MATERNAL NEWBORN
MOM CARE:
A nurse is teaching about effective breastfeeding to a pt who is 3 days postpartum. Which of the
following info should the nurse include? –inform pt that milk will replace colostrum 3 to 4 days
postpartum, and breasts will feel firm and heavy. Continue to feed newborn on demand during this
period; breasts should feel soft after feeding; newborn should void 6-8 times a day and have at least 3
stools per day. It is not uncommon for breastfed newborns to have a stool with each feeding; newborn
should appear content after each feeding.
A nurse is planning care for a pt who is in labor and is requesting epidural anesthesia for pain control.
Which of the following actions should the nurse include in the plan of care? –plan to position the pt
upright in order to allow the anesthetic solution to flow downward. If additional pain management is
needed for a c-section birth, the nurse can place pt supine with her head and shoulders elevated and at
a lateral tilt to increase perfusion to the fetus; plan to administer 500 to 1000 mL of lactated Ringer’s or
0.9% sodium chloride 15-30 minutes prior to the administration of the first dose of anesthetic solution in
order to decrease the maternal risk for hypotension; monitor pt’s BP every 5 minutes following the first
dose of anesthetic solution; NPO status not needed for this procedure.
A nurse is assessing a pt who is 12 hr postpartum. The pt’s fundus is 2 fingerbreadths above the
umbilicus, deviated to the right of the midline, and less firm than previously noted. Which action to
take? –assist the pt to the bathroom to void because a distended bladder inhibits the uterus from
contracting normally and can cause uterine atony.
A nurse is reviewing the medical record at 1800 for a pt who is at 34 weeks of gestation. Based on the
chart findings (Lecithin/sphingomyelin ration 1.4:1) the nursing plan of care should include what? –
administer terbutaline to stop contractions because the lab results indicate that the fetus’s lungs are not
mature enough for delivery.
A nurse is assessing a pt who is at 26 weeks of gestation. Which clinical manifestation needs to be
reported to provider? –decreased urine output, increased BP, proteinuria, and decreased fetal activity
which are indications of preeclampsia.
Normal clinical manifestations at 26 weeks gestation (don’t need to be reported)? –periodic numbness
of fingers during second and third trimesters; supine hypotension during second and third trimesters;
leukorrhea is expected during all stages of pregnancy. It is a white discharge that is a result of hormone
secretion during pregnancy.
A nurse is providing teaching to a pt about physiological changes that occur during pregnancy. The pt is
at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following pt
statements indicates understanding? –“I will likely need to use alternative positions for sexual
intercourse.” The weight gain of pregnancy will likely require alternative positions.
Recommended weight gain for pt who has a BMI in the expected reference range (18.5-24.9) is 25 to 35
lbs.
Recommended weight gain for pt who has BMI above expected reference range (25>) is 15 to 20 lb.
, A breast reduction does not prevent breast enlargement from happening during pregnancy.
Instruct pt that is at 8 weeks of gestation to increase her daily intake of? –iron. 27g/day for pregnant
women. Vitamin D intake is the same with pregnant or nonpregnant women (600 IU/day); calcium intake
is the same with pregnant or nonpregnant women (1300mg/day <19; 1000mg/day >19); Vitamin E
intake is the same with pregnant and nonpregnant women (15mg/day).
A nurse is assessing a pt who is in active labor and notes early decels in the FHR on the monitor. The pt is
at 39 weeks of gestation and is receiving a continuous IV infusion of oxytocin. Which action to take? –
continue monitoring the pt because these are considered benign. They occur due to the compression of
the fetal head during contractions, vaginal exams, and pushing during the second stage of labor. No
intervention is necessary.
A nurse is teaching a pt who has pregestational type 1 diabetes mellitus about management during
pregnancy. Which statement by pt indicates understanding? –“I will continue taking my insulin if I
experience nausea and vomiting to prevent hypoglycemic and hyperglycemic episodes during illness.”;
ensure pt avoids snacks and foods that are high in refined sugar; avoid exercise during periods of
hyperglycemia and when positive ketones are present; maintain fasting blood glucose level between 60
and 99mg/dL.
A nurse is providing discharge teaching to a pt who is postpartum. For which of the following clinical
manifestations should the nurse instruct the pt to monitor and report to the provider? –unilateral breast
pain. Chills, fever, and unilateral breast pain can be indications fo mastitis, an infection of the breast
tissue; report large amount of lochia and large clots; temperature of 100.4 or higher indicates infections;
Normal postpartum findings? –brownish-red discharge on day 5 (normal from days 3-10); temperature
lower than 100.4; persistent abdominal striae (stretch marks).
Adverse effect of carboprost (given for postpartum hemorrhage)? –hypertension (carboprost is a
vasoconstrictor); fever; nausea; diarrhea; headache; vomiting; chills.
Latent phase (1st) is characterized by? –cervical dilation of 0 to 3cm and contractions every 5 to 30 min
each lasting 30 to 45 seconds.
Active phase (2nd) is characterized by? –cervical dilation of 4 to 7cm and contractions every 3 to 5 min,
each lasting 40 to 70 seocnds.
Transition phase (3rd) is characterized by? –cervical dilation of 8 to 10 cm and contractions every 2 to 3
min, each lasting 45 to 90 seconds.
Descent phase is characterized by? –active pushing with contractions every 1 to 2 min, each lasting for
90 seconds.
Folic acid importance? –inform pt that neural tube defects are more common in newborns born to
mothers who had inadequate folic acid intake. Food sources of folic acid include fortified cereals and
grain products, oranges, artichokes, liver, broccoli, and asparagus.
Teaching about levonorgestrel contraception (plan B pill)? –take medication within 72 hours following
unprotected sex; Pt should be evaluated for pregnancy if she does not menstruate within 21 days
MOM CARE:
A nurse is teaching about effective breastfeeding to a pt who is 3 days postpartum. Which of the
following info should the nurse include? –inform pt that milk will replace colostrum 3 to 4 days
postpartum, and breasts will feel firm and heavy. Continue to feed newborn on demand during this
period; breasts should feel soft after feeding; newborn should void 6-8 times a day and have at least 3
stools per day. It is not uncommon for breastfed newborns to have a stool with each feeding; newborn
should appear content after each feeding.
A nurse is planning care for a pt who is in labor and is requesting epidural anesthesia for pain control.
Which of the following actions should the nurse include in the plan of care? –plan to position the pt
upright in order to allow the anesthetic solution to flow downward. If additional pain management is
needed for a c-section birth, the nurse can place pt supine with her head and shoulders elevated and at
a lateral tilt to increase perfusion to the fetus; plan to administer 500 to 1000 mL of lactated Ringer’s or
0.9% sodium chloride 15-30 minutes prior to the administration of the first dose of anesthetic solution in
order to decrease the maternal risk for hypotension; monitor pt’s BP every 5 minutes following the first
dose of anesthetic solution; NPO status not needed for this procedure.
A nurse is assessing a pt who is 12 hr postpartum. The pt’s fundus is 2 fingerbreadths above the
umbilicus, deviated to the right of the midline, and less firm than previously noted. Which action to
take? –assist the pt to the bathroom to void because a distended bladder inhibits the uterus from
contracting normally and can cause uterine atony.
A nurse is reviewing the medical record at 1800 for a pt who is at 34 weeks of gestation. Based on the
chart findings (Lecithin/sphingomyelin ration 1.4:1) the nursing plan of care should include what? –
administer terbutaline to stop contractions because the lab results indicate that the fetus’s lungs are not
mature enough for delivery.
A nurse is assessing a pt who is at 26 weeks of gestation. Which clinical manifestation needs to be
reported to provider? –decreased urine output, increased BP, proteinuria, and decreased fetal activity
which are indications of preeclampsia.
Normal clinical manifestations at 26 weeks gestation (don’t need to be reported)? –periodic numbness
of fingers during second and third trimesters; supine hypotension during second and third trimesters;
leukorrhea is expected during all stages of pregnancy. It is a white discharge that is a result of hormone
secretion during pregnancy.
A nurse is providing teaching to a pt about physiological changes that occur during pregnancy. The pt is
at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following pt
statements indicates understanding? –“I will likely need to use alternative positions for sexual
intercourse.” The weight gain of pregnancy will likely require alternative positions.
Recommended weight gain for pt who has a BMI in the expected reference range (18.5-24.9) is 25 to 35
lbs.
Recommended weight gain for pt who has BMI above expected reference range (25>) is 15 to 20 lb.
, A breast reduction does not prevent breast enlargement from happening during pregnancy.
Instruct pt that is at 8 weeks of gestation to increase her daily intake of? –iron. 27g/day for pregnant
women. Vitamin D intake is the same with pregnant or nonpregnant women (600 IU/day); calcium intake
is the same with pregnant or nonpregnant women (1300mg/day <19; 1000mg/day >19); Vitamin E
intake is the same with pregnant and nonpregnant women (15mg/day).
A nurse is assessing a pt who is in active labor and notes early decels in the FHR on the monitor. The pt is
at 39 weeks of gestation and is receiving a continuous IV infusion of oxytocin. Which action to take? –
continue monitoring the pt because these are considered benign. They occur due to the compression of
the fetal head during contractions, vaginal exams, and pushing during the second stage of labor. No
intervention is necessary.
A nurse is teaching a pt who has pregestational type 1 diabetes mellitus about management during
pregnancy. Which statement by pt indicates understanding? –“I will continue taking my insulin if I
experience nausea and vomiting to prevent hypoglycemic and hyperglycemic episodes during illness.”;
ensure pt avoids snacks and foods that are high in refined sugar; avoid exercise during periods of
hyperglycemia and when positive ketones are present; maintain fasting blood glucose level between 60
and 99mg/dL.
A nurse is providing discharge teaching to a pt who is postpartum. For which of the following clinical
manifestations should the nurse instruct the pt to monitor and report to the provider? –unilateral breast
pain. Chills, fever, and unilateral breast pain can be indications fo mastitis, an infection of the breast
tissue; report large amount of lochia and large clots; temperature of 100.4 or higher indicates infections;
Normal postpartum findings? –brownish-red discharge on day 5 (normal from days 3-10); temperature
lower than 100.4; persistent abdominal striae (stretch marks).
Adverse effect of carboprost (given for postpartum hemorrhage)? –hypertension (carboprost is a
vasoconstrictor); fever; nausea; diarrhea; headache; vomiting; chills.
Latent phase (1st) is characterized by? –cervical dilation of 0 to 3cm and contractions every 5 to 30 min
each lasting 30 to 45 seconds.
Active phase (2nd) is characterized by? –cervical dilation of 4 to 7cm and contractions every 3 to 5 min,
each lasting 40 to 70 seocnds.
Transition phase (3rd) is characterized by? –cervical dilation of 8 to 10 cm and contractions every 2 to 3
min, each lasting 45 to 90 seconds.
Descent phase is characterized by? –active pushing with contractions every 1 to 2 min, each lasting for
90 seconds.
Folic acid importance? –inform pt that neural tube defects are more common in newborns born to
mothers who had inadequate folic acid intake. Food sources of folic acid include fortified cereals and
grain products, oranges, artichokes, liver, broccoli, and asparagus.
Teaching about levonorgestrel contraception (plan B pill)? –take medication within 72 hours following
unprotected sex; Pt should be evaluated for pregnancy if she does not menstruate within 21 days
