Maternal Newborn Practice B 2019 With Rationale
Vaginal Examination, umbilical cord protruding from vagina, action to take:
Apply internal upward pressure to the presenting part using 2 gloved fingers
Rational: Prolapse of the umbilical cord during labor can result in decreased perfusion
to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should
relieve the compression on the umbilical cord by applying upward internal pressure on
the presenting part with two gloved fingers. The nurse should not move their hand.
2hr postpartum, interventions during taking-hold phases of behavior adjustment:
Demonstrate to the client how to perform a newborn bath.
36 wk gestation, nonstress test:
"You will be offered orange juice to drink during the test."
Nutritional intake, 8 wk gestation, inc daily intake of:
Iron (Fe)
35 wk placenta previa, action to take:
Initiate continuous external fetal monitoring.
Rational: client who has a placenta previa and is actively bleeding is at an increased
risk for preterm labor and hemorrhage. The nurse should initiate interventions such as
bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-
being and the presence of contractions. The nurse should obtain IV access and monitor
laboratory values. Also, the nurse should implement interventions to prepare for an
emergency birth.
FHR, fetal position left occipital anterior, area to apply ultrasound transducer to
assess point of maximum intensity:
Left lower Quadrant
Admin of azithromycin, 16 wks gestation, positive chlamydia culture
Admin 1g orally NOW
Avail: 250mg tablets
How many tablets should the nurse admin?
1g into 1000 mg
1000mg/250mg=
4 tablets
Newborn undergoing phototherapy, tx hyperbilirubinemia, action to take:
Cover the newborns eyes while under the phototherapy light
Teaching about levonorgestrel contraception, info to include In teaching:
"You should take the med w/in 72hrs following unprotected sexual intercourse."
Rational: Levonorgestrel is an emergency contraceptive which inhibits ovulation to
prevent conception. The nurse should instruct the adolescent to take this medication as
soon as possible within 72 hr after unprotected sexual intercourse.
Teaching about family planning, new prescription for diaphragm:
"You should leave the diaphragm in place for at least 6hrs after intercourse."
22wks gestation, concern abt blotchy hyperpigmentation on forehead, action to
take:
, Explain to the client this is an expected occurrence.
Rational: Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown
hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most
often in dark-skinned women and is caused by an increase in melanotropin during
pregnancy. This condition appears after 16 weeks of gestation and increases gradually
until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client
that this is an expected occurrence which usually fades after delivery.
Teaching art preterm labor terbutaline, indication of understanding:
" I will have blood test b/c my potassium might dec."
Rational: a/e hypokalemia
Newborn assessment, client took SSRI during pregnancy, manifestation thats
identified as withdrawal:
Vomiting
Rational: Expected manifestations associated with fetal exposure to SSRIs include
irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last
2 days.
12hr old new born assessment, manifestation that requires intervention:
Substernal chest retractions while sleeping
Rational: Can indicate respiratory distress syndrome in newborn
Assess adaptation to pregnancy, "happy one minute & crying the next":
Emotional lability
Rational:
recognize and interpret the client's statement as an indication of emotional lability. Many
clients experience rapid and unpredictable changes in mood during pregnancy. Intense
hormonal changes may be responsible for mood changes that occur during pregnancy.
Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.
Antepartum unit, client thats priority:
A client who is at 34 wks gestation & reports epigastric pain
Rational: When using the urgent vs nonurgent approach to client care, the nurse should
assess the client who reports epigastric pain. Epigastric pain is a manifestation of
preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore,
the nurse should identify this client as the priority.
30 wks gestation, routine visit, finding to report:
Swelling of the face
Rational:
Swelling of the face, sacral area, and fingers can indicate gestational hypertension or
preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid
moves out of the intravascular compartment into the tissues, causing edema.
Discharge teaching for postpartum, manifestation to monitor & report:
Vaginal Examination, umbilical cord protruding from vagina, action to take:
Apply internal upward pressure to the presenting part using 2 gloved fingers
Rational: Prolapse of the umbilical cord during labor can result in decreased perfusion
to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should
relieve the compression on the umbilical cord by applying upward internal pressure on
the presenting part with two gloved fingers. The nurse should not move their hand.
2hr postpartum, interventions during taking-hold phases of behavior adjustment:
Demonstrate to the client how to perform a newborn bath.
36 wk gestation, nonstress test:
"You will be offered orange juice to drink during the test."
Nutritional intake, 8 wk gestation, inc daily intake of:
Iron (Fe)
35 wk placenta previa, action to take:
Initiate continuous external fetal monitoring.
Rational: client who has a placenta previa and is actively bleeding is at an increased
risk for preterm labor and hemorrhage. The nurse should initiate interventions such as
bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-
being and the presence of contractions. The nurse should obtain IV access and monitor
laboratory values. Also, the nurse should implement interventions to prepare for an
emergency birth.
FHR, fetal position left occipital anterior, area to apply ultrasound transducer to
assess point of maximum intensity:
Left lower Quadrant
Admin of azithromycin, 16 wks gestation, positive chlamydia culture
Admin 1g orally NOW
Avail: 250mg tablets
How many tablets should the nurse admin?
1g into 1000 mg
1000mg/250mg=
4 tablets
Newborn undergoing phototherapy, tx hyperbilirubinemia, action to take:
Cover the newborns eyes while under the phototherapy light
Teaching about levonorgestrel contraception, info to include In teaching:
"You should take the med w/in 72hrs following unprotected sexual intercourse."
Rational: Levonorgestrel is an emergency contraceptive which inhibits ovulation to
prevent conception. The nurse should instruct the adolescent to take this medication as
soon as possible within 72 hr after unprotected sexual intercourse.
Teaching about family planning, new prescription for diaphragm:
"You should leave the diaphragm in place for at least 6hrs after intercourse."
22wks gestation, concern abt blotchy hyperpigmentation on forehead, action to
take:
, Explain to the client this is an expected occurrence.
Rational: Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown
hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most
often in dark-skinned women and is caused by an increase in melanotropin during
pregnancy. This condition appears after 16 weeks of gestation and increases gradually
until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client
that this is an expected occurrence which usually fades after delivery.
Teaching art preterm labor terbutaline, indication of understanding:
" I will have blood test b/c my potassium might dec."
Rational: a/e hypokalemia
Newborn assessment, client took SSRI during pregnancy, manifestation thats
identified as withdrawal:
Vomiting
Rational: Expected manifestations associated with fetal exposure to SSRIs include
irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last
2 days.
12hr old new born assessment, manifestation that requires intervention:
Substernal chest retractions while sleeping
Rational: Can indicate respiratory distress syndrome in newborn
Assess adaptation to pregnancy, "happy one minute & crying the next":
Emotional lability
Rational:
recognize and interpret the client's statement as an indication of emotional lability. Many
clients experience rapid and unpredictable changes in mood during pregnancy. Intense
hormonal changes may be responsible for mood changes that occur during pregnancy.
Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.
Antepartum unit, client thats priority:
A client who is at 34 wks gestation & reports epigastric pain
Rational: When using the urgent vs nonurgent approach to client care, the nurse should
assess the client who reports epigastric pain. Epigastric pain is a manifestation of
preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore,
the nurse should identify this client as the priority.
30 wks gestation, routine visit, finding to report:
Swelling of the face
Rational:
Swelling of the face, sacral area, and fingers can indicate gestational hypertension or
preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid
moves out of the intravascular compartment into the tissues, causing edema.
Discharge teaching for postpartum, manifestation to monitor & report:
