetal heart tones - CORRECT ANSWER ✔✔- notify
provider
- stop pitocin to decrease contractions & promote relaxation to help with blood flow to fetus
- turn or reposition on left or right or knee chest position (cord may be in the way)
- oxygen, if maternal oxygen sat is low, 10 L/min on a non breather, try to do this intervention
last because it causes more stress to mom (anxiety)
- increase IV fluid rate, get IV fluid bolus
- look for any underlying cause like fever, post term, pain meds, epidural?
- provide reassurance, if this doesn't work we may have to do a C section , let mom know
- modify pushing in the 2nd stage to improve fetal oxygenation
- document intervention and changes in FHR
- prepare for an expeditious surgical birth, let mom and other nurses in NICU know
Intrauterine resuscitation category 3 & we need to execute interventions? - CORRECT ANSWER
✔✔- reposition mother
- fluid bolus
- oxygen 10L/min on non rebreather mask
