MATERNAL NEWBORN ATI REMEDIATION
1. Medical Conditions: Priority Action for a Client Who is Having a Seizure
A. Airway breathing circulation (ABC) framework
-The ABC framework identifies, in order, the three basic needs for sustaining life
-An open airway is necessary for breathing, so it is the highest priority
-Breathing is necessary for oxygenation of the blood to occur
-Circulation is necessary for oxygenated blood to reach the body’s tissues
-The severity of manifestations should also be considered when determining
priorities. A severe circulation problem can take priority over a minor breathing
problem
-Some frameworks also include “D” for disability and “E” for exposure
B. Seizure Precautions
-Make sure rescue equipment is at the bedside including oxygen, an oral airway,
suction equipment, and padding for the side rails. Clients at high risk for
generalized seizures should have a saline lock in place for immediate access.
2. Fetal Assessment During Labor: Applying an External Transducer
A. Location of the fetus’s back to assess for fetal heart tones
-Vertex presentation: fetal heart tones should be assessed below the client’s
umbilicus in either the right or left lower quadrant of the abdomen
-Breech presentations: fetal heart tones should be assessed above the client’s
umbilicus in either the right or left upper quadrant of the abdomen
3. Fetal Assessment During Labor: Identifying the Steps of Leopold Maneuvers
A. Evidence-based practice
-Use current data to make informed clinical decisions to provide the best
practice. Best practice is determined by current research collected from several
sources that have desirable outcomes.
-Use knowledge of evidence-based practice to guide prioritization of care and
interventions (responding to clients experiencing would dehiscence or crisis).
For example, initiating CPR in the proper steps for a client experiencing cardiac
arrest
-Methods to promote evidence-based practice:
-Use a variety of sources of research
-Keep current on new research by reading professional journals and
collaborating with other nurses and professionals in other disciplines
-Change traditional nursing practice with new research-based practices.
B. Considerations
-Preparation of the client
-Ask the client to empty the bladder before beginning the assessment
, -Place the client in the supine position with a pillow under the head, and
have both knees slightly flexed
-Place a small, rolled towel under the client’s right or left hip to displace
the uterus off the major blood vessels to prevent supine hypotension
syndrome
-Ongoing care
-Identify the fetal part occupying the fundus. The head should feel
round, firm, and move freely. The breech should feel irregular and soft.
This maneuver identifies the fetal lie (longitudinal or transverse) and
presenting part (cephalic or breech).
-Locate and palpate the smooth contour of the fetal back using the palm
of one hand the irregular small parts of the hands, feet, and elbows using
the palm of the other hand. The maneuver validates the presenting part.
-Determine the part that is presenting over the true pelvis inlet by gently
grasping the lower segment of the uterus between the thumb and
fingers. If the head is presenting and not engaged, determine whether
the head is flexed or extended. This maneuver assists in identifying the
descent of the presenting part into the pelvis.
-Face the client’s feet and outline the fetal head using the palmar surface
of the fingertips on both hands to palpate the cephalic prominence. If
the cephalic prominence is on the same side as the small parts, the head
is flexed with vertex presentation. If the cephalic prominence is on the
same side as the back, the head is extended with a face presentation.
This maneuver identifies the fetal attitude.
-Interventions
-Auscultate the FHR post-maneuvers to assess the fetal tolerance to the
procedure
--Document the findings from the maneuvers
4. Contraception: Identifying Adverse Effects of Combined Oral Contraceptives
-Adverse effects include:
-Headache, nausea, breast tenderness, and breakthrough bleeding
-Estrogen can cause nausea, breast tenderness, fluid retention
-Progestin can cause increased appetite, fatigue, depression, breast tenderness,
oily skin and scalp, and hirsutism
5. Early Onset of Labor: Expected Outcomes of Betamethasone
-A glucocorticoid that is administered IM in two injections 24 hr. apart
-Requires 24 hr. to be effective
-Therapeutic action is to enhance fetal lung maturity and surfactant production in
fetuses between 24 to 34 weeks’ gestation
6. Bleeding During Pregnancy: Laboratory Testing for Suspected Placental Abruption
-Kleihauer-Betke Test- used to detect fetal blood in maternal circulation
1. Medical Conditions: Priority Action for a Client Who is Having a Seizure
A. Airway breathing circulation (ABC) framework
-The ABC framework identifies, in order, the three basic needs for sustaining life
-An open airway is necessary for breathing, so it is the highest priority
-Breathing is necessary for oxygenation of the blood to occur
-Circulation is necessary for oxygenated blood to reach the body’s tissues
-The severity of manifestations should also be considered when determining
priorities. A severe circulation problem can take priority over a minor breathing
problem
-Some frameworks also include “D” for disability and “E” for exposure
B. Seizure Precautions
-Make sure rescue equipment is at the bedside including oxygen, an oral airway,
suction equipment, and padding for the side rails. Clients at high risk for
generalized seizures should have a saline lock in place for immediate access.
2. Fetal Assessment During Labor: Applying an External Transducer
A. Location of the fetus’s back to assess for fetal heart tones
-Vertex presentation: fetal heart tones should be assessed below the client’s
umbilicus in either the right or left lower quadrant of the abdomen
-Breech presentations: fetal heart tones should be assessed above the client’s
umbilicus in either the right or left upper quadrant of the abdomen
3. Fetal Assessment During Labor: Identifying the Steps of Leopold Maneuvers
A. Evidence-based practice
-Use current data to make informed clinical decisions to provide the best
practice. Best practice is determined by current research collected from several
sources that have desirable outcomes.
-Use knowledge of evidence-based practice to guide prioritization of care and
interventions (responding to clients experiencing would dehiscence or crisis).
For example, initiating CPR in the proper steps for a client experiencing cardiac
arrest
-Methods to promote evidence-based practice:
-Use a variety of sources of research
-Keep current on new research by reading professional journals and
collaborating with other nurses and professionals in other disciplines
-Change traditional nursing practice with new research-based practices.
B. Considerations
-Preparation of the client
-Ask the client to empty the bladder before beginning the assessment
, -Place the client in the supine position with a pillow under the head, and
have both knees slightly flexed
-Place a small, rolled towel under the client’s right or left hip to displace
the uterus off the major blood vessels to prevent supine hypotension
syndrome
-Ongoing care
-Identify the fetal part occupying the fundus. The head should feel
round, firm, and move freely. The breech should feel irregular and soft.
This maneuver identifies the fetal lie (longitudinal or transverse) and
presenting part (cephalic or breech).
-Locate and palpate the smooth contour of the fetal back using the palm
of one hand the irregular small parts of the hands, feet, and elbows using
the palm of the other hand. The maneuver validates the presenting part.
-Determine the part that is presenting over the true pelvis inlet by gently
grasping the lower segment of the uterus between the thumb and
fingers. If the head is presenting and not engaged, determine whether
the head is flexed or extended. This maneuver assists in identifying the
descent of the presenting part into the pelvis.
-Face the client’s feet and outline the fetal head using the palmar surface
of the fingertips on both hands to palpate the cephalic prominence. If
the cephalic prominence is on the same side as the small parts, the head
is flexed with vertex presentation. If the cephalic prominence is on the
same side as the back, the head is extended with a face presentation.
This maneuver identifies the fetal attitude.
-Interventions
-Auscultate the FHR post-maneuvers to assess the fetal tolerance to the
procedure
--Document the findings from the maneuvers
4. Contraception: Identifying Adverse Effects of Combined Oral Contraceptives
-Adverse effects include:
-Headache, nausea, breast tenderness, and breakthrough bleeding
-Estrogen can cause nausea, breast tenderness, fluid retention
-Progestin can cause increased appetite, fatigue, depression, breast tenderness,
oily skin and scalp, and hirsutism
5. Early Onset of Labor: Expected Outcomes of Betamethasone
-A glucocorticoid that is administered IM in two injections 24 hr. apart
-Requires 24 hr. to be effective
-Therapeutic action is to enhance fetal lung maturity and surfactant production in
fetuses between 24 to 34 weeks’ gestation
6. Bleeding During Pregnancy: Laboratory Testing for Suspected Placental Abruption
-Kleihauer-Betke Test- used to detect fetal blood in maternal circulation
