Nursing: PN Maternal, Assessment Example

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Assessment

Safety and infection control

  1. What should the nurse teach the family about car seats?

Nurses should instruct parents regarding proper installation of an approved car safety seat. The infant should always be in the rear facing car seat from birth up to weighing 9.1 kg or (20lbs) and 1 year of age. After age 1 year toddlers should always ride in the rare and face front until they have attained the height and weight limit instructed by manufacturers of the equipment to do otherwise. Also, the car seat should be secured with straps provided in the rare seat with shoulder straps being securely tightened to avoid sagging or falling off.

  1. What are the signs and symptoms of abstinence withdrawal syndrome?

Signs and symptoms of abstinence withdrawal syndrome are tremors (trembling); irritability (excessive crying); sleep problems; high-pitched crying; tight muscle tone; hyperactive reflexes; seizures; yawning, stuffy nose, and sneezing; poor feeding and suck; vomiting; diarrhea; dehydration; sweating and fever or unstable temperature.

Health Promotion and Maintenance

  1. What kind of birth control would be contraindicated for bread feeding mother?

Birth control contraindicated includes contraceptive pills and intrauterine devices because breast feeding is a contraceptive in itself.

  1. List two contraindications to diaphragms?

Two contraindications to diaphragms use are history of toxic shock syndrome and frequent urinary tract infection.

  1. When should a woman be refitted for her diaphragm?

A woman should be refitted for a diaphragm after delivery of an infant.

Antepartum

  1. What is the definition for oligohydramnious?

Oligohydramious means less than normal amniotic fluid circulation within the membranes.

  1. What is the definition for polihydramnious?

Polihydramnious is excessive aminotic fluid circulating in the amniotic sac.

  1. How does the nurse determine the expected date of delivery or due date and what is it called?

The expected date of delivery is calculated by adding 14 days to the first day of the client’s last menstrual period plus 40 weeks or nine months. This is known as the EDD.

  1. What food contains a large amount of folic acid?

Foods that contain large amounts of folic acid are fresh green leafy vegetable, beans, whole whet bread, cereals, rice and pasta.

Physiological adaptation

  1. What are three physiological changes of pregnancy during the first trimester?

Three physiological changes of pregnancy are enlargement of the mammary glands; marked increase in the size of the uterus accompanied by quickening and cloasma

  1. Gestational diabetes is diagnosed with what test?

This is diagnosed using a glucose tolerance test (GTT).

  1. What are the risk factors from gestational diabetes?

The risk factors are obesity, maternal age older than 30 years; family history of diabetes and previous large still born.

  1. At what point should the mother feel her baby kicking and what this is called?

The fetus’ kicking should be felt between 12 – 16 weeks of gestation and this is called quickening.

  1. List at least five danger signs during pregnancy or symptoms the client should always report to the provider.

Danger symptoms and signs which should always be reported are bleeding, ruptured membranes; meconium stained liquor, prolapsed umbilical cord and severe frontal headaches with blurred vision.

Fill in the blanks

  1. If the Father of the infant is Rh positive and the mother Rh negative and the coombs test is positive an injection of RhoGram will be administered 28 week and within 72 hours of birth.

Complications of pregnancy

  1. List three signs of impending pregnancy induced hypertension.

Three signs are rapid weight gain, marked increase in blood pressure above normal levels and edema of extremities.

  1. The medication of choice to prevent seizures is magnesium sulfate.
  2. List three signs of magnesium sulfate toxicity.

They are decreased level of consciousness; urine output less than 30 mls per hour and respiration less than 12 breaths per minute.

  1. What patients are at highest risk for placenta abrupto and what are the symptoms?

Patients with HELP syndrome and gestational hypertension are at highest risk for abrupto placenta. The symptoms are pain in the lower abdomen and back accompanied by vaginal bleeding and irregular contractions

  1. Signs and symptoms of placenta previa and nursing actions

They are painless bright red vaginal bleeding before the onset of labor beginning in the second trimester of pregnancy after 24 weeks gestation. Nursing actions include monitoring the blood flow by counting the number of pads changed within twenty four hours and encouraging bed rest.

  1. What are the 4P’s of birth?

They are the passage; the passenger; powers of labor and psyche.

  1. How should the nurse assess uterine contractions?

This should be done by evaluating the strength, length and frequency of contractions.

  1. When the fetal head drifts into the material pelvis this is call engagement
  2. List and describe the four stage of labor and phases
  • First stage – Onset and cervix 1cm dilated -12 -18 hours
  • Latent phase – last about 30-45 sec when there is no pronounced dilatation of cervix and effacement.
  • Active phase-rapid dilatation of effacement cervix
  • Transition phase— Very tong contractions –patient is tired and restless.
  • Second stage – cervical os is fully effaced and dilated infant is delivered 30 minutes
  • Third stage- placental separation and delivery 15-30 minutes
  • Fourth stage – monitoring of vital signs and involution of uterus
  1. What is the most common adverse effect of epidural administration?

A common adverse effect of epidural is breathing disorders infants after delivery.

  1. Briefly describe early decelerations, late decelerations and variable decelerations. What nursing actions should be taken?

Early deceleration is when the fetus heart beat begins to decrease due to compression of the head within the pelvis. Late decelerations occurs when the fetal heart rate goes down long before the contraction begins and takes a long time to regain rhythm after it has passed. Variable deceleration is when there is an inconsistency in the fetal heart rate during labor. The nurse could change the position of the mother as well as administer oxygen.

  1. What is the purpose of an aminoinfusion?

The purpose is to increase intrauterine aminotic fluid

  1. What are some of the fetal risk associated with vacuum assisted delivery?

Some of the risks of vacuum assisted delivery are superficial scalp markings; subgaleal hematomas; cephalhematoma; intracranial and retinal hemorrhage.

  1. List two risk factors of cord prolapse.

Two risk factors are premature rupture of membranes with the fetal head not engaged and long umbilical cord.

Postpartun Nursing Care

  1. At what rate should involution occur?

Immediately after delivery of the third stage the uterus raises midway between the symphysis pubis and the umbilicus. Thereafter it falls back into the pelvis at the rate of one to two cm every twenty four hours.

  1. What is lochia called immediately after birth; 3-4 days following and 10 days later?

They are lochia ruba immediately after birth; lochia; lochia serosa pinkish 3-4 days after and lochia alba 10 days later- yellowish.

  1. Reason for deviation of fundus to the left?

This could be due to a distended full bladder.

  1. Uterine atony- What do you expect to see? What are your actions?

Uterine atony manifests as postpartun bleeding and loss of uterine muscle tone. Actions that can be taken are to elevate foot of the bed and treat as if shock is eminent. Monitor vital signs.

  1. What should you teach a bottle feeding mother about reducing the symptoms of breast encouragement?

She should wear a firm well fitted brassiere and express the milk manually or with a pump.

  1. What should the nurse teach the client about resuming sexual activity following child birth?

If the delivery was normal without episiotomy she should wait at least six weeks before returning to sexual activity in cases where episiotomy was done she should wait until it heals fully.

  1. List 5 factors that would increase the risk of postpartum infection.

Factors that increase the risk of postpartun infections include Improper care of the episiotomy; prolonged labor; anemia; frequent vaginal examinations during labor; C- Section.

  1. List the four most common types of postpartun hemorrhage.

Four types of postpartun hemorrhage are primary/ secondary, atonic, traumatic and mixed.

  1. List four risk factors for post partum hemorrhage.

They are uterine atony; pelvic infection, retained placental products and uterine lacerations.

  1. What are the signs and symptoms of postpartum depression? What are the risk factors and what are the interventions?

The symptoms include persistent feeling of sadness and intense mood swings. The risk factors are decreased social support; anxiety on becoming a new mother; hormonal changes; physical discomfort of pueripueriun. Nursing interventions include encouraging mother to notify primary care physician regarding feelings; reinforcing that it is a normal feeling which should subside and provide information of agencies which support mother suffering from postpartum depression.

Interventions

  1. How would you describe postpartun psychosis? What are you interventions?

Postpartun psychosis relates to a set of symptoms causing mental disturbances which occur soon after child birth. They can be considered mania symptoms and can last many moths if untreated. Medical intervention includes psychotic medications.

  1. What are the signs and symptoms of perineal hematoma?

This manifests as pain; swelling and tenderness of the perineum.

Newborn Nursing care

  1. Describe average for gestational age (AGA); Large for gestational age (LGA) and small for gestational age (SGA).

Average gestational age means the infant is between 10th and 90th percentile rage;             large for gestational age means that the infant is above the 90th percentile and small for gestational age the infant is 2, 500gs or less.

  1. Why are circumcisions not done soon after birth?

Circumcisions are not performed soon after birth because the infant is not physiology adapted to the outer environment to undergo a surgery which is not an emergency.

  1. What are Mongolian spots

Mongolian spots are birth marks scientifically known as congenital dermal melanocytosis. They appear as blue spots around the body.

  1. What is the fine downy hair on the new born back called?

It is called lanugo.

  1. When the new born cheek is stoked and he/she turns the head in the direction of the stoke what is this reflex called? This is called the rooting reflex.
  2. What two prophylactic medications do all newborns receive within the first hour of life?

They are vitamin K and eye drops.

  1. A newborn has hyperbilubrubiemia and is receiving phototherapy why?

This is done to reduce the bilirubin activity in the blood.

  1. What are two complications of the therapy and how do you prevent the?

Two complications of this therapy are blindness, dryness of the skin dehydration. To prevent blindness the eyes are covered and the infant is fed lots of fluids.

  1. Explain the complications of cold stressing a neonate. Explain how you would promote thermoregulation with this infant to prevent complications.

Complications can occurring due to over exposure to cold which significantly alters the body temperature in infants whose temperature control mechanism is not well established as older children.

Thermoregulation promotion is accomplished by monitoring signs and symptoms for hyperthermia; checking extremities for cyanosis in ensuring that the infant is kept warm.

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