NR 327 exam 2 study guide Verified
Questions and Answers
normal fetal HR - CORRECT ANSWER-110-160 beat/min
Accelerations in FHR - CORRECT ANSWER-■ Temporary increase -
■ Reassuring - no interventions
Early decelerations - CORRECT ANSWER-■ Normal - no interventions, expected
finding
■ Cause: compression of head on the pelvis
Late deceleration: response after contraction - CORRECT ANSWER-■Non-reassuring -
needs intervention
■ Interventions: side-lying position, fluids, d/c oxytocin, O2, notify the provider, palpate
uterus for tachysystole
■ Cause: uteroplacental insufficiency
Variable decelerations - CORRECT ANSWER-■ Requires intervention
■ Intervention: knee to chest position or side-side reposition, d/c oxytocin, O2,
notify provider
■ Cause: cord compression
VEAL CHOP MINE - CORRECT ANSWER-Menomic for decelerations
■ Variable Cord compression Move the patient
■ Early Head compression Identify labor progress
■ Accelearate Okay No action
■ Late Placental insufficiency Execute "STOP"
(stop
Pitocin, turn patient on side, O2 via face mask, plain IV fluid increased)
Fetal bradycardia - CORRECT ANSWER-FHR drops below 110 for at least 10 minutes
Fetal Bradycardia - Cause & Intervention - CORRECT ANSWER-■ Causes:
uteroplacental insufficiency, umbilical cord prolapses, maternal
hypotension, anesthetic meds mom received
■ Interventions: stop oxytocin, left side position, O2, notify provider
,Fetal tachycardia - CORRECT ANSWER-FHR increases above 160 for over 10 minutes
Fetal tachycardia - Cause & Intervention - CORRECT ANSWER-■ Causes: infection,
cocaine use, dehydration
■ Interventions: antipyretics, oxygen, IV fluid bolus
(B)UBBLE - CORRECT ANSWER-Breasts
(size, contour, asymmetry, engorgement, redness, nipples: cracking, inverted,
bleeding)
B(U)BBLE - CORRECT ANSWER-Uterus
(Fundal Height, Uterine Placement, and Consistency)
■ 2 hrs after birth- Fundus is between the umbilicus and the symphysis pubis
■ 6-12 hrs after birth the fundus usually is at the level of the umbilicus
■ The fundus progresses downward at a rate of 1 fingerbreadth (or 1 cm) per day
after childbirth
■ If the fundus is not firm gently message the uterus using a circular motion until it
becomes firm
BUB(B)LE - CORRECT ANSWER-Bladder
■ Assess the bladder for distention and adequate emptying after efforts to void
■ Note the location and condition of the fundus , a full bladder tends to displace
the uterus up and to the right
■ Be alert for signs of infection, including infrequent or insufficient voiding (less
than 200 ml)
BU(B)BLE - CORRECT ANSWER-Bowels and GI function
■ Spontaneous bowel movements may NOT occur for 2-3 days after giving birth b/c
of a decrease in muscle tone in the intestines during labor
■ Normal patterns of bowel elimination usually return within 8-14 days after birth
■ Inspect the woman's abdomen for distention, auscultate for bowel sounds in all 4
quadrants, & palpate for tenderness
■ Ask the woman if she has had a bowel movement or has passed gas since giving
birth
Lochia rubra - CORRECT ANSWER-Rubra- red 1-3 days
Reddish or red-brown vaginal discharge that occurs immediately after childbirth;
composed mostly of blood.
(COAT)
, Lochia serosa - CORRECT ANSWER-Serosa- pink 3-10 days
Lochia alba - CORRECT ANSWER-Alba- white 10-14 days
Lochia Scant - CORRECT ANSWER-The amount of lochia on the perineal pad is
described as follows:
Scant: 1-2-inch lochia stain or approx. a 10 mL loss
Lochia light - CORRECT ANSWER-The amount of lochia on perineal pad is described
as follows:
Light or small: an approx. 4-inch stain or a 10-25 mL loss
Lochia moderate - CORRECT ANSWER-The amount of lochia on the perineal pad is
described as follows:
Moderate: a 4-6-inch stain w/ an estimated loss of 25-50 mL
Lochia large or heavy - CORRECT ANSWER-The amount of lochia on the perineal pad
is described as follows:
Large or heavy: a pad is saturated within 1 hour after changing it
BUBB(L)E - CORRECT ANSWER-Lochia
■ the postpartum vaginal discharge that typically continues for 4-6 weeks after childbirth
■Report any abnormal findings, such as heavy, bright-red lochia w/ large tissue
fragments or a foul odor to the physician
■ Teach patient about frequent changing of perineal pads, continuous use of the
peribottle, and proper handwashing before & after changing the pad
BUBBL(E) - CORRECT ANSWER-Episiotomy/Perineum:
■ Inspect the episiotomy for irritation, ecchymosis, tenderness, hematomas
■ Assess for hemorrhoids
■ Redness, swelling , increased discomfort, or purulent drainage may indicate
infection
■ Ice can be applied to decrease comfort and reduce edema; sitz baths can also
promote comfort and perineal healing
Questions and Answers
normal fetal HR - CORRECT ANSWER-110-160 beat/min
Accelerations in FHR - CORRECT ANSWER-■ Temporary increase -
■ Reassuring - no interventions
Early decelerations - CORRECT ANSWER-■ Normal - no interventions, expected
finding
■ Cause: compression of head on the pelvis
Late deceleration: response after contraction - CORRECT ANSWER-■Non-reassuring -
needs intervention
■ Interventions: side-lying position, fluids, d/c oxytocin, O2, notify the provider, palpate
uterus for tachysystole
■ Cause: uteroplacental insufficiency
Variable decelerations - CORRECT ANSWER-■ Requires intervention
■ Intervention: knee to chest position or side-side reposition, d/c oxytocin, O2,
notify provider
■ Cause: cord compression
VEAL CHOP MINE - CORRECT ANSWER-Menomic for decelerations
■ Variable Cord compression Move the patient
■ Early Head compression Identify labor progress
■ Accelearate Okay No action
■ Late Placental insufficiency Execute "STOP"
(stop
Pitocin, turn patient on side, O2 via face mask, plain IV fluid increased)
Fetal bradycardia - CORRECT ANSWER-FHR drops below 110 for at least 10 minutes
Fetal Bradycardia - Cause & Intervention - CORRECT ANSWER-■ Causes:
uteroplacental insufficiency, umbilical cord prolapses, maternal
hypotension, anesthetic meds mom received
■ Interventions: stop oxytocin, left side position, O2, notify provider
,Fetal tachycardia - CORRECT ANSWER-FHR increases above 160 for over 10 minutes
Fetal tachycardia - Cause & Intervention - CORRECT ANSWER-■ Causes: infection,
cocaine use, dehydration
■ Interventions: antipyretics, oxygen, IV fluid bolus
(B)UBBLE - CORRECT ANSWER-Breasts
(size, contour, asymmetry, engorgement, redness, nipples: cracking, inverted,
bleeding)
B(U)BBLE - CORRECT ANSWER-Uterus
(Fundal Height, Uterine Placement, and Consistency)
■ 2 hrs after birth- Fundus is between the umbilicus and the symphysis pubis
■ 6-12 hrs after birth the fundus usually is at the level of the umbilicus
■ The fundus progresses downward at a rate of 1 fingerbreadth (or 1 cm) per day
after childbirth
■ If the fundus is not firm gently message the uterus using a circular motion until it
becomes firm
BUB(B)LE - CORRECT ANSWER-Bladder
■ Assess the bladder for distention and adequate emptying after efforts to void
■ Note the location and condition of the fundus , a full bladder tends to displace
the uterus up and to the right
■ Be alert for signs of infection, including infrequent or insufficient voiding (less
than 200 ml)
BU(B)BLE - CORRECT ANSWER-Bowels and GI function
■ Spontaneous bowel movements may NOT occur for 2-3 days after giving birth b/c
of a decrease in muscle tone in the intestines during labor
■ Normal patterns of bowel elimination usually return within 8-14 days after birth
■ Inspect the woman's abdomen for distention, auscultate for bowel sounds in all 4
quadrants, & palpate for tenderness
■ Ask the woman if she has had a bowel movement or has passed gas since giving
birth
Lochia rubra - CORRECT ANSWER-Rubra- red 1-3 days
Reddish or red-brown vaginal discharge that occurs immediately after childbirth;
composed mostly of blood.
(COAT)
, Lochia serosa - CORRECT ANSWER-Serosa- pink 3-10 days
Lochia alba - CORRECT ANSWER-Alba- white 10-14 days
Lochia Scant - CORRECT ANSWER-The amount of lochia on the perineal pad is
described as follows:
Scant: 1-2-inch lochia stain or approx. a 10 mL loss
Lochia light - CORRECT ANSWER-The amount of lochia on perineal pad is described
as follows:
Light or small: an approx. 4-inch stain or a 10-25 mL loss
Lochia moderate - CORRECT ANSWER-The amount of lochia on the perineal pad is
described as follows:
Moderate: a 4-6-inch stain w/ an estimated loss of 25-50 mL
Lochia large or heavy - CORRECT ANSWER-The amount of lochia on the perineal pad
is described as follows:
Large or heavy: a pad is saturated within 1 hour after changing it
BUBB(L)E - CORRECT ANSWER-Lochia
■ the postpartum vaginal discharge that typically continues for 4-6 weeks after childbirth
■Report any abnormal findings, such as heavy, bright-red lochia w/ large tissue
fragments or a foul odor to the physician
■ Teach patient about frequent changing of perineal pads, continuous use of the
peribottle, and proper handwashing before & after changing the pad
BUBBL(E) - CORRECT ANSWER-Episiotomy/Perineum:
■ Inspect the episiotomy for irritation, ecchymosis, tenderness, hematomas
■ Assess for hemorrhoids
■ Redness, swelling , increased discomfort, or purulent drainage may indicate
infection
■ Ice can be applied to decrease comfort and reduce edema; sitz baths can also
promote comfort and perineal healing
