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UWORLD NCLEX REVIEW-MATERNAL AND CHILD NURSING/UWORLD NCLEX REVIEW-MATERNAL AND CHILD NURSING
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UWORLD NCLEX REVIEW-MATERNAL AND CHILD NURSING/UWORLD NCLEX REVIEW-MATERNAL AND CHILD NURSING
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UWORLD NCLEX REVIEWMATERNAL & CHILD NURSING
Batch 14
12/18/17
Supine hypotensive syndrome occurs when the weight of the abdominal contents compresses the vena
cava causing decreased venous return to the heart. This results in low cardiac output (maternal
hypotension) and reflex tachycardia. Manifestations include dizziness, pallor, and cold and clammy skin.
The client should be immediately repositioned onto the right or left side until the symptoms subside.
Prevention of this condition includes using a wedge under the client's hip while in a supine position.
(Option 1) Decreased maternal cardiac output can result in decreased placental blood flow and fetal heart
rate (FHR) abnormalities. FHR assessment also follows after the client is placed in the right or left lateral
position.
(Option 2) When supine hypotension is suspected, the client should first be placed in a lateral position.
Blood pressure and pulse are checked to confirm the diagnosis. Assessing lung and heart sounds is not a
priority.
(Option 3) The HCP is notified after placing the client in a lateral position and completing the assessment.
Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal occiput
rotates and faces the mother's posterior or sacrum. OP fetal position can cause increased back pain or
"back labor." Many fetuses in OP position during early labor spontaneously rotate to occiput
anterior position (occiput facing the mother's anterior or pubis).
,The nurse or labor support person can apply counterpressure to the client's sacrum during contractions to
help alleviate back pain associated with OP fetal positioning. Firm, continuous pressure is applied with a
closed fist, heel of the hand, or other firm object (eg, tennis ball, back massager) (Option 1).
(Option 2) Clients should be encouraged to change positions frequently (every 30-60 minutes) during labor
to promote fetal rotation/descent and increase maternal comfort. Remaining in bed during early labor
increases the risk for persistent fetal malposition and slows labor progression.
(Option 3) Left lateral positioning is better for uteroplacental blood flow and fetal oxygenation than supine
positioning when the client is resting in bed. However, it may not alleviate the client's back pain.
(Option 4) Although epidural anesthesia can provide effective pain relief, it can limit client mobility and
contribute to persistent fetal malposition. This client is also still in early labor and has not requested an
epidural at this time.
Precipitous birth occurs when the newborn is delivered ≤3 hours after the onset of contractions. In the
event of precipitous labor, the nurse should be prepared to assist with the birth if the health care provider is
unable to arrive in time.
Immediately after the birth, the newborn should be dried and placed skin-to-skin on the mother's abdomen at
uterine level to promote warmth; this prevents cold stress that can lead to newborn hypoglycemia or
respiratory distress (Option 3). If the newborn is stable, the cord can be clamped and cut with sterile
scissors after it has stopped pulsating or after the placenta has been expelled.
(Option 1) The perineal area can be cleansed if needed once the placenta has been expelled.
(Option 2) To avoid uterine inversion or cord avulsion (tearing or snapping), the nurse should not pull on the
cord. Once placental separation occurs, signified by cord lengthening, a gush of blood, uterine cramping,
and vaginal pressure, the mother can bear down gently to expel the placenta.
(Option 4) Fundal massage is performed after expulsion of the placenta to increase uterine tone and
decrease bleeding.
,The enlarging pregnant uterus should be just above the symphysis pubis at approximately 12 weeks
gestation (Option 4). At 16 weeks gestation, the fundus is roughly halfway between the symphysis pubis
and the umbilicus. It reaches the umbilicus at 20-22 weeks gestation and approaches the xiphoid
process around 36 weeks gestation. At 38-40 weeks, the fetus engages into the maternal pelvis and the
fundal height drops. After 20 weeks gestation, the fundal height, measured in centimeters from the
symphysis pubis to the top of the fundus, correlates closely to the weeks of gestation.
, (Options 1, 2, and 3) At 12 weeks gestation, the uterine fundus should be just above the symphysis pubis
Subjective, objective & positive signs of pregnancy
Subjective
Objective (probable) Positive (diagnostic)
(presumptive)
Uterine & cervical changes
o Goodell sign
o Chadwick sign
o Hegar sign
o Uterine enlargement
Amenorrhea Fetal heartbeat heard with
Braxton Hicks contractions
Nausea & vomiting Doppler device
Ballottement
Urinary frequency Fetal movement palpated by
Fetal outline palpation
Breast tenderness health care provider or visible
Uterine &funicsouffle
Quickening fetal movements
Skin pigmentation changes
Excessive fatigue Visualization of fetus by use
o Chloasma
of ultrasound
o Linea nigra
o Areola darkening
Striaegravidaru
Positive pregnancy tests
Subjective (presumptive) signs of pregnancy are self-reported by a client. This client's symptoms could
originate from pathologic causes (eg, urinary tract infection [UTI], sexually transmitted infection), but
collectively these symptoms may be indicative of early pregnancy. Any client with possible
signs/symptoms of early pregnancy should be asked about menstrual history (Option 3).
(Option 1) Regular breast self-exams are an important part of breast self-awareness and may alert the
client to early pathologic breast changes. However, breast tenderness is a common sign of early pregnancy,
which should be ruled out first.
(Option 2) Leukorrhea (ie, whitish, mucoid vaginal discharge) increases during pregnancy in response to
rising hormone levels. The client should be questioned about color, odor, and consistency of discharge to
rule out infection, but this response from the nurse does not address the larger picture.
(Option 4) Increased urinary frequency may result from hyperglycemia, and clients with diabetes are at
increased risk for infections (eg, UTI, yeast infection). Reviewing home blood sugar logs would help the nurse
assess the client's level of glycemic control over time but would not address the complete picture of the
client's acute symptoms.
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