Maternal NB(18 actual expert
curated questions and answers |
Passed
Clara Guidry
Scenario 2
Assessment reveals a very distended bladder, displacing fundus 3
cm above the umbilicus and displaced to the patient's right
patient unable to void due to lingering effects of epidural. A
physician order is received to insert an indwelling urinary
catheter. SELECT THE FIRST TWO NURSING ACTIONS IN THE
ORDER THAT THEY SHOULD BE IMPLEMENTED:
1. Educate patient regarding indwelling urinary catheter
placement, Wash hands.
2 .Insert indwelling urinary catheter and connect to collection
bag, secure to patient's thigh.
3. Measure urine return in collection bag; Reassess uterine tone,
response to massage, level in relation to umbilicus, and position
in abdomen.
4. Reassess vaginal bleeding and presence for clots; change
underpads as needed.
5. Wash hands, document findings and completion of procedure.
Clara Guidry Scenario 3
Following indwelling urinary catheter placement, and upon
reassessment, bladder is non-distended, fundus is 1 cm. below
the umbilicus, beginning to firm up with massage, but bleeding
remains excessive with large clots continuing. Patient remains
pale and is anxious. SELECT THE FIRST TWO NURSING ACTIONS IN
THE ORDER THAT THEY SHOULD BE IMPLEMENTED:
,1. Reassess vital signs.
2. Set plain Lactated Ringers to Bolus rate on IV pump.
3. Administer Methergine 0.2 mg IM per healthcare provider order.
4. Assist healthcare provider with exam to assess for cervical or
vaginal lacerations/hematoma or retained placental pieces.
5. Anticipate laboratory studies: CBC, blood typing and
crossmatch, coagulation studies.
Clara Guidry Scenario 4
Further assessment: no cervical or vaginal lacerations;
coagulation studies are WNL, BP 84/56, P 114, R 24, SAO2 94%,
fundus firms with massage but otherwise boggy, excessive bright
red vaginal bleeding with large clots. Patient complains of feeling
more light-headed and is paler. Other registered nurses are caring
for the newborn and providing education and support to the
husband. SELECT THE FIRST TWO NURSING ACTIONS IN THE
ORDER THAT THEY SHOULD BE IMPLEMENTED:
1. Administer Oxygen via nonrebreather face mask at 10-12L/min
2.Assist healthcare provider with administration of misoprostol
(Cytotec) 1000 mcg rectally
3. Establish an additional IV line and anticipate additional
crystalloids (Lactated Ringer's), colloids (albumin), blood and
blood products
4. Continue to closely monitor vital signs, uterine fundus
tone/level and vaginal bleeding
5. Anticipate healthcare provider insertion of postpartum balloon
and/or return to operating room
Scenario 5
, Further assessment: BP 106/64, P. 86, R 22, SAO2 97%, fundus
firm, 2 cm below umbilicus, lochia moderate, no clots, patient is
alert and oriented, less pale, but too tired to breastfeed baby. She
expresses a concern about baby not being held or fed. SELECT
THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY
SHOULD BE IMPLEMENTED:
1. Use therapeutic communication/active listening to assess
patient's concerns and interest in pumping for colostrum
2. Consult Lactation Consultant or provide education to patient
and assist with pumping.
3. Discuss with patient's partner for willingness/interest to feed
baby colostrum.
4. Assist partner in feeding pumped colostrum and partner skin-
to-skin contact.
5. Assess patient's ability to hold infant and assist patient with
holding baby skin-to-skin after feeding for maternal-infant
bonding.
Stephanie Gold Scenario 1
The nurse completes an initial assessment. T 37.4 C, 99.3 F; Heart
rate 90, regular; RR 20, regular; BP 142/90 mmHg; FHR 145,
moderate variability, 2 accelerations to 160 in 20 minutes, no
decelerations. No contractions on electronic fetal monitoring or by
palpation. Abdomen soft but tender in right upper quadrant. Urine
negative for protein on dipstick. No vaginal bleeding or leaking of
fluid. No pedal edema. DTR +3 bilaterally. Repeat blood pressure
noted to be 144/90 mmHg. The HCP is notified of the assessment
and orders are received. SELECT THE FIRST TWO NURSING
ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:
1. Explain all plan of care to client and significant
other.Explanation of plan of care helps put client and significant
other at ease, decrease anxiety. The must be done first.
curated questions and answers |
Passed
Clara Guidry
Scenario 2
Assessment reveals a very distended bladder, displacing fundus 3
cm above the umbilicus and displaced to the patient's right
patient unable to void due to lingering effects of epidural. A
physician order is received to insert an indwelling urinary
catheter. SELECT THE FIRST TWO NURSING ACTIONS IN THE
ORDER THAT THEY SHOULD BE IMPLEMENTED:
1. Educate patient regarding indwelling urinary catheter
placement, Wash hands.
2 .Insert indwelling urinary catheter and connect to collection
bag, secure to patient's thigh.
3. Measure urine return in collection bag; Reassess uterine tone,
response to massage, level in relation to umbilicus, and position
in abdomen.
4. Reassess vaginal bleeding and presence for clots; change
underpads as needed.
5. Wash hands, document findings and completion of procedure.
Clara Guidry Scenario 3
Following indwelling urinary catheter placement, and upon
reassessment, bladder is non-distended, fundus is 1 cm. below
the umbilicus, beginning to firm up with massage, but bleeding
remains excessive with large clots continuing. Patient remains
pale and is anxious. SELECT THE FIRST TWO NURSING ACTIONS IN
THE ORDER THAT THEY SHOULD BE IMPLEMENTED:
,1. Reassess vital signs.
2. Set plain Lactated Ringers to Bolus rate on IV pump.
3. Administer Methergine 0.2 mg IM per healthcare provider order.
4. Assist healthcare provider with exam to assess for cervical or
vaginal lacerations/hematoma or retained placental pieces.
5. Anticipate laboratory studies: CBC, blood typing and
crossmatch, coagulation studies.
Clara Guidry Scenario 4
Further assessment: no cervical or vaginal lacerations;
coagulation studies are WNL, BP 84/56, P 114, R 24, SAO2 94%,
fundus firms with massage but otherwise boggy, excessive bright
red vaginal bleeding with large clots. Patient complains of feeling
more light-headed and is paler. Other registered nurses are caring
for the newborn and providing education and support to the
husband. SELECT THE FIRST TWO NURSING ACTIONS IN THE
ORDER THAT THEY SHOULD BE IMPLEMENTED:
1. Administer Oxygen via nonrebreather face mask at 10-12L/min
2.Assist healthcare provider with administration of misoprostol
(Cytotec) 1000 mcg rectally
3. Establish an additional IV line and anticipate additional
crystalloids (Lactated Ringer's), colloids (albumin), blood and
blood products
4. Continue to closely monitor vital signs, uterine fundus
tone/level and vaginal bleeding
5. Anticipate healthcare provider insertion of postpartum balloon
and/or return to operating room
Scenario 5
, Further assessment: BP 106/64, P. 86, R 22, SAO2 97%, fundus
firm, 2 cm below umbilicus, lochia moderate, no clots, patient is
alert and oriented, less pale, but too tired to breastfeed baby. She
expresses a concern about baby not being held or fed. SELECT
THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY
SHOULD BE IMPLEMENTED:
1. Use therapeutic communication/active listening to assess
patient's concerns and interest in pumping for colostrum
2. Consult Lactation Consultant or provide education to patient
and assist with pumping.
3. Discuss with patient's partner for willingness/interest to feed
baby colostrum.
4. Assist partner in feeding pumped colostrum and partner skin-
to-skin contact.
5. Assess patient's ability to hold infant and assist patient with
holding baby skin-to-skin after feeding for maternal-infant
bonding.
Stephanie Gold Scenario 1
The nurse completes an initial assessment. T 37.4 C, 99.3 F; Heart
rate 90, regular; RR 20, regular; BP 142/90 mmHg; FHR 145,
moderate variability, 2 accelerations to 160 in 20 minutes, no
decelerations. No contractions on electronic fetal monitoring or by
palpation. Abdomen soft but tender in right upper quadrant. Urine
negative for protein on dipstick. No vaginal bleeding or leaking of
fluid. No pedal edema. DTR +3 bilaterally. Repeat blood pressure
noted to be 144/90 mmHg. The HCP is notified of the assessment
and orders are received. SELECT THE FIRST TWO NURSING
ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:
1. Explain all plan of care to client and significant
other.Explanation of plan of care helps put client and significant
other at ease, decrease anxiety. The must be done first.
