 To prepare a pregnant client for an ultrasound the nurse should collect when the last time she

voided, because she needs a full bladder to ensure that the test will be accurate.
 To determine the expected date of birth using Nagele’s rule, using the Last menstrual period by
counting back by 3 months and adding 7 days.
 When teaching a pregnant client in the 3rd trimester with pre-eclampsia about oxytocin, the
nurse should reinforce a contraindication is active genital herpes, because they would require a
C-Section to reduce the chance of passing the infection through the birth canal.
 Mom with active genital herpes simplex virus type 2, the nurse would reinforce her need for a C-
Section prior to onset of labor to reduce the chances of neonatal transmission of herpes
o Erythromycin eye ointment is used prophylactically for gonorrhea and chlamydia
o Metronidazole is for a bacterial vaginosis, versus acyclovir is prescribed for herpes
 Pregnant patient complaining of nausea and vomiting, the nurse should tell the client to eat a
cracker before rising from the bed in the morning.
o Should eat foods at cool temperatures, do not brush immediately after meals and try
not to drink while eating to prevent overdistention
 Mom who wants to formula feed her baby, should place ice packs on her breast 4x daily to
reduce milk production
o The mom should keep hot/warm water off breast, avoid stimulating the breast and
should continue to wear bra’s to support her breast.
 When caring for a pt at 36 wks gestation that has pre-eclampsia, the nurse identifies as the
priority is nonreactive nonstress test as this could be a sign that the baby may be in distress.
o Proteinuria and high blood pressure are expected finding in pre-eclampsia that should
be closely monitored, but not priority. And a low fundal height for gestation should be
closely monitored and reported as well, but not priority in this scenario.
 Caring for a newborn who was born to a pt on narcotic use disorder. A contraindication for
caring for this child is frequent stimulation as this can cause irritability and stress to the baby.
o Nurse wants to promote maternal-newborn bonding, swaddle baby tightly to discourage
hyperactivity and provide comfort, and provide small, frequent feedings as they are at
high risk for aspiration.
 When teaching a pt about breastfeeding, the nurse should reinforce the baby to have 15-20
bursts of sucks or swallows at a time as this shows breastfeeding is effective.
o Baby should feed for 30-40 mins at a time to ensure they are receiving adequate
nutrition, have 6-8 dirty diapers per day, see greenish yellow stool on the 4th day of life.
 The baby at the highest risk for hypoglycemia is a baby with a large gestational age.
o Rh incompatibility will have erythroblastosis fetalis, will see jaundice (bc of
hyperbilirubinemia)
o Pathogenic jaundice could have acute bilirubin encephalopathy
o Fetal alcohol syndrome will have respiratory (tachypnea, nasal flaring, chest
retractions), neurologic (irritability, tremors, incessant crying) and/or GI dysfunction
(uncoordinated swallowing/sucking reflex, incessant hunger and vomiting)
 When teaching a client about using a diaphragm, the patient will replace the diaphragm every 2
years. Should be cleaned with mild soap and water, leave in place at lease 6 hrs and use no oils
or lubricants for insertion
 Formula feeding a baby, the parents will warm the bottle in a pan of hot water, test the temp
allow the milk to cool for no more than 30 mins. And can only store prepared bottles for up to
48 hours.
 A normal weight gain for pregnancy is 25-35 lbs, only 4lbs in the 1st trimester and 12lbs each for
the 2nd and 3rd
 A baby at 43 weeks gestation should find an absent vernix, an absence of lanugo, decrease in
subQ fat and long and hard nails.
 Discharge instructions for a patient who had the removal of a hydatidiform mole is they should
not become pregnant for at least 1 year to allow close monitoring for choriocarcinoma. The hcG
levels should be checked weekly for the 1st 3 weeks and then every 4 weeks for the next 6-12
months.
 A newborn who is 12 hours old, the nurse notes mild jaundice of the face and trunk.. The nurse
should obtain a stat prescription for a bilirubin level because it is pathologic in the first 24
hours of life.
o Phytonadione IM is to prevent/ treat hemorrhagic disease in a newborn
 When teaching a client about a nonstress test, the client will press the button when she feels
the baby move.
o Mom does not need to be NPO for the test, because it will help the baby be more active.
And for a contraction stress test, the mom would perform a nipple stimulation to induce
a contraction, and rarely would oxytocin be used to induce a contraction unless for a
oxytocin challenge test.
 A newborn baby HR when sleeping should be between 80-100 bpm. Respirations are from 30-
60/ min. Chest circumference is 30-33, as it is 2-3 cm less than head circumference. Smaller than
30 could indicate prematurity. Hypoglycemia in a newborn is <40 mg/dl but would be treated
when <50mg/dl
 When administering betamethasone to a mom at 33 weeks of gestation to stimulate fetal lung
maturity, an adverse effect on the newborn is decreased blood sugar, as the medicine can cause
hyperglycemia in the mom and can predispose the newborn to hypoglycemia in the first hours
after delivery.
 A risk factor for ectopic pregnancy is pelvic inflammatory disease.
 Contraindication for an IUD for contraception is menorrhagia, severe dysmenorrhea or a history
of ectopic pregnancy.
 A nurse assisting assisting a pregnant mom at 35 wks of gestation, an important lab test to
obtain at his time is the Group B strep so they can know if they need to give propylactic
antibiotics during labor
o The rubella titer is taken at the 1st prenatal visit. Blood type is taken at the 1st prenatal
visit to determine if the mom needs Rho-gam at 28 wks. Glucose test is taken at 24-28
wks for gestational diabetes.
 When caring for a client at 34 wks gestation that has a prescription for terbutaline for preterm
labor, a concern for the nurse would be if the mom complains of her heart feeling racy. The
terbutaline
 should be held at >120/130 bpm
 When assisting for the plan of care for a newborn who requires phototherapy for
hyperbilirubinemia, the nurse should ensure the newborn’s eyes are closed before applying the
eye shields, as it can damage the newborn’s corneas.
o The baby’s skin should be exposed as much as possible so the phototherapy lights can
reduce the bilirubin levels. The baby should maintain adequate hydration, to ensure the
baby can excrete the bilirubin in stools and do not apply lotion because the baby’s skin
can burn under the lights.
 Mom who is first day post partum, has the nurse assess that her fundus is firm, one
fingerbreadth is above and to the right of the umbilicus with moderate lochia rubra with small
clots, has a temp of 99.2 and pulse of 52, the nurse should ask the mom when was the last time
she voided because her fundus is deviated which indicates a full bladder.
o Oxytocic agents are only ordered for increased lochia rubra or with a boggy fundus to
promote uterine contractions. Only massage a boggy fundus. And moms temp will be
slightly elevated for 6-10 days after birth.
 When assisting with a Rh-negative mom, the nurse should administer the Rh(D) immune
globulin 28 weeks gestation
 A nurse caring for a client with trichomoniasis with a prescription for metronidazole, the nurse
should tell the client the partner should also take the medication and use condoms until the
cultures are negative or abstain from sex.
 At 8 wks gestation, the nurse reports the provider if the mom has a small amount of brown
vaginal discharge as this can be a sign of ectopic pregnancy
 When caring for a newborn with neonatal abstinentce syndrome, the nurse should expect to see
exaggerated reflexes a sign is hyperactivity within the CNS, with an increased muscle tone,
show signs of respiratory distress if >60/min.
 Caring for a pt at 16 weeks gestation with severe iron-deficiency anemia with an order for iron
dextran IM, the nurse should administer the medication with a 20-guage needle using a z track
method to prevent staining of tissues in the ventrogluteal muscle.
 When teaching a post partum mom who is breastfeeding, the nurse should tell her to increase
Vitamin C while breastfeeding to promote tissue formation and integrity
o Incrase to 115-120 mg
o Iron is important for fetal iron and maternal hemoglobin, but would be decreased to 9-
10 mg post partum
o Folate is important for prevention of fetal neural tube defects but would be decreased
to 500 mg
o Calcium is important for fetal growth and maternal bone mineralization, but it could be
1000-3000 mg as was with pregnancy
 When caring for a newborn with an irregular RR of 52/min with several periods of apnea lasting
approx. 5 seconds and the baby is pink with acrocyanosis, the nurse should continuously
monitor the newborn as this is normal for a young newborn.
 When caring for a newborn with myelomengocele, the nurse should initiate a latex free
environment because these babies are more prone to latex allergies.
o The baby should be in a prone postion because their sac can tear easily and allow
cerebrospinal fluid to leak which increases risk of infection; the nurse should cover the
 sac with a sterile, moist dressing and no rectal temps as they have a poor anal sphincter
tone that could result in rectal prolapse.
 When preparing to elicit the fencing reflex from a newborn the nurse should turn the
newborn’s head quickly to one side so the newborn can extend their extremities in the
direction they are facing with the opposite extremities are flexing.
o Moro reflex, when you clap your hands directly over the newborn to see if the newborn
will extend their arms and fan out the fingers with the legs following a similar response.
o Myerson sign, is when the nurse taps the bridge of the newborn’s nose when their eye
is open to see if the newborn will blink for the first four to five taps
o To check for a crossed extension reflex, the nurse will extend one of the newborn’s legs
and press down on the extended leg’s knee to see if the newborn’s leg will flex, adduct
then extend in the opposite leg.
 Teaching a pregnant patient, the nurse should tell her fluoride-based toothpaste to prevent
dental caries.
o They should not take any over the counter pain meds as it can be dangerous to the
babies development, do not eat soft cheeses, unpasteurized milk, lunch meat and deli
prepared salads to prevent contracting listeriosis; and they should not roll their nipples
with inverted nipples as this can cause uterine contractions, but instead use a breast
shield to push the nipples out.
 Caring fora newborn who is on oxygen therapy a potential complication could be retinopathy in
premature newborns, where the vessels grow abnormally from the retina into the clear gel that
fills in the back of the eye, which can reduce vision or result in complete blindness.
 A mom who is 2 hours Post partum, that has a large amount of lochia rubra with several clots on
their peri pad, the nurse should first massage the fundus as this could be a sign of a boggy
uterus (uterine atony) and the nurse wants to prevent hemorrhage.
 If the client calls the antepartum clinic to say that she is 37 wks and gets very dizzy while lying in
bed in the morning, but it goes away when she turns to the side, the nurse should tell her about
vena cava syndrome and measures to prevent it. By her lying on her side (Left) it can promote
uterine perfusion and fetoplacental oxygenation to prevent hypotension from lying supine.
 Car safety teaching for a parent with a newborn, if the car has no back seat, then the passenger
air bag must be turned off to prevent potential injuries caused by air bag deployment.
o A child should be rear-facing until they are at the maximum height and weight or 2 years
old. You should secure a car seat with the vehicle’s seat belt. A baby should be at a 45
degree angle because 90 degrees can compromise a baby’s airway.
 Newborns hemoglobin levels are 14-24 g/dl; platelets 150,000-300,000/mm^3; glucose 30-60
mg/dL; WBC 9,000-30,000/mm^3
 Assisting a mother during the active phase of labor, the nurse should help the client to perform
breathing techniques to promote comfort.
o A pudendal nerve block is administered during the second stage of labor 10-20 mins
before birth. A sedative is administered no less than 12 hours before birth as it can
cause respiratory depression. The mom should only push in the second stage of labor
only when the cervix is dilated to 10 cm.
 A women should lie on her left side with her head elevated on a pillow to prevent supine
hypotension. Support stocking help with varicose veins.
 To administer terbutaline to a client experiencing preterm labor, the route is subQ every 4
hours
 When reviewing a MAR for a pt receiving nifedipine for gestational hypertension that a
contraindication is magnesium sulfate.
 Reinforcing teaching about butorphanol tartrate with a client who is in labor, the medication
will make the pt dizzy as it is an opioid med that can cause dizziness, sedation, hallucinations,
respiratory depression, constipation, nausea, vomiting, and last for 3-4 hours.
 Caring for a newborn who is receiving phototherapy, the nurse should place an opaque mask
over the newborns eyes to prevent damage to the retinas.
o Reposition the child every 2-3 hrs so the body can be exposed to lights. Do not
supplement with water or sugar water for hydration as it can delay excretion of
bilirubin. No lotion because the baby could burn.
 Caring for newborn who is large for gestational age and is jittery, the nurse should first check
the newborn’s glucose level. (always assess the problem 1st)
 Caring for a newborn in the nursery, and a grandparent wants to take the baby back to the
mom’s room.. The nurse should tell the grandfather that she will wash her hands and take the
grandson back to the mother because only facility personnel with appropriate ID badges care
allowed to transport the baby in a designated bassinet.
 When administering phytonadione (Vitamin K) to a newborn the nurse should use the vastus
lateralis as the injection site. It would be administered immediately after birth or after initial
breastfeeding to prevent hemorrhage, using a 5/8-in needle as a single dose.
 Collecting data on a newborn who is 8 hrs old, the nurse should report to the provider an apical
pulse of 90/min when crying as a HR of 80-100/min is only acceptable when the infant is
sleeping, and can be up to 180/min while crying
o Apneic episodes of 20 seconds or less are acceptable as their respirations are normally
shallow and irregular.
 Teaching a client who is at 9 weeks gestation and reports of frequent episodes of nausea and
vomiting, the nurse should tell her to consume small meals frequently each day, eat cool or
room temperature foods, avoid drinking liquids while eating, and eat snacks high in
carbohydrates (crackers) before getting out of bed in the morning.
 Teaching a breastfeeding mom about breast engorgement, the mom should breastfeed at least
every 2 hours as more frequent feedings soften the breast and decrease pain.
o Mom should pump her breast during engorgement to empty her breast and soften
them, should use a cold compress after each feeding or use a warm compress before
feeding to soften and decrease comfort, and do not decrease fluids as this can decrease
her milk production
 Pregnancy lab values- BUN 10-20 mg/dL; platelets 150,000-400,000mm^3; hematocrit >33%;
creatine 0.5-1.0mg/dl
 Tonic neck reflex – nurse turns newborn’s head quickly to one side, the arms and legs on the
same side are extended, while the arm and leg on the opposite side flex
o Crawling reflex- nurse places baby on abdomen, and the baby will appear to make
crawling movements with arms and legs
o Magnet reflex- the newborn will push against the examiner’s hands when pressure is
applied to the soles of their feet
 o Moro reflex- nurse claps loudly near the baby, then the baby will abduct then extend
their arms with the finger’s widly open and index fingers from a C shape. The lower
extremities may extend then abduct toward the abdomen.
 Caring for a client who delivered vaginally 6 hours ago, the nurse should report a soaked peri
pad within 15 mins as this may be a sign of postpartum hemorrhage
 A client who had a vaginal birth 6 hours go who is going to breastfeed, has pain of 6/10, has mild
perineal edema w/ ecchymosis with a fundus that is 2 cm above the umbilicus with deviation to
the right, the nurse should first help the client ambulate to the toilet to prevent hemorrhage
from uterine atony, so emptying the bladder will help her uterus to contact.
 2-hour old baby with respiratory distress, the nurse should report if the baby has tachypnea
>60/min, nasal flaring, retractions or expiratory grunting
o Acrocyanosis is a bluish discoloration of the hands and feet and are expected for 24
hours of birth
 Reinforcing teaching about preventing newborn abduction, the parents will let the nurse take
the baby to the nursery when mom wants to a nap so the baby is not left unattended in the
room. Assistive personnel should always have a name badge on to be able to care for the baby
or remove the baby from the room, the baby will always be taken out in designated bassinet,
and never take off the security band (and if it is taken off an alarm will sound off)
 On a postpartum unit, the caring for a client with a hypotonic uterus with excessive vaginal
bleeding the nurse will first massage the fundus to increase uterine muscle tone and express
blood clots to decrease the bleeding.
 Mom who is bathing her 1day old newborn, the mom would wash the newborn’s hair before
unwrapping the baby to prevent heat loss.
o Mom’s should never shake powder onto a newborn’s skin because it can cause
inhalation in the newborn causing respiratory distress, the mom should also avoid
cotton-tipped swabs to clean their ears to prevent injury (use moistened cotton or
washcloth) and do not rinse under running water as it can cause scalding injury or
hypothermia bc of water temp changes that could occur
 The importance of folic acid supplements for a client who is planning to become pregnant is
because it can prevent certain kinds of defects (neural tube defects).
o Supplemental iron helps facilitate the storage of iron in the fetus’ liver
 A client on a new prescription for ferrous sulfate (iron), the nurse will tell the client to increase
fluid intake to decrease the chances of constipation. Do not take with milk as it could inhibit
absorption, but rather consume citrus fruits for the vitamin C, and should not take a double
dose at once, has a 13hr window to take the missed dose.
 A potential complication for a mother who is at 33 weeks gestation is epigastric pain as it could
be a sign preeclampsia.
o Leg cramps, tingling of fingers and varicose veins are common discomforts of pregnancy
 Discussing family planning who is requesting information about contraceptive methods, the
client should use water-soluble lubricant when my partner wears a condom so the rubber will
not compromise the integrity.
o The diaphragm should be left in place at least for 6hr after intercourse. The sponge
should be taken out less 24 hours to prevent toxic shock syndrome. And the birth
 control patch should be changed weekly for 3 weeks, with 1 week of not wearing the
patch.
 A pregnant woman at 30 weeks gestation, the nurse will report to the provider if the the mom
has 2+ urinary protein as this could be a sign of preeclampsia.
 Client with preeclampsia who is receiving magnesium sulfate continuous IV, the nurse will tell
the client that her fluid intake can be no more that 125 ml/hr to prevent fluid overload, her BP
will be monitored every 15-30 to check for hypotension, the medicine will cause respiratory
depression and the baby will be continuously monitored for fetal distress.
o The antidote for magnesium sulfate with a RR of <12/min is calcium gluconate
 Naloxone is the antidote opioid toxicity
 Protamine sulfate is the antidote for heparin toxicity
 Caring for a client who is receiving methylergonovine, the nurse will identify and document as
an adverse effect is hypertension. The med is used as to stimulate uterine contractions used for
postpartum hemorrhage that can cause nausea, vomiting, cramping, headache, and dizziness.
But the med can cause hypertension or hypotension that should be reported
 A mom who at 16 weeks gestation who is positive for hep B, the nurse will explain that the mom
will receive hep B immune globulin immediately to decrease risk of transmission.
 Nifedipine is used to decrease uterine contractions by relaxing the smooth muscle of the uterus
o Dexamethasone is a glucocorticoid that p)promotes the acceleration of fetal lung
maturity; glyburide is an oral hypoglycemic to help control blood sugars;
metoclopramide, is an antiemetic that decreases maternal nausea.
 24 hours after birth, it expected for the mom to have diuresis to excrete excess fluid that was
retained during pregnancy, discharge of clear yellow fluid from breast (colostrum which gives
babies antibodies and nutrients until mothers milk comes in and lower abd cramping from
contraction of the uterus as it is decreasing it’s size.
o A soft boggy uterus can cause excessive bleeding (bad sign) and mom will have lochia
rubra discharge, lochia serosa (pink or brown) will occur 3-4 days after birth
 When teaching parents about formula feeding newborns the parents will allow 20-30 mins for
feedings to prevent the newborn from eating too quickly and swallowing too much air
o The baby will usually eat 15-30 oz during the first 24 hours and will increase to about 90-
150 ml by the end of the 2nd week of life
o Newborns usually self-regulate their formula intake, so forcing intake can cause
vomiting due to overeating. And parents should burp periodically throughout the feeds
to relieve gas and decrease risk of vomiting.
 Postpartum mom who is experiencing hypovolemic shock, the nurse will insert an indwelling
urinary catheter to monitor output closely. The legs will be elevated at least 30 degrees to
increase venous return. giving terbutaline subQ will increase bleeding.
 Planning the care of a newborn who was circumcised with a plastic bell device, the nurse will
apply pressure with a sterile gauze if bleeding occurs at the site. The nurse should not use
petrolatum gauze for a plastic bell, but rather a circumcision with a gomoco or mogen clamp
was used. Nurse should use plain warm water with each diaper change, and avoid soap until the
site is healed (5-6 days after). And the diaper should be applied loosely to avoid pressure.
 At 36 weeks prenatal examination, a finding that should be reported is blurred vision as this is a
sign of preeclampsia.
 A mother at 11 weeks of gestation who reports frequent vomiting. a sign that the mother could
have hyperemesis gravidarum is ketonuria, which occurs due to a breakdown of fat secondary
to malnutrition or starvation. She would have tachycardia and tachypnea due to dehydration
o Proteinuria is a sign of preeclampsia.
 Client using hydrotherapy for pain management during labor, the nurse would tell the client
that she would have to be in active labor before she could use the therapy because using it in
the latent phase of labor can slow the progression of labor.
o The nurse would perform intermittent monitoring of the FHR with a doppler
stethoscope bc an internal fetal monitor can cause electric shock. The mom can be in
the tub for as long as she desires as the FHR is within the expected reference range. It is
more effective for pain is if mom is in their 30-60 mins followed by a break. And the
water temperature should be 96.8 to 98.6 degrees F to prevent overheating the client,
with her shoulders out of the water to allow dissipation of heat.
 A mother who is 32 hours postpartum, the nurse should expect urine output of 3,000 ml in 24
hour as mother is excreting excess fluid.
o The mom’s fundus should be 1-2 cm below the umbilicus as it should descend 1 cm per
day after birth. A soaked peri pad within 15 mins could be a hemorrhage that cold lead
to hypovolemic shock. The temp should be no more than 100.4 degrees F.
 Assisting for a client who is breastfeeding with mastitis, the nurse should recommend the
mother to apply warm compresses to the affected breast to decrease inflammation and edema
and allow the effective emptying of the breast to prevent milk stasis. Mom should continue to
breastfeed on the affected breast to empty the breast and decrease pressure. She should not
use underwire bras because they can plug milk ducts. And use antibiotics for 10-14 days.
 To prevent engorgement during lactation suppression for a mom who is bottle-feeding the
newborn, the mother should apply cold cabbage leaves throughout the day or icepacks to her
breast. She can take mild analgesics and wear a well-fitting supportive bra. She should not
massage or breast pump her breast which will cause milk production.
 A nurse in the prenatal clinic is caring for a group of clients, the nurse should see first 37 weeks
of gestation with a persistent headache because this could be a sign of preeclampsia.
 A nurse who is 40 weeks of gestation in is in active labor, the nurse would report prolonged
decelerations of FHR bc this could be an emergency that could be uterine rupture or umbilical
cord prolapse.
 A food high in folate is ½ cup of dried peas, has 600 mcg.
 Nurse receiving prenatal record of a mom at 34 weeks gestation, should see a reactive
nonstress test as this indicates fetal well-being.
o A negative rubella titer indicates they are not immune and will need immunization in
postpartum.
o A blood sugar of 150 mg/dl after a 1-hr glucose tolerance test could indicate the mom
might have gestational diabetes and will need further testing.
o A hemoglobin level of anything <10g/dl could indicate anemia.
 Collecting data for a mom in her second trimester of pregnancy, the nurse should report to the
provider if the mom has frequent uterine contractions bc it could indicate that the mom is
going into preterm labor as the cervix may be opening too early.
 Teaching about newborn home safety precautions with a group of new mothers, the nurse
would tell them that crib slats should be no more than 2.5 inches apart to prevent infant
entrapment that could lead to extremity fractures and suffocation
o The space between the mattress and the sides of the crib should be less than 2 fingers
widths or less than 2 cm to prevent infant entrapment. The parents should check smoke
detectors once per month and replace the batteries twice per year. Water heater should
be 120.2 degrees F or less.
 Reinforcing teaching with a client at 16 wks gestation with diabetes mellitus with a bmi of 31,
the nurse should tell her that her intake should be 25 calories per kilogram of her body weight
or less per day because of her BMI
o The mom should eat on a schedule and never skip meals to prevent hypoglycemia and
ketoacidosis. The diet should include 55% carbs, 20% protein and 25% fat; and should
eat a large bedtime snack with at least 25 grams of complex carbs.
 A nurse is planning to reinforce discharge teaching about formula feeding with the guardian of a
newborn, the newborn should instruct them to provide the newborn with 6-8 feedings during a
24 hr period as the newborn would eat every 3-4 hours. They would drink around 15-30 ml per
feeding during the first 24-48 hr. Do not provide water as formula contains enough nutrition and
calories for the baby. Always burp the newborn a few times during the feeding to decrease the
chances of the baby spitting up.
 Collecting data on a client at 12 wks gestation, the nurse would use an ultrasound stethoscope
to listen to fetal heart tones as this is usually taken at the end of the 1st trimester.
o A blood sample for maternal serum alpha-fetoprotein (MSAFP) screen is taken at 15-20
wks of gestation. A vaginal and anal specimen for group B Strep (GBS) is taken 35-37 wks
of gestation. Fundal height is taken regularly between 18-30 wks of gestation.
 Caring for a client who is 18-hour Postpartum with a 4th-degree perineal laceration, the pt
complains of pain on a 4/10. The nurse would promote the use of witch hazel, ice packs, a cool
sitz bath to reduce edema and discomfort esp during the first 24 hours, and relaxation
techniques.
o A soft pillow is not a good intervention as they should sit on a hard surface to compress
the buttocks and reduce pressure on the perineum.
 Reinforcing teaching for a client with a new prescription for medroxyprogesterone acetate
injections (Depo shots) for contraception is that she may gain weight.
o She can breastfeed but should wait 6 weeks after delivery to start the medication if she
is breastfeeding. The injections would be administered every 11-13 wks (4 times a year)
and she should increase her calcium and vitamin D intake as this med can decrease bone
mineral density.
 Collecting data on a client at 38 wks gestation, the nurse would report glycosuria as this could
be a complication of gestational diabetes.
 Teaching client who is trying to become pregnant, should get the best source of folate in 1 cup
of cooked spinach.
 Caring for a client in preterm labor is receiving betamethasone, the nurse would inject the med
in the vatus lateralis muscle and administer a second dose 24 hr later.
o It does not affect their blood pressure, magnesium level (for magnesium sulfate) or
cause dizziness (for terbutaline)
 Collecting data for a 28-year-old who is requesting a prescription for oral contraception, the
nurse sees that a contraindication would be frequent headaches with visual changes as this
could indicate a cardiovascular condition, which could cause CVA, MI or thromboembolism.
o She may need to receive antibiotics or antivirals before taking the contraception, as they
could reduce its effectiveness. Gallbladder and liver cirrhosis are contraindications as
they can cause indigestion, but occasional heartburn is not. Irregular menstrual cycles
with dysmenorrhea are usual reasons that oral contraceptives are prescribed to relieve
those symptoms.
 Teaching about preventing a UTI for a client who is 25 weeks gestation, the nurse would tell her
that she should empty her bladder before she goes to bed at night to prevent stasis of urine.
She should only do Kegel exercises for urinary incontinence. Always wipe from front to back to
prevent transferring fecal bacteria, and wear cotton underwear to avoid trapping heat and
moisture.
 A way to prevent newborn abduction for a newly delivered mom, the mom would understand
that an alarm will sound if someone removes the baby’s safety device or if someone removes
the newborn past an established facility parameter.
o Only transport the baby in a bassinet by facility personnel with a badge and the mother
should never leave the newborn unattended while showering.
 During a nonstress test with a client at 33 wks gestation, the mother would press a button when
she feels the baby move as they are looking for accelerations in the FHR with fetal movement.
 Mother should make sure that the baby sleeps on firm mattress in their crib. Never apply
powder (can cause respiratory distress), never cover the crib comforter or place the newborn on
their stomach as this can increase the baby is chances of sudden infant death syndrome.
 Car seat safety with the guardian of a newborn, they would position the retainer clip at the
level of the baby’s armpits and not over the neck or abdomen, the shoulder harness straps
should be at or below the level of the newborn’s shoulders and at a 45 degree angle to prevent
the newborn’s head from falling forward.
 The mom who is pregnant that has intermittent constipation, should drink 2L of water.
o Stool softeners could lead to dependence and electrolyte imbalances, hypertonic
enemas should be avoided as they could cause injury to mom or fetus or could trigger
labor. And avoid mineral oil as it could deplete stores of the fat-soluble vitamins that are
needed for fetal development.
 Caring for a client who is receiving oxytocin, the nurse would report more than 5 contractions in
10 mins or a contraction lasting longer than 2 mins (called uterine tachysystole) but a common
adverse effect is nausea, vomiting, headache and hypotension.
 Teaching a new mother about formula preparation, the nurse would tell her overdiluted
formula can result in inadequate growth which can stress the newborn’s renal system.
o The water can either be sterile or tap water if it free of contamination and boiled in 1-2
mins and cooled for no longer than 30 mins. And the milk should be discarded after a
feeding because of potential for bacterial contamination.
 Caring for a client in the active phase of the 1st stage of labor, the nurse would report green fluid
from the vagina as this could indicate the fetus has passed meconium stool that could place the
fetus as risk for developing meconium aspiration syndrome.
 o Expected range for FHR in the active phase is 110-160/min, with uterine contractions
lasting 40-90 seconds. Early decelerations could be expected as this is a sign of fetal
head compression
 Collecting data from a client who gave birth 18-hr ago, a postpartum complication could be the
fundus is palpable at 2 cm above the umbilicus.
o A fever may be expected in first 24 hrs due to dehydration, lochia could be increased
after breastfeeding due to the maternal oxytocin releases causes uterine contractions
which helps decrease the risk of postpartum hemorrhage, and the pad may contain
small blood clots.
 A nurse would report absent deep-tendon reflexes for a client receiving magnesium sulfate, as
magnesium toxicity could lead to respiratory or cardiac arrest.
 A mom who is going to take a 1-hr glucose tolerance test should avoid caffeine the morning of
the test because it could increase the glucose levels.
o For the 3 hr glucose test, she may need to provide a urine sample, may need to fast for
an extended period and should eat an adequate amount of carbs for at least 3 days but
will fast overnight before the test.
 A post-partum mom WBC’s could increase up to 25,000/mm^3 for the 1st 10-12 days. But
anything higher than that could indicate infection.
 Caring for a 12-hr male newborn who was delivered breech, the nurse would report to the
charge nurse baby’s skin appears jaundice as pathologic jaundice can leas to severe neurologic
disorders.
o The scrotum would be edematous that would subside in a few days. They have 24 hours
to have their 1st void. And if an umbilical cord that only has 1 artery could indicate a
renal anomaly.
 Caring for a client following a C-section, the nurse would have the client ambulate several times
a day to decrease the risk of developing thrombophlebitis because it would increase circulation
in the lower extremities.
o The nurse should not administer aspirin because it could increase post-partum bleeding.
The mom should report pain or tenderness in her legs, and should apply SCD’s to
prevent, and apply warm compresses if she does develop thrombophlebitis.
 Teaching a breastfeeding mother to a 12-hr newborn, the nurse should reinforce that the mom
should wake the baby up to feed during the feeding as they should be on a 3-4 hour schedule
for the first 24-48 hr after birth.
o Colostrum should not be wiped off as it provides passive immunity to the newborn.
Baby will need to ingest iron-fortified cereal or iron rich foods at 6 months and the mom
should not pump after feedings as this can cause an oversupply of breast milk until
breast-feeding has been well-established and can pump intermittently.
 Teaching a client about IUDs, the nurse would tell the client that she should report pain during
intercourse.
 Teaching home care with the parent of a newborn, the mom should ensure the water temp
during maintained at 100 degrees F (below can cause cold stress, above could cause burns).
o Babies should not be covered in a blanket (sleeper or sleep sack) , bathe babies every 2-
3 days to maintain their skin integrity. The newborn diaper area and face daily. And
wash babies hair 1-2 times a week.
 The first action that the nurse should take when performing a heel stick for glucose monitoring
after washing hands and donning gloves is warm the newborn’s heel for 5-10 mins to dilate the
vessels in the area.
 Report 48 hrs after birth is reddened area on calf (sign of deep-vein thrombosis), dysuria (sign
of UTI), and cracked nipples (sign of breastfeeding difficulties that could lead to mastitis)
 Monitoring a client in the 1st stage of labor receiving IV fentanyl citrate 10 mins ago, that is now
having slurred speech with an altered mental status. The nurse should first determine the
client’s O2 saturation
 Risk factor for a mom with 26 weeks of gestations of developing preeclampsia is rheumatoid
arthritis and systemic lupus erythematosus (connective tissue diseases), BMI higher than 30,
multifetal gestation, infection and chronic hypertension.
 A client with hyperemesis gravidarum, the nurse would monitor the pts intake and output to
evaluate the client’s hydration status and if other interventions are needed. She needs a low-fat
and high-protein diet, should get a urinalysis and CBC, BMP (electrolytes), liver enzymes and
bilirubin, and should eat liquids and solids separately.
o Uric acid levels are for preeclampsia
 2 hr postpartum mom notes that the clients fundus is 2cm above the umbilicus with
displacement to the right of the midline and is boggy; a complication of this finding is bladder
distention as it can push the client’s uterus out of the pelvis and displace it to the right of the
midline.
o Uterine bleeding is expected, but excessive bleeding contains large blood clots with a
relaxed, distended uterus.
o Cervical laceration is slow, oozing trickle of blood while the fundus is firm
o Retention of placental fragments can lead to uterine atony and excessive vaginal
bleeding, but displacement of the uterus can indicate a full bladder.
 Planning care for a client with eclampsia, the priority intervention immediately following a
seizure is administering oxygen via facemask at 10 L/min
 Caring for a postpartum client receiving carboprost, the nurse tells the client that the med will
slow down bleeding to treat postpartum hemorrhage.
o Iron supplements treat anemia, Rh (D) immune globulin treats Rh incompatibility, and
opioids treat perineal discomfort.
 Collecting data from a client who is primigravida with hyperthyroidism, the nurse would expect
diaphoresis, heat intolerance, and tachycardia.
o Hypothyroidism- lethargy, hoarseness and cold intolerance.
 The nurse would report to the provider of a client at 37 weeks gestation, is blurred vision as this
could be a sign of gestational hypertension or preeclampsia.
 Newborn umbilical cord care, the mom would report any drainage from the umbilical cord as it
could be a sign of infection. The mother should only clean with warm water, the diaper should
be secured below to prevent infection and promote dryness, and it would fall off within 10-14
days.
 Discharge instructions for a client with mastitis on the left breast that the mom would pump the
affected breast frequently. Mastitis does not contaminate the milk supply and does not spread
from breast to breast so there is no need to apply a nipple shell on the unaffected breast, and
 emptying the breast helps provide comfort. Cabbage leaves are for engorgement and should
only be applied for formula fed.
 Teaching a client 8 weeks pregnant, the nurse would tell her to expect white vaginal discharge
during pregnancy because of increased estrogen and progesterone.
o Mom would expect to feel fetal movement (quickening) at 16-20 wks. And she may start
to show 14th week of pregnancy.
 Caring for a client who gave birth to a baby who is large for gestational age 16 hrs ago. A
complication of the birth could be hemorrhage
 Giving a client magnesium sulfate IV for preeclampsia, a sign of mag toxicity is respiratory rate
of <12/min.
 Postpartum client who had endometritis and 48hr PP following a C-section would see increased
HR, increased RR, elevated WBCs and increased erythrocyte sedimentation rate >20mm/hr,
chills, fever, nausea, anorexia, fatigue, pelvic pain and lochia that has a foul odor.
 The nurse would promote a parent parent-newborn attachment to a parent who is afraid to pick
her up would first demonstrate to the parent how to hold the newborn ensure the safety of
the newborn.
 Mom who is taking metronidazole for a bacterial vaginosis should tell her to suspend
breastfeeding for 8-10 days because it can be present in breast milk, so mom should pump and
discard while taking med and for 24-48 hrs after last dose. Dark urine and metallic taste is an
adverse effect, and should not douche. She should have teaching about preventing other genital
tract infections like urinate before and after intercourse.