ATI CAPSTONE MATERNAL NEWBORN ASSESSMENT ATI CAPSTONE MATERNAL NEWBORN ASSESSMENT

ATI CAPSTONE MATERNAL NEWBORN ASSESSMENT EXAM

1. Which of the following are components of a prenatal history?
   A. Family history, fetal care, and the mother’s diet
   B. Maternal sequelae, family history, and fetal care history
   C. Maternal sequelae, fetal care history, and type of insurance
   D. Maternal sequelae, family history, and the mode of transportation to
   the hospital
   PRENATAL HISTORY
   A prenatal history is imperative to the comprehensive care of each newborn and should
   cover the maternal sequelae, family history, and fetal care history. Maternal history
   consists of information concerning past pregnancies, including complications, and
   specifics of labor and maternal illness, including infections and the use of alcohol or
   drugs. It should also elicit information regarding the current pregnancy, such as the
   quality and quantity of prenatal care, current laboratory values (including blood type and
   Rh factor and the results of standard group B streptococcus screening), and the presence
   of any significant risk factors to the fetus. Obtaining a family history involves inquiring
   regarding past illnesses, genetic issues, and physiological problems of parents and
   siblings. The neonatal history encompasses factors such as vital signs, Apgar scores,
   required stabilization interventions, and the newborn’s general appearance and reaction to
   the environment.
2. Which of the following complications may develop in infants of
   diabetic mothers?
   A. Jaundice
   B. Hypoglycemia
   C. Shoulder dystocia
   D. All of the above
   Gestational diabetes affects approximately 4% of all pregnancies. Factors that place
   women at higher risk for developing gestational diabetes include age of 25 years or older,
   obesity, and a family history of type 2 diabetes.The infant of a diabetic mother,
   regardless of whether the cause is gestational diabetes or pre-existing disease, is affected
   in a multitude of ways. The effects are more pronounced in “brittle” cases. Fetuses that
   are continuously exposed to high blood glucose levels will produce more insulin in
   response, leading to excessive fetal growth and infants who are large for gestational age.
   This in turn can place them at higher risk for birth trauma and shoulder dystocia. In the
   neonatal

period, infants of diabetic mothers are also more likely to experience hypoglycemia that
results from the precipitous drop in available blood sugar while they continue to produce
excessive amounts of insulin. This can lead to serious neurological damage with
complications including developmental delay, heart failure, and seizures. Infants of
diabetic mothers are also at higher risk for neonatal jaundice, and women with diabetes
are at higher risk for developing pre-eclampsia.

3. The placenta should be assessed for:
   A. odor, bleeding, and umbilical cord placement.
   B. bleeding, thickness, number of lobes, and odor.
   C. size, color, odor, and umbilical cord placement.
   D. size, color, odor, and the presence and number of membranes.
   PLACENTAL EXAMINATION
   A thorough assessment of the placenta at the time of delivery may assist with age
   determination and present significant diagnostic information. The placenta should be
   assessed for size, color, odor, and the presence and number of membranes.
4. What are the ABCs of neonatal resuscitation?
   A. Always be careful
   B. Apgar, Bleeding, Circulation
   C. Airway, Blueness, Calmness
   D. Airway, Breathing, Circulation
   IMMEDIATE POST-BIRTH CARE
   All nurses should be familiar with the ABCs of resuscitation: airway, breathing, and
   circulation. Because newborns are wet when they are born, they can suffer rapid heat loss
   if a warm environment is not maintained. Therefore, it is critical to maintain a warm, or
   thermoneutral, environment for the infant throughout the first hours and days of life. This
   can be accomplished by placing the infant on the mother’s abdomen, with warm blankets
   placed over them both to maintain body heat. Alternatively, if the need for further
   intervention is anticipated, or if the caregiver prefers, the infant should be placed on a
   preheated radiant warmer.
5. A thermoneutral environment can be maintained by
   A. placing the infant on an infant scale as soon as possible.
   B. assuring that the infant remains naked for the first day of life.
   C. placing the infant on the mother’s abdomen and leaving exposed.
   D. placing the infant on the mother’s abdomen and covering with warm blankets.
6. Apgar scores measure the infant’s
   A. Gestational age
   B. Weight and height
   C. Response to extrauterine life
   D. Length of periods of reactivity
   APGAR SCORE
   In 1953, an anesthesiologist named Virginia Apgar designed a tool for evaluating
   newborn infants. The Apgar scores grade the infant’s response to extrauterine life in five
   categories:

• Heart rate
• Respiratory effort
• Muscle tone
• Reflex irritability
• Color

3. In order to receive 2 points for color in Apgar scoring, the infant should
   A. be blue, gray, or dusky.
   B. be mostly pink with acrocyanosis.

• C. be completely pink, including the hands and feet.
  D. demonstrate several different skin color variations.
  APGAR SCORE
  

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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:
d. Mother Rh negative; Coombs negative; baby Rh positive CorrectCorrect. If the baby is Rh negative, the mother will not be exposed to positive antigens and will not need RhoGAM. An indirect Coombs test indicates the presence or absence of antibodies. If the indirect Coombs test is positive, the mother’s blood is producing anti-Rh (D) antibodies, and it is too late for RhoGAM to do any good.

A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?
d. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux.
The effects of progesterone on the GI tract include relaxation of the cardiac sphinter and delayed gastric emptying.

A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?
d. Reduce intake of caffeinated and carbonated beverages.

Correct. The nurse should instruct the client to limit her daily fluid intake; reduce the intake of fluids and foods that may be irritating to the urinary system and bladder; to avoid constipation by increasing fiber in the diet; and to perform Kegel exercises regularly to strengthen the pelvic floor.

A nurse is caring for a postmenopausal client prescribed the aromatase inhibitor, anastrozole for the treatment of breast cancer. Which of the following should the nurse tell the client she may experience?
b. Muscle and joint pain CorrectCorrect. Muscle and joint pain are potential side effects of anastrozole and can be treated with mild analgesic as prescribed.

During a breast examination on a 24-year-old client the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
a. An irregularly shaped, nontender lump is palpable in the right breast. CorrectCorrect. Irregularly shapped, nontender lumps are consistent with the diagnosis of breast cancer.

Which of the following would increase a client’s risk of ovarian cancer?
c. Endometriosis
Correct. Endometriosis has shown to increase the risk of developing ovarian cancer

A client tells the nurse that she suspects she is pregnant because she is able to feel the baby move. The nurse knows that this is
presumptive

CORRECT sign of pregnancy. Fill in the blank with the correct choice: presumptive, probable, possible, positive.

Quickening is a presumptive sign of pregnancy because self reported feelings of fetal movement could be gas or peristalsis instead of actual fetal movement. Probable signs of pregnancy include positive serum pregnancy tests, Chadwick’s sign, and Goodell’s sign. Positive signs of pregnancy include fetal heart tones by doppler or fetal stethoscope and fetal movement palpated by an examiner.

For breast engorgement, fresh cabbage leaves placed inside the bra can help alleviate pain associated with breast engorgement. T/F?
TRUE

A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?
petroleum jelly

Bathing a newborn by submerging the infant in water is allowed 72 hours after birth. T/F?
False.

Bathing a newborn by submerging in water should not occur until the cord has fallen off. Most cords fall off within the 10 to 14 days.

A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following is a factor strongly associated with this postpartum complication?
c. Cesarean birth
Correct. Cesarean birth doubles the risk for deep-vein thrombosis.

Cesarean birth doubles the risk for deep-vein thrombosis. Other risk factors include pregnancy, operative vaginal birth, pulmonary embolism, immobility, obesity, smoking, multiparity, age greater than 35 years, history of thromboembolism and diabetes mellitus.

Disadvantages of a nonstress test include a high rate of false nonreactive results with fetal movement due to sleep cycle of the fetus and nicotine use. T/F?
TRUE

Prior to an amniocentesis, what action by the client will need to be completed?
a. Empty the bladder. CorrectCorrect–Prior to the amniocentesis procedure the nurse will instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture.

A client is being treated with eclampsia. What is a priority nursing intervention?
Assess for hyperreflexia.

Progressive change in effacement
True labor

Bloody show not present
False Labor

Fetus moves to anterior position
True Labor

Contractions intermittent and painless
False Labor

Contractions regular in frequency
True Labor

When a newborn demonstrates respiratory distress and routine suctioning with the bulb syringe is unsuccessful, the nurse will deliver chest thrusts.
True

If bulb suctioning is unsuccessful, mechanical suction and/or back blows and chest thrusts can be used, as well as the institution of emergency procedures.

If bulb suctioning is unsuccessful, mechanical suction and/or back blows and chest thrusts can be used, as well as the institution of emergency procedures.

To decrease the incidence of sudden infant death syndrome (SIDS), the parents will position the newborn in a
Supine position

leopold maneuvers

• performing external palpations of the maternal uterus through the abdominal wall to determine the number of fetuses, the presenting part, fetal lie, fetal attitude, degree of descent of the presenting part into the pelvis, and the location of the fetus’s back to assess the fetal heart tones

vertex presentation
Fetal heart tones should be assessed below the mother’s umbilicus in either the right or left lower quadrant of the abdomen

breech presentation
Fetal heart tones should be assessed above the mother’s umbilicus in either the right- or left-upper quadrant of the abdomen.

considerations

• ask the client to empty the bladder before beginning the assessment
• place client in supine position with a pillow under the head, and have both knees flexed
• place a small , rolled towel under the client’s right or left hip to displace the uterus off the major blood vessels to prevent supine hypotensive syndrome

intermittently auscultate during the latent phase

• every 30-60 minutes

intermittently auscultate during the active phase

• every 15-30 minutes

intermittently auscultate during the second stage

• every 5-15 minutes

indications for leopold maneuvers

• determine active labor
• rupture of membranes spontaneously or artificially
• preceding and subsequent to ambulation
• prior to following administration of or a change in medication analgesia
• at peak action of anesthesia
• following vaginal examination
• following expulsion of an enema
• after urinary catheterization
• abnormal or excessive uterine contractions

normal FHR
110-160 w/ increases and decreases from baseline

continuous electronic fetal monitoring

• accomplished by securing an ultrasound transducer over the clients abdomen, which records the FHR pattern and a tocotransducer on the fundus that records the uterine contraindications

indications for electronic fetal monitoring

• multiple gestations
• oxytocin infusion
• placenta previa
• fetal bradycardia
• maternal complications
• intrauterine growth restriction
• post-date gestation
• active labor
• meconium stained amniotic fluid
• abruptio placentae
• abnormal nonstress test or contraction stress test
• abnormal uterine contractions
• fetal distress

Three Tier System

• fetal monitoring system with FHR interpretation system
• category 1
• baseline FHR of 110-160 /min
• baseline FHR variability: moderate
• accelerations present or absent
• early decelerations: present or absent
• variable/late decelerations: absent

Category 2

• tracings include all FHR tracings not categorized as category 1 or 3.
• baseline rate (tachycardia, bradycardia not accompanied by absent baseline variability)
• baseline FHR variability (minimal baseline variability, absent baseline variability not accompanied by recurrent decelerations, marked baseline variability)
• episodic or periodic decelerations ( prolonged FHR decel equal or greater than 2 min but less than 10 min, recurrent late decelerations w/ moderate baseline variability, recurrent variable decels w/ minimal or moderate baseline variability
• variable decels w/ additional characteristics including overshoots, shoulders, or slow return to baseline FHR

category 3

• FHR tracings include either sinusoidal pattern, absent baseline FHR variability (recurrent late/variable decels, bradycardia)
• increment, acme, decrement

increment uterine contractions

• beginning of the contraction as intensity is increasing

adme uterine contractions

• peak intensity of the contraction
• decrement uterine contractions
• the decline of the contraction intensity as contraction is ending

accelerations

• Variable transitory increase in the FHR above baseline

causes of accelerations

• healthy fetal/placental exchange
• vaginal exam
• fundal pressure
• intact CNS response to fetal movement
• uterine contractions
• fetal scalp stimulation

nursing interventions for accelerations

• be reassuring
• no interventions required
• indicate reactive nonstress test

fetal bradycardia

• FHR less than 110/min for 10 min or more

causes of fetal bradycardia

• uteroplacental insufficiency
• umbilical cord prolapse
• materanl hypotension
• prolonged umbilical cord compression
• anesthetic medications
• fetal congenital heart block
• viral infections
• maternal hypoglycemia
• fetal heart failure
• maternal hypothermia

nursing interventions for fetal bradycardia

• discontinue oxytocin if being administered
• assist the client to a side-lying position
• administer oxygen by mask at 10 L/min via non-rebreather face mask
• insert IV catheter if one is not in place and administer maintenance IV fluids
• administer tocolytics
• notify HCP

Fetal tachycardia

• FHR greater than 160/min for 10 minutes or more

causes of fetal tachycardia

• maternal infection
• fetal anemia
• fetal cardiac dysrhythmias
• maternal use of cocaine or meth
• maternal dehydration
• maternal or fetal infection
• maternal hyperthyroidism

nursing interventions for fetal tachycardia

• administer prescribed antipyretics for maternal fever if present
• administer O2 by mask at 10 L/min via nonrebreather mask
• admin IV fluid bolus

early decels of FHR

• slowing of FHR at start of contraction w/ return of FHR to baseline at end of contraction
• causes of early decels of FHR
• compression of fetal head resulting from uterine contraction
• uterine contractions
• vaginal exam
• fundal pressure

nursing interventions for early decels of FHR

• no interventions required

late decels of FHR

• slowing of FHR after contraction has started w/ return of FHR to baseline well after contraction has ended
• causes of late decels of FHR
• uteroplacental insufficiency causing inadequate fetal oxygenation
• insert an IV catheter if not in place, and increase rate of IV fluid admin
• discontinue oxytocin
• admin oxygen by mask at 8 L/min via nonrebreather face mask
• elevate client’s legs
• notify HCP
• prep for assisted vaginal vaginal birth or c-section

variable decels of FHR

• transitory, abrupt slowing of FHR 15/min or more below baseline for at least 15 seconds, variable in duration, intensity, and timing in relation to uterine contractions

causes of variable decels of FHR

• umbilical cord prolapse
• short cord
• prolapsed cord
• nuchal cord (around fetal neck)

nursing interventions for variable decels of FHR

• reposition client from side to side or into knee-chest
• discontinue oxytocin
• admin oxygen by mask at 8 L/min via nonrebreather face mask
• perform or assist w/ vaginal exam
• assist w/ amnioinfusion if prescribed

continuous internal fetal monitoring

• with scalp electrode is performed by attaching a small spiral electrode to the presenting part of fetus to monitor the FHR
• wires attached to a leg plate thats placed on the client’s thigh and then attached to fetal monitor

indications for continuous internal fetal monitoring

• can be used in junction with IUPC
• to detect abnormal FHR patterns
• accurate assessment of FHR variability
• accurate measurement of uterine contraction intensity
• allows greater maternal freedom of movement bc tracing is not affected by fetal activity, maternal position changed, or obesity

disadvantages of continuous internal fetal monitoring

• membranes must be ruptured to use
• cervix must be adequately dilated to min of 2-3 cm
• presenting part must have descended to place electrode
• potential risk of injury to fetus if electrode is not properly applied
• HCP, NP, RN, or midwife must perform it
• risk of infection

complications of continuous internal fetal monitoring

• misinterpretation of patterns
• maternal or fetal infection
• fetal trauma if fetal monitoring electrode of IUPC are inserted into th vagina improperly
• supine hypotension secondary to internal monitor placement

discharge teaching includes

• newborn care
• bathing
• umbilical cord care
• circumcision
• car seat safety
• environmental safety
• newborn behaviors
• feeding
• elimination
• clinical findings of illness

quieting techniques for newborn crying

• swaddling
• skin to skin contact
• nonnutritive sucking w/ pacifier
• rhythmic noises to stimulate utero sounds
• movement (car ride, chair, infant swing)
• bounce legs on lap
• stimulation

cradle hold

• Cradle the newborn’s head in the bend of the elbow. This permits eye‑to‑eye contact and is a good position for feeding

upright hold

• hold the newborn upright, and face them toward the holder while supporting the head, upper back, and buttocks
• football hold
• Support half of the newborn’s body in the holder’s forearm with the newborn’s head and neck resting in the palm of the hand
• This is a good position for breastfeeding and when shampooing the newborn’s hair

how many BMs should the breast-fed newborn have a day?

• 3 or more

how many wet diapers should the breast-fed newborn have a day?

• 6 or more

cord care

• sponge baths given until cord falls off
• fold cord underneath the top of the diaper
• keep it dry

Dependent Phase of maternal role attainment

• taking‑in phase
• First 24 to 48 hr
• Focus on meeting personal needs
• Rely on others for assistance
• Excited, talkative
• Need to review birth experience with others

dependent-independent phase of maternal role attainment

• taking-holding phase
• begins on day 2-3
• lasts 10 days to several weeks
• focus on baby care and improving care and caregiving competency
• want to take charge but need acceptance from others
• want to learn and practice
• dealing w/ physical and emotional discomforts, can experience baby blues

interdependent phase of maternal role attainment

• letting‑go phase
• Focus on family as a unit
• Resumption of role (intimate partner, individual)

Sibling Adaptation

• let sibling be one of the first tp see infant
• provide gift for from infant to the sibling
• arrange for one parent to spend time with sibling while other parent is caring for infant
• allow older siblings to help in providing care for infant
• provide preschool aged sibling with a doll to care for

first stage of labor

• lasts from onset of regular uterine contractions to full effacement and dilation of cervix (longer than 2nd and 3rd stages combined)

assessment of first stage of labor

• perform leopold maneuvers
• perform a vaginal exam as indicated
• encourage to take slow, deep breaths prior to exam
• monitor cervical dilation and effacement
• monitor station and fetal presentation prepare for impending delivery as presenting part moves into positive stations and begins to push against the pelvic floor (crowning)
• perform bladder palpation on regular basis to prevent distention
• form a temperature assessment every 4 hours

first stage of labor
Latent, Active and Transition

Latent phase of labor

• contractions are irregular, mild to moderate
• frequency of 5-30 min
• duration of 30-45 seconds
• dilation of 0-3 cm

active phase of labor

• contractions are more regular, moderate-strong
• frequency of 3-5 minutes
• duration of 40-70 seconds
• dilation of 4-7 cm

transition phase of labor

• contractions are strong to very strong
• frequency of 2-3 minutes
• duration of 45-90 seconds

second stage of labor

• lasts from time cervix is fully dilated to the birth of fetus
• begins w/ complete dilation and effacement
• BP, pulse, and RR measured every 5-30 minutes
• uterine contractions
• pushing efforts by client
• increase in bloody show
• shaking of extremities
• FHR every 5-15 minutes and immediately following birth

first degree laceration
laceration extends through the skin of the perineum and does not involve the muscles

second degree laceration
laceration extends through the skin and muscles into the perineum but not the anal sphincter

third degree laceration
laceration extends through the skin, muscles, perineum, and external anal sphincter

fourth degree laceration
laceration extends through skin, muscles, anal sphincter, and the anterior rectal wall

nursing actions during the active phase

• provide the client/fetal monitoring
• encourage frequent position changes
• encourage voiding at least every 2 hours
• encourage deep cleansing breaths before and after modified paced breathing
• encourage relaxation
• provide nonpharm comfort
• provide pharmacol pain relief PRN

nursing actions during the transition phase

• continue to void every 2 hours
  -continue to monitor and support client and fetus
• encourage rapid pant-pant blow breathing pattern if client has not learned a pattern
• discourage pushing efforts until cervix is fully dilated
• listen for expressions about BMs
• prepare for birth
• observe for perineal bulging or crowning
• encourage client to begin bearing down once cervix is dilated

nursing actions for second stage of birth

• continue to fetal monitor fetus and client
• assist in positioning the client for effective pushing
• assist in partner involvement with pushing efforts
• provide rest between contractions
• provide comfort measures like cold compresses
• cleanse the clients perineum as needed if fecal matter is expelled during pushing
• prepare for episiotomy
• provide feedback on labor progress to the client
• prepare for neonate

third stage of labor

• lasts from birth of the fetus until the placenta is delivered

assessment during third stage of labor

• BP, pulse, RR every 15 minutes
• clinical findings of placental separation from the uterus as indicated by the fundus firmly contracting, swift gush of dark blood from introitus, umbilical cord appears to lengthen as placenta descends, vaginal fullness on exam
• assignment of 1 and 5 min APGAR scores to neonate

nursing actions during the third stage of labor

• instruct the client tp push once findings of placental separation are present
• administer oxytocics as prescribed to stimulate the uterus to contract and prevent hemmorhage
• admin analgesics
• gently cleanse perineal area with warm water and apply perineum pad or ice pack to perineum
• promote baby-friendly activities

fourth stage of labor

• begins with delivery of placenta and includes at least the first 2 hours after birth

assessment in the fourth stage of labor

• maternal vital signs
• fundus
• lochia
• urinary output
• baby~friendly activities of the family

nursing actions in the fourth stage of labor

• assess maternal BP and HR every 15 min for first 2 hours and determine temperature at the beginning of the recovery period , then assess every 4 hours for the first 8hour after birth, then at least every 8 hour
• assess fundus and lochia every 15 min for first hour and then acording to facility protocol
• massage uterine fundus and or maintain uterine tone and to prevent hemorrhage
• encourage voiding to prevent bladder distention
• assess episiotomy or laceration repair for erythema
• promote an opportunity for paternal-newborn bonding
• give mother time to rest after bonding with baby and eating

Calandar (rhythm) Method

• involves determining fertile days by tracking the menstrual cycle to estimate the time of ovulation, which occurs about 14 days before the onset of the next menstrual cycle

client education for the Calendar (rhythm) Method

• maintain a diary
• the start of the fertile period is figured out by subtracting 18 days from the number of days in the shortest menstrual cycle
• the end of the fertile period is established by subtracting 11 days from the number of days of the longest cycle

standard days method (cycle beads)

• more modern form of the calendar method that uses a standard number of fertile days for each cycle
• the cycle beads are color-coded and located on a stringed necklace

client education for the standard days method

• start the 1st day of the menstrual cycle
• red bead: 1 1st bead and marks the 1st day of the cycle
• brown beads: non-fertile` days
• white beads: fertile days

basal body temperature

• BBT is the temperature of the body at rest
• prior t o ovulation, the temperature drops slightly and rises during ovulation
• identifying the time ovulation is a symptom based method that can be used to facilitate or avoid conception

cervical mucus ovulation detection mthod

• fertility awareness method is a symptom based method in which the client analyzes cervical mucous to determine ovulation
• following ovulation, the cervical mucus becomes thin and flexible under the influence of estrogen and progesterone to allow for sperm viability and motility
• ability for mucus to stretch between the fingers is greatest during ovulation

2 day method

• a symptom based method that involves checking for vaginal secretions daily, w/ no analysis of secretions
• after 2 days w/o presence of secretions, the fertile period has passed
• if vaginal secretions are present 2 days in a row, avoid unprotected intercourse to prevent pregnancy

barrier methods

• male condom
• female condom
• spermicide
• diaphragm
• cervical cap
• contraceptive sponge

hormonal methods

• combined oral contraceptives (COCs)
• progestin-only pills
• emergency oral contraceptive
• transdermal contraceptive patch
• injectable progestins
• contraceptive vaginal ring
• implantable progestin
• IUD

transcervical sterilization

• Insertion of small flexible agents through the vagina and cervix into the fallopian tubes. This results in the development of scar tissue in the tubes preventing conception.
• Examination must be done after 3 months to ensure fallopian tubes are blocked.

male condoms

• Covers the penis
• keeps sperm out of the vagina
  -protects against STD’s
  82% effective with typical use
• 98% effective with perfect use
• Over-The-Counter
• Advantages: most effective form of contraception
• Disadvantages: must be must every time you have sex

female condoms

• vaginal sheath made of nitrile, a nonlatex synthetic rubber with flexible rings on both ends that is pre-lubricated with spermicide
• closed end of condom pouch is inserted into vagina by the client prior to intercourse and anchored around cervix

spermicide
chemical barrier that is available in variety of forms, and destroys sperm before they can enter the cervix

• causes vaginal flora to be more acidic
• insert 15 min before intercourse
• only effective for 1 hour after insertion but shouldn’t be removed until 6 hours after intercourse
• fold films prior to insertion into vagina where it dissolves

diaphragm

• a dome-shaped cup with a flexible rim made of silicone that fits snugly over the cervix
• replace every 2 years
• be properly fitted by a HCP
• requires proper insertion and removal
• must be inserted 6 hours prior to intercourse and stay in place until 6 hours after but no more than 24 hours after
• empty bladder prior to insertion to decrease urethral pressure
• wash with mild soap and warm water after each use
• must be reapplied with each act of intercourse

cervical cap

• a silicone rubber cap that fits tightly around the base of the cervix
• insert up to 6 hours before intercourse and leave in at least 6 hours after but no more than 48 hours at a time
• replace every 2 years and refit after any gyno surgery, birth, or major weight fluctuation

contraceptive sponge

• a contraceptive device made of polyurethane sponge that contains enough spermicide to be effective for 24 hours after being inserted into the vagina
• one size fits all
• can have repeated intercourse w/ it

Combined oral contraceptives (COCs)

• hormonal contraception containing estrogen and progestin, which acts by suppressing ovulation, thickening the cervical mucus to block semen, altering the uterine decidua to prevent implantation
• requires prescription and follow up

Progestin-only pills

• oral progestins that provide the same action as combined oral contraceptives, which decreases the chance of fertilization and implantation
• take the pill at same time everyday
• do not miss a pill
• may need second form of birth control during first month

Emergency oral contraceptive

• morning after pill that prevents fertilization from taking place inhibiting ovulation and the transport of sperm
• taken within 72 hours after unprotected sex

Transdermal contraceptive patch

• contains estrogen and progesterone/progestin which is delivered at continuous levels through the skin into SQ tissue
• apply patch to dry skin overlying SQ tissue of butt, abdomen, upper arm, or torso (not breast)
• replace patch once a week
• apply patch same day of week for 3 weeks w/ no application fourth week

Injectible progestins

• medroxyprogresterone is an IM or SQ injection given to females every 11-13 weeks
• inhibits ovulation and thickens cervical mucus
• start of injections should be during first 5 days of menstrual cycle and every 11-13 weeks thereafter
  -maintain adequate intake of calcium and engage in weight-bearing exercise to decrease risk of osteoporosis
• don’t massage injection site after

contraceptive vaginal ring

• flexible silicone ring that contains etonogestrel and ethinyl estradiol that is delivered at continuous levels vaginally
• perform ring replacement after 3 weeks and placement of new ring within 7 days
• insertion should occur at same day of week monthly
• if removed for greater than 4 hours, replace w/ new ring and use barrier method of contraception for 7 days

implantable progestin

• small thin rods consisting of progestin that are implanted by the provider under the skin of the inner upper aspect of the arm
• avoid trauma to implantation area
• wear condoms for protection against STIs

IUDs

• chemically active T shaped device that is inserted through the cervix and placed in the uterus by the provider
• monitor device monthly
• consent form needed
• pregnancy test, pap smear, and and cervical cultures need to be negative prior to insert

cystocele risk factors

• obesity
• advanced age
• family history
• multiparity
• increased abdominal pressure during pregnancy
• strain and injury during vaginal birth

rectocele risk factors
pelvic strucutre defects

• obesity
• aging
• constipation
• family history
• difficult vaginal childbirth (tear repair needed)

cystocele expected findings

• urinary frequency/urgency
• stress incontinence
• Hx of frequent urinary tract infections
• dyspareunia
• fatigue
• back/pelvic pain

rectocele expected findings

• constipation and need to place fingers in vagina to elevate the rectocele to complete feces evacuation
• sensation of a mass in vagina
• pelvic.rectal pressure/pain
• fecal incontinence
• uncontrollable flatus
• hemmorhoids

cystocele diagnostic procedures

• pelvic exam reveals bulging of anterior vaginal wall when pt bears down
• bladder ultrasound measures residual urine
• urine C and S is used to diagnose UTI associated w/ urinary stasis
• cystography is performed to ID degree of bladder protrusion
• x ray helps assess degree of cystocele

rectocele diagnostic procedures

• pelvic exam reveals bulging in posterior wall when clearing down
• rectal exam reveals presence of rectocele

intravaginal estrogen
used to prevent atrophy of pelvic muscles in clients who are postmenopasusal

bladder training
contributes to urinary continence

vaginal pessary

• removable rubber plastic, or silicone device inserted into vagina to provide support and block protrusion of other organs into vagina

kegal exercises

• a series of pelvic muscle exercises used to strengthen the muscles of the pelvic floor

transvaginal repair

• performed to treat prolapse of pelvic organs
• vaginal mesh or tape is used to create a sling that supports the pelvic floor

anterior-posterior repair
surgical repair of cystocele and rectocele

fibrocystic breast condition risk factors

• postmenopausal status
• post menopausal hormone replacement therapy

fibrocystic breast condition expected findings
breast pain and tender lumps (commonly in upper/outer quadrant)

fibrocystic breast condition diagnostics

• breast ultrasound
• fine-needle aspiration

fibrocystic breast condition nursing care

• reduce intake of salt before menses
• wear supportive bra
• apply heat/cold packs locally to reduce pain
• discuss risks
• journal pain treatment effectiveness
• doesn’t increase risk of breast cancer

nutrition during protein

• increase calories
• increase protein intake
• folic acid
• iron supplements
• calcium intake
• fluids (8-10 glasses/day)
• limit caffeine