Maternal/Newborn ATI Final REVIEW
What is the fourth stage of labor and when does it start?
Postpartum period- starts after the delivery of the placenta
What are the greatest risks during the postpartum period?
Hemorrhage
Shock
Infection
When is RH immune globulin (RhoGAM) administered to post partum women?
Administered 72 hours for women who are Rh-negative and gave birth to infants who
are Rh-positive
This prevents sensitization to Rh in future pregnancies
What is included in the postpartum nursing assessment?
Monitoring vital signs
Assessing uterine firmness & location in relation to umbilicus
Uterine position in relation to midline (if deviated, assist mom in emptying bladder)
Amount of vaginal bleeding (lochia)
How often should vitals be monitored after delivery?
Every 15 min for the first hour
Every 30 minutes for second hour
Every 4-8 hr depending on remaining medication regimen
This occurs with contractions of the uterine smooth muscle, whereby the uterus
returns to its pre-pregnant state
Involution
Defined as blood flow from the uterus during postpartum period
Lochia
This type of lochia is bright red in color, bloody consistency, fleshy odor, may
contain small clots
Lochia rubra
This type of lochia is pinkish brown in color & serosanguineous consistency
Lochia serosa
This type of lochia is yellowish, white creamy color, fleshy odor
Lochia alba
When is colostrum present in the new mother's breasts?
During pregnancy and 2-3 days immediately after birth
Defined as an infection in a milk duct of the breast with concurrent flulike
symptoms
Mastitis
What are therapeutic and approved holding positions when breast feeding?
Cradle hold
Side-lying hold
Football hold
What does breast feeding cause the release of? What does this prevent?
Breast feeding causes the release of oxytocin which stimulates uterine contractions (will
prevent hemorrhage)
,What are normal lab values in the post partum period?
Increased Hct & Hgb up to 72 hours
Leukocytosis (WBC count up to 20,000-25,000 for the first 10-14 days, without
presence of infection)
Increased coagulation factors
Increased fibrinogen
A medical condition during pregnancy defined as excessive nausea and vomiting
that is prolonged past 12 weeks of gestation. Results in weight loss & electrolyte
imbalance
Hyperemesis gravidarum
What are nursing responsibilities when caring for a patient diagnosed with
hyperemesis gravidarum?
Monitor client's I&O
Assess client's skin turgor/mucous membranes
Monitor vital signs
Monitor client's weight
Have client remain NPO for 24-48 hours
This medical condition occurs during pregnancy due to inadequacy in maternal
iron stores and consuming insufficient amounts of dietary iron
Anemia
This medical condition is defined as an impaired tolerance to glucose with the
first onset or recognition during pregnancy
Gestational diabetes mellitus
What is the ideal blood glucose level during pregnancy?
70-110mg/dL
What are the clinical manifestations of hypoglycemia?
Nervousness
Headache
Weakness
Irritability
Hunger
Blurred vision
Tingling of mouth/extremities
What are the clinical manifestations of hyperglycemia?
Thirst
Nausea
Abdominal pain
Frequent urination (diuresis)
Flushed dry skin
Fruity breath
What are the glucose levels that diagnostically, indicate gestational diabetes
mellitus?
Blood glucose screening of 130-140mg/dL or greater, indicating 3-hr oral glucose test is
indicated
, This disorder begins after the 20th week of pregnancy where BP s elevated at
140/90 mm Hg or greater recorded at least twice, 4-6 hours apart within a 1 week
period
Gestational hypertension (GH)
This disorder is defined as gestational hypertension with the addition of
proteinuria greater than 1+
Mild preeclampsia
This disorder is defined as maternal BP of 160/100 mm Hg or greater, protenuria
greater than 3+, oliguria, elevated Cr greater than 1.2mg/dLm visual disturbances,
hyperreflexia, pulmonary/cardiac involvement, extensive peripheral edema,
hepatic dysfunction & thrombocytopenia
Severe preeclampsia
This disorder is defined as severe preeclampsia symptoms along with the onset
of seizure activity or coma
Eclampsia
This syndrome of pregnancy is a variant of gestational hypertension in which
hematologic conditions coexist with severe preeclampsia involving hepatic
dysfunction
HELLP syndrome
H- hemolysis (anemia and jaundice)
EL- elevated liver enzymes (Elevated ALT/AST, nausea/vomiting)
LP- low platelets (thrombocytopenia, DIC)
What are antihypertensive medications that are approved to be taken during
pregnancy?
Methyldopa (Aldomet)
Nifedipine (Adalat, Procardia)
Hydralazine (Apresoline, Nesopresol)
Labetalol (Normodyne)
AVOID ACE INHIBITORS & ARBs
What is an anticonvulsant medication used during pregnancy?
Magnesium sulfate
What are signs of magnesium sulfate toxicity?
Absence of patellar deep tendon reflexes
Urine output less than 30mL/hr
Respirations less than 12/min
Decreased LOC
Cardiac dysrhythmias
If magnesium sulfate toxicity is suspected, what is the priority nursing action?
Discontinue infusion & administer antidote CALCIUM GLUCONATE. Also, prepare to
prevent respiratory/cardiac arrest
Including what vitamin in the diet will increase absorption of iron
supplementation?
Vitamin C
This syndrome results from the chronic or periodic intake of alcohol during
pregnancy; Alcohol is considered teratogenic
Fetal alcohol syndrome
What is the fourth stage of labor and when does it start?
Postpartum period- starts after the delivery of the placenta
What are the greatest risks during the postpartum period?
Hemorrhage
Shock
Infection
When is RH immune globulin (RhoGAM) administered to post partum women?
Administered 72 hours for women who are Rh-negative and gave birth to infants who
are Rh-positive
This prevents sensitization to Rh in future pregnancies
What is included in the postpartum nursing assessment?
Monitoring vital signs
Assessing uterine firmness & location in relation to umbilicus
Uterine position in relation to midline (if deviated, assist mom in emptying bladder)
Amount of vaginal bleeding (lochia)
How often should vitals be monitored after delivery?
Every 15 min for the first hour
Every 30 minutes for second hour
Every 4-8 hr depending on remaining medication regimen
This occurs with contractions of the uterine smooth muscle, whereby the uterus
returns to its pre-pregnant state
Involution
Defined as blood flow from the uterus during postpartum period
Lochia
This type of lochia is bright red in color, bloody consistency, fleshy odor, may
contain small clots
Lochia rubra
This type of lochia is pinkish brown in color & serosanguineous consistency
Lochia serosa
This type of lochia is yellowish, white creamy color, fleshy odor
Lochia alba
When is colostrum present in the new mother's breasts?
During pregnancy and 2-3 days immediately after birth
Defined as an infection in a milk duct of the breast with concurrent flulike
symptoms
Mastitis
What are therapeutic and approved holding positions when breast feeding?
Cradle hold
Side-lying hold
Football hold
What does breast feeding cause the release of? What does this prevent?
Breast feeding causes the release of oxytocin which stimulates uterine contractions (will
prevent hemorrhage)
,What are normal lab values in the post partum period?
Increased Hct & Hgb up to 72 hours
Leukocytosis (WBC count up to 20,000-25,000 for the first 10-14 days, without
presence of infection)
Increased coagulation factors
Increased fibrinogen
A medical condition during pregnancy defined as excessive nausea and vomiting
that is prolonged past 12 weeks of gestation. Results in weight loss & electrolyte
imbalance
Hyperemesis gravidarum
What are nursing responsibilities when caring for a patient diagnosed with
hyperemesis gravidarum?
Monitor client's I&O
Assess client's skin turgor/mucous membranes
Monitor vital signs
Monitor client's weight
Have client remain NPO for 24-48 hours
This medical condition occurs during pregnancy due to inadequacy in maternal
iron stores and consuming insufficient amounts of dietary iron
Anemia
This medical condition is defined as an impaired tolerance to glucose with the
first onset or recognition during pregnancy
Gestational diabetes mellitus
What is the ideal blood glucose level during pregnancy?
70-110mg/dL
What are the clinical manifestations of hypoglycemia?
Nervousness
Headache
Weakness
Irritability
Hunger
Blurred vision
Tingling of mouth/extremities
What are the clinical manifestations of hyperglycemia?
Thirst
Nausea
Abdominal pain
Frequent urination (diuresis)
Flushed dry skin
Fruity breath
What are the glucose levels that diagnostically, indicate gestational diabetes
mellitus?
Blood glucose screening of 130-140mg/dL or greater, indicating 3-hr oral glucose test is
indicated
, This disorder begins after the 20th week of pregnancy where BP s elevated at
140/90 mm Hg or greater recorded at least twice, 4-6 hours apart within a 1 week
period
Gestational hypertension (GH)
This disorder is defined as gestational hypertension with the addition of
proteinuria greater than 1+
Mild preeclampsia
This disorder is defined as maternal BP of 160/100 mm Hg or greater, protenuria
greater than 3+, oliguria, elevated Cr greater than 1.2mg/dLm visual disturbances,
hyperreflexia, pulmonary/cardiac involvement, extensive peripheral edema,
hepatic dysfunction & thrombocytopenia
Severe preeclampsia
This disorder is defined as severe preeclampsia symptoms along with the onset
of seizure activity or coma
Eclampsia
This syndrome of pregnancy is a variant of gestational hypertension in which
hematologic conditions coexist with severe preeclampsia involving hepatic
dysfunction
HELLP syndrome
H- hemolysis (anemia and jaundice)
EL- elevated liver enzymes (Elevated ALT/AST, nausea/vomiting)
LP- low platelets (thrombocytopenia, DIC)
What are antihypertensive medications that are approved to be taken during
pregnancy?
Methyldopa (Aldomet)
Nifedipine (Adalat, Procardia)
Hydralazine (Apresoline, Nesopresol)
Labetalol (Normodyne)
AVOID ACE INHIBITORS & ARBs
What is an anticonvulsant medication used during pregnancy?
Magnesium sulfate
What are signs of magnesium sulfate toxicity?
Absence of patellar deep tendon reflexes
Urine output less than 30mL/hr
Respirations less than 12/min
Decreased LOC
Cardiac dysrhythmias
If magnesium sulfate toxicity is suspected, what is the priority nursing action?
Discontinue infusion & administer antidote CALCIUM GLUCONATE. Also, prepare to
prevent respiratory/cardiac arrest
Including what vitamin in the diet will increase absorption of iron
supplementation?
Vitamin C
This syndrome results from the chronic or periodic intake of alcohol during
pregnancy; Alcohol is considered teratogenic
Fetal alcohol syndrome
