Maternal Health ATI remediation
Accident/Error/Injury Prevention: Medical Conditions - care for patient with a seizure -
answer-Severe preeclampsia consists of bp greater than 160/110, proteinuria, oliguria,
elevated serum creatinine greater than 1.1, hyperreflexia, epigastric and right upper
quadrant pain, thrombocytopenia
-ecclampsia has severe ecclampsia manifestations with seizure activity as well
-HELLP sydrome: H - hemolysis resulting in anemia and jaundice; EL: elevated liver
enzmes resulting in elevated ALT or AST, epigastric pain, and N/V; LP - low platelets
resulting in thrombocytopenia, abnormal bleeding and clotting time
-nursing care for patient seizing: assess level of consiousness, obtain pulse ox, monitor
urine output and obtain a clearcatch urine sample to assess for proteinuria, obtain daily
weights, monitor VS carefully especially BP, encourgae lateral positioning, perfrom NST
and daily kick counts, monitor I&O
Reference:
Maternal Newborn Nursing Edition 10.0 Ch. 9
Ante/Intra/Postpartum and Newborn Care: Fetal assessment during labor - late
decelerations - answer-fetal heart monitoring can be done continuously with a
transducer across the moms abdomen
-heart rate is broken into a 3 tier system:
~catergory one which includes baseline HR of 110-160 bpm, moderate HR variability,
present or absent accelerations or early decelerations, no late or variable decelerations
~catergory 2: baseline is tachy or bradycardia, variability is either marked, absent, or
minimal, episodic or periodic decelerations are present, absense of induced
accelerations after fetal stimulation
~catergory 3: sinusoidal pattern, absent baseline variabilitty, recurrent late decels,
bradycardia
-late decelerations can happen because of uteroplacental insufficiency, maternal
hypotension, preeclampsia, placenta previa, abruptio placenta, late or post-term
pregnancies, maternal diabetes mellitus
-nursing interventions for late decels: place client in side lying position, increase IV fluid
rate, discontinue oxytocin, administer oxygen by mask at 8-10 L/min via nonrebreather
mask, elevate clients legs, notify provider, prepare for an assisted vag birth or cesarean
birth
Reference:
Maternal Newborn Nursing Edition 10.0 ch. 13
Developmental stages and transitions: Newborn assessment - expected physical
findings of a newborn - answerweight: 2500-4000 g (5.5-8.8 lb)
length: 45-55 cm (18-22 in)
RR: 30-60 breaths/min with short periods of apnea
HR: 110-160 bpm - assses apical rate
BP: 60--50
temp: 36.5-37.5 C (97.7-99.5 F)
, Maternal Health ATI remediation
skin: pink or acrocynatic with no jaundice, skin turgor is present, dry, soft, smooth,
lanugo (fine hair over body) is normal, vernix caseoa (protective, thick cheesy layer) is
normal
head: larger than chest by 2-3 cm, anterior fontanel should be palpated and
approximately 5 cm and diamond shaped, post fontanel is smaller and triangle shaped,
sutures should be palpable, seperated, and can be ovelapping, caput is normal
(swelling of sutures), cephalohematoma is normal and caused from trauma to head
during labor/delivery
eyes: symmetrical, blue or gra following birth, pupillary and red reflex are present
ears: cartilage is firm and well formed, newborn should respond to voices and other
sounds
nose: midline, flat, lack of bridge, some mucous but no drainage, obligate nose
breathers
mouth: lips are symmettrical, saliva should be scant, assess strength of suctioning,
epstein pearls (small white cyst like formations on the gums, tongue should move
symmetrically and not protrude, soft and hard palate should be intact
neck: short, thick, surrounded by skin folds ad exhibit no webbing
chest: barrel shaped, absense of retracions, breast nodules are 3-10 mm
abdomen: umbilical is odorless and exhibit no internal structures, bowel sounds are
present 1-2 hrs after birth
anogenital: anus is present, meconium passes 24-48 hrs after birth, testes should be
present in scrotum, vaginal blood tinged discharge is a normal finding
extremeties: symmetrical, full ROM, and spontaneous movements, asses for bow
legged, nail beds hsould be pink, no extra digits are found
Reference:
Maternal Newborn Nursing Edition 10.0 ch. 23
Grief and loss: Therapeutic communication - caring for a client following perinatal death
- answer-Patients door should be markd with symbol signifying death of newborn
-nurse should provide sympathetic and empathetic care
-different family and cultural variations can influence the meaning of loss to each
patient; every situation is unique and the nurse needs to refer to patients situations
individually
Reference:
Lowdermilk's Maternity and Women's Health care edition 11.0 Ch. 37
Nonpharmacological Comfort Interventions: Nursing care of newborns - minimizing pain
- answerWhen assessing an infant, it is important for the nurse to keep the patient in the
most comfortable of positions
when doing a heel prick on an infant, it is important to swaddle the infant and comfort
them if they show signs of agitation or irritation
Reference:
Maternal Newborn Nursing Edition 10.0 Ch. 27
Accident/Error/Injury Prevention: Medical Conditions - care for patient with a seizure -
answer-Severe preeclampsia consists of bp greater than 160/110, proteinuria, oliguria,
elevated serum creatinine greater than 1.1, hyperreflexia, epigastric and right upper
quadrant pain, thrombocytopenia
-ecclampsia has severe ecclampsia manifestations with seizure activity as well
-HELLP sydrome: H - hemolysis resulting in anemia and jaundice; EL: elevated liver
enzmes resulting in elevated ALT or AST, epigastric pain, and N/V; LP - low platelets
resulting in thrombocytopenia, abnormal bleeding and clotting time
-nursing care for patient seizing: assess level of consiousness, obtain pulse ox, monitor
urine output and obtain a clearcatch urine sample to assess for proteinuria, obtain daily
weights, monitor VS carefully especially BP, encourgae lateral positioning, perfrom NST
and daily kick counts, monitor I&O
Reference:
Maternal Newborn Nursing Edition 10.0 Ch. 9
Ante/Intra/Postpartum and Newborn Care: Fetal assessment during labor - late
decelerations - answer-fetal heart monitoring can be done continuously with a
transducer across the moms abdomen
-heart rate is broken into a 3 tier system:
~catergory one which includes baseline HR of 110-160 bpm, moderate HR variability,
present or absent accelerations or early decelerations, no late or variable decelerations
~catergory 2: baseline is tachy or bradycardia, variability is either marked, absent, or
minimal, episodic or periodic decelerations are present, absense of induced
accelerations after fetal stimulation
~catergory 3: sinusoidal pattern, absent baseline variabilitty, recurrent late decels,
bradycardia
-late decelerations can happen because of uteroplacental insufficiency, maternal
hypotension, preeclampsia, placenta previa, abruptio placenta, late or post-term
pregnancies, maternal diabetes mellitus
-nursing interventions for late decels: place client in side lying position, increase IV fluid
rate, discontinue oxytocin, administer oxygen by mask at 8-10 L/min via nonrebreather
mask, elevate clients legs, notify provider, prepare for an assisted vag birth or cesarean
birth
Reference:
Maternal Newborn Nursing Edition 10.0 ch. 13
Developmental stages and transitions: Newborn assessment - expected physical
findings of a newborn - answerweight: 2500-4000 g (5.5-8.8 lb)
length: 45-55 cm (18-22 in)
RR: 30-60 breaths/min with short periods of apnea
HR: 110-160 bpm - assses apical rate
BP: 60--50
temp: 36.5-37.5 C (97.7-99.5 F)
, Maternal Health ATI remediation
skin: pink or acrocynatic with no jaundice, skin turgor is present, dry, soft, smooth,
lanugo (fine hair over body) is normal, vernix caseoa (protective, thick cheesy layer) is
normal
head: larger than chest by 2-3 cm, anterior fontanel should be palpated and
approximately 5 cm and diamond shaped, post fontanel is smaller and triangle shaped,
sutures should be palpable, seperated, and can be ovelapping, caput is normal
(swelling of sutures), cephalohematoma is normal and caused from trauma to head
during labor/delivery
eyes: symmetrical, blue or gra following birth, pupillary and red reflex are present
ears: cartilage is firm and well formed, newborn should respond to voices and other
sounds
nose: midline, flat, lack of bridge, some mucous but no drainage, obligate nose
breathers
mouth: lips are symmettrical, saliva should be scant, assess strength of suctioning,
epstein pearls (small white cyst like formations on the gums, tongue should move
symmetrically and not protrude, soft and hard palate should be intact
neck: short, thick, surrounded by skin folds ad exhibit no webbing
chest: barrel shaped, absense of retracions, breast nodules are 3-10 mm
abdomen: umbilical is odorless and exhibit no internal structures, bowel sounds are
present 1-2 hrs after birth
anogenital: anus is present, meconium passes 24-48 hrs after birth, testes should be
present in scrotum, vaginal blood tinged discharge is a normal finding
extremeties: symmetrical, full ROM, and spontaneous movements, asses for bow
legged, nail beds hsould be pink, no extra digits are found
Reference:
Maternal Newborn Nursing Edition 10.0 ch. 23
Grief and loss: Therapeutic communication - caring for a client following perinatal death
- answer-Patients door should be markd with symbol signifying death of newborn
-nurse should provide sympathetic and empathetic care
-different family and cultural variations can influence the meaning of loss to each
patient; every situation is unique and the nurse needs to refer to patients situations
individually
Reference:
Lowdermilk's Maternity and Women's Health care edition 11.0 Ch. 37
Nonpharmacological Comfort Interventions: Nursing care of newborns - minimizing pain
- answerWhen assessing an infant, it is important for the nurse to keep the patient in the
most comfortable of positions
when doing a heel prick on an infant, it is important to swaddle the infant and comfort
them if they show signs of agitation or irritation
Reference:
Maternal Newborn Nursing Edition 10.0 Ch. 27
