Maternity & Child Exam 5

Maternity & Child Exam 5 Upon assessment, the nurse got the following findings: 2 perineal pads highly saturated with blood within 2 hours postpartum, PR= 80 bpm, fundus soft and boundaries not well defined. The appropriate nursing diagnosis is: A Inadequate tissue perfusion related to hemorrhage B Normal blood loss C Hemorrhage secondary to uterine atony D Blood volume deficiency Rationale: All the signs in the stem of the question are signs of hemorrhage. If the fundus is soft and boundaries not well defined, the cause of the hemorrhage could be uterine atony. The following are common causes of dysfunctional labor. Which of these can a nurse, on her own manage? A Pelvic bone contraction B Extension rather than flexion of the head C Full bladder D Cervical rigidity Rationale: Full bladder can impede the descent of the fetal head. The nurse can readily manage this problem by doing a simple catheterization of the mother. Which of the following techniques during labor and delivery can lead to uterine inversion? A Massaging the fundus to encourage the uterus to contract B Applying light traction when delivering the placenta that has already detached from the uterine wall C Fundal pressure applied to assist the mother in bearing down during delivery of the fetal head D Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation Rationale: When the placenta is still attached to the uterine wall, tugging on the cord while the uterus is relaxed can lead to inversion of the uterus. Light tugging on the cord when placenta has detached is alright in order to help deliver the placenta that is already detached. When delivering the baby's head the nurse supports the mother's perineum to prevent tear. This technique is called A Duncan maneuver B Schultze maneuver C Ritgen's technique D Marmet's technique Rationale: Ritgen's technique is done to prevent perineal tear. This is done by the nurse by support the perineum with a sterile towel and pushing the perineum downard with one hand while the other hand is supporting the baby's head as it goes out of the vaginal opening. The following are natural childbirth procedures EXCEPT: A Dick-Read method B Lamaze method C Ritgen's maneuver D Psychoprophylactic method Rationale: Ritgen's method is used to prevent perineal tear/laceration during the delivery of the fetal head. Lamaze method is also known as psychoprophylactic method and Dick-Read method are commonly known natural childbirth procedures which advocate the use of non-pharmacologic measures to relieve labor pain. When doing perineal care in preparation for delivery, the nurse should observe the following EXCEPT A Use mild soap and warm water B Use up-down technique with one stroke C Clean from the mons veneris to the anus D Paint the inner thighs going towards the perineal area Rationale: Painting of the perineal area in preparation for delivery of the baby must always be done but the stroke should be from the perineum going outwards to the thighs. The perineal area is the one being prepared for the delivery and must be kept clean To ensure that the baby will breath as soon as the head is delivered, the nurse's priority action is to A Clamp the cord about 6 inches from the base B Suction the nose and mouth to remove mucous secretions C Check the baby's color to make sure it is not cyanotic D Slap the baby's buttocks to make the baby cry Rationale: Suctioning the nose and mouth of the fetus as soon as the head is delivered will remove any obstruction that maybe present allowing for better breathing. Also, if mucus is in the nose and mouth, aspiration of the mucus is possible which can lead to aspiration pneumonia. (Remember that only the baby's head has come out as given in the situation.) When the baby's head is out, the immediate action of the nurse is A Deliver the anterior shoulder B Cut the umbilical cord C Check if there is cord coiled around the neck D Wipe the baby's face and suction mouth first Rationale: The nurse should check if there is a cord coil because the baby will not be delivered safely if the cord is coiled around its neck. Wiping of the face should be done seconds after you have ensured that there is no cord coil but suctioning of the nose should be done after the mouth because the baby is a "nasal obligate" breather. If the nose is suctioned first before the mouth, the mucus plugging the mouth can be aspirated by the baby. The mechanisms involved in fetal delivery is A Descent, extension, flexion, external rotation B Internal rotation, extension, external rotation, flexion C Descent, flexion, internal rotation, extension, external rotation D Flexion, internal rotation, external rotation, extensio Rationale: The mechanism of fetal delivery begins with descent into the pelvic inlet which may occur several days before true labor sets in the primigravida. Flexion, internal rotation and extension are mechanisms that the fetus must perform as it accommodates through the passageway/birth canal. Eternal rotation is done after the head is delivered so that the shoulders will be easily delivered through the vaginal introitus. When the shiny portion of the placenta comes out first, this is called the ___ mechanism. A Marmets B Schultze C Duncan D Ritgens Rationale: There are 2 mechanisms possible during the delivery of the placenta. If the shiny portion comes out first, it is called the Schultze mechanism; while if the meaty portion comes out first, it is called the Duncan mechanism. When determining the duration of a uterine contraction the right technique is to time it from A The beginning of one contraction to the end of the same contraction B The beginning of one contraction to the end of another contraction C The acme point of one contraction to the acme point of another contraction D The end of one contraction to the beginning of another contraction Rationale: Duration of a uterine contraction refers to one contraction. Thus it is correctly measure from the beginning of one contraction to the end of the same contraction and not of another contraction When shaving a woman in preparation for cesarean section, the area to be shaved should be from ___ to ___ A Under breast to mid-thigh including the pubic area B Xyphoid process to the pubic area C The umbilicus to the mid-thigh D Above the umbilicus to the pubic area Rationale: Shaving is done to prevent infection and the area usually shaved should sufficiently cover the area for surgery, cesarean section. The pubic hair is definitely to be included in the shaving ..........