Exam 2: PRN 1831/ PRN1831 (Latest 2024/ 2025 Update) Principles of Maternal Child Health Nursing Review| Questions and Verified Answers|100% Correct| Grade A- Rasmussen
Exam 2: PRN 1831/ PRN1831 (Latest 2023/
2024 Update) Principles of Maternal Child
Health Nursing Review| Questions and
Verified Answers|100% Correct| Grade ARasmussen
Q: Priority nursing interventions for the 4th stage of labor?
Answer:
Assessing VS, fundus, and bleeding every 15 min for 1-2 hr
Q: Medications given as opioid antagonist: what medication? Why is it given?
Answer:
Naloxone Given to women in labor or postpartum to counteract the effects of narcotic/opioid
medications. To counteract the side effects (respiratory depression)
Q: Provide teaching and planning for a postpartum woman who is not immune to rubella
Answer:
Should be administer a dose of MMR following delivery, before discharge Teaching: client
should not get pregnant for 28 days following the immunization
Q: Be able to provide instruction re: breastfeeding and maternal pain medications
Answer:
Offer pain medication immediately after feed so that it has ample time to be metabolized prior to
next feed.
Q: Which breastfeeding position would be best for a mom after c/s
Answer:
Football hold
Q: Who gets Rhogam and why?
Answer:
All Rh-negative clients who have newborns who are Rh-positive (administered IM) o Why: to
suppress antibody formation in the mother
Q: What should you do if a fundus is boggy on assessment? Why?
Answer:
Have the mom try to empty her bladder/massage o Why: full bladder can impede the uterus
ability to stay firmly contracted and result in increased bleeding/hemorrhage
Q: Identify types of lochia and when to expect them
Answer:
Lochia rubra: (through day 3) dark red menstrual period like discharge fleshy odor o Lochia
serosa: (4-10 days) pinkish brown and serosanguineous consistency o Lochia alba: (10 days – 8
weeks) yellowish white creamy color, fleshy odor
Q: Bathing and pericare after c/s
Answer:
Ensure stability during ambulation
o Keep stream of water on back away from incision
o Keep incision covered with an occlusive dressing
o Provide shower chair if needed
Q: Provide teaching on pericare (understand the rationales
Answer:
After vaginal: Use warm water in squeeze bottle after every void (front to back) Pat dry, front to
back Use optional topical anesthetic (dermaplast) if episiotomy or laceration Apply ice packs
(first 24 hrs) Optional: use sitz bath (first 24 hrs)
Q: Preventing breast engorgement in the bottle feeding mom
Answer:
Supportive sports bra/ace wrap breasts o Ice packs to the breasts o Apply cabbage leaves to draw
out milk
Q: Dietary sources of calcium
Answer:
-milk and milk products
-soy milk
-broccoli
-fortified orange juice
-fish with bones (sardines)
Q: symptoms of preeclampsia
Answer:
Headache o Visual disturbances o Epigastric pain o Edema o Proteinuria o Brisk DTRs o Clonus
o Seizure (Eclampsia)
Q: Expected findings in the postpartum period (fundal assessment)
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Advantages of Birth Center
it is dedicated to provide labor and delivery care only, the mom is encouraged to make her own designs, she can give birth in any position she wants, she can have family and friends there, it is affiliated with a hospital incase of an emergency
Advantages of Hospital Birth
It is the safest environment for high-risk patients, Emergency equipment and personnel are available at all times, The pediatrician can be present for the delivery if a problem is anticipated, It is the only option if a cesarean delivery is required, and Until discharge, the woman has 24-hour support from nurses.
How much postpartum bleeding is too much?
Should not saturate more than a pad in an hour
What is involution?
the return of the uterus to a non pregnant state after birth Typically, 1 cm per day
What happens during the 3rd stage of labor?
delivery of placenta
Nursing diagnoses for the 4th stage of labor?
Risk for injury related to hemorrhage
Priority nursing interventions for the 4th stage of labor?
Assessing VS, fundus, and bleeding every 15 min for 1-2 hr
Medications given as opioid antagonist: what medication? Why is it given?
Naloxone Given to women in labor or postpartum to counteract the effects of narcotic/opioid medications. To counteract the side effects (respiratory depression)
Provide teaching and planning for a postpartum woman who is not immune to rubella
Should be administer a dose of MMR following delivery, before discharge Teaching: client should not get pregnant for 28 days following the immunization
Be able to provide instruction re: breastfeeding and maternal pain medications
Offer pain medication immediately after feed so that it has ample time to be metabolized prior to next feed.
Which breastfeeding position would be best for a mom after c/s
Football hold
Who gets Rhogam and why?
All Rh-negative clients who have newborns who are Rh-positive (administered IM) o Why: to suppress antibody formation in the mother
What should you do if a fundus is boggy on assessment? Why?
Have the mom try to empty her bladder/massage o Why: full bladder can impede the uterus ability to stay firmly contracted and result in increased bleeding/hemorrhage
Identify types of lochia and when to expect them
Lochia rubra: (through day 3) dark red menstrual period like discharge fleshy odor o Lochia serosa: (4-10 days) pinkish brown and serosanguineous consistency o Lochia alba: (10 days – 8 weeks) yellowish white creamy color, fleshy odor
Bathing and pericare after c/s
Ensure stability during ambulation
o Keep stream of water on back away from incision
o Keep incision covered with an occlusive dressing
o Provide shower chair if needed
Provide teaching on pericare (understand the rationales
After vaginal: Use warm water in squeeze bottle after every void (front to back) Pat dry, front to back Use optional topical anesthetic (dermaplast) if episiotomy or laceration Apply ice packs (first 24 hrs) Optional: use sitz bath (first 24 hrs)
Preventing breast engorgement in the bottle feeding mom
Supportive sports bra/ace wrap breasts o Ice packs to the breasts o Apply cabbage leaves to draw out milk
Dietary sources of calcium
-milk and milk products
-soy milk
-broccoli
-fortified orange juice
-fish with bones (sardines)
symptoms of preeclampsia
Headache o Visual disturbances o Epigastric pain o Edema o Proteinuria o Brisk DTRs o Clonus o Seizure (Eclampsia)
Expected findings in the postpartum period (fundal assessment)
At about an hour after childbirth, your fundus should be around your belly button (where it was at 20 weeks). After that, it should steadily decrease 1 centimeter every 24 hours. At about one week postpartum, your fundus should be at your pubic bone (where it was at 12 weeks)
How does the bladder impact involution and bleeding
A distended bladder pushes the uterus upward and usually to one side of the abdomen. The fundus may be boggy or firm. If not emptied, a distended bladder can result in uterine atony and hemorrhage because it interferes with the normal contraction of the uterus.
Postpartum blues, depression Baby blues
resultant from hormonal shift after delivery First few postpartal days peak on the 5th day subside over the next several days.
Postpartum depression
symptoms are persisting beyond 2 weeks postpartum Get adequate rest Take help from support person Know expected changes (baby blues), & when to report symptoms to provider
Symptoms of endometritis
Temperature elevation o Tachycardia o Uterine tenderness, subinvolution o Malaise o Heavy, foul-smelling lochia
Symptoms of magnesium toxicity
Assess every hour respiratory status/respirations, deep tendon reflexes, and LOC o
Antidote: Calcium gluconate
Symptoms of mastitis
Firm, red, swollen, tender breast w/ fever, myalgias, chills, malaise
cause of mastitis
common cause is the hemolytic staphylococcus aureus, introduced from the infant’s mouth through a fissure in the nipple
Rubin’s phases “taking in”
Dependent First 24-48 hr Focus on meeting personal needs Rely on others for assistance Excited, talkative Need to review birth experience with others
Rubin’s phases “taking hold”
Begins on day 2 or 3 Lasts 10 days to several weeks Focus on baby care and improving caregiving competency Want to take charge but need acceptance from others Want to learn and practice, Dealing with physical and emotional discomforts, can experience “baby blues”
Rubin’s phases “letting go”
Focus on family as a unit Resumption of role (intimate partner, individual)
BUBBLEHE assessment
Breasts, Uterus, Bladder, Bowels, Lochia, Episiotomy, Homan’s Sign, Emotional Status
perineal assessment
Manage inflammation/edema – cool/ice packs o After first 24 hrs – sitz bath (heat)
Importance of folate in pregnancy what conditions does it prevent in the newborn?
Started 3 months prior to becoming pregnant
Spina bifida, anencephaly, myeolomenigocele
Normal Newborn Vital Signs
HR: 110-160 bpm
o R: 30-60 breaths/min
o T: 36.5-37.4
Which newborn blood glucose would require immediate intervention?
Normal blood glucose: 40-60 mg/dL o Anything below or above normal range
What is a code pink?
Infant abduction/missing infant
What is a code pink preventive measures
ID band should be verified against the client’s ID band Photo ID badges Newborn is not given to anyone who does not have a photo Locked maternal-newborn units Sensor device on the ID band or umbilical cord clamp that sounds an alarm
Recognize newborn rash – Milia
small raised pearly or white spots on the nose, chin, and forehead.
Recognize newborn rash – Telangiectatic Nevi “Stork Bite”
flat pink or red marks that easily blanch and are found on the back of the neck, nose, upper eyelids, and middle of forehead.
umbilical cord care
-keep clean, dry, clean stump with water, watch swelling/redness/purulent d/c
- fold diaper edge down to keep stump dry
- will fall of after 10-14 days
Newborn Reflexes: Rooting
stroke cheek near corner of mouth (helps infant find nipple) Sucking – infant sucks finger (permits feeding)
Newborn Reflexes: Moro (Startle)
infant makes an “embracing” motion by arching back, extending legs, throwing arms outward, and the bringing arms in toward the body (may have helped infant cling to mother)
Newborn Reflexes: sucking
Stimulation: Place finger in infant’s mouth
Response: infant sucks finger rhythmically
Age of disappearance: replaced by voluntary sucking after 4 months
Function: permits feeding
Understand newborn weight loss and when they regain
Loss of 5% – 10% after birth is normal o Infants should regain weight and return to normal birth weight by 10-14 days after birth o Gain 110-200 g/week for first 3 mos
Indications of dehydration or poor feeding
o dry mucous membranes
o dry sunken eyes
o depressed or sunken fontanelle
Understand impaired thermoregulation in the newborn- why?
o Newborn has an unstable heat-regulating system
o Newborn cannot adapt to changes in temp Little subcutaneous fat High body water content
Circumcision care
Keep area clean o Apply diaper loosely o Apply petroleum jelly w/each diaper change for at least 24 hrs after the circumcision to keep the diaper from adhering to the penis o Do not give tub bath *trickle warm water gently over penis o Notify the provider: redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from newborn
Newborn immunity
Temporary immunity is passed from mom and lasts the first 3 mos of life
o Infant gradually produces his/her own immunoglobulin, until adult levels are reached by puberty
o IgA is an immunoglobulin produced after the neonatal period (about 1 mos of age) that is contained in breast milk and provides some resistance to respiratory and GI infections
SIDS & prevention
o Teaching: teach the parent about the importance of the “back-to-sleep” concept to prevent SIDS
o Infants should be positioned for sleep on their backs on a firm, flat mattress in a crib, both for their safety
Newborn Identification and Security
o Nurse should verify the match each time she brings the baby to mom o Apply matching identification bands on the infant and the mother as well as the father or other designated birth support person. Infants ID band are placed snugly enough so that when the initial weight loss occurs, the ID band does not fall of
measuring adequacy of feeds for the nursing infant
adequacy of breastfeeds is eval via weight gain and the number of wet diapers: 6/day
Newborn Output
o Stools: meconium first 24-48
o Breastfed infants: transition to yellow, liquid, seedy stools
o If dry diapers for 8hrs or more notify provider
newborn vision
intermittent eye crossing is normal
Ophthalmic Ointment
The application is delayed sometimes to facilitate bonding
What do apgar scores indicate? At 1 min, at 5 min?
At 1 min: How the baby tolerated the delivery process
At 5 min: How the baby is adjusting to life outside the uterus
APGAR Scoring: A = Appearance
Appearance (skin color) 0 Points: blue;pale 1 Point: pink body; blue extremities 2 points: pink
APGAR Scoring: P = Pulse
Absent – 0 points Below 100 bpm – 1 point Over 100 bpm – 2 points
APGAR Scoring: G – Grimace
(reflex irritability) Floppy – 0 points Minimal response to stimulation – 1 point Prompt response to stimulation – 2 points
APGAR Scoring: A – Activity
(muscle tone) Absent – 0 points Flexed arms and legs – 1 point Active – 2 points
APGAR Scoring: R – Respirations
Absent – 0 points Slow & Irregular – 1 point Vigorous Cry – 2 points
caput succedaneum
diffuse edema of the fetal scalp that crosses the suture lines. reabsorbs within 1 to 3 days
Cephalohematoma
Swelling caused by bleeding between the osteum and periosteum of the skull. This swelling does not cross suture lines.
Congenital Hip Dysplasia
o Assess posterior legs for symmetry of gluteal asymmetry possible dysplasia
o Assess bilateral leg length for symmetry asymmetric length possible hip dysplasia
o Perform Ortolani and Barlow test positive indicators possible HD
Immediate actions in the care of the newborn and why
o Dry the infant thoroughly to prevent heat loss/cold stress
o Application of ID bands to mom and baby Matching serial numbers that will be verified each time baby is brought to mom to ensure right mom/right baby
hyperbilirubinemia
Caused by the rapid destruction of excess RBC, which the infant does not need now because he/she is in an atmosphere that contains more oxygen than was available during prenatal life
hyperbilirubinemia s/s
Appearance: yellow skin and mucous membranes, scleral icteris (yellow discoloration)
Testing: indirect and direct bilirubin mainly
hyperbilirubinemia risks?
If levels too high kernicterus (brain damage)
hyperbilirubinemia nursing care
Shield the eyes and genitals
Encourage feeds q2-3 hr
Monitor temp
Monitor I&O
Vitamin K
o Administer 0.5 to 1 mg IM into the vastus lateralis (where muscle development is adequate) within 1 hr after birth
Gestational Age Assessment:
o Ballard Scale
Maternal hydration
2-3 L of water daily
Caloric Intake
Mom will burn an + 500 calories daily above her basal rate while breastfeeding
Stimulation of the breasts to produce
Frequent stim of breasts via nursing or pumping (at least q 2 hrs) o Alternate breasts
Avoid combination contraceptives
Estrogen will inhibit milk production
Breastfeeding Assessment o Education:
Feed on demand Advise mom to alternate breasts when feeding baby Express a small amount of breastmilk/colostrum, apply to the nipple and allow to air dry
Understand patterns of growth:
Doubles by age 5-6 months and triples by age 1 yr
patterns of growth: Birth-1 mo
Height/length: 19-21 inches Weight: 7.5lbs Head circumference: 13-14 inches Chest Circumference: 12-13 inches
patterns of growth: 1-2 mo
Weight: increases 1.5lb per month Height: increases 1 inch per month
Head circumference: increases 0.5 in per month
patterns of growth: 3-6 mo
Weight: double the birth weight by 6 months Height: increases by 1 inch per month
patterns of growth: 9-12 mo
Weight: triple the birth weight Height: increases 1 inch per month Head & Chest circumference: same at 12 months of age
Adolescence should increase what?
Increase in caloric intake and rest
Adolescence growth spurt girl vs. boy
Females have growth spurts approximately 2 years earlier than males
Erikson’s stages of development Infancy
Infancy (birth to 18 months)Trust vs. Mistrust – Feeding
Erikson’s stages of development Early Childhood
Early Childhood (2 to 3 years)Autonomy vs. Shame and DoubtToilet Training
Erikson’s stages of development Preschool
(3 to 5 years)Initiative vs. GuiltExploration
Erikson’s stages of development Nursing care
developmental stages are assessed to determine if the client is at the expected level of growth and development, to plan care that is age and developmentally appropriate and to modify care as based on the age related characteristics and needs
What is cephalocaudal development?
Development proceeds from head to toe.
Cephalocaudal development example
The infant is able to raise his/her head before being able to sit, and he/she gains control of the trunk before walking.
What is stranger anxiety? When does it occur?
Results from the ability to discriminate between familiar and unfamiliar faces
When does stranger anxiety occur?
Between 6-8 months, peaks at 8 months.
appropriate toys according to the developmental stage: birth to 2 months
Mobiles 8-10in from the face
appropriate toys according to the developmental stage: 2-4 Months
Rattle and cradle Gym
appropriate toys according to the developmental stage: 4-6 Months
Bright-colored toys
appropriate toys according to the developmental stage: 6-9 months
large toys with bright colors w/- movable parts- noise makers
appropriate toys according to the developmental stage: 9-12 months
Books with large pictures Large push-pull toys Teddy Bears
appropriate toys according to the developmental stage: Toddlers
Toddlers Push-pull toy Low Rocking Horses, Dolls, Stuffed Animals
appropriate toys according to developmental stage Pre-school aged
Play-ground Materials Housekeeping toys Coloring Books Tricycles
Immunizations: what vaccines should a child have when starting kindergarten
Require a second MMR & a DTaP booster
Normal development in infancy: Fine motor
1 month: Has a strong grasp reflex
4 months: Grasps objects with both hands
6 months: Holds bottle
12 months: Tries to build a two-block tower w/out success Can turn pages in a book
Normal development in infancy: Gross motor
2 months: Lifts head off mattress when prone
7 months: Bears full weight on feet Sits, leaning forward on both hands
8 months: Sits unsupported
11 months: Cruises or walks while holding onto something
12 months: Sits down from a standing position w/out assistance Walks with one handheld
Adolescents and body image
o Peer interactions are highly valued
o Developing a sense of self.. figuring out who they are
Adolescents and body image concerns
related to scars, having body parts shaved for surgery, use of assistive devices that make them “different”
School-aged children: Social
o Prefers to interact with same-sex peer groups
School-aged children Task oriented focus
Mastery of tasks & skills provides a sense of ability
Preschoolers’ Thought Patterns:
Magical thinking. Be sure to orient them to conditions to alleviate fears related to magical thinking