NUR 316 Exam 1 Questions And
Answers
AWHONN's role in establishing Standards of Care that influence nursing interventions - ANS
-Standards of care establish minimum criteria for competent, proficient delivery of nursing care.
Agency policies, procedures, and protocols also provide appropriate guidelines for care
standards.
-Clinical practice guidelines are comprehensive interdisciplinary care plans for a specific
condition that describe the sequence and timing of interventions that should result in expected
patient outcomes. --> Adopted within a healthcare setting to reduce variation in care
management, to limit costs of care, and to evaluate the effectiveness of care.
-Standards of care do not carry the force of law, they have important legal significance. Any
nurse who fails to meet appropriate standards of care invites allegations of negligence or
malpractice
Transcultural question on appropriate cultural sensitivity, and nutritional practices - ANS
-Incorporate family's cultural values into care plan, family is more likely to accept and comply
with the needed care
-Nurses should avoid imposing personal cultural values on the women and family in care
-Include religious, social, beliefs about health care and wellness/illness, physical contact with
strangers, education
Goals of healthy People 2020—
reflect on the nurse's role in advocating for their achievement. - ANS 1. Attain high-quality,
longer lives free of preventable disease, disability, injury, and premature death;
2. Achieve health equity, eliminate disparities, and improve the health of all groups;
3. Create social and physical environments that promote good health for all
4. Promote quality of life, healthy development, and healthy behaviors across all life stages
-Reduce fetal and infant deaths
-Increase % of women who receive early prenatal care
-Increase the proportion of mothers who breastfeed their babies
-Reduce Cesarean deliveries
-Decrease preterm births
-Increase % of babies but to sleep on their backs
-Increase abstinence from substance abuse among pregnant women
, Normal assessments in BUBBLEHED - ANS -Breasts: Palpate both breasts for
engorgement/filling. Check nipples for pressure sores, cracks, or fissures
-Uterus: Fundus should be midline, firm
-Bladder: Palpate for distention above the symphysis pubis, if bladder is full fundus will be off to
right or left of umbilicus. If pt has not voided in 6-8 hr post delivery, use a catheter per doctor's
order. Be alert for s/s of UTI: infrequent voiding, urinary retention, frequent voiding, dysuria,
burning
-Bowel: Assess for presence of bowel sounds, gastric motility is sluggish after birth bc of
lingering progesterone and decreased abdominal wall tone. First BM usually occurs on or after
2nd PP day. Encourage early ambulation, increased fluid intake, increased fiber, stool
softeners/laxatives.
Lochia: Assess peripad daily (1x each shift) for color, amount, type, and for any foul odor.
Instruct pt to notify nurse if she passes clots, note size and number of clots.
Episiotomy: Assess using REEDA (redness, edema, ecchymosis, discharge, approximation)
every shift. 3rd degree extension = laceration extends to rectum, 4th degree extension =
laceration extends through rectum. Assess for presence of swelling or hemorrhoids.
Homan's Sign: Assess every shift, and for warm, tender, reddened areas on legs, watching due
to increased amount of blood volume during pregnancy, and the activation of blood clotting
factors after delivery.
Emotional status: "Taking in"- immediately after delivery, till up to 2 days postpartum. Focus on
self and meeting basic needs such as rest and sleep. "Taking hold" - Focus on caring for baby,
optimal time for teaching. "Letting go"- Reestablishes relationships with others with outward
focus.
Diastasis Recti: A separation of the rectus abdominis muscles. Examine the abdomen by asking
mother to lift her head and place her chin on her chest. Nurse
Normal changes in fundus after delivery (expectations) - ANS -Palpate fundus, should be
firm
-Located midline to the umbilicus
-Fundus descends 1 fingerbreadth each day
Expected changes in lochia postpartum - ANS -Rubra
Bright red for 2-3 days post delivery, contains blood and shreds of the decidual, bacteria small
nickel size clots are common
