Nursing Interventions And Assessments In
Maternity Care 2025
Labor Management and Interventions
Managing Leg Cramps in Labor
A 28-year-old client in active labor may experience leg cramps due
to increased pressure and changes in circulation.
The recommended intervention is to extend the leg and dorsiflex
the foot (Option B) to relieve the cramp effectively.
Massaging the calf and foot (Option A) can provide temporary
relief but may not address the underlying issue.
Lowering the leg off the side of the bed (Option C) may not be
effective and could increase discomfort.
Elevating the leg above the heart (Option D) is not advisable as it
may exacerbate the cramping sensation.
Breathing Techniques and Complications
During labor, clients may use accelerated blow breathing to
manage pain, but it can lead to hyperventilation.
Symptoms of hyperventilation include tingling fingers and
dizziness, indicating the need for intervention.
The appropriate action is to have the client breathe into her cupped
hands (Option C) to restore normal carbon dioxide levels.
Administering oxygen (Option A) is not necessary unless the client
shows signs of severe distress.
, Notifying the healthcare provider (Option B) is premature unless
symptoms persist.
Timing for Childbirth Preparation Classes
The optimal time for expectant parents to attend childbirth
preparation classes is around 30 weeks gestation (Option D).
Attending classes too early (e.g., 16 or 20 weeks) may lead to
forgetting important information by the time of delivery.
Classes at 24 weeks may be beneficial but could be too early for
practical application of skills learned.
The focus should be on ensuring parents feel prepared and
informed as they approach labor.
Newborn Assessments and Interventions
Fontanel Closure in Newborns
The anterior fontanel typically closes between 12 to 18 months
(Option D), while the posterior fontanel closes by the end of the
second month.
Understanding fontanel closure is crucial for assessing normal
growth and development in infants.
Delayed closure of fontanels can indicate underlying health issues,
such as hydrocephalus or malnutrition.
Parents should be educated on the significance of fontanel
monitoring during pediatric visits.
Monitoring for Hemorrhage Post-C-Section
After a cesarean section, checking the firmness of the uterus every
15 minutes (Option D) is essential to prevent hemorrhage.
, A firm fundus indicates good uterine tone, while a boggy fundus
may suggest uterine atony and increased risk of bleeding.
Monitoring urinary output (Option A) and assessing dressings
(Option B) are also important but secondary to fundal assessment.
Administering IV fluids (Option C) may be necessary but does not
directly assess uterine tone.
Complications and Emergency Responses
Signs of Abruptio Placentae
Clients with suspected abruptio placentae may present with dark
red vaginal bleeding (Option A) and increased uterine irritability
(Option D).
Rigid abdomen (Option F) is a critical sign indicating potential
complications and requires immediate attention.
Lower back pain (Option B) and premature rupture of membranes
(Option C) may also be present but are less definitive.
Early recognition of these signs is vital for timely intervention and
management.
Assessing Newborns for Complications
Central cyanosis when crying (Option D) is a concerning finding
that should be reported immediately to the healthcare provider.
Other findings such as blood glucose levels or blood pressure may
require monitoring but are less urgent.
Assessing for jaundice (Option A) in a newborn with
cephalohematoma is important but not as critical as cyanosis.
Maternity Care 2025
Labor Management and Interventions
Managing Leg Cramps in Labor
A 28-year-old client in active labor may experience leg cramps due
to increased pressure and changes in circulation.
The recommended intervention is to extend the leg and dorsiflex
the foot (Option B) to relieve the cramp effectively.
Massaging the calf and foot (Option A) can provide temporary
relief but may not address the underlying issue.
Lowering the leg off the side of the bed (Option C) may not be
effective and could increase discomfort.
Elevating the leg above the heart (Option D) is not advisable as it
may exacerbate the cramping sensation.
Breathing Techniques and Complications
During labor, clients may use accelerated blow breathing to
manage pain, but it can lead to hyperventilation.
Symptoms of hyperventilation include tingling fingers and
dizziness, indicating the need for intervention.
The appropriate action is to have the client breathe into her cupped
hands (Option C) to restore normal carbon dioxide levels.
Administering oxygen (Option A) is not necessary unless the client
shows signs of severe distress.
, Notifying the healthcare provider (Option B) is premature unless
symptoms persist.
Timing for Childbirth Preparation Classes
The optimal time for expectant parents to attend childbirth
preparation classes is around 30 weeks gestation (Option D).
Attending classes too early (e.g., 16 or 20 weeks) may lead to
forgetting important information by the time of delivery.
Classes at 24 weeks may be beneficial but could be too early for
practical application of skills learned.
The focus should be on ensuring parents feel prepared and
informed as they approach labor.
Newborn Assessments and Interventions
Fontanel Closure in Newborns
The anterior fontanel typically closes between 12 to 18 months
(Option D), while the posterior fontanel closes by the end of the
second month.
Understanding fontanel closure is crucial for assessing normal
growth and development in infants.
Delayed closure of fontanels can indicate underlying health issues,
such as hydrocephalus or malnutrition.
Parents should be educated on the significance of fontanel
monitoring during pediatric visits.
Monitoring for Hemorrhage Post-C-Section
After a cesarean section, checking the firmness of the uterus every
15 minutes (Option D) is essential to prevent hemorrhage.
, A firm fundus indicates good uterine tone, while a boggy fundus
may suggest uterine atony and increased risk of bleeding.
Monitoring urinary output (Option A) and assessing dressings
(Option B) are also important but secondary to fundal assessment.
Administering IV fluids (Option C) may be necessary but does not
directly assess uterine tone.
Complications and Emergency Responses
Signs of Abruptio Placentae
Clients with suspected abruptio placentae may present with dark
red vaginal bleeding (Option A) and increased uterine irritability
(Option D).
Rigid abdomen (Option F) is a critical sign indicating potential
complications and requires immediate attention.
Lower back pain (Option B) and premature rupture of membranes
(Option C) may also be present but are less definitive.
Early recognition of these signs is vital for timely intervention and
management.
Assessing Newborns for Complications
Central cyanosis when crying (Option D) is a concerning finding
that should be reported immediately to the healthcare provider.
Other findings such as blood glucose levels or blood pressure may
require monitoring but are less urgent.
Assessing for jaundice (Option A) in a newborn with
cephalohematoma is important but not as critical as cyanosis.
