ATI Capstone Maternal Newborn Pre-Assessment

ATI Capstone Maternal Newborn Pre-Assessment Severe preeclampsia symptoms with seizure activity or coma. Eclampsia A variant of gestational hypertension where hematologic conditions coexist with severe preeclampsia and hepatic dysfunction. HELLP syndrome Hypertension beginning after the 20th week of pregnancy with no proteinuria. Gestational Hypertension Impaired tolerance to glucose with the first onset or recognition during pregnancy. Gestational Diabetes Severe morning sickness with unrelenting, excessive nausea or vomiting that prevents adequate intake of food and fluids. Hyperemesis gravidum Hypertension beginning after the 20th week of pregnancy with 1 to 2+ proteinuria and a weight gain of more than 2 kg per week in the second and third trimesters. Mild preeclampsia 24-48 hours after birth: dependent, passive; focuses on own needs; excited, talkative taking in Focuses on family and individual roles. letting go 2nd-10th day postpartum, or up to several weeks: focuses on maternal role and care of the newborn; eager to learn; may develop blues. taking hold A postpartum client's fundus is firm, 3 cm above the umbilicus and displaced to the right. Which of the following interventions should the nurse take? Assist the client to void then reassess the fundus. Correct Displacement of the uterus is a sign of bladder distention. The nurse should assist the client to void then reassess the fundus Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent? Cold stress Correct The use of a radiant warmer following delivery prevents cold stress which can lead to increased metabolism and physiological demands. A client has been prescribed raloxiphine. As the nurse you know that raloxiphine is used to treat: b. Osteoporosis Correct Raloxiphine (Evista) is used to prevent and treat bone loss (osteoporosis) in women after menopause. It is not used for migraines, hypertension, or heart disease. A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action? Change the client's position. Late decelerations are associated with insufficient placental perfusion which requires immediate intervention to restore adequate blood flow. Changing the client's position will displace the weight of the uterus off of the vena cava and thus increase maternal circulation to the placenta. A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy? Maintain an eye mask over the newborn's eyes. CorrectThe nurse should maintain an eye mask over the newborn's eye to protect the corneas and retinas from phototherapy. A pregnant client's last menstrual period was May 4th, 2013. What is this client's estimated delivery date using Naegele's Rule? d. February 11, 2014 CorrectCorrect. The estimated date of birth is February 11th, 2014. To determine the due date using Naegele's rule, 3 months is subtracted from the date of the last menstrual period then 7 days and 1 year are added. A laboring client received meperidine IV one hour prior to delivery. Which of the following medications should the nurse have available to counteract the effects of this medication on the newborn? c. Naloxone is used to reverse the effects of narcotics such as demerol. A nurse has provided education to a client who has been prescribed oral contraception. Which of the following client statements indicates a need for further education? a. "If I miss three pills I will double up each day until back on schedule." In the event of a client missing a dose the nurse should instruct the client that if one pill is missed to take as soon as possible. If two or three pills are missed the client should follow the manufacturer's instructions and use an alternative form of contraception. A home care nurse is following up with a postpartum client. Which of the following is a risk factor that places this client at risk for postpartum depression? c. Hormonal changes with a rapid decline in estrogen and progesterone levels CorrectCorrect! Risk factors for postpartum depression include hormonal changes with a rapid decline in estrogen and progesterone levels; postpartum physical discomfort and/or pain; individual socioeconomic factors; decreased social support system; anxiety about assuming new role as a mother; unplanned or unwanted pregnancy; history of previous depressive episode; low self-esteem; and a history of domestic violence. A laboring client's membranes have just ruptured. What is the nurse's next action? Assess fetal heart rate pattern An antepartal client is Rh negative and understands that she will receive a RhoGAM injection during her pregnancy. The client asks the nurse if she will also receive a RhoGAM injection after the birth of her baby. The client will receive RhoGAM after the birth if blood tests are: