Obstetrical Nursing

OBSTETRICAL NURSING EXCERPT Birth usually feels like a steamy kitchen—similar to holiday preparations, except the smells are different. The smell of sweat is more acrid, there are some fetid odors, there is the smell and steam rising from blood. The air is thick, pungent, fertile. It is hard not to be reminded of fresh straw and night stars. There is near and heady promise. ~ Penny Armstrong & Sheryl Feldman, A Midwife's Story ~ Overview of Philippine Obstetrics Latin origin: Obstetrix Midwife FROM WOMB TO TOMB

PUBERTAL DEVELOPMENT Puberty 9-12 years of age in females 12-14 years old in males Central nervous system control Hypothalamus Pituitary gland Pubertal Development Androgen adrenarche Estrogen thelarche menarche Secondary Sex Characteristics

ANATOMY AND PHYSIOLOGY OF THE MALE REPRODUCTIVE SYSTEM External Structures Scrotum Testes Penis Internal Structures Epididymis Vas Deferens Seminal ducts Ejaculatory ducts Prostate gland Bulbo-urethral glands Urethra

ANATOMY AND PHYSIOLOGY OF FEMALE EXTERNAL STRUCTURES Glans Clitoris Urethral Meatus Vaginal Orifice / Vaginal Opening Vestibule Perineum

ANATOMY AND PHYSIOLOGY OF FEMALE INTERNAL STRUCTURES VAGINA Passageway for menstrual discharges Organ of Copulation: receives penis during sexual penetration Forms part of the birth canal

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UTERUS Hollow, pear-shaped fibromuscular organ Functions: Organ of menstruation Site of implantation Retainment and nourishment of product of conception Consists of 3 parts: Corpus Isthmus Cervix Composed of 3 muscle layers: Perimetrium Myometrium Endometrium FALLOPIAN TUBES 4 inches long from each side of the fundus Peristaltic movements in the tubes cause the transport of the mature ovum from the ovaries to the uterus. AMPULLA – widest part at the outer third or outer half where fertilization takes place OVARIES Sex glands Produce and expel ova or egg per cycle Produce estrogen and progesterone Estrogen Inhibits production of FSH (Follicle Stimulating Hormone) Causes hypertrophy of Myometrium Stimulates growth of the ductile structures in the Breasts Increases quantity and pH of the cervical mucus causing it to become thin and watery Progesterone Inhibits production of LH (Luteinizing Hormone) Facilitates transport of the fertilized ovum through the fallopian tube Increases endometrial tortousity. Inhibit uterine and gastrointestinal motility. Decreases muscle tone of the urinary tract Increase musculoskeletal motility Decreases renal threshold for lactose and dextrose. Causes fluid retention. Increases basal fibrinogen levels thus decreasing hematocrit and hemoglobin levels. Increases basal body temperature after ovulation.

ANATOMY AND PHYSIOLOGY PELVIS STRUCTURES made of 4 bones: Ilium – iliac crest Antero-posterior iliac spines Ischium Pubis Sacrum Coccyx True and False Pelvis False Pelvis offers landmark for pelvic measurement Supports the growing uterus during pregnancy Directs the fetus into the true pelvis at the latter part of the gestation. True Pelvis Inlet Diameter:

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Antero-posterior Transverse 13cm Oblique 13cm Mid Pelvis SIPSS Sacral promontory accessible Ischial spines are not prominent Pelvic wall are not convergent Sacrum is curved Sub pubic arch is wide Outlet Anteroposterior 9.5 to 11cm Intertubrous 11cm Posterior sagital 7cm Pelvic Types or Variations Gynecoid Anthropoid Platypelloid Android

MENSTRUAL CYCLE Amenorrhea Menorrhagia Metrorrhagia Polymenorrhea Oligomenorrhea Menstrual cycle Regular occurance of ovulation throughout the reproductive life of a woman It is divided into two phases: Follicular (proliferative) Luteal (secretory) Menstrual Cycle STRUCTURES INVOLVED Hypothalamus Anterior Pituitary Gland Ovary Uterus Menstrual Cycle Two simultaneous cycles: ovarian cycle and Follicular, Ovulatory, Luteal phase Menstrual phase endometrial cycle Proliferative Ovulation Secretory Menstrual phase

NEUROENDOCRINOLOGY OF REPRODUCTION Hypothalumus GnRH Intermittent, pulsatile cyclic manner controls the release of gonadotropins by the anterior lobe of the pituitary gland HORMONES REGULATING MENSTRUAL CYCLE FSH (Follicle Stimulating Hormone) LH (Luteinizing Hormone) Gonadotrophins Estrogen

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Inhibits production of FSH (Follicle Stimulating Hormone) Causes hypertrophy of Myometrium Stimulates growth of the ductile structures in the Breasts Increases quantity and pH of the cervical mucus causing it to become thin and watery Progesterone Inhibits production of LH (Luteinizing Hormone) Facilitates transport of the fertilized ovum through the fallopian tube Increases endometrial tortousity. Inhibit uterine and gastrointestinal motility. Decreases muscle tone of the urinary tract Increase musculoskeletal motility Decreases renal threshold for lactose and dextrose. Causes fluid retention. Increases basal fibrinogen levels thus decreasing hematocrit and hemoglobin levels. Increases basal body temperature after ovulation.

THE GROWING FETUS The beginning of pregnancy Ovum Zygote Embryo Conceptus Fertilization of one ovum by one sperm resulting in a fertilized ovum (zygote). Usually occurs in the distal outer third of fallopian tube Implantation Blastocyst Trophoblast Embryoblast

THE PROCESS OF APPOSITION EMBRYONIC STRUCTURES The decidua It is the pregnant endometrium if fetilization occurs. Deciduabasalis Deciduacapsularis Decidua Vera Chorionic Villi Serves as the anchor of the trophoblast on the deciduas Syncytiotrophoblast Cytotrophoblast The Amniotic Membranes Amnion Chorion Amniotic Fluid Produced by the amnion 500ml to 1L clear yellowish fluid Oligo- and poly- hydramnios Embryonic structures The placenta From trophoblastic layers Weighs 1/6th of the fetus (400-600Gm) Compesd to 30 cotelydons Has circulatory and endocrine function

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Endocrine function of the placenta hCG maintains levels of estrogen and progesterone Suppress immunologic response Estrogen Progesterone hPL The umbilical cord Formed from fetal membranes Connects fetus and placenta 2 arteries and I vein Protected by the wharton’s Jelly Origin and Development of Organ Systems ECTODERM MESODERM ENDODERM Origin and Development of Organ Systems Cephalocaudal Implantation : BLASTOCYST Amniotic cavity (ectoderm) yolk sac ( Entoderm) Yolk sac : supply nourishment until implantation Source of RBC until about 12th week (mesoderm)

ORIGIN AND DEVELOPMENT OF ORGAN SYSTEMS EMBRYONIC PERIOD: Prone to teratogenics At 8 weeks: the end of embryonic period, all organ systems complete CARDIOVASCULAR SYSTEM First system to be functional in intrauterine life, forms as early as 16th day and beats as early as the 24th day Doppler: from 10th – 12th week Fetal circulation 3 unique structures of the heart and of the fetus: Ductusvenosus Foramen ovale Ductusarteriosus Fetal hemoglobin Composed of 2 alpha and 2 gamma chains Normal hemoglobin level for newborn is 17.1g/100ml (adult is at 11g/dl) Newborn Hct is 53% (adult is at 45%) RESPIRATORY SYSTEM 4TH Week septum begins to divide the esophagus to the trachea 6th week lung buds extend down into the abdomen and diaphragm becomes complete at the end of 7th week 24th week, SURFACTANT is formed and excreted by the alveolar cells SURFACTANT: Has two components: Lecithin : surge production at about 35 weeks and becomes chief component Sphingomyelin: chief component at early formation of surfactant NERVOUS SYSTEM 3rd and 4th week of life development of nervous system and sense organ has already begun

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Neural plate becomes apparent at 3rd week and differentiates into Neural tube neural crest (CNS:brain and SC) (PNS) DIGESTIVE SYSTEM 4TH Week: digestive system is separated from the respiratory tract The endothelial cells will later form the meconium Meconium : at 16th week GIT is sterile before birth causing low level of vitamin K in newborn At 36 weeks : GIT has ability to enzymes Except AMYLASE : which is secreted 3 months after birth. MUSCULOSKELETAL SYSTEM Cartilage forms as early as 2 weeks of fetal life which provides support and position At 12th week: ossification of bones begin and continue throughout fetal life until adulthood REPRODUCTIVE SYSTEM Determined at the moment of conception by the spermatozoon carrying an X or a Y chromosome At about 6 weeks : gonads are formed Can be determined as early as 8weeks URINARY SYSTEM Present as early as 4th week Urine is formed by the 12th week At term : 500ml per day INTEGUMENTARY SYSTEM Thin and almost transparent Covered by vernixcaseosa IMMUNE SYSTEM IgG maternal anibodies cross the placenta during the 3rd trimester No immunity to herpes virus

MILESTONES OF FETAL GROWTH AND DEVELOPMENT END OF 4 GESTATION WEEKS Spinal cord is formed, rudimentary heart appears Arms and legs are budlike structures Rudimentary eyes, ears and nose END OF 8 GESTATION WEEK Organogenesis is complete Heart is beating regularly Facial features are discernible External genitalia are present but indistinguishable by simple observation END OF 12 WEEKS Sex is distinguishable by outward appearance Spontaneous movement are possible, but too faint to be felt by mother Bone ossification centers are forming Heartbeat is audible by doppler END OF 16 WEEKS Fetal heart sounds are audible by ordinary stethoscope Lanugo is well formed Sex can be determined by ultrasound Fetus actively swallows amniotic fluid END OF 20WEEKS Spontaneous fetal movements felt by mother Fetal heartbeat is strong to be audible

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Vernixcaseosa begins to form Definite sleep and activity patterns END OF 24 WEEKS Active production of lung surfactant Passive antibody transfer from mother to fetus Pupils capable or reacting to light Hearing can be demonstrated by response to sudden sound END OF 28 WEEKS Lung alveoli begin to mature Testes begin to descend into scrotal sac Eyes open Blood vessels of etina are extremely sensitive to high levels of O2 END OF 32 WEEKS Active moro reflex is present Fetus is aware of sounds outside mother’s womd Birth position may be assumed END OF 36 GESTATION WEEKS Body stores of glycogen, iron, carbohydrate and calcium augmented Lanugo begins to diminish Most babies turn into a vertex presentation END OF 40 WEEKS Fetus kicks actively enough to cause discomfort Fetal hemoglobin begins its conversion to adult hemoglobin Vernix is fully formed Creases of the sole cover 2/3 of the surface

DIAGNOSIS OF PREGNANCY PRESUMTPIVE SYMPTOMS OF PREGNANCY 1. Nausea with or without vomiting 2. Disturbance in urination 3. Perception of fetal movement 4. Breast tenderness and tingling sensation 5. Amenorrhea 6. Anatomic Breast changes 7. Changes in vaginal mucosa 8. Skin pigmentation 9. Thermal signs : increased temp by 0.3 to 0.5 for > 3weeks PROBABLE EVIDENCE OF PREGNANCY 1. Enlargement of the abdomen 2. Changes in the shape, and consistency of the uterus 3. Anatomical changes in the cervix 4. Braxton Hick’s Contraction 5. Ballottment 6. Physical outlining of the fetus 7. Positive pregnancy test : B HcG levels POSITIVE EVIDENCE OF PREGNACY 1. Identification of fetal heart tones separately from mother 2. perception of active fetal movement by the examiner 3. Ultrasound or radiologic evidence

THE BEGINNING OF PREGNANCY GESTATIONAL (MENSTRUAL AGE) : measured from the 1st day of the last menstrual period, in completed days or weeks OVULATION (POST CONCEPTION AGE): 2 weeks less the gestational age VIABILITY:

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-Beyond 20th week of pregnancy or the stage of abortion OBSTETRIC SCORE: FULL TERM, PREMATURE, ABORTION, LIVE CHILDREN FULL TERM: from 37 to less than 42 completed weeks PRE TERM : less than 37 completed weeks POST TERM : 42 completed weeks or more Eg : G7P6 TPAL (5,0,1,5) GRAVIDA : woman who is or has been pregnant irrespective of pregnancy outcome Primigravid Multigravida Nulligravid PARITY : number of pregnancies reaching viability. Parity is same whether a single or multiple fetuses were born alive/ stillborn Primipara Multipara Nullipara

RUBIN’S FRAMEWORK FOR MATERNAL ROLE ASSUMPTION PSYCHOSOCIAL ASSESSMENT First Trimester Ambivalence Baby is “part” of her Second Trimester Feels well, happy Focus is on self Fantasizes about baby Quickening felt Psychosocial Assessment Third Trimester Nesting Energy surge as due date approaches Desire to get to the end of the pregnancy Focus on baby, delivery

REPRODUCTIVE CHANGES DURING PREGNANCY Ovaries Increased vascularity Corpus luteum persists until the 12th week of pregnancy after which it is taken over by the placenta. Uterus Pear-shaped Size enlarges compatible with age of gestation Braxton Hicks contractions Structural changes include: Changes in the endometrium Changes in the myometrium Increased blood supply Formation of the lower uterine segment With onset of labor, contractions are regular synchronous with fundal dominance. Cervix GOODELL’S SIGN Increased mucus secretion of the cervical glands.

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Mucus accumulates within cervical canal that provides a barrier against infections. Vagina Increased in length, distensibility Increased vascularity CHADWICK’S SIGN Increased shedding of the glycogen rich squamous cell resulting in increased whitish, creamy, highly acid vaginal secretion. Breasts Enlargement, tenderness or pain on slight pressure Darkening of primary areola, fluid expressed from the nipple Colostrum Cardiovascular Changes during pregnancy Increase in heart rate Increase in cardiac output about 30-50% 4 periods where there is increase in cardiac output: On the 28th week of gestation During labor Immediately postpartum During 1st week of puerperium Respiratory Changes during pregnancy Increased estrogen causes increased vascularization of upper respiratory tract Progesterone causes respiratory alkalosis compensated by mild metabolic acidosis. Gastro-intestinal Changes during pregnancy Smooth muscle atony and decreased tone of lower esophageal sphincter, causing esophageal regurgitation. Renal Changes during pregnancy Increase in renal pelvis and ureter called “physiologic hydroureter of pregnancy” more on the right side. Endocrine Changes during pregnancy Anterior Pituitary gland hypertrophies with increased activity, posterior lobe increases production of oxytocin necessary for contraction next to term. Normal ovarian function is suspended, corpus luteum activity exists only until 12th week when placenta replaces its role for secretion of hormones. Thyroid gland has increased vascularity, with hyperplasia and enhanced functioning. Hypertrophy and hyperplasia of parathyroid gland also occurs with increased activity to provide adequate amount of calcium to fetus and mother. HCG HPL Hematologic Changes during pregnancy Increased blood volume due to increased plasma volume gradually happening at the end of first trimester and stays high throughout the pregnancy. Increase in blood coagulation factors, increased fibrinogen levels, increase in plasminogen levels and fibrin degradation products. Increased plasma iron binding capacity. Total iron requirement for pregnancy is one gram or 6-7mg per day. Maternal Metabolism In Pregnancy Weight gain of 25-35lbs First trimester Second trimester Third trimester - average of 14 oz or 1 lb/week

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average of 1 lb/mo or 14 lbs total Water and sodium metabolism Water retention - 6.5 liters Increased plasma volume - 1.5 liters Sodium retention is 3 grams/week but in inactive form PRENATAL CARE

Gen Data…

ESTIMATION OF THE DURATION OF PREGNANCY… EDC LEOPOLD’s MANEUVER PE and ROS PELVIC EXAM LAB TESTS Frequency of visits Every 4 weeks until 28 weeks Then every 2 weeks until 36 weeks Weekly thereafter Pre-Natal Visits Personal data Obstetrical data • GPTPAL Past pregnancies • Method of delivery • Place of delivery • Risks or Problems experienced Present Pregnancy • Main concern • Danger signals Medical data Review of systems –G - Gravida – number of pregnancy the woman is having presently –P - Para – total number of viable pregnancies regardless of outcome –T – Number of full term –P – Number of premature if any –A – Number of abortions or aborted pregnancies if any –L – Number of living children Pre-Natal Visits Fundal Height used to assess gestational age and fetal growth.

SIGNIFICANT MEASUREMENTS AND ESTIMATES Age of Gestation Nägele's Rule - estimates expected date of confinement (EDC). McDonald’s Method – AOG in months. Measure distance from symphysis pubis to the top of uterine fundus designated as fundal height in centimeters (cm). ESTIMATING FETAL GROWTH MC DONALD’S RULE: •Note fundic height •Between 20 to 31st week of pregnancy: height (symphisis to fundus) in cms in equal to the AOG in weeks •Usually inaccurate at the 3rd trimester •Over symphisispubis : 12th week

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•Umbilicus: 20th week •Xiphoid process: 36 weeks Age of Gestation Bartholomew’s – AOG is estimated by the position of uterus in the abdominal cavity. Done thru palpation. Length of Fetus in Centimeters Haase’s Rule • During first half of pregnancy – square the number of the month • Second half of pregnancy – multiply the month by five (5)

ESTIMATING WEIGHT OF FETUS IN GRAMS Johnson’s Rule - Formula – “n multiplied by k” • “k” – constant, it is always 155 • “n” – 11 if fetus is not yet engaged / 12 if fetus is already engaged LEOPOLD’S MANEUVER LM1 ( Fundal grip) •What fetal pole or part occupies the fundus? –BREECH : irregular, nodular –CEPHALIC : round LM2 ( Umbilical grip) •Which side is the fetal back? –Back : linear, convex –Small Parts : numerous nodulation LM3: (PAWLIC’s grip) •What fetal lies above the pelvic inlet? –Head engaged or not. LM4 : (Pelvic Grip) •Which side is the cephalic prominence? –Cephalic prominence –Flexion –Extension

IDENTIFICATION OF HIGH RISK PREGNANCY Maternal age Maternal height Weight Social factors OB HISTORY (high risk) •Multiparity •PROM, IUGR •Premature labor •Macrosomia •Multiple pregnancy •AF abnormalities •UTI, DM, HPN •Uterine/ ovarian diseases

thyroid disease PTB Previous CS Abnormal presentations Placental abn.

URINE EXAMINATION Biological Tests •The presence of HCG in the urine will cause hemorrhagic reaction on the ovaries and testes of the animal. Progesterone Withdrawal Test • Negative result – menstruation within 10-15 days • Positive result – No menstruation after taking pills Urinary Pregnancy Tests • HCG (Human Chorionic Gonadotrophin)

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Urine Examination The night before procedure: no water after 8 pm – to concentrate urine to be collected. Morning: collect first morning urine, midstream in a clean dry container. If urine is to be tested more than one hour after collection: refrigerate since HCG is unstable on room temperature. DM SCREENING Pregnancy is diabetogenic due to impairment of peripheral insulin action as a consequence of the action of PLACENTAL LACTOGENS, ESTROGENS and PROGESTERONE Insulin does not cross the placenta fetal hyperglycemia Criteria for the diagnosis of Gestational DM (OGTT) Usually at the 2nd trimester (24th to 28th week) 50 g OGCT if>130mg/dl in 1 hr proceed to 3 hr 100g OGTT after an overnight fast •OGTT: then plasma glucose is measured hourly

ASSESSING FETAL WELL BEING Fetal movement SANDOVSKY METHOD –Average normal finding: 2x every 10 minutes or average of 10 to 12x an hour CARDIFF METHOD: “COUNT TO TEN METHOD” •records time interval to feel 10 fetal movements; usually this occurs within 60 minutes Fetal Heart Tones •can be assessed through Doppler ultrasound device or by fetoscope •ranges from 120-160 beats per minute. Rhythm strip testing Semi fowlers position Using external FHT and uterine contraction monitors attached abdominally Record FHT for 20 minutes Non stress testing Results of non stress test Movement : FHT should increase to about 15 beats per minute and remain elevated for 15 seconds If no increase in FHT on fetal movement: poor oxygen perfusion of the fetus Done for 10 to 20 minutes Results: •REACTIVE (good) •NON REACTIVE If no movement in 20 minutes: may denote fetus is sleeping •Stimulate fetus : high carb snack, bell/ loud sound IF NON REACTIVE: •Schedule for : 1. Contraction stress test 2.BPS ( biophysical profile) Contraction stress testing Measure of uteroplacental function FHT analyzed in conjunction with contractions Source of OXYTOCIN : nipple stimulation Steps: •Attach monitor for FHT and uterine contractions •Get baseline FHT •Nipple stimulation( rolls nipple between her fingers and thumb until contractions begin) Pre requisites of valid contraction stress test 3 contractions with a duration of 40 seconds or more in a 10 minute period RESULTS :

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•Negative : (normal) •Positive : (abnormal) 3 types of fetal heart rate pattern •Early decelerations •Late •Variable Early Decelerations Late Decelerations Variable Decelerations Ultrasound Uses : 1. diagnose pregnancy as early as 6 weeks –(gestational sac at 5 to 6 wks) –(CRL )crown rump length at 12-14weeks –Biparietal diameter (BDD)or femoral length(FL) onwards 2. confirm presence ,size and location of placenta and amniotic fluid Ultrasound 3. establish that fetus is growing and has no gross defects 4. establish presentation and position of fetus ( sex can be diagnosed if penis is revealed) 5. Others : complications of pregnancy Other Types of ultrasound B mode scanning : gray scale, sonogram Real time scanning : multiple wave, allows screen picture to move LAB TESTS RH incompatibility Rh : the surface of human RBC may or may not contain the (Rhesus Antigen). If with this antigen: RH (+) Half of all antigens in the fetus come from the father, and half come from the mother The problem with RH sensitization Parenteral combination to worry about: •Mother Rh (-) and •fatherRh(+) •antibodies --cross placenta and attach fetal RBC’s-fetal hemolysis When does sensitization happen? RH (-) mother becomes sensitized during earlier pregnancy in which the child was Rh (+) ERYTHROBLASTOSIS FETALIS RhoGAM : treatment for exposure If Rh(-) mother is exposed to fetal blood, RhoGAM is given RhoGAM is RhIgG TRIPLE SCREENING Uses 3 indicators: •AFP; •unconjugatedestriol, and •HCG Yields more reliable results (70-80% of Down syndrome cases) MATERNAL SERUM AFP AFP : (Alpha feto protein) produced by fetal liver •Produced at 11wks AOG at a steady rise until term CHORIONIC VILLI SAMPLING Biopsy and analysis of chorionic villi •Used for chromosomal analysis COELOCENTESIS: transvaginal aspiration of fluid from the extraembryonic cavity Avoid isoimmunization AMNIOCENTESIS Aspiration of amniotic fluid from pregnant uterus for examination

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What information do we get in amniocentesis? Color: normally the color of water, slightly tinged yellow late in pregnancy •strong yellow •Green color Lecithin/Sphingomyelin ratio •Ratio of 2:1 : lung maturity Phosphatidyl Glycerol and desaturatedphosphatidylcholine •positive : fetal lung maturity Bilirubin determination: if a blood incompatibility is suspected Chromosome analysis: fetal skin cells cultured and stained for karyotyping Fetal Fibronectin: preterm labor AMNIOCENTESIS Inborn errors of metabolism: presence of enzymes Alpha fetoprotein Acetyl cholinesterase PERCUTANEOUS UMBILICAL CORD SAMPLING CORDOCENTESIS/ FUNICENTESIS Aspiration of blood from umbilical vein for analysis: usu to check blood dyscrasias

CRITICAL FACTORS IN LABOR Birth Passageway The true pelvis and soft tissues of the cervix, vagina, and the pelvic floor form the birth passageway. The true pelvis is divided into three sections: the inlet, the pelvic cavity (midpelvis), and the outlet. Birth Passageway The four classic types of pelvises are Gynecoid Android Arthropoid Platypelloid Birth Passenger (Fetus) The Fetal Head Fetal Attitude Fetal Lie Fetal Presentation Fetal Position. Fetal Head The fetal head is composed of bony parts, which can either hinder childbirth or make it easier. Once the head (the least compressible and largest part of the fetus) has been born, the birth of the rest of the body is rarely delayed. The fetal skull has three major parts: the face the base of the skull (cranium) the vault of the cranium (roof). The bones of the face and cranial base are well fused and essentially fixed. The base of the cranium is composed of the two temporal bones, each with a sphenoid bone and an ethmoid bone. The bones composing the vault are the two frontal bones, the two parietal bones, and the occipital bone

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Frontal (mitotic) suture: Sagittal suture: Coronal sutures: Lambdoidal suture: The cranial bones overlap under pressure of the powers of labor and the demands of the unyielding pelvis. This overlapping is called MOLDING The intersection of several cranial sutures forms an irregular space that is enclosed by a membrane and called a FONTANELLE. The greater, or anterior, fontanelle (bregma) The lesser, or posterior, fontanelle •Following are several other important landmarks of the fetal skull: –Mentum: –Sinciput: –Vertex: –Occiput: Fetal Attitude •Fetal attitude refers to the relation of the fetal body parts to one another. •The normal attitude of the fetus is termed general flexion Fetal Lie Relationship of the long, or cephalocaudal, axis (spinal column) of the fetus to the long, or cephalocaudal, axis of the mother. The fetus may assume either a longitudinal (vertical) transverse (horizontal) Fetal Presentation •Refers to the body part of the fetus that enters the maternal pelvis first • determined by fetal lie •Fetal presentation may be: –cephalic (head first) –breech (buttocks or feet first) –shoulder. Fetal Presentation The most common presentation is Cephalic. Malpresentations. Breech and shoulder presentations Fetal Presentation

CEPHALIC PRESENTATION Vertex Presentation when the presenting part is the occiput, the presentation is noted as vertex. Most common type of presentation. The smallest diameter of the fetal head (suboccipitobregmatic) presents to the maternal pelvis Sinciput Presentation The fetal head is partially flexed. The occipitofrontal diameter presents to the maternal pelvis The top of the head is the presenting part Brow Presentation. The fetal head is partially extended. The occipitomental diameter, the largest anteroposterior diameter, is presented to the maternal pelvis Face presentation The fetal head is hyperextended (complete extension). The submentobregmatic diameter presents to the maternal pelvis The face is the presenting part.

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Breech Presentation the lower extremities or buttocks. classified according to the attitude of the fetus's hips and knees. In all variations of the breech presentation the sacrum (the bone on the buttocks that is felt when palpating) is the landmark. Complete Breech The fetal knees and hips are both flexed, the thighs are on the abdomen, and the calves are on the posterior aspect of the thighs. The buttocks and feet of the fetus present to the maternal pelvis. Frank Breech The fetal hips are flexed, and the knees are extended. The buttocks of the fetus present to the maternal pelvis. Footling Breech The fetal hips and legs are extended. The feet of the fetus present to the maternal pelvis. In a single footling one foot presents; in a double footling both feet present. Shoulder Presentation When the fetal shoulder is the presenting part, the fetus is in a transverse lie and the acromion process of the scapula is the landmark. Relationship of Maternal Pelvis and Presenting Part Engagement Engagement of the presenting part occurs when the largest diameter of the presenting part reaches or passes through the pelvic inlet. The intertrochanteric diameter (transverse diameter between the right and left trochanter) is the largest to pass through the inlet in a breech presentation. Engagement The presenting part is said to be floating (or ballottable) when it is freely movable above the inlet. When the presenting part begins to descend into the inlet, before engagement has truly occurred, it is said to be dipping into the pelvis Station Relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis. In a normal pelvis the ischial spines mark the narrowest diameter through which the fetus must pass. The ischial spines as a landmark have been designated as zero station.

FETAL POSITION Refers to the relationship of the landmark on the presenting fetal part to the anterior, posterior, or sides (right or left) of the maternal pelvis. The landmarks Occiput, Mentum, Sacrum Acromion Scapula. In summary, three notations are used to describe the fetal position: 1. Right (R) or left (L) side of the maternal pelvis 2. The landmark of the fetal presenting part: occiput (O), mentum (M), sacrum (S), or acromion (scapula[Sc]) process (A) 3. Anterior (A), posterior (P), or transverse (T), depending on whether the landmark is in the front, back, or side of the pelvis The fetal position influences labor and birth.

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The most common fetal position is occiput anterior. Malpositions. Physiologic Forces of Labor •The primary force is uterine muscular contractions, •The secondary force is the use of abdominal muscles CONTRACTIONS Uterine contractions are rhythmic tightenings and shortenings of the uterine muscles during labor. Each contraction has three phases: (1) increment, (2) acme, (3) decrement, •When describing uterine contractions during labor, •intensity •Frequency •Duration Intensity refers to the strength of the uterine contraction during acme. In most instances the intensity is estimated by palpating the contraction, but it may be measured directly with an intrauterine catheter attached to an electronic fetal monitor. When estimating intensity by palpation, the nurse determines whether it is mild, moderate, or strong by judging the amount of indentability of the uterine wall during the acme of a contraction. Bearing down. The combined involuntary pressure of the uterine contractions and the voluntary muscle contractions of the abdomen force the fetus toward the outlet so birth can occur. Possible

Causes

of

Labor

Onset

Labor usually begins between the 38th and the 42nd week of gestation, when the fetus is mature and ready for birth. •PROGESTERONE WITHDRAWAL HYPOTHESIS –Progesterone produced by the placenta relaxes uterine smooth muscle by interfering with conduction of impulses from one cell to the next. (Challis, 2004). PROSTAGLANDIN HYPOTHESIS preterm labor may be stopped by using an inhibitor of prostaglandin synthesis such as indomethacin (Challis, 2004). •CORTICOTROPIN-RELEASING HORMONE HYPOTHESIS –CRH levels are elevated in multiple gestations. Finally, CRH is known to stimulate the synthesis of prostaglandin F and prostaglandin E by amnion cells (Vogel, Thorsen, Currey et al., 2005). •ROLE of ESTROGEN –Estrogen is known to stimulate uterine muscle contractions to permit softening, stretching, and eventual thinning of the cervix. Myometrial Activity In true labor the uterus divides into two portions. This division is known as the physiologic retraction ring. With each contraction, the muscles of the upper uterine segment shorten and exert a longitudinal traction on the cervix, causing effacement. In primigravidas effacement usually precedes dilatation. The uterine muscle remains shorter and thicker and does not return to its original length. This phenomenon is known as brachystasis. The uterus elongates with each contraction, decreasing the horizontal diameter. The cervical os and cervical canal widen from less than 1 cm to approximately 10 cm, allowing birth of the fetus.

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Premonitory Signs of Labor Lightening describes the effects that occur when the fetus begins to settle into the pelvic inlet (engagement) •the woman may notice the following –Leg cramps or pains –Increased pelvic pressure –Increased venous stasis, –Increased urinary frequency –Increased vaginal secretions BRAXTON HICKS CONTRACTIONS–the irregular, intermittent contractions that have been occurring throughout the pregnancy CERVICAL CHANGES. This softening of the cervix, called ripening, is under the influence of hormonal factors.

BLOODY SHOW With softening and effacement of the cervix, the mucous plug is often expelled a sign of impending labor, usually within 24 to 48 hours. RUPTURE OF MEMBRANES If membranes rupture and labor does not begin spontaneously within 12 to 24 hours, labor may be induced to avoid infection. If engagement has not occurred, the danger exists that the umbilical cord may be expelled with the fluid (prolapsed cord). SUDDEN BURST OF ENERGY Some women report a sudden burst of energy approximately 24 to 48 hours before labor. The cause of the energy spurt is unknown. Differences Between True Labor and False Labor STAGES OF LABOR AND BIRTH First Stage The first stage begins with the beginning of true labor and ends when the cervix is completely dilated at 10 cm. First stage (Latent phase) Begins with the onset of regular contractions. Nullipara: averages 8.6 hours Multiparas: averages 5.3 hours

< 20 hours <14 hours

ACTIVE PHASE Cervix dilates from about 4 to 7 cm. Fetal descent is progressive. Cervical dilatation Nulliparas 1.2 cm per hour Multiparas 1.5 cm per hour TRANSITION PHASE Nulliparas should not be longer than 3 hour Multiparas at least 1 hour Cervical dilatation slows as it progresses from 8 to 10 cm and the rate of fetal descent increases. Descent nulliparas at least 1 cm per hour and multiparas 2 cm per hour Second Stage The second stage of labor begins when the cervix is completely dilated (10 cm) and ends with birth of the infant. Primigravida: 2 hours Multiparas: average 15 minutes

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•As the fetal head descends, the woman has the urge to push. •Crowning occurs

POSITIONAL CHANGES OF THE FETUS For the fetus to pass through the birth canal, the fetal head and body must adjust to the maternal pelvis by certain positional changes. These changes are called cardinal movements or mechanisms of labor. Descent Descent is thought to occur because of four forces: (1) pressure of the amniotic fluid, (2) direct pressure of the fundus of the uterus on the breech of the fetus, (3) contraction of the abdominal muscles, and (4) extension and straightening of the fetal body. Flexion Flexion occurs as the fetal head descends and meets resistance from the soft tissues of the pelvis, the musculature of the pelvic floor, and the cervix. As a result of the resistance, the fetal chin flexes downward onto the chest. Internal Rotation The fetal head must rotate to fit the diameter of the pelvic cavity, which is widest in the anteroposterior diameter. As the occiput of the fetal head meets resistance from the levatorani muscles and their fascia, the occiput rotates from left to right, and the sagittal suture aligns in the anteroposterior pelvic diameter. Extension The resistance of the pelvic floor and the mechanical movement of the vulva opening anteriorly and forward assist with extension of the fetal head as it passes under the symphysis pubis. With this positional change the occiput, then brow and face, emerge from the vagina. External Rotation As the shoulders rotate to the anteroposterior position in the pelvis, the head is turned farther to one side (external rotation). Expulsion After the external rotation and through expulsive efforts of the laboring woman, the anterior shoulder meets the undersurface of the symphysis pubis and slips under it. As lateral flexion of the shoulder and head occurs, the anterior shoulder is born before the posterior shoulder. The body follows quickly. Third Stage The third stage of labor is defined as the period of time from the birth of the infant until the completed delivery of the placenta. SIGNS OF PLACENTAL SEPARATION These signs are a globular-shaped uterus a rise of the fundus in the abdomen a sudden gush or trickle of blood further protrusion of the umbilical cord out of the vagina. PLACENTAL DELIVERY •A placenta is considered to be retained if more than 30 minutes have elapsed from completion of the second stage of labor. PLACENTAL SEPARATION •Types of placental delivery •Schultze mechanism •Duncan mechanism The Newborn Physiologic Response of the Newborn The newborn period Neonatal transition During this period, the newborn adjusts from intrauterine to extrauterine life.

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RESPIRATORY ADAPTATIONS FETAL LUNG DEVELOPMENT At 20 to 24 weeks, alveolar ducts begin to appear, followed by primitive alveoli at 24 to 28 weeks. Type I cells (structures necessary for respiratory gas exchange) and Type II cells (structures that provide for the synthesis and storage of surfactant) RESPIRATORY ADAPTATIONS At 28 to 32 weeks of gestation the number of type II cells increases further, and peaks at about 35 paralleling late fetal lung development. The peak production of lecithin corresponds closely to the marked decrease in incidence of idiopathic respiratory distress syndrome RESPIRATORY ADAPTATIONS Initiation of Breathing 1. Pulmonary ventilation must be established through lung expansion following birth. 2. A marked increase in the pulmonary circulation must occur. So begins the transition from a fluid-filled environment to an air-breathing, independent, extrauterine life. MECHANICAL EVENTS Approx 80 to 110 mL of fluid remains in the respiratory passages of a normal term fetus at the time of birth. “Thoracic squeeze” the process of labor is primarily responsible for the initial movement of lung fluid out of the lungs (Polin et al., 2004). RESPIRATORY ADAPTATIONS Newborns may have problems clearing the fluid in the lungs and beginning respiration for a variety of reasons: • The lymphatic system may be underdeveloped, thus decreasing the rate at which the fluid is absorbed from the lungs. • Complications that occur before or during labor and birth can interfere with adequate lung expansion, causing failure to decrease pulmonary vascular resistance, resulting in decreased pulmonary blood flow. RESPIRATORY ADAPTATIONS CHEMICAL STIMULI The first breath is the natural result of normal vaginal birth with cessation of placental gas exchange when the cord is clamped. THERMAL STIMULI Excessive cooling may result in profound respiratory depression and evidence of cold stress. SENSORY STIMULI A number of physical and sensory influences help respiration begin. They include the numerous tactile, auditory, and visual stimuli of birth. RESPIRATORY ADAPTATIONS Factors Opposing the First Breath (1) alveolar surface tension; (2) viscosity of lung fluid within the respiratory tract (3) lung compliance. RESPIRATORY ADAPTATIONS Obligate nose breather. Respiratory rates of 60 to 70 bpm Watch-out for dyspnea, cyanosis, or nasal flaring and expiratory grunting occur or any increased use of the intercostal muscle

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CARDIOVASCULAR ADAPTATIONS Five major areas of change in cardiopulmonary adaptation are: 1. 2. 3. 4. 5.

Increased aortic pressure and decreased venous pressure. Increased systemic pressure and decreased pulmonary artery pressure. Closure of the foramen ovale. Closure of the ductusarteriosus. Closure of the ductusvenosus.

HEART RATE The average resting heart rate in the first week of life is 120 to 160 bpm (Thureen et al., 2005). Auscultation of Apical pulse. Peripheral pulses of all extremities Capillary refill should be less than 2 to 3 secs BLOOD PRESSURE The blood pressure tends to be highest immediately after birth, Blood pressure values during the first 12 hours of life vary with the birth weight. The mean blood pressure is 5 to 55 mm Hg (Thureen et al., 2005) HEMATOPOIETIC ADAPTATIONS After birth, the increases in oxygen saturation and arterial oxygen levels shut off the production of erythropoietin. Hemoglobin rise 1 to 2 g/dL above fetal levels placental transfusion, low oral fluid intake, and diminished extracellular fluid volume HEMATOPOIETIC ADAPTATIONS physiologic anemia of infancy. Neonatal RBCs have a lifespan of 80 to 100 days Leukocytosis is a normal finding because the stress of birth stimulates increased production Blood volume of the term infant is estimated to be 80 mL/kg of body weight. 1. Delayed cord clamping and the normal shift of plasma to the extravascular spaces. 2. Gestational age. 3. Prenatal or perinatal hemorrhage. 4. Site of the blood sample TEMPERATURE REGULATION Newborn requires higher environmental temperatures to maintain a neutral thermal environment. Temperature regulation is the maintenance of thermal balance by losing heat to the environment at a rate equal to heat production Thermoregulation in the newborn is closely related to the rate of metabolism and oxygen consumption. Several newborn characteristics affect establishment of thermal stability. The newborn has less subcutaneous fat Blood vessels of the newborn are closer to the skin The flexed posture of the term infant decreases the surface area exposed Size and age affect the establishment of an NTE Heat Loss Two major routes of heat loss: 1. from the internal core of the body to the body surface and 2.from the external body surface to the environment. The transfer is accomplished through an increase in oxygen consumption, depletion of glycogen stores, and metabolizing of brown fat. Heat loss from the body surface to the environment takes place by four avenues Convection Radiation Evaporation Conduction

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Heat Production (Thermogenesis) increased basal metabolic rate, muscular activity, and chemicalthermogenesis (also called nonshiveringthermogenesis [NST]) (Polin et al., 2004). HEPATIC ADAPTATION Iron Storage and Red Blood Cell Production Total body Hgb content and length of gestation last until 5 months of age. Carbohydrate Metabolism At term the newborn's cord blood glucose is 70% to 80% of the maternal blood glucose level (Kalhan&Parimi, 2006). Glucose is the main source of energy in the first 4 to 6 hours after birth (Kalhan&Parimi, 2006) Conjugation of Bilirubin Total serum biliconjugated (direct) and unconjugated (indirect) bilirubin. Unconjugated (indirect) bilirubin not in an excretable form and is a potential toxin. crosses the placenta to be excreted Total bilirubin at birth is less than 3 mg/dL The newborn liver has relatively less metabolic and enzymatic activity decreases the liver's ability to conjugate bilirubinincreases susceptibility to jaundice. Physiologic Jaundice Maisels (2005) describes six factors—several of which can also be related to pathologic events—whose interactions may give rise to physiologic jaundice: 1. Increased amounts of bilirubin delivered to the liver. 2. Defective uptake of bilirubin from the plasma. 3. Defective conjugation of the bilirubin 4. Defect in bilirubin excretion 5. Inadequate hepatic circulation. 6. Increased reabsorption of bilirubin from the intestine About 50% of full-term and 80% of preterm newborns exhibit physiologic jaundice on about the second or third day after birth. The signs of physiologic jaundice appear after the first 24 hours postnatally. Peak bilirubin levels are reached between days 3 and 5 in the full-term infant and between days 5 and 7 in the preterm infant. Several newborn care procedures will decrease the probability of high bilirubin levels: Maintain the newborn's skin temperature at 36.5C (97.8F) or above, because cold stress results in acidosis. Monitor stool for amount and characteristics. Encourage early feedings to promote intestinal elimination and bacterial colonization and to provide caloric and protein intake necessary for the formation of hepatic binding proteins. If jaundice becomes apparent, nursing care is directed toward keeping the newborn well hydrated and promoting intestinal elimination. In breast milk jaundice, the bilirubin begins to rise after the first week of life, when physiologic jaundice is waning. The level peaks at 5 to 10 mg/dL at 2 to 3 weeks of age and declines over the first several months of life (Maisels, 2005). The absence of normal intestinal flora needed to synthesize vitamin K in the newborn gut results in low levels of vitamin K and creates a transient blood coagulation alteration GASTROINTESTINAL ADAPTATIONS The full-term newborn has adequate intestinal and pancreatic enzymes to digest most simple carbohydrates, fat, and proteins. Lactose is the primary carbohydrate in the breastfeeding newborn and is generally easily digested and well absorbed. Adequate digestion and absorption are essential for newborn growth and development. Caloric intake is often insufficient for weight gain until the newborn is 5 to 10 days old. A shift of intracellular water to extracellular space and insensible water loss account for the 5% to 10% weight loss.

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Term newborns normally pass meconium within 8 to 24 hours of life—and almost always within 48 hours. Meconium Transitional Stool of breastfeeding

URINARY ADAPTATIONS Kidney Development and Function Certain physiologic features of the newborn's kidneys 1. The term newborn's kidneys have a full complement of functioning nephrons by 34 to 36 weeks of gestation. 2. The glomerular filtration rate of the newborn's kidneys is low 3. The juxtamedullary portion of the nephron has limited capacity to reabsorb HCO3 and H and concentrate urine. The ability to concentrate urine fully is attained by 3 months of age Concentrating and dilutional limitations of renal function are important considerations in monitoring fluid therapy to avoid dehydration and overhydration.

IMMUNOLOGIC ADAPTATIONS Three major types of immunoglobulins IgG, IgA, and IgM. active acquired immunity. passive acquired immunity Because the maternal immunoglobin is transferred primarily during the third trimester, In general, newborns have maternally induced immunity to: tetanus, diphtheria, smallpox, measles, mumps, poliomyelitis

IMMUNOLOGIC ADAPTATIONS Elevated levels of IgM at birth may indicate placental leaks or, more commonly, fetal antigenic stimulation in utero. Syphilis TORCH syndrome (toxoplasmosis, rubella, cytomegalovirus, or herpes virus hominis type 2 infection). IgA appears to provide protection mainly on secreting surfaces such. Colostrum has very high levels of IgA. Begin producesecretoryIgA in their intestinal mucosa at about 4 weeks after birth. Newborn Care The two broad goals of nursing care during this period are: (1) to promote the physical well-being of the newborn, and (2) to support the establishment of a well-functioning family unit. Three time frames of assessment Done in the birthing area immediately after birth to determine the need for resuscitation or other interventions Done by the nursery nurse as part of the routine admission procedure. estimate gestational age and evaluate the newborn's adaptation to extrauterine life Done before discharge behavioral assessment and a complete physical examination to detect any emerging or potential problems. Nursing Assessment and Diagnosis Reviews of prenatal record and risk factors assessment for the infant and review of delivery infectious disease screening results, drug or alcohol use by the mother, gestational diabetes, prolonged rupture of membranes,

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instrument or vacuum delivery, use of narcotic analgesia, presence of meconium Nursing Diagnosis Nursing diagnoses are based on an analysis of the assessment findings. Ineffective Airway Clearance related to presence of mucus and retained lung fluid Risk for Altered Body Temperature related to evaporative, radiant, conductive, and convective heat losses Altered Peripheral Tissue Perfusion related to ineffective thermoregulation Acute Pain related to heel sticks for glucose or hematocrit tests or vitamin K injection Physiologic Interventions ~Establish airway ~Perform APGAR scoring at 1 and 5 minutes after birth. ~Perform rapid, overall physical and neurologic exam. ~Identify congenital anomalies ~Count vessels on cord. (2 arteries, one vein) ~Identify injuries for birth trauma APGAR SCORING ~Cord Clamping ~Feel for pulsation and clamp if it stops ~Prevent heat loss. ~Dry infant immediate after birth. ~Wrap newborn warmly, cover head, or place in especially warmed area. ~Place newborn on warm surfaces and cover cool surfaces, such as weighing scales with cloth. Perform complete physical and neurologic exam when temperature stabilizes. Administer medications as ordered. ▀ 0.5% erythromycin or 1% tetracycline into conjunctival sac to prevent ophthalmianeonatorum. ▀ Vitamin K to prevent hemorrhage. ▀Hepa B vaccine during the first 24 hours up to the second day. Measure and weigh newborn.Bathe and dress newborn and place in an open crib. Vitamin K1 Phytonadione (AquaMEPHYTON)Used in prophylaxis and treatment of vitamin K deficiency bleeding (VKDB), formerly known as hemorrhagic disease of the newborn. IM injection in the vastuslateralis thigh muscle. A one-time-only prophylactic dose of 0.5 to 1 mg given in the birthing area or within 1 hour of birth (Wilson et al., 2007. used as prophylactic treatment of ophthalmianeonatorum and ophthalmic chlamydial infections. Ophthalmic ointment (0.5%) is instilled as a narrow ribbon or strand, 0.5 to 1 cm long, along the lower conjunctival surface of each eye Psychological Interventions ÷Properly identify mother and infant with matching bands. ÷ Allow parents to hold infant, or place in warmed area in Trendelenburg’s position to facilitate drainage of mucus. ÷ Promote bonding through early nursing or by having parents hold newborn. Institute daily care routine ▀ Take weight. ▀ Monitor vital signs every shift. ▀ Bathe daily. Give diaper area care. ▀ Cord care after each diaper change. ▀ Establish feeding schedule. ▀ Continue assessment for anomalies. ▀ Note urine and stools output. ▀Male infants may need circumcision care. Newborn Screening RA 9288 Perform screening tests before discharge. ▀Phenylketonuria (PKU) ▀Galactosemia ▀ Congenital Hypothyroidism ▀Homocystinuria

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▀Sickle cell anemia.

REVIEW QUESTIONS Contains FSH to stimulate the ovaries to perform oogenesis or gametogenesis? a. MOM c. Syntocinon b. Clomid d. Methergin 2. This is given to contract uterus and remove retained secundines to prevent bleeding and infection? a. Yutopar c. Prednisone b. Methylergonovine maleate d. Tamoxifen 3. One of this medication counteracts oxytocin to stop preterm labor? a. Pitocin c. Methergin b. Syntocinon d. Terbutaline 4. Anti-estrogen helps suppress growth of breast tumor that is supported by estrogen? a. Teslac c. Nolvadex b. Halostiten d. Methergix 5. Helps relieve severe labor pain, best given at 6-7 cm cervical dilatation or at active phase of the 1st stage of labor? a. Allopurinol c. Dolfenal b. Demerol d. Indomethacin 6. Sim’s Hunher test is ordered after a normal semen analysis. Which two of the following results are normal? I. 15-20 live motile sperm per hpf II. Mucus stretches 8-10 cms per hpf III. Less than 15 live motile sperm per hpf IV. Mucus stretches 5-7 cms a. II and III b. I and II c. I and IV d. II and IV 7. What method of delivery is based on the theory of stimulus-response conditioning to reduce pain sensation during labor? a. Lamaze c. Leboyer b. Bradley d. Natural childbirth 8. Which of the following is not observed in Leboyer method? a. Birth occurs in a well-lighted and quiet room b. The cord is cut after the pulsation ceases c. Neonate is placed immediately on the mother’s abdomen d. Neonate is emerged in a tub of warm water 9. Jenny, a severe pre-eclamptic, has been on IV magnesium sulfate for 12 hours. Which of the following is not a sign overdose? a. Absence of deep tendon reflexes b. Respiration rate slower than 12 per minute c. Urinary output less than 30 cc per hour d. Decrease BP

10. Ritodrine hydrochloride has been infusing IV for several hours to stop Jane’s preterm labor. Since there are no contraindications for inhibiting labor and Jane is 30 weeks gestation, what other standard tocolytic therapy might the nurse use in place of ritodrine? a. Indomethacin b. Demerol and Vistaril IM c. Magnesium sulfate

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d. Morphine sulfate 11. Pat has a history of genital herpes during pregnancy. She is now term, in labor. Her cervical cultures for the last 2 months were negative. She delivers vaginally. The day after delivery, Pat has lesion on her labia majora. What medication can the nurse use to help alleviate the pain. a. Acyclovir b. T-stat (erythromycin lotion) c. Hydrocortisone cream d. Ampicillin 12. During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea and her skin becomes pale and clammy. The nurse’s immediate reaction is to: a. Notify the physician b. Elevate the client’s legs c. Check for vaginal bleeding d. Monitor the FHR every 3 minutes 13. A client who was admitted inactive labor has only progressed from 2-3 cm in 8 hours. She is diagnosed having hypotonic dystocia and is given oxytocin (Pitocin) to augment her contractions. The most important aspect of nursing at this time is to: a. Monitor the FHR b. Check the perineum for bulging c. Time and record length of contractions d. Preparing for an emergency ceasarian delivery 14. A client in the midphase of labor becomes very uncomfortable and asks for medication. Meperidine (Demerol) 50 mg and Phenergan 50mg are ordered. These medications: a. Act to produce anesthesia b. Act as preliminary anesthetics c. Induce sleep until the time of delivery d. Increase the client’s pain threshold, resulting in relaxation 15. Overstretching of perineal supporting tissues as a result of childbirth can bring about a rectocele. The most common symptom is: a. Crampy abdominal pain b. A bearing down sensation c. Urinary stress incontinence d. Recurrent urinary tract infection 16. During pregnancy, the uterine musculature hypertrophies and is greatly stretched as the fetus grows. This stretching: a. By itself inhibits uterine contraction until oxytocin stimulates the birth process b. Is prevented from stimulating uterine contraction by high levels of estrogen during late pregnancy c. Inhibits uterine contraction along with combined inhibitory effects of estrogen and progesterone d. Would ordinarily stimulate contraction but is prevented by high levels of progesterone during pregnancy 17. The nurse would suspect an ectopic pregnancy if the client complained of: a. An adherent painful ovarian mass b. Sharp lower left abdominal pain radiating to the shoulder c. Leukorrhea and dysuria a few days after the first missed period d. Sharp lower left or right abdominal pain radiating to the shoulder 18. When obtaining the nursing history from a client with diagnosis of ruptured tubal pregnancy, the nurse should expect the client to indicate that her symptoms of pain in the lower abdomen and vaginal bleeding started: a. About 6th week of pregnancy b. At the beginning of the last trimester c. Midway through the second trimester d. Immediately after implantation 19. A client is on magnesium sulfate therapy for severe preeclampsia. The nurse must be alert for the first sign of an excessive blood magnesium level, which is: a. Change in level of consciousness

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b. Severe persistent headache c. Epigastric pain d. Disappearance of the knee-jerk reflex 20. A client with preeclampsia with two preschool children is prescribed bed rest at home. To help stimulate compliance plans for the client’s care should include: a. A suggestion to find a housekeeper b. An explanation as to why bed rest is necessary c. A warning of the risks involved in non-compliance d. A contract that 4 hours of nap time will neet the requirement 21. A post partum mother with diagnosis of thrombophlebitis has been placed on Coumadin therapy. The nurse knows the client understands teaching about Coumadin when she states: a. “If I miss a dose, I will double the next dose.” b. “I should eat plenty of green leafy vegetables.” c. “If my arthritis flares up again, I’ll take only 2 aspirins every 6 hours.” d. “I will use a soft toothbrush and stop flossing my teeth.” 22. Warfarin sodium (Coumadin) is ordered for a client along with the medications listed below. Which of the following medications should the nurse question before administering the drug? a. Ascorbic acid (Vitamin C) c. Cimetidine b. Secobarbital (Seconal) d. Psyllium 23. Which nursing care measure is not appropriate for client with thrombophlebitis? a. Careful leg massages c. Elevating the legs b. Elastic stockings d. Leg exercises 24. Which of the following the postpartum mother with diagnosis of thrombophlebitis should avoid? a. Helping the client avoid straining at stool b. Telling the client to avoid sudden movements c. Assisting the client to dangle on the side of the bed 3 times a day d. Teaching the client to avoid bumping the legs against other objects 25. A client with deep vein thrombosis is started on Heparin therapy. Which nursing action is not indicated during heparin administration? a. Having vitamin K available if bleeding occurs b. Observing for hematoma at IV puncture site c. Suggesting that the client use a soft bristled toothbrush d. Using an IV control device for drug administration 26. A client has thrombophlebitis. Heparin SC q 8hrs is prescribed. Nursing interventions related to the administration of heparin include: a. Monitoring the client’s UO b. Checking the client’s INR before administration c. Checking the client for ecchymosis d. Informing the client that NSAIDS may be taken for discomfort 27. The patient who has a deep vein thrombosis has been receiving heparin sodium. Which of these findings will evidence the desired effect of heparin therapy? a. A reduction of pedal edema b. A rapid capillary refill after squeezing the big toe c. An increase in blood sedimentation rate d. An elevation of the prothrombin time 28. Which statement by the client with thrombophlebitis indicates a need for further instructions? a. I can cross my legs at the knee but not the ankle b. I need to elevate the foot of the bed during sleep c. I need to avoid prolonged sitting or standing d. I should continue to wear elastic hose for at least 6-8 weeks 29. All of the following measures may be performed when a patient with diagnosis of previa is being admitted to the labor room except:

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a. Auscultating the FHT with a fetoscope b. Performing Leopold maneuvers c. Determined cervical dilatation d. Checking the vaginal discharge with nitrazine paper 30. Which of these comments, if made by the woman would indicate accurate knowledge of the non stress test? a. “I know that I can’t eat anything after midnight on the day of the test.” b. “I hope that they can find a vein for the test. Often my veins seem to disappear.” c. “I hope that my baby is active when I come to the clinic for the test.” d. “I’ll have to drink about 4 glasses of water within the hour before the test.” 31. Which sign helped confirm the diagnosisof severe PIH? a. Proteinuria +3 on reagent strip b. Elevated BP 155/98 c. Marked edema of lower extremities (+2) d. Deep tendon hyperreflexia (+3) 32. During labor the woman is receiving magnesium sulfate IV. It is essential the nurse have which of the following drugs available to counteract the potential adverse effect? a. Oxytocin (Pitocin) b. Sodium bicarbonate c. Phenytoin sodium (Dilantin) d. Calcium gluconate 33. Which of the following position is best indicated in woman with diagnosis of PIH? a. Semi-fowler’s, alternating sides b. Left lateral position c. Supine with head elevated on a small pillow d. Right lateral Sim’s 34. A woman with diagnosis of PIH tells the nurse that she has severe headache and asks for medication to relieve it. The nurse should: a. Notify the physician immediately b. Explain that headaches are common in PIH c. Offer some tea and toast d. Administer prescribed prn pain medications 35. Twenty-fours after delivery the woman with history of PIH has BP of 150/100mmhg. The nurse should recognize that: a. PIH can continue for 48 hours after delivery b. This may be precursor of chronic hypertension c. Kidney damage has probably occurred d. There is no longer a danger of a convulsion 36. A woman who has PIH is receiving magnesium sulfate therapy. Which of the following manifestations would the nurse expect the woman to have if the magnesium sulfate is having the desired effect? a. Reduction in patellar reflex response from +4 to +2 b. Decreased in urine output from 100ml/hr to 50 ml/hr c. Increase in frequency of contractions from every 5 minutes to every 3 minutes d. Increase in respiratory rate from 12/minute to 18/minute 37. A 26 year old woman is brought to the emergency room, complaining of severe left lower quadrant pain. She tells the nurse that she performed a home pregnancy test and believes that she is 8 weeks pregnant. On the admission the patient’s v/s are: pulse 90, BP 110/70, respirations 20. a half hour later her v/s are pulse 120, BP 85/50, respirations 26. The nurse interprets the change in the patient’s v/s to mean that: a. The patient’s pain may have increased b. The patient may be bleeding internally c. The patient may be frightened d. The patient may have an infection 38. A 23 year old woman comes to the clinic at 32 weeks gestation. A diagnosis of PIH is made. The nurse performs teaching. Which of the following statements made by the patient indicates to the nurse that further teaching is required? a. “Lying in bed on my left side is likely to increase my urinary output.”

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b. “If the bed rest works. I may lose a pound of two in the next few days.” c. “I should be sure to maintain a diet that has a good amount of protein.” d. “I will have to keep my room darkened and not watch much television.” 39. A 30 week pregnant attending the prenatal clinic has symptoms of PIH. Which of the following findings is indicative of this condition? a. The woman has been getting short of breath when climbing the second flight of stairs in the family’s apartment b. The woman has a craving for salty foods lately c. The woman has a BP of 124/80mmhg, compared with 90/60mmhg a month ago d. The woman has gained 3 lbs (1.4kgs) during the past month 40. At 33 weeks gestation, a woman who has been treated for PIH is admitted to the hospital because her condition has not improved. She is placed on bed rest and started on magnesium sulfate therapy. Which of the following assessment is essential for the nurse to make? a. Obtaining the woman’s weight daily b. Assessing the woman’s abdominal circumference daily c. Observing the woman for jaundice d. Checking the equality of the woman’s femoral pulse 41. A patient with history of abruptio placenta bleeds continuously after delivery. A diagnosis of Couvelaire uterus is mad. The nurse should: a. Prepare the client for a uterine examination and insertion of vaginal packing. b. Return the client to the DR for curettage c. Add 10U of oxytocin (Pitocin) to the IV infusion d. Ask the client to sign consent for a hysterectomy 42. While in the recovery room a patient with history of abruptio placenta begins to hemorrhage after delivery. Which is the most likely cause of hemorrhage? a. Her uterus was not massaged adequately b. She developed hypofibrinogenemia, a coagulation defect c. Her rigid abdomen resulted in atony of the uterine muscles d. Placental fragments remained in her uterus 43. A 34 yearl old G4P2 is admitted in active labor. She complains of severe pain that does not subside between contractions and her abdomen has become rigid. A diagnosis of abruption placenta is made. The priority nursing actions for the patient is/are to prepare for a blood transfusion and: a. Observe for changes in her v/s and skin color b. Obtain a clean catch urine specimen for culture and sensitivity c. Prepare a solution of calcium gluconate for IV infusion d. Maintain her in supine position 44. A woman who is hospitalized because of abruptio placenta would be carefully monitored for which of the following complications? a. Toxic shock syndrome b. Pulmonary embolism c. Cerebrovascular accident d. Disseminated intravascular coagulation 45. In which type of high risk pregnancy would abruptio placenta most likely occur? a. Cardiac disease c. Drug addiction b. Chronic hypertension d. Hyperthyroidism 46. The fetal monitoring strip shows an FHR deceleration occurring midway during contraction; the FHR return to baseline midway between contractions. With this type of deceleration; the nurse’s first action should be to: a. Place the woman in trendelenburg or knee-chest position b. Call the physician c. Position the woman in labor on the left side d. Stop infusion of oxytocin 47. A woman in labor with complete cervical dilatation begins pushing during contractions, the FHR drops to approximately 90 BPM and then quickly returns to the baseline when she stops pushing. This sudden change is probably the result of: a. Maternal position b. Decreased utero-placental perfusion

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c. Fetal distress d. Umbilical cord compression 48. The fetal monitor strips shows an FHR deceleration occurring during the increment of a contraction, reaching its lowest point at the acme of the contraction, and returning to baseline during the decrement of the contraction. This type of deceleration indicates: a. Fetal distress b. Uteroplacental perfusion c. Fetal vagal nerve stimulation d. Umbilical cord compression 49. The fetal monitor strips shows an FHR deceleration occurring during the increment of contraction, reaching its lowest point at the acme of the contraction, and returning to baseline during the decrement of the contraction. This type of deceleration indicates: a. Maternal hypoxia c. Fetal movement b. Fetal lung maturity d. Fetal well-being 50. The electric monitor tracing shows the FHR is not smooth and straight between contractions. This indicates that: a. The monitor cannot record the FHR accurately b. The fetus is jumpy between contractions c. The healthy FHR has beat to beat variability and should be not smooth d. Application of internal monitor is necessary 51. Which of the following FHR patterns would indicate to the nurse that the fetus may be experiencing distress? a. A baseline rate of 140-150 between contractions with moderate variability. b. Consistent heart rate accelerations that coincide with the fetal movements c. A heart rate that slows midway during contraction and returns to baseline 30 seconds after the contraction ends d. Gradual slowing of the heart rate that begins with the onset of the contraction and return quickly to the baseline 52. An electronic fetal monitor is attached. The fetal monitoring strip shows an FHR deceleration occurring about 30 seconds after each contraction begins and the FHR return to baseline after the contraction is over. This type of deceleration is caused by: a. Fetal head compression b. Umbilical cord compression c. Uteroplacental insufficiency d. Cardiac anomalies 53. Which one would clue the nurse to suspect pregnancy in a woman with history of diabetes mellitus since she was 10 years old and hospitalization for DKA? a. Nausea and vomiting c. Listless and fatigue b. Urinary frequency d. Breast sensitivity 54. A woman who is 20 weeks pregnant has history IDDM. The nurse understands that her insulin dosage has been increased to her prepregnant dose and will probably be further increased as her pregnancy progresses in order to: a. Utilize the increase caloric intake of the second half of pregnancy b. Limit the total pregnancy weight gain to 12.5 kg (27.5 lbs) c. Meet the increasing glucose demands of the rapidly growing fetus d. Counteract the effects of insulin antagonists produced by the placenta 55. When discussing diet with a newly diagnosed pregnant woman who is diabetic and taking insulin, the nurse should: a. Emphasize the normalcy of pregnancy and the fact that her prescribed pregnancy diet will be suitable b. Explain that pregnancy increases the need for protein and calcium but that will be the only needed diet adjustment c. Confirm that dietary and insulin needs may vary throughout the pregnancy thus requiring close follow-up d. Instruct her to self-regulate her diet and insulin based on daily urine tests for glucose 56. The woman is 6 weeks pregnant. She has history of IDDM. Her insulin dosage has been lowered at this time because: a. Fetal insulin crosses the immature placent and enters maternal circulation b. Increasing fetal demands deplete maternal blood glucose levels

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c. Diabetic dietary needs decrease and less insulin is required d. Maternal glucose levels decrease in direct proportion to increased maternal metabolism 57. Before amniocentesis, the amniotic sac should be located with the aid of: a. Ultrasonography c. Amniography b. X-ray photography d. Fetoscopy 58. Physical preparation for the amniocentesis includes: a. No solid food between the previous midnight and the time of the procedure b. Ingestion of 8 glasses of water 2 hours before the procedure c. An enema on the morning of the procedure d. Emptying the bladder just before the procedure 59. The woman is admitted with diagnosis of placenta previa. She is taken to the delivery room for a double set-up examination. Nursing responsibilities include preparing the woman for regional or inhalation anesthesia and: a. vaginal or rectal examination b. vaginal delivery or ceasarian section c. ceasarian section d. hysterectomy 60. Which ultrasound finding helped confirm the diagnosis of H-mole? a. Multiple gestation of at least 4 fetuses b. No discernible fetal skeleton or soft parts c. Fetal anencephaly with hydrocephalus d. Large fetal meningomyelocele 61. After removal of H-mole by D&C, which of the following finding would indicate that it would be safe to start another pregnancy? a. Albumin/globulin ratio of 2:1 b. Negative HCG c. Blood urea nitrogen of 18 mg/dl d. Negative-C reactive protein 62. Fifteen minutes after the administration of epidural anesthesia the nurse observes decelerations of the FHR midway during contractions. The nurse should first: a. Notify the physician b. Administer O2 c. Record the findings q 5mins d. Assess the maternal BP 63. In the patient’s chart, the nurse notes doctor’s order of Ergonovine maleate (Ergotrate) 0.4mg 4 x a day. The primary reason for the nurse to question the order of Ergonovine maleate to the post partum with history of RHD is that Ergotrate: a. Can be administered either by oral or IM route b. Is rarely ordered more than 2 days with a maximum of 1 week c. Is usually prescribed in a dosage of 0.2 mg 4 x a day d. Is usually contraindicated for cardiac clients 64. A teenager who is 4 months pregnant verbalizes that she has herpes genitalis. She asks if her baby will have the virus. The best response by the nurse should be: a. If treatment is started during pregnancy, her baby will probably protected b. That is one of the few vaginal diseases that does no affect the baby before, during or after delivery c. If she has an active infection at term, a CS will probably protect her baby d. Her baby will be protected by vaccine that will be administered immediately after delivery

65. A woman with diagnosis of PIH is placed on bed rest. An IV of LR has been started. The nurse has started an indwelling catheter to measure urine output because: a. Incontinence may occur if preeclampsia progresses to eclampsia b. Some urine may be lost when voiding on a bedpan c. UO should be measured hourly to detect increasing oliguria

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d. A 24hour urine collection is needed to measure total daily protein excretion 66. Which of the following side effect of ritodrine administration that would require physician’s notification? a. Diuresis of 100ml/hr b. Maternal tachycardia of over 120 bpm c. Nausea followed by projectile vomiting d. Fetal bradycardia of 110 bpm 67. Betamethasone (Celestone) a glucocorticoid is ordered to patient with premature labor because this medication: a. Acts as mild tranquilizer during pregnancy and will enhance uterine relaxation b. Promotes fetal lung maturity, which can prevent respiratory distress syndrome in a premature infant c. Is an anti-inflammatory agent and will decrease the irritability of her uterine muscles d. Elevates maternal blood glucose levels, which could lessen hypoglycemia in the premature infant 68. Which of the following responses would a nurse expect to find in a reactive non-stress test? a. Acceleration of the fetal heart rate with fetal movement b. Deceleration of the FHR without fetal movement c. No change in the FHR with fetal movement d. No change in FHR without fetal movement 69. Which of the following symptoms would be most significant when assessing a woman who has PIH? a. Severe headache b. Urine output of 200ml in the last 4 hours c. Dependent edema d. Patellar reflex of +2 70. A woman who is at 34 weeks pregnant is experiencing a sudden painless bright red vaginal bleeding. A nurse observes a colleague taking all of the following measures with the woman. Which one would the nurse question? a. Palpating uterine firmness b. Performing Leopold maneuvers c. Preparing a vaginal exam d. Preparing a non-stress test 71. Which of the following clients would the nurse prepare for an emergency CS? a. A woman who has prolapsed cord b. A woman with twin gestation c. A woman who has meconium-stained amniotic fluid d. A woman who has a non-reactive non-stress test Mrs. Dantes, gravida 2 para 1 is admitted to the labor unit by ambulance and deliver is imminent. She keeps bearing down and after two contractions the baby’s head is crowning. 72. The nurse should: a. Tell her to breathe through her mouth and pant during contractions b. Tell her to breathe through her mouth the not to bear down c. Transfer her immediately by stretcher to the delivery room d. Tell her to pant while supporting the perineum with the hand to prevent tearing 73. With the nest contraction Mrs. Dantes delivers a large baby boy spontaneously. The nurse’s initial action should be: a. Ascertain the condition of the fundus b. Establish airway for the baby c. Quickly tie and cut the umbilical cod d. Move mother and baby to the delivery room.

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74. The physician arrives and cares for the baby and delivers the placenta. Pitocin, an oxytocic drug, is administered IM. Since Mrs. Dantes has had a precipitous delivery, it is important to observe for: a. Bleeding b. Sudden chilling c. Elevation of RR d. Respiratory insufficiency in the baby 75. If involution is progressing normally, few hours after birth the nurse should expect the fundus to be located: a. Three cm above the umbilicus b. At the level of the umbilicus c. 2 cm below the umbilicus d. 2 cm above the symphysis pubis Mrs. Roldan was admitted to the OB ward in active labor. 76. During contraction, the nurse observes a 15-beat per minute deceleration of the FHR. The most appropriate action would be to: a. Prepare for immediate delivery because the fetus is in distress b. Call the physician immediately and await the orders c. Turn Mrs. Roldan on her left side to increase venous return d. Record this normal fetal response to contractions in the chart. 77. The patient begins to experience contractions 2-3 minutes apart that last about 45 seconds. Between contractions, the nurse records a fetal heart rate of 100 bpm. The nurse should: a. Closely monitor maternal vital signs b. Chart the rate as a normal response to contractions c. Notify the physician immediately d. Continue to monitor the fetal heart rate 78. During delivery, episiotomy was performed. When caring for the patient during the post partum period, the nurse encourages sitz bath TID for 15 mins. Sitz baths primarily aid the healing process by: a. Softening the incision site b. Promoting vasodilation c. Cleansing the perineal area d. Tightening the perineal sphincter 79. When preparing Mrs. Roldan to care for her episiotomy after discharge, the nurse should include, as a priority, instructions to: a. Continue the Sitz bath TID if it provides comfort b. Discontinue the sitz bath once she is at home c. continue perineal care after toileting until healing occurs d. avoid stair climbing for at least a few days after discharge Mrs. Walang, a 32 year old G3P2, spontaneously delivers a 4082g baby boy in route after a brief labor. 80. The nurse should be aware that the chief hazard to a child in precipitate delivery is: a. Brachial palsy c. Dislocated hip b. Intracranial hemorrhage d. Fractured clavicle 81. Perineal laceration is a common complication of precipitate delivery. In addition to regular perineal care, Mrs. Walang’s nursing care should include: a. Encouraging early and frequent ambulation b. Encouraging perineal exercises to strengthen the muscles c. Telling the client to expect slower healing d. Providing a high protein, high roughage diet 82. Baby Walang sustained a tear in the tentorial membrane which leads to intracranial bleeding. The nurse should expect the baby to display: a. Extreme lethargy b. Weak, timorous cry c. Abnormal respirations d. Generalized purpura

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83. Nursing care of Baby Walang should include: a. Stimulating frequently to monitor level of consciousness b. Elevating his head higher than his hips c. Checking reflexes every 15 minutes d. Weighing him daily before feeding 84. The nurse who has been caring for the baby decides on a plan of care for the mother as well. The plan calls for: a. Setting up a schedule for teaching the mother how to care for her baby. b. Discussing the matter with her in a non-threatening way c. Showing by example how to care for the infant and satisfy her own needs d. Supplying emotional support to the mother and encouraging her dependence. Mercedes, age 41, is admitted to the labor and delivery unit at 4:00 pm. While taking the history, the nurse notes the following: gravida 8, para 7, 41 weeks AOG, membranes ruptures at 10:00 am that day, contractions occur every 3 minutes; strong intensity with a duration of 60seconds. 85. What nursing action would take the highest priority at this time? a. Get blood and urine samples b. Do perineal prep and give enema c. Attach monitor to the client d. Determine extent of cervical dilation 86. Mercedes has just been given epidural anesthesia. What is the most important assessment at this time? a. Maternal blood pressure b. Fetal heart rate c. Maternal level of consciousness d. Fetal position 87. Mercedes had a normal spontaneous delivery. Why would she be considered at risk for development of postpartal hemorrhage? a. Grand multiparity b. Premature rupture of membranes c. Post term delivery d. Anesthesia Sylvia Mariano has just delivered a 10-lb girl. 88. In assessing Sylvia immediately after delivery, which of the following would the nurse most likely to find? a. Fundus located halfway between the symphysis pubis and umbilicus, lochia rubra b. Fundus displaced to the right and 3 cm above the umbilicus, lochia serosa c. Fundus located at the umbilicus, lochia rubra d. Fundus located halfway between the symphysis pubis and the umbilicus, lochia serosa 89. Sylvia is having vaginal bleeding of bright red blood that is continuously trickling from the vagina. Her fundus is firm and in the midline. What is the most likely cause of this bleeding? a. Lacerations b. Subinvolution c. Uterine atony d. Retained placental fragment 90. Which of the following conditions predispose a client to postpartal hemorrhage? a. Twin pregnancy b. Breech presentation c. Premature rupture of membranes d. Ceasarian section 91. After 24 hours, Sylvia has a temperature of 38 degrees Celsius, has voided 2,000ml since delivery, and her skin is diaphoretic. Nursing actions should include which of the following? a. Notify the physician of the findings

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b. Notify the nursery to feed the baby in the nursery, as the mother has a fever c. Explain to Sylvia that these symptoms are very normal for a woman who has just delivered d. Suspect a postpartal infection and isolate the mother and the newborn 92. Sylvia’s sister warned her to suspect afterpains. The nurse’s teaching is based on the knowledge that the most likely candidate for afterpains is the: a. Primipara who is bottle-feeding b. Grand multipara who is breast feeding twin boys c. Primipara who delivered prematurely and who is pumping her breasts d. Adolescent primipara who is breastfeeding 93. Sylvia is using bottlefeeding for her baby and asks when she should expect her first menses. The appropriate response would be: a. It usually takes at least 3 months before menstruation resumes after delivery b. “As you aren’t breastfeeding, it should occur in 4-6 weeks.” c. Two weeks is the average time for menses to return d. “Ask your doctor. I’m sure that after doing a pelvic exam, she can tell you.” Sheila, 32 weeks AOG, enters the emergency room complaining of premature labor. 94. Which of the following nursing actions is appropriate when caring for Sheila? a. Prepare for an oxytocin challenge test to determine fetal status b. Prepare for application of an internal monitor c. Give frequent analgesia to relieve anxiety and promote comfort d. Discuss the potential problems and preparations being made for the infant 95. Bed rest is prescribed for Sheila primarily because: a. It will keep the pressure of the fetus off the cervix b. May stop the labor by decreasing uterine irritability c. Will promote and reduce anxiety d. Will reduce fetal activity 96. A tocolytic agent is administered to suppress her labor. Which of the following nursing actions would be most appropriate in preventing side effects from this type of drug? a. Side lying, anitembolic stockings, adequate hydration b. Reduction in extraneous stimuli, frequent assessment of FHT c. Use of side rails, frequent monitoring of uterine contractions d. Frequent monitoring of BP and pulse 97. Which of the following drugs is considered a tocolytic agent? a. Levallorphan c. Phenobarbital b. Terbutaline d. Betamethasone 98. Attempts to stop labor were unsuccessful and a baby boy was born weighing 4lb 2 oz. Which of the following observations of the baby suggest a gestational age of less than 40 weeks? a. Small amounts of lanugo and vernix, testes descended, palmar and plantar creases b. Parchment-like skin, no lanugo, full areola in breast c. Upper pinna of ear well curbed with instant recoil, small amounts of lanugo, pink in color d. Dark red skin, testes undescended with few rugae, abundant lanugo 99. Which of the following is an important difference between a premature and a term infant? a. Owing to size, a premature infant will have a more efficient metabolic rate for heat productions and maintenance b. In proportion to size, the premature infant will have more lanugo, and more vernix than a full-term infant c. GI motility is decreased in preterm infant. Stools may be infrequent resulting in abdominal distention d. Heat production is low in premature infant because of the greater boy surface related to weight and lack of subcutaneous fat Situation: Susan delivered her first child, a boy, 24 hours ago. She had a normal vaginal delivery with midline episiotomy and is breast feeding.

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100. Instructions to Susan regarding care of the perineal area should include which of the following? a. Separate the labia while cleansing b. Cleanse the perineum with soap and water after elimination c. Pour sterile water over the perineum after elimination d. Perform perineal care only if an episiotomy is performed

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