VATI Maternal Newborn
What is abstinence syndrome?
Symptoms of drug withdrawal as a result of physical dependence of the mother
What are the indications for a non-stress test?
Pregnancy problems such as suspected intrauterine growth restriction (IUGR), maternal
diabetes, or when mother has twins in womb
Over how much time should morphine be administered over?
4-5 minutes to prevent hypotension and respiratory depression
A client who does not wish to breastfeed can alleviate engorgement and swelling
by wearing what type of bra?
Tight-fitting bra or breast binders to alleviate engorgement and swelling
A nurse is planning care for a client who has Hep B with jaundice. What
intervention should the nurse include in the plan?
Provide high-calorie, high protein diet. Clients w/ Hep B are at increased risk for
inadequate nutrition d/t N/V, anorexia, and fatigue
A nurse is caring for a client in active labor who has meconium staining of the
amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal
monitor. What action should the nurse perform?
Prepare equipment needed for newborn resuscitation
*endotracheal suctioning occurs if newborn has poor respiratory effort, decreased
muscle tone, and bradycardia after delivery
What is the Bishop score?
Used to determine maternal readiness for labor by evaluating whether the cervix is
favorable by rating the following: 1. dilation, 2. effacement, 3. cervical consistency, 4.
cervical position and 5. station of presenting part
A nurse in a clinic is providing education to a client at 32 weeks gestation who
has pruritis gravidarum. What should the nurse teach as the treatment.
Slightly increase exposure to sunlight b/c it can reduce itching. Pruritis gravidarum is a
condition of pregnancy that causes generalized itching without the presence of a rash
d/t stretching of the skin
For what clients is isotretinoin cream contraindicated in?
(Accutane).. Contraindicated in pregnant clients b/c it is teratogenic
What is the moro reflex?
startle reflex-initiated by clapping hands and infant will have symmetric movement of
arms and legs
How long does it take for respiratory depression to occur after an IV bolus of
morphine?
Can occur within 7 minutes after
What are characteristics of the fetus that are reviewed to determine the
biophysical profile (BPP) during an ultrasound?
-Fetal tone
-Relative FHR in relation to activity
-Fetal breathing movements
-Gross body movements (body and libms)
-Qualitative amniotic fluid volume
, A nurse is caring for a newborn with fetal alcohol syndrome. What clinical
findings should the nurse anticipate?
-Facial anomalies- eyes with epicanthal folds, strabismus, ptosis, mouth with a poor
suck, small teeth, cleft lip or palate,
-Deafness
-Heart defects -Developmental delays and neurological delays
-Growth retardation
-Sleep disturbance
A nurse is caring for a client who is in active labor with ROM. On assessment, the
nurse notes the client has extrusion of the umbilical cord at the vaginal introitus.
What is the priority nursing intervention?
Use a sterile gloved hand and apply finger pressure to elevate the presenting part of the
fetus. Compression of cord prevents adequate fetal blood flow and can cause anoxic
brain damage. Nurse should emergently elevate part of fetus that is compressing the
umbilical cord
A client complaining of pain or vaginal pressure and has a large amount of bright
lochia with a firm uterus likely has what?
A perineal laceration
What are the types of perineal lacerations?
1st degree-4th degree depending on size and depth of cut
1st degree-only perineal skin (skin between vaginal opening and rectum). Typically
heals on its own
4th degree-extends through anal sphincter and into mucous membrane lining rectum
A nurse notes late decelerations on the fetal monitor. What priority actions
should the nurse take?
-Monitor BP-Turn client onto side
-Administer IV fluids
-Discontinue oxytocin
-Give O2
-Prepare for delivery
What are the indications for an amniotomy?
Inducing or expediting labor or in anticipation of the placement of internal monitors
(uterine pressure catheters or fetal scalp electrodes)
Ptosis
Eyelid drooping. Upper eyelid is lower than it should be in infants and children (can
occur in one or both eyes)
When does breast engorgement occur and how should it be managed?
3-5 days after birth.
-Cold compresses applied AFTER breastfeeding
-Warm shower or warm compresses applied before breastfeeding can increase milk
flow and facilitate letdown reflex
-Applying a small amount of breast milk to sore nipples and letting them air dry after
feeding will soothe discomfort and promote healing (fats and protein in milk increase
healing of cracks and fissures that develop)
What is abstinence syndrome?
Symptoms of drug withdrawal as a result of physical dependence of the mother
What are the indications for a non-stress test?
Pregnancy problems such as suspected intrauterine growth restriction (IUGR), maternal
diabetes, or when mother has twins in womb
Over how much time should morphine be administered over?
4-5 minutes to prevent hypotension and respiratory depression
A client who does not wish to breastfeed can alleviate engorgement and swelling
by wearing what type of bra?
Tight-fitting bra or breast binders to alleviate engorgement and swelling
A nurse is planning care for a client who has Hep B with jaundice. What
intervention should the nurse include in the plan?
Provide high-calorie, high protein diet. Clients w/ Hep B are at increased risk for
inadequate nutrition d/t N/V, anorexia, and fatigue
A nurse is caring for a client in active labor who has meconium staining of the
amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal
monitor. What action should the nurse perform?
Prepare equipment needed for newborn resuscitation
*endotracheal suctioning occurs if newborn has poor respiratory effort, decreased
muscle tone, and bradycardia after delivery
What is the Bishop score?
Used to determine maternal readiness for labor by evaluating whether the cervix is
favorable by rating the following: 1. dilation, 2. effacement, 3. cervical consistency, 4.
cervical position and 5. station of presenting part
A nurse in a clinic is providing education to a client at 32 weeks gestation who
has pruritis gravidarum. What should the nurse teach as the treatment.
Slightly increase exposure to sunlight b/c it can reduce itching. Pruritis gravidarum is a
condition of pregnancy that causes generalized itching without the presence of a rash
d/t stretching of the skin
For what clients is isotretinoin cream contraindicated in?
(Accutane).. Contraindicated in pregnant clients b/c it is teratogenic
What is the moro reflex?
startle reflex-initiated by clapping hands and infant will have symmetric movement of
arms and legs
How long does it take for respiratory depression to occur after an IV bolus of
morphine?
Can occur within 7 minutes after
What are characteristics of the fetus that are reviewed to determine the
biophysical profile (BPP) during an ultrasound?
-Fetal tone
-Relative FHR in relation to activity
-Fetal breathing movements
-Gross body movements (body and libms)
-Qualitative amniotic fluid volume
, A nurse is caring for a newborn with fetal alcohol syndrome. What clinical
findings should the nurse anticipate?
-Facial anomalies- eyes with epicanthal folds, strabismus, ptosis, mouth with a poor
suck, small teeth, cleft lip or palate,
-Deafness
-Heart defects -Developmental delays and neurological delays
-Growth retardation
-Sleep disturbance
A nurse is caring for a client who is in active labor with ROM. On assessment, the
nurse notes the client has extrusion of the umbilical cord at the vaginal introitus.
What is the priority nursing intervention?
Use a sterile gloved hand and apply finger pressure to elevate the presenting part of the
fetus. Compression of cord prevents adequate fetal blood flow and can cause anoxic
brain damage. Nurse should emergently elevate part of fetus that is compressing the
umbilical cord
A client complaining of pain or vaginal pressure and has a large amount of bright
lochia with a firm uterus likely has what?
A perineal laceration
What are the types of perineal lacerations?
1st degree-4th degree depending on size and depth of cut
1st degree-only perineal skin (skin between vaginal opening and rectum). Typically
heals on its own
4th degree-extends through anal sphincter and into mucous membrane lining rectum
A nurse notes late decelerations on the fetal monitor. What priority actions
should the nurse take?
-Monitor BP-Turn client onto side
-Administer IV fluids
-Discontinue oxytocin
-Give O2
-Prepare for delivery
What are the indications for an amniotomy?
Inducing or expediting labor or in anticipation of the placement of internal monitors
(uterine pressure catheters or fetal scalp electrodes)
Ptosis
Eyelid drooping. Upper eyelid is lower than it should be in infants and children (can
occur in one or both eyes)
When does breast engorgement occur and how should it be managed?
3-5 days after birth.
-Cold compresses applied AFTER breastfeeding
-Warm shower or warm compresses applied before breastfeeding can increase milk
flow and facilitate letdown reflex
-Applying a small amount of breast milk to sore nipples and letting them air dry after
feeding will soothe discomfort and promote healing (fats and protein in milk increase
healing of cracks and fissures that develop)
