6 - FTT & FAS - Merged
6 - FTT & FAS - Merged
6 - FTT & FAS - Merged
Maternity
ATI Question
Causes & Risk Factors Signs & Symptoms: ... failure to thrive. Which of the
Socioeconomic following findings should the nurse
Poverty: “unemployed” Signs of malnutrition anticipate in this infant?
Primary caregiver cognitive disabilities Developmental delays The infant will avoid making
Abuse: child or spousal
Lack of nutritional knowledge
Abnormal feeding behaviors eye contact
Parents social or emotional isolation Increased metabolism
No eye contact HESI Question
Physiological
Anorexia nervosa prior to having children What clinical manifestations would
Preterm birth the nurse expect in an infant
Breast feeding difficulties diagnosed with failure to thrive?
Gastroesophageal reflux Malnutrition, developmental
Cleft Palate delays, feeding disorders
Kaplan Question
Nursing Interventions
Observe the child feeding NCLEX TIP ... failure to thrive... The nurse instructs the
toddler’s parents about mealtimes. Which
Develop a structured routine for suggestion by the nurse is most appropriate?
bathing, sleeping, and playing Develop a structured routine for bathing,
Assess overall parenting skill sleeping, and playing
NCLEX TIP
NAS & RDS
Maternity
Most full term babies can naturally produce surfactant, but is not always the case with premature infants.
Mature lungs in a baby have a 2 to 1 L:S ratio - the Lecithin Sphingomyelin ratio unless mom has diabetes -
which delays surfactant production
Pathophysiology
Diagnostics:
Risk Factors Saunders Question
Silverman-Anderson Index HESI
Preterm birth KAPLAN ... monitoring a preterm newborn for respiratory
distress syndrome. Which assessment finding should
IUGR - Intrauterine growth restriction alert the nurse to the possibility of this syndrome? Nursing Interventions
PPROM Select all that apply.
Steroids
Maternal DM, HTN, or drug use Cyanosis
Neonatal sepsis Tachypnea Betamethasone
Retractions
Audible grunts
Surfactant (via ET tube) HESI
Signs & Symptoms Admit to NICU for stabilization
Absent breathing or crying at birth HESI
Nasal flaring
Intercostal retractions HESI Question Feature Score 1 Score 2
Respiratory
Score 3
Seesaw
Audible grunting Chest Equal Lag Respiratory
Movement
Cyanosis & Tachypnea Which infant behavior would the Intercostal
nurse recognize as indicating Retraction
None Minimal Marked
Expiratory Audible w/
None Audible
Grunt stethoscope
Notes
SIDS & Neonatal Sepsis
Maternity
Sudden Infant Death Syndrome is the unexpected death of an infant less 1. Place infants in supine position during sleep
than 1 year old. It occurs most frequently during sleeping in infants less “Put to sleep on their back” in a safe crib
Dress newborn in “wearable blanket”
than 6 months.
“sleep sack”
Memory Trick 2. Breastfeed the infant
HESI Question
... high risk of developing sudden infant death
Risk factors syndrome (SIDS)?
An infant whose mother smokes
Boys are at higher risk than girls Infant with an Apgar score of 4
Neonatal Sepsis
Risk Factors
Infection contracted by the neonate before, during, or after delivery, due
to the newborn’s limited immunity and inability to localize infection, Premature birth, PROM,
infections can spread quickly into the bloodstream. prolonged labor
Maternal TORCH infection
Meconium aspiration
HESI Question
Signs & Symptoms ... signs of neonatal sepsis?
Select all that apply.
Lethargy
Lethargy, irritability, poor Tachypnea
muscle tone Apnea
Respiratory distress:
Apnea or Tachypnea ATI Question
Heart rate instability ... immediately prioritized for assessment and care? Nursing Interventions
Temperature instability
A 3-week-old infant who has been feeding
poorly with a temperature of 100.5 F and Assess infection risks
sunken fontanelle
Vomiting/diarrhea → Draw labs/cultures
sunken fontanelles IV access
Poor feeding 100.5ᴼF
Blood glucose instability
Fetal Heart Monitoring IV
Maternity
HESI questions
240
180
120
60
which factor?
30
100
50
25
Normal UC pattern
Tachysystole Complication!
Over 5 contractions in 10 minutes
Too many contractions → Fetal Distress!
Including Hypoxia & reduced placental
blood flow
Tachysystole pattern
10 mins
Fetal Heart Monitoring V
Maternity
180 210
180
150
100 120
90
60
30
Causes
Umbilical Cord Compression! NCLEX TIP
Critical: Oxygen tube is compressed!
120 120 120
100 100 100
Decreased amniotic 80 80 80
60 60 60
Interventions 40 40 40
Prolapsed cord 20 20 20
Memory Trick 0 0 0
CRITICAL Findings! TOP TESTED Top Missed NCLEX Question Kaplan Question
A new nurse is evaluating the fetal monitoring strip of a client in labor who is receiving
7 . Late decelerations an oxytocin infusion. Which of the following actions should the nurse take next?
… fetus is experiencing distress if which heart
Click the exhibit Select all that apply.
Decreased FHR after contractions with prolonged rate pattern is observed?
time before returning to baseline Slow the oxytocin infusion
1. 2.
150 150 150
Causes
60 60 60 180 180 180 180 180 180
30 30 30
150 150 150 150 150 150
90 90 90
60 60 60
Interventions
30 30 30
3. 4.
3.
“Crash C-section”
240 240 240 240 240 240
240 240 240
210 210 210 210 210 210
210 210 210
180 180 180 180 180 180
180 180 180
90 90 90 90 90 90 90 90 90
60 60 60 60 60 60
60 60 60
30 30 30
30 30 30 30 30 30
Critical finding!
100 100 100
80 80 80 100 100 100 100 100 100
60 60 60 80 80 80 80 80 80
40 40 40 60 60 60 60 60 60
20 20 20 40 40 40 40 40 40
0 0 0 20 20 20 20 20 20
0 0 0 0 0 0
4.
Intervention required
240 240 240
90 90 90
60 60 60
Sinusoidal FHR
30 30 30
Contraindication
Performed after 28 weeks of gestation. C-sections can either be planned or an unplanned emergency.
Surgical Procedure
- The client is put to sleep with anesthesia or awake with local anesthesia.
- Then Incisions are made on the abdomen through the uterus and the
health care provider will rupture the amniotic sac to deliver the baby.
- The entire process typically takes only a few minutes to get the baby out.
But can take longer in certain cases.
Complications
After a c-section, the highest priority is to monitor the client for hemorrhage & shock. This severe bleeding will
lead to low blood pressure that will kill the client!
Post-Operative Care
Obviously the client will be in pain with a big incision that is healing.
Surgical Wound Dressing
The key point is focused on removal of the surgical wound dressing.
ONLY the surgeon removes the initial (first) dressing!
The initial (first) dressing is ONLY removed by the surgeon …
Not the nurse, not the aid, not the student, NOBODY but the surgeon!
If the surgical site is bleeding, do you remove the surgical dressing then?
No, only the surgeon removes the initial dressing.
If it’s bleeding, just keep adding pads to the site & call the surgeon. DO NOT REMOVE!
Once the surgeon removes the initial dressing, then you can assess the wound like normal.
Always assess for infection with any surgical site:
-Warm
-Red
-Draining
Epidural & Pain Control I
Maternity
Non Pharmacological
This means no medications are used for pain control during labor.
NCLEX
Monitor for nonverbal signs
of ineffective coping with labor
Panic
Anxiety
Squirming movements
Pain medication
Medication SEDATIVES
Pain control during labor with pain medications, like sedatives & opioids, are best given
during the early stages of labor, as they can cause serious side effects like respiratory Opiates
depression when given closer to birth!
These medications can be VERY DEADLY - we like babies with strong cries,
NOT FLOPPY BABIES. It’s best to give these 2-4 hours BEFORE birth so that the drug
has time to wear off BEFORE birth. 2 - 4 hours
Notes
Epidural & Pain Control II
Maternity
Epidural Anesthesia
Epidural anesthesia also called an epidural block, is an injection into the lower back that temporarily blocks
pain from the waist down. For the procedure, clients will lie on their side with knees tucked in or sit up right & lean
forward. To help visualize the position, nurses tell clients to curl over like a cooked shrimp.
When in the correct position, the provider will insert a needle into the client’s epidural space between the
dura mater & the vertebral wall just outside of the spinal cord.
A catheter is threaded through and secured as the epidural needle is removed. The catheter is used by the provider
to administer pain relief when needed.
NCLEX Questions
Q1: Which laboratory value is the priority to
Epidural Anesthesia report to the provider prior to epidural
anesthesia?
Epidural Block
Platelet count of 95,000
Blocks sensation from waist down:
umbilicus (belly button) to legs NCLEX Questions
After the cervix is 4 cm dilated Q2: An epidural was administered 20 minutes
ago and now the client reports feeling dizzy and
Less than nauseated. Which action should be performed
Caution ≤ 150,000
Normal first?
Maternal hypotension (low BP) 150,000 - 400,000 Bleed Risk! Obtain blood pressure
Fetal bradycardia (low HR)
Low platelet count in the mother Kaplan Question
Normal 150k - 400k
A client is 6 cm dilated and ready for epidural
Less than 150k = risky! BLEED RISK anesthesia. Which position will the nurse assist
the client?
On the left side, shoulders parallel, legs
flexed, and back arched
Spinal Anesthesia
Spinal Block
C-section
100% loss of motor movement &
sensation
Spinal Anesthesia
Preterm Labor refers to labor that begins too early between 20 - 37 weeks of pregnancy
characterized by CERVICAL change (that can be dilation or effacement), where as labor after Preterm Labor
37 weeks is considered full term and labor before 20 weeks is categorized as spontaneous 20 - 37 weeks of pregnancy
abortion - as the newborn will not survive.
Preterm labor is the number 1 cause of neonatal mortality, as babies born prematurely
do not have fully developed organs.
For example, the lungs do not have maturity to breathe on their own & the chambers in the
heart have not fully closed yet, just to name a few. Sort of like a cake coming out of the oven
too soon - it is not fully cooked.
In the same way, the baby is like a bun in the oven that comes out too soon & does not
have enough time to fully cook or develop. Naturally, we will see less complications the longer
the baby stays in the womb.
Preventative Measures
12 - 28 weeks
Prophylactic Cervical Cerclage
To prevent preterm delivery
Cervical insufficiency
Signs of Preterm Labor Notify the HCP
12 to 28 weeks gestation
Stitches are removed at 36 - 37 weeks 1. Rupture of membranes
Report watery discharge from vagina ATI
Interventions
2. Low back pain NCLEX TIP NCLEX TIP
Education (after cerclage)
Activity restriction & bed rest 3. Contractions & pelvic pressure
No sexual intercourse
Mild abdominal cramping is expected
Assess fetal movement daily HESI
Continuous fetal monitoring Clients who have had a history of preterm labor are
Amniotomy (AROM) is the manual commonly prescribed progesterone throughout the PROGESTERONE
induction of labor by rupturing the pregnancy, as it will reduce the risk for future preterm
amniotic membranes & is contraindicated! labor.
Notes
PROM & AROM
Maternity
PROM Pathophysiology
PPROM PROM
As you know, the baby is floating in amniotic fluid within the P Preterm
chorioamniotic membrane, making up the amniotic sac.
P Premature P Premature
This is held inside the uterus, which we call the baby apartment Aminiotic fluid
since it is where the baby lives during fetal development. Chorioamniotic R Rupture R Rupture
membrane
Aminiotic sac
O Of O Of
The cervix is the door to the apartment that holds it all in. M Membranes M Membranes
In PROM, the mother’s water breaks too early & this amniotic
fluid leaks out! *Before 37 weeks *After 37 weeks
Risk factors
Treatment Over 37 Weeks
Anything that weakens the strength of
the chorioamniotic membrane Prevent infection HOURS
Diagnostics
Nitrazine Test
Speculum exam (”Pooling”) Saunders Question
A speculum is placed inside the vagina A pregnant 39 week-gestation ... has had a positive group HCP
& the client is asked to cough or bear B streptococcus (GBS) ... the cervix is dilated 6 cm and
down. If amniotic fluid is seen coming 90% effaced. Which should be the nurse’s first action? Prophylactic
Antibiotics
out of the cervix when this pressure is Call the health care provider (HCP) to obtain a
prescription for intravenous antibiotic prophylaxis
applied, the client has ROM.
Ultrasound
Screening for STIs
AROM
Amniotomy - this is a procedure performed by the health care provider to manually HESI Question
induce labor by rupturing the amniotic membrane or in other words breaking the Amniotomy ... Immediately after the procedure what is
client’s water. most important information for the nurse to obtain?
Fetal heart rate
Amniotomy 1st Priority
cord compression
R Rupture 4 NCLEX TIPS: Interventions
Normal NOT Normal
1. Assess fetal heart rate
O Of BEFORE & AFTER
Clear
Colorless
Yellow-green fluid
Meconium
No foul odor Strong foul odor
2. Assist to upright position after
M Membranes
Infection
Amniotomy
Manual induction of labor by
rupturing the amniotic membrane
Risk for Umbilical Cord Prolapse
Causing fetal bradycardia due to
cord compression
NCLEX TIP
Forceps spoon like devices used to assist delivery
Bishop Score
HESI Question
Caution! Never apply fundal pressure during forcep use System for assessing cervical
Uses: fetal distress or abnormal fetal presentation
Complication... forceps-assisted delivery? readiness for induction of labor.
Complication Presence of vaginal lacerations
Uterine rupture
OVER 6 - 8 score indicates
Bladder injury induction will be successful
Vaginal Lacerations
Symptoms Interventions
Sudden chest pain Notify the provider!
Hypotension (low BP) IV fluids & blood transfusion
Tachycardia (fast HR) Assist with intubation
Dyspnea (difficulty breathing) Oxygen
Cyanosis (blue, pale skin)
0.9% PRBC 0₂
Sodium Chloride 0₂
0₂
NORMAL
0₂
HIGH
LOW
0₂
0₂
Dystocia
Pathophysiology Interventions
Slow or difficult labor or delivery Reposition or ambulate the mother
Oxytocin: induce labor
Memory trick
Amniotomy: the provider manually
D - Dystocia
breaks the water
D - Difficult Labor
Oxytocin
Saunders Question
Causes & Risk Factors ... labor dystocia... which risk factors in the client’s
history placed her at risk for this complication?
Macrosomia (big baby over 8lbs 13 oz) Select all that apply.
Age 54
Overweight (BMI over 25) Body mass index of 29
Over 8lbs 13oz
Older age Previous difficulty with fertility
Shoulder Dystocia
0₂
Shoulder Dystocia
Precipitous Labor
This is quick labor - some professors call these “cannonball” babies, because they shoot out with impressive force
and everything can get damaged - baby & mom included!
Pathophysiology Risks
Labor within 3 hours or less! Hypertonic uterine contractions
After the onset of contractions
Use of Oxytocin
Memory trick:
Multiparous mother
P - Precipitous Labor
P - Pretty Quick labor (multiple previous births)
Within 3 hours or less
Complications Interventions
Prepare to assist with birth
1. Mom:
Keep the infant warm! NCLEX TIP
Postpartum hemorrhage
Uterine rupture O2 Dried & placed skin-to-skin on the
mothers abdomen
Amniotic fluid embolism
AVOID NCLEX Traps
2. Baby
APGAR SCORE
2 points
Do NOT pull on the cord!
Intracranial hemorrhage → Uterine inversion or cord avulsion
Fundal massage ONLY after placenta is
Hypoxia delivered
Labor Complications III
Maternity
Uterine Rupture
Causes
Pathophysiology Previous C-section attempting a vaginal
delivery (weak spots in the uterus that
Spontaneous tearing of the uterus that
can rupture)
may result in the fetus being expelled
Forceps delivery
into the peritoneal cavity Uterine Rupture
Traumatic events (car accident or fall)
Overdistension of uterus: Twins,
triplets, or more
Uterine Inversion
0.9% PRBC
AVOID
Sodium Chloride
AVOID
Labor Complications IV
Maternity
HESI Question
… cause of variable fetal heart rate (FHR)
deceleration is which factor?
Umbilical cord compression
Saunders Question
… umbilical cord compression if which is noted on
the external monitor tracing during a contraction?
Variable decelerations
Notes
Labor Complications V
Maternity
DIC
Pathophysiology This is severe bleeding inside & outside the mother’s body.
As the body uses up all clotting factors & platelets, it makes little clots all
DIC = disseminated intravascular over the body & uses up all means to stop bleeding elsewhere in the body,
coagulation leaving the mother with no means to stop bleeding anywhere!
Interventions
Signs & Symptoms Priority! NCLEX TIP Coagulation Fibrinogen
test
External bleeding: venipuncture site Draw coagulation tests, fibrinogen,
Internal bleeding: petechiae & ecchymosis & platelet count
Organ damage: Administer blood products, volume Platelet
Contraindication
APGAR SCORE
0 points 1 points 2 points
The APGAR is a simple quick assessment tool used to rapidly describe a newborn's well-being
immediately after birth & how they’re adjusting to life outside the womb.
Infants are rated on a scoring system from 0 to 10. The higher the score the healthier the baby
1
It's important to note it is done twice - at 1 minute & at 5 minutes after delivery. min
& It may be reassessed for a 3rd time at 10 minutes if the score is less than 7. 1st
5
mins
7 or Less = Reassess
mins
3rd
Always remember to start with 10 points & then focus on what’s BAD! Start subtracting bad signs so:
REALLY BAD - subtract 2 points
KINDA BAD - subtract 1 point.
TEST TIP Be sure to write out this chart at least 10 - 15 times, every day the week of your exam.
It's vital to know these numbers & how to rate it. P Pulse (heart rate) Absent Less than OVER
100/ min. 100/ min.
You need to spot lower ratings - as this means the newborn
Grimace (reaction & reflex) Absent Grimace Cry & Pull
is in severe distress! G away
Notes
Apgar Score II
Maternity
G G <100 >100
A A
R Acrocyanosis R
R R
Apgar score of 6
P Pulse (heart rate)
1 2 Sign 0 points 1 points 2 points
G
Appearance Blue/ Pale Blue arms Completely
Grimace (reaction & reflex)
115 A
6
(skin color) Core & legs Pink
Pink Body
R
Activity Limp Minor flexion Active flexion
A
Respiratory effort (muscle tone) & extension
2 1
Respiratory Absent Weak cry Strong cry Respiratory Absent Weak cry Strong cry
R effort R effort
4 2 1 1
130 8
When should the nurse plan to 1st 2nd ... Apgar score of 10 at 1 minute after birth?
An infant having no difficulty adjusting
determine the Apgar score?
to extrauterine life but who should be
At 1 minute after birth and assessed again 5 minutes after birth
5 minutes afterbirth 1 min 5 mins
Newborn Assessment III
Maternity
HESI Question
... newborn’s cord care at home?
Allow the cord to air-dry as much as possible
24 - 48 hrs
Notes
NRP & NEC
Maternity
G Grimace
(reflex irritability)
Floppy
Minimal Response
to Stimulation
Prompt Response
to Stimulation
Critical Interventions
A Activity
(muscle tone)
Absent Flexed Arms
and Legs
Active
Necrotizing Enterocolitis
This is an inflammatory disease of the gastrointestinal mucosa due to ischemia (low oxygenation), resulting in necrosis
(dead tissue within the GI tract), & perforation of the bowel (basically an explosion of the bowel).
Pathophysiology
Hyperbilirubinemia
Hyperbilirubinemia, or jaundice, is the yellowing of skin from too much bilirubin - those dead RBCS in the blood.
Patho & Causes
Pathologic
Structural defects in the liver HESI Question
→ build up of bilirubin
… highest priority to which finding?
Physiologic
RBCs breakdown (from birth trauma) Skin color that is slightly jaundiced YES!
1 Always report yellow skin!
produces bilirubin
Immature & can’t keep up
hyperbilirubinemia → Jaundice Saunders Question
Can cause multisystem organ damage
& irreparable brain damage Which assessment finding should alert the
nurse to suspect the potential for jaundice
Signs & Symptoms in this infant?
Yellowish hues Report to HCP Presence of cephalhematoma
Face or eyes (sclera)
Trunk & extremities
Treatment
Phototherapy - In the hospital setting most commonly include fiberoptic phototherapy blankets & pads.
Bili lights (lamps) - where the baby is placed under heat lamps like a food item at a buffet
Treatment: Phototherapy
Nursing Interventions PRIORITY ATI Question
1. Skin Care
Monitor skin temperature closely
37.5
… plan of care for an infant
Reposition every 2 hours receiving phototherapy?
Giving additional fluids
Saunder
2. Dehydration risk → Give fluids NCLEX
Notes
Newborn Complications II
Maternity
Interventions 5 NCLEX TIPS hypoxia, & hyperbilirubinemia! and dry him with a towel
Saunders Question
Skin-to-skin contact newborn & mother
Dry the newborn immediately after delivery … most effective in preventing heat loss
& place hat by evaporation?
Provide care under radiant warmers Drying the infant with a warm blanket
Cover scale with warmed blankets
before weighing the newborn HESI Question
Use prewarmed incubator when transporting Which nursing action ... immediately
following the vaginal birth?
Drying the infant on the mother’s chest
and then placing a hat on the infant
Hypoxia
As you know the newborn must transition quickly from a fluid-filled environment to an air-filled environment
so the lungs must expand with the help of surfactant which prevents collapse of the alveoli within the lungs
Causes Interventions
Signs of Respiratory Distress Fluid or mucus Dry, stimulate, suction
obstruction
Pathologic apnea 00:15
Intercostal retractions Prematurity Support ventilation
Central cyanosis (lack of surfactant)
Give surfactant
Nasal flaring (Betamethasone)
Grunting, wheezing
Cardiac Defect Monitor & Surgery
Intercostal retractions
(PDA or PFO)
Hypoglycemia
Newborn blood glucose should be kept above 40mg/dL at all times. Risk Factors
Mom with diabetes (all types)
Newborns are at risk for hypoglycemia because the placenta (the source HYPOTHERMIA
of maternal glucose) is removed & the infant’s pancreas is still producing Sepsis
insulin at a rate that matches the levels of maternal glucose during pregnancy.
Signs & Symptoms
Less than 40 mg/dL
Shaking, sweating, & irritability
Lethargy
>40 High-pitched or weak cry
Seizures
Nursing Interventions
Breast feeding is #1 !
Identify high risk newborns
Keep infant warm