NCLEX-RN Case Study: Women’s Health Nursing

Women’s Health Nursing

Ava is a 16-year-old high school student who is involved with a 20-year-old man; she comes to the free clinic for birth control (BC).Ava is taught the basic differences among all methods of BC.The nurse explains that there are basically three types of BC: mechan- ical, hormonal or chemical, and surgical.

Multiple-choice:

The nurse understands that when a 16-year-old reveals she is sexually active with a 20-year-old male, the implications are:
A. The nurse should counsel the teenager against continuing the relationship.
B. The nurse is obligated to tell the teenager’s parents.
C. The teenager is emancipated as a result of being sexually active.
D. The nurse may be obligated to tell authorities.

Matching:

Classify each method listed by matching the type of birth control (BC) in Column A with the method in
Column B (the methods in Column A may be used more than once):

Match: Birth Control Methods
Match: Birth Control Methods

Fill in the blanks:

Which birth control (BC) method is most effective against sexually transmitted diseases (STDs)?
_________________________________________________________________
Which BC method may be ineffective with the antibiotic rifampin?
_________________________________________________________________
Which BC method can be effective for 5 or 10 years?
_________________________________________________________________
Which BC method may not be effective if the patient is more than 200 lb? Which BC method is implanted under the skin?
_________________________________________________________________
Which BC method is administered intramuscularly (IM)?
_________________________________________________________________

Ava talks to the nurse about BC and openly expresses some of her ideas.The nurse uses therapeutic communication skills and listens to all Ava’s concerns and provides informa- tion when needed.

Multiple-choice:

The nurse understands that Ava needs additional information when she states:
A. “If I use the pills and I miss a day I may need emergency contraception.”
B. “I can use the RU-486 pill as emergency contraception.”
C. “If I become sick, I should tell my primary care provider (PCP) that I am on birth control (BC) before
she prescribes antibiotics.”
D. “If I skip my progesterone-only pill I should take it as soon as I remember.”

Ava chooses to use BC pills on a 4-week cycle.The nurse then does a Pap test to screen Ava for any cervical anomalies. The nurse also takes culture swabs to test Ava for any sexually transmitted diseases (STDs).

Multiple-choice:

The nurse also tells Ava about Gardasil, the quadrivalent vaccine to prevent which sexually transmitted disease (STD)?
A. Hepatitis B (hep B)
B. Herpes type II
C. Herpeszoster
D. Human papillomavirus (HPV)

Gardasil is Food and Drug Administration (FDA) approved and is given in three doses within 6 months.

Multiple-choice:

The nurse explains that Gardasil is given to:
A. Bothmenandwomentopreventcervicalandpenilehumanpapillomavirus(HPV),whichcancausecancer
B. Both men and women to prevent cervical cancer and penile dysfunction disease
C. Just women, to prevent cervical warts and vulva cancers
D. Just men, to prevent genital warts and penile and testicular cancer

Gynecological History

Ava had menarche at the age of 12 years and has regular menstrual cycles of 28 to 30 days. She has dysmenorrhea on the first day of menstruation, for which she takes ibuprofen 400 mg orally every 6 hours.Ava understands the concepts of the menstrual cycle and when her “fertile” time may be.The nurse reviews this with her just to make sure she understands how important it is to take BC regularly.The nurse reviews the hormones that affect the menstrual cycle to further Ava’s understanding.

Matching:

Match the hormones in Column A to the effects in Column B:

Match hormones
Match hormones

Ava seems to understand the information provided to her at the clinic and makes an appointment to return in 6 months for a follow-up visit.

Ava’s Next Clinic Appointment

Ava frantically calls the clinic during her senior year of high school and says that she has skipped her pills while away on a spring break trip and had unprotected sex. She comes to the office and is given emergency contraception or the morning-after pill.There are several types of emergency contraception available. Some types currently available are:
■ Progestin-only pills, which are approved for unrestricted (over-the-counter) sale and have very few side effects.They are 88% effective in preventing pregnancy (FDA approved).
■ Ulipristal acetate which is available by prescription (FDA approved).
■ Progestin and estrogen pills are used many times in increased dosages.These have a
75% effective rate (not FDA approved).
■ A fourth type of pill contains mifepristone and is sold only in specific countries, not in the United States.This is often called “the abortion pill” because it can ter- minate an established pregnancy (not FDA approved).

Multiple-choice:

The nurse is counseling Ava and realizes that she needs further information when she states:
A. “I can’t take emergency contraception because it has been 4 days since I had sex.”
B. “I may have some slight side effects but they should not be severe.”
C. “My next period should come about the same time it is supposed to.”
D. “I know that emergency contraception is most likely not causing an abortion.”

Select all that apply:

Possible side effects of high-dose progesterone pills include:
A. Nausea
B. Vomiting
C. Rash
D. Diarrhea
E. Bleeding

Multiple-choice:

The nurse tells Ava about another method of emergency contraception that is 99% effective but Ava does not consider it because in the past it has had some bad publicity concerning uterine infection rates. There- fore, Ava rejects the suggestion of using a(n):
A. Diaphragm
B. Vaginalring
C. Intrauterinedevice
D. Femalecondom

Ava continues to have inconsistent BC use. She comes to the clinic after a missed period on August 19 and states that she thinks she is pregnant.Ava performed an at-home preg- nancy test.Ava tells the nurse she feels tired and nauseous in the mornings.These are two presumptive signs of pregnancy.

Multiple-choice:

At-home pregnancy tests detect which of the following hormones in the urine?
A. Progesterone
B. Estrogen
C. Prolactin
D. Human chorionic gonadotropin (hCG)

The nurse reviews the presumptive and probable signs of pregnancy with Ava

Presumptive and Probable Signs of Pregnancy
Presumptive and Probable Signs of Pregnancy

Select all that apply:

Positive signs of pregnancy include the following:
A. Ultrasound
B. Chadwick’s sign (6–8 weeks)
C. Hegar’s sign (6–12 weeks)
D. Fetal movement felt by the mother
E. Fetal movement felt by the examiner

Matching:

Match the terms in Column A with the definitions in Column B:

Matching Terms
Matching Terms

After Ava’s pregnancy is confirmed with an hCG-positive urine test, an ultrasound is ordered to visualize the fetal heart (FH).

The FH can be seen beating. By the crown–rump length measurement, the fetus is at 7 weeks gestation.That would coincide with Ava’s last menstrual period (LMP ), which was July 1.The nurse compliments Ava for seeking help after her first missed period and not waiting. Now health care and education are able to begin early and often to ensure a good pregnancy outcome.

Multiple-choice:

Using Naegel’s rule, Ava’s baby is due on:
A. March8
B. May8
C. April1
D. April8

Select all that apply:

During Ava’s first prenatal visit, an assessment is performed and plans are being made. Select all the appropriate components of a first prenatal visit.
A. Blood drawn for type and Rh
B. Amniocentesis
C. Venereal Disease Research Laboratory (VDRL) test or rapid plasma reagin (RPR) test
D. Dietaryhistory
E. Nonstress test (NST)

Also, during the first prenatal visit, the nurse documents Ava’s complete health status and does a physical assessment and weight check, records vital signs, and teaches Ava about caring for herself and organogenesis. Ava’s blood type is O−. Her Venereal Disease Research Laboratory (VDRL) test or rapid plasma reagin (RPR) test is negative, and her Rubella titer is positive; therefore, she is negative for syphilis and she is immune to German measles (Rubella) and will not need the vaccine.

Multiple-choice:

It is clear Ava needs more information about immunizations when she states:
A. “I know I should receive an influenza vaccine this winter.”
B. “I am glad I am immune to German measles, I would hate to have it again.”
C. “I will get the rubella vaccine so my baby is protected against mumps.”
D. “I understand that varicella is a live vaccine so I cannot receive it.”

Social History

Ava lives with her mother and two younger brothers. Ava has a high school education and works full time in retail. She is a licensed driver and has health insurance. She is involved with the baby’s father but has no plans, at this point in time, to move in with him or to get married. She states her mother is upset about the pregnancy but will be supportive. Ava’s mother works full time.Ava’s house has electricity, plumbing, and a refrigerator. She has her own room and plans to keep the baby in her room on the second floor.

Select all that apply:

Safety issues that should be discussed with Ava include:
A. Firesafety
B. Properrefrigeration
C. Well-watersterilization
D. Infant sleeping safety
E. Safe childcare options

Health History

Ava’s health history is unremarkable.As a child the only surgeries she had are an ade- noidectomy and a tonsillectomy. She is up to date on her immunizations. She had chicken pox as a child.The only referral that the nurse provides to Ava is to see a dentist, because she has not seen one in 2 years.

Multiple-choice:

The nurse understands the importance of prenatal dental care because:
A. Pregnant women may drink too many soft drinks in an effort to decrease nausea.
B. Periodontal disease is associated with preterm labor.
C. Pregnant women often lose teeth because of the fetus’s needs.
D. Tooth decay is accelerated during pregnancy.

Family History

Ava’s mother is 48 years old and in good health.Ava has two healthy younger brothers. Ava’s father is not part of her life and she never interacts with him, but as far as she knows he is alive and in good health. Her grandparents on her mother’s side are alive and well. Her grandfather takes medication for high cholesterol. She does not know her grandparents on her father’s side but thinks one may have died.

Dietary History

Ava eats supper at home and her mom normally cooks a full meal. For lunch, she has fast food and she has only coffee for breakfast.

Multiple-choice:

Ava’s body mass index (BMI) is 22.9; therefore, she should gain:
A. 15 to 25 lb
B. 25 to 35 lb
C. 35 to 45 lb
D. 45 to 55 lb

Fill in the blanks:

The nurse makes the following recommendations for Ava’s diet:
Protein intake should be ____________ g/d.
Iron intake/d should be 30 mg/d. Take supplement with _________ to increase absorption.
Have ________ servings of fruits and vegetables each day.
To prevent neural tube defects, take _____ mg of folic acid each day.

Ava is given a prescription for prenatal vitamins and she is told not to have any alcohol because of the risk of fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE).Ava does not smoke and denies using street drugs. She is told to check with the nurses at the clinic before consuming any herbal medications.

Matching:

Match the trimester(s) in Column A that the common complaints and discomfort are most likely to occur
in to the discomfort described in Column B:

Match: common complaints and discomfort
Match: common complaints and discomfort

Matching:

Match the common discomfort in Column A with the physiologic reason in Column B:

Match: discomfort in - physiologic reason
Match: discomfort in – physiologic reason

Physical Examination

A complete physical examination is performed on Ava; here are some of the findings:

Vital signs: Temperature: 98.2°F, heart rate (HR): 74 beats per minute (bpm), respi- ratory rate (RR): 18 breaths per minute, and blood pressure (BP): 104/62 mmHg
Weight and height: 125 lb at 5ʹ2ʺ
Her heart and lung sounds are normal.

Ava asks the nurse whether she will have to have genetic testing for her baby because she heard another mother speaking about a procedure that can “look at the baby’s cells.” The nurse asks Ava whether she is concerned about anything. Ava says that she is not concerned about anything specifically.The nurse discusses risk factors with Ava.

Exhibit-format:

A complete physical examination is performed on Ava and here are some of the findings:
Vital signs: Temperature: 98.2°F, heart rate (HR): 74 beats per minute (bpm), respiration rate (RR): 18 breaths per minute, and blood pressure (BP): 104/62 mmHg

Weight and height: 125 lb at 5ʹ2ʺ
Her heart and lung sounds are normal

Understanding Ava’s history, what risk factors does she have?
A. Advanced maternal age and poor family history
B. Poor family and social history
C. Mental health and physical risk factors
D. Emotional and economic risk factors

Multiple-choice:

The genetic test that Ava was referring to can be completed at 10 to 12 weeks gestation and can be performed transcervically or abdominally, guided by ultrasound. The test is:
A. Amniocentesis
B. Chorionic villi sampling
C. Biophysicalprofile
D. Level III ultrasound

Before Ava leaves the clinic, two appointments are made for her:

■ An appointment for a level II ultrasound for fetal nuchal translucency (FNT), which is done by ultrasonography (USG) at 10 to 14 weeks.The nape of the neck is measured and can indicate genetic disorders.
■ Her next clinic appointment is made for 4 weeks hence.

Also before Ava leaves for the day, danger signs (manifestations that indicate compli-
cations) are reviewed.

Matching:

Match the manifestation in Column A with the possible complication in Column B (complications can be
used more than once):

Match: manifestation in - possible complication
Match: manifestation in – possible complication

Prenatal Visit 2: 15 Weeks, September 16

At the second prenatal visit, a quad screen is done on Ava to check four parameters in the maternal serum:
Alpha-fetoprotein (AFP): a protein that is produced by the fetus. hCG: a hormone produced within the placenta.
Estriol: an estrogen produced by both the fetus and the placenta. Inhibin-A: a protein produced by the placenta and ovaries.

Multiple-choice:

The nurse realizes that Ava needs a better understanding of a quad screen when she states:
A. Elevated alpha-fetoprotein (AFP) may indicate neural tube defects or Down syndrome.
B. To maintain the pregnancy, human chorionic gonadotropin (hCG) is important in the first trimester.
C. Decreased AFP indicates fetal alcohol syndrome (FAS) or fetal alcohol effects (FAE).
D. The amount of hCG decreases in the second trimester.

Ava is now officially in her second trimester and other fetal surveillance tests for fetal well-being are sometimes done at approximately the 15th week.These include amnio- centesis, percutaneous umbilical blood sampling, and Doppler studies.

Matching:

Match the fetal surveillance tests in Column A to the descriptions of the tests in Column B:

Match: fetal surveillance tests - descriptions of the tests
Match: fetal surveillance tests – descriptions of the tests

Ava has gained 2 lb and is now 127 lb. She walks eight blocks to work every day for exercise.Ava’s BP is 106/70 mmHg and her urine is negative for glucose and protein when tested by dipstick analysis.Ava complains of occasional leg cramps that wake her up at night. She has started to take her lunch to work and is now eating breakfast. Dis- comfort of the second trimester is discussed.

Matching:

Match the discomfort in Column A to the appropriate nursing actions in Column B:

Match: discomfort in - nursing actions
Match: discomfort in – nursing actions

Ava listens to the instructions for the second trimester and asks questions about her care.

Multiple-choice:

Ava understands the teaching when she states:
A. “I know my heartburn is caused by human chorionic gonadotropin (hCG).”
B. “I think my heartburn has to do with eating fast.”
C. “Estrogen increases heartburn.”
D. “Progesterone increases heartburn.”

Ava leaves the clinic well informed and has supplemental reading material and, of course, numbers to call should she experience any issues or danger signs.

Prenatal Visit 3: 19 Weeks, October 11

The routine assessments are completed for Ava’s third visit. A urine dipstick is done to monitor for any developing hypertension of pregnancy (protein) and pregnancy-onset diabetes (glucose). Ava is excited because she can finally “feel the baby.” This feeling occurs at about 18 weeks in multiparous women (women with more than one preg- nancy) and at about 20 weeks in nulliparous women (women with no gestations past 20 weeks) or primigravidas (first pregnancy).

Multiple-choice:

The nurse explains to Ava that the maternal perception of feeling the baby move is called:
A. Lightening
B. Ballottement
C. Softening
D. Quickening

Ava is interested in what manifestations of pregnancy are called; so the nurse teaches her some terminology and Ava writes down the words so that she can search them later on the Internet.

Crossword
Crossword

Ava has gained an additional 3 lb and is 128 lb. Her blood pressure is 110/70 mmHg. Ava has no complaints and is excited because she is going to have an ultrasound, and she and her boyfriend would like to know the baby’s gender.A transabdominal ultrasound or a level II ultrasound is recommended at 18 to 20 weeks for an anatomy check because congenital anomalies are best seen at this time. Pregnancy dating is done by biparietal diameter (BPD) and femur length.

Select all that apply:

Nursing care for a second-trimester transabdominal ultrasound includes the following interventions:
A. Fillbladder
B. Elevate head of bed
C. Place in stirrups
D. Tilt to the left side
E. Use gel conductor

The baby is a BOY!

Prenatal Visit 4: 23 Weeks, November 9

Ava has now gained 5 lb since her last visit, for a total weight gain of 10 lb. Her blood pressure is 120/76 mmHg and her urine is negative for protein and glucose. She is regis- tered for prenatal classes. Her mother will be going with her because she and the father of the baby are no longer together. She has a new boyfriend and is unsure whether she will give the baby the father’s last name and ask him to sign paternity papers.Vaginal cul- tures are done on Ava since she reports being sexually active with her new boyfriend.The nurse also explains to Ava that the reason for measuring her belly with a tape measure is to assess fundal height and it is a good clinical method to estimate the growth of the baby.

Multiple-choice:

The nurse explains to Ava that her fundal height at 23 weeks gestation should measure:
A. 22 to 24 in.
B. 22 to 24 cm
C. 24 to 26 in.
D. 24 to 26 cm

Ava’s culture is positive for chlamydia, and Ava is prescribed an antibiotic. She is encour- aged to tell her new boyfriend so he can also get treatment.Ava comes in to pick up the prescription and the nurse reviews STDs and their implications to the baby.

Fill in the blank:

If Ava is positive for chlamydia, what other sexually transmitted diseases (STDs) would you suspect that
she might have?
____________________________________________________________________

The nurse reviews some of the common STDs with Ava

Prenatal Visit 5: 27 Weeks, December 6

Ava has gained another 5 lb. Her blood pressure is 118/74 mmHg and her urine is neg- ative for protein and glucose.The FH rate (FHR) is 138 bpm.Ava is given Rh immune globulin (RhoGAM®) intramuscular (IM), which is administered to all Rh-negative mothers at approximately 28 weeks gestation.

Multiple-choice:

The nurse explains the reason for RhoGAM correctly when she states that Rh-negative mothers need RhoGAM to:
A. Change them to Rh positive temporarily
B. Produceantibodiesagainstthefetalbloodcells C. Produce antigens against the RhoGAM
D. Change antibodies to antigens

The nurse also explains that Ava should start doing a daily fetal movement count (DFMC). The nurse provides Ava with a chart on which to record her DFMC and explains DFMC is done each day by the mother. Ava is to record the number of kicks for 2 hours each day.Ava should feel at least 10 kicks during that time.A repeat hemo- globin (Hgb) and hematocrit (Hct) are drawn as well as another RPR.The repeat Hct it is slightly lower than the initial.


Exhibit-format:
Laboratory data: Hematocrit (Hct), 30.1; rapid plasma regain (RPR), negative
Vital signs: Temperature: 97.8°F, heart rate (HR): 68 beats per minute (bpm), respiratory rate (RR): 18 breaths per minute, blood pressure (BP): 110/72 mmHg
Fetal heart rate (FHR): 150 bpm

The nurse understands that Ava’s slight drop in Hgb during the second trimester is caused by:
A. All patients get anemic during pregnancy, so it expected at this time.
B. There is an increase in fetal utilization of iron, so the baby is taking more.
C. Iron is poorly absorbed because of the gravid uterus pressing on the gastrointestinal (GI) tract.
D. The cellular content of blood increases at a lesser rate than the plasma.

Also at 28 weeks gestation, the nurse schedules Ava for a glucose tolerance test (GTT).

Multiple-choice:

The nurse understands that if Ava’s repeat glucose tolerance test (GTT) is greater than 140 mg/dL she will be a candidate for:
A. Insulintherapy
B. Oral hypoglycemic medication
C. A 3-hour GTT
D. A fasting GTT

In addition, before Ava leaves the clinic, the discomfort of the third trimester is reviewed with Ava.

Matching:

Match the common third-trimester discomfort in Column A with the description that matches in Column B:

Matching:

Match the third-trimester discomfort in Column A to the teaching that the nurse should provide in
Column B:

Ava goes into spontaneous labor at 28 and 1/7 weeks gestation. She is contracting every 5 minutes and calls the clinic.Ava is told to go right to the emergency department (ED) at the hospital for assessment because of her gestational age (GA).When Ava arrives at the ED, she is admitted directly to the high-risk perinatal unit. She is given terbutaline (Brethine),a tocolytic agent to stop preterm labor.With three doses of terbutaline 0.25 mg subcutaneously (subq), her contractions stop.

Calculation:

Order: Give terbutaline (Brethine) 0.25 mg subq, stat
On hand: Terbutaline 1 mg in 1 mL
How much do you give? ____________________

Ava is also given betamethasone (Celestone) 12 mg IM now and again in 12 hours to help increase fetal lung maturity.

Calculation:
Order: Betamethasone 12 mg intramuscular (IM), stat
On hand: Betamethasone 50 mg/5 mL
How much do you give? ____________________

Ava’s contractions become intermittent and she is monitored on the high-risk perinatal
unit for the next 2 days, and then discharged to home on modified bed rest.


While Ava was on the perinatal unit, Jane was admitted into the next room. Jane’s LMP was October 1, and it is January 15.This makes her 15 and 3/7 weeks gestation. Jane put off the first prenatal visit as this is her seventh child. Jane’s case came through the ED because she has dark-brown vaginal discharge and she believes this time it is much more than in the past. Jane is hoping it is not twins again. On examination, the nurse assesses Jane’s blood pressure and it is 154/92 mmHg. Jane denies a history of hypertension. Her past prenatal records are retrieved and verify that there was no gestational hypertension. Her uterus is large and measures 24 weeks gestation and the nurse cannot locate a FHR by Doppler. Jane also has very high hCG levels in her blood.

Fill in the blanks:

Jane is pregnant for the seventh time. She has a 13-year-old girl who was delivered at 34 weeks gesta- tional age (GA) but is doing well. She had a set of twins at 38 and 1/7 weeks who are now 10 years old. Jane has a 7-year-old and 5-year-old who were term babies. Jane had a miscarriage and then a preterm baby 3 years ago, who has mild cerebral palsy (CP).
Jane is a: G ____ P _____ T _____ A ______ L

Multiple-choice:

The nurse understands that the patient should most likely be prepared for which diagnostic procedure?
A. Ultrasound
B. Biophysicalprofile
C. Cesareansection
D. Amniocentesis

The primary care provider (PCP) visualizes clear vesicles throughout the uterine cavity and makes the diagnosis of hydatidiform mole, a precancerous condition. No invasion into the uterus itself is visualized.

Multiple-choice:

The most important education that the nurse can provide Jane after dilatation and curettage (D&C) of the hydatidiform mole is that she must:
A. Exercise regularly to get her abdominal tone back
B. Go to a support group for hydatidiform mole victims
C. Make sure she adheres to her birth control pills for at least a year
D. Get a second opinion about radiation therapy


While in the high-risk perinatal unit,Ava shared a room with Miracle. Miracle is on com- plete bed rest at 36 weeks gestation for pregnancy-induced hypertension (PIH). She is a G1, 19-year-old patient whom Ava previously met in the clinic. Miracle has a blood pressure of 142/92 mmHg while resting on her left side. She has an intermittent frontal headache and 2+ edema of both ankles and calves. Miracle also has 2+ deep tendon reflexes (DTRs).

Multiple-choice:

The nurse caring for Miracle and Ava has a nursing student with her. The nurse assesses that the nursing
student understands the patient’s care when he states:
A. “Miracle’s edema is slightly severe, I will continue strict input and output (I&O).”
B. “Miracle’s edema is severe and pitting on palpation.”
C. “Miracle’s deep tendon reflexes (DTRs) are hypoactive.”
D. “Miracle’s DTRs are hyperactive.”

When Miracle arrived in the high-risk perinatal unit, she was given magnesium sul- fate (MgSO4) to prevent seizures by decreasing the neuromuscular transmissions at the junctions.The nurse has an order to hang a new bag of MgSO4 and it is delivered from pharmacy premixed with 40 g in 500 mL.The order is to administer a continuous intra- venous (IV) drip at 4 g/hr.

Calculation:

Order: Magnesium sulfate (MgSO4) 4 g/hr
On hand: 40 g/500 mL
How much do you give? ____________________

Later that day, the phlebotomist draws blood on Miracle for liver enzymes and clotting factors to rule out HELLP syndrome, which is hemolytic anemia, elevated liver enzyme, and low platelets.

Multiple-choice:

A diagnostic finding in HELLP (hemolytic anemia, elevated liver enzyme, and low platelets) syndrome
includes:
A. Decreasedfibrinogen
B. Increasedplatelets
C. Decreasedleukocytes
D. Increased fibrin-split products

Multiple-choice:

Miracle’s labs show that her platelet count is 90,000/mm3. This would place her in which category?
A. ClassI
B. ClassII
C. ClassIII
D. ClassIV

Multiple-choice:

The interprofessional group of health care providers has determined that Miracle is not in disseminated
intravascular coagulation (DIC) because Miracle’s laboratory results demonstrate:
A. A decrease in fibrin-split products
B. An increase in platelets
C. An increase in fibrin-split products
D. An increase in red blood cells (RBCs)

Miracle is also receiving daily nonstress tests (NSTs) because the baby has been diagnosed with intrauterine growth restriction (IUGR), which may indicate the infant will be small for gestational age (SGA).This is a consequence of vasoconstriction caused by the hypertension.

Fill in the blank:

Small-for-gestational-age (SGA) babies’ weights fall below the ___ percentile for weight when compared
on the growth chart for their weeks of gestation.

Nonstress Test

This test is done after the 28th week by attaching the patient to the external fetal mon- itor (EFM) and assessing FHR in relation to movement. For a reactive test, there should be three movements with an acceleration of FHR 15 bpm for at least 15 second in 20 minutes.

Select all that apply:

Nursing care for a patient having a nonstress test (NST) should include:
A. Tilting the patient to the side to prevent supine hypotension
B. Increasing the intravenous (IV) fluids to 250 mL/hr
C. Explaining the procedure to the patient and family
D. Keeping the room as quiet as possible
E. Placing a Foley catheter into the bladder

If the NST was questionable, two other tests may be ordered:

Biophysical Profile

The biophysical profile (BPP) tests and scores five fetal wellness parameters as 0, 1, or 2. It scores the NST, amniotic fluid volume (AFV), fetal breathing movements, gross body movements, and fetal tone. A low score indicates fetal distress.

Contraction Stress Test

Exogenous oxytocin (IV oxytocin [Pitocin]) or (less often) nipple stimulation is used to stimulate uterine contractions (UCs).This evaluates placenta functioning and reserve. The goal is to stimulate three UCs of 40- to 60-second duration in 10 minutes and to evaluate the FHR.A negative result is a positive sign, meaning no fetal distress.A positive result indicates fetal distress.

Select all that apply:

Miracle has been informed that because of its small-for-gestational-age (SGA) status, when the baby is
born the newborn may need extra blood testing for:
A. Glucose
B. Polycythemia
C. Thyroid-stimulating hormone (TSH)
D. Phenylketonuria(PKU)
E. Bilirubin


Janelle is another patient on the high-risk unit where Ava was admitted. Janelle is a 32-year-old G3,T0, P2,A0, L2. She is 14 weeks pregnant and 1 postoperative day from a cerclage for an incompetent cervix. Her previous babies were born at 24 and 32 weeks, respectively. She had a cerclage placed with the second pregnancy after the diagnosis of incompetent cervix.

Select all that apply:

The following conditions place women at high risk for an incompetent cervix:
A. Diethylstilbestrol (DES) exposure while in utero
B. Cervicaltrauma
C. Congenitally shorter cervix
D. Largebabies
E. Uterineanomalies
F. Overdistended bladder
G. Previous loop electrosurgical excision procedure (LEEP), cone, or other surgical procedures
H. Multiple gestations


Ava was discharged from the hospital and is scheduled to return to the clinic every 2 weeks until 36 weeks, at which time she is seen every week (Table 4.3).

At 36 weeks gestational age Ava is cultured (vaginal and rectal) for group B Strep- tococcus (GBS), which is known to cause sepsis in otherwise healthy newborns. GBS is present in 10% to 30% of all women. It is colonized in the vagina, yet most women are usually asymptomatic. GBS has the potential to cause urinary tract infections (UTIs), which are one of the leading causes of preterm labor and neonatal septicemia.

Multiple-choice:

Ava’s group B streptococcal culture is positive, so the nurse would anticipate the following order once
Ava shows signs of true labor:
A. Gentamycin every 2 hours until delivery
B. Ampicillin 4 hours before delivery
C. Pitocin 1 mU/min to start regular uterine contractions (UCs)
D. Terbutaline 0.25 subq to increase the time until delivery

Ava’s Prenatal Record
Ava’s Prenatal Record

Ava calls the clinic at 36 and 5/7 weeks and states she is in labor. It is 3 a.m. and the answering service instructs her to go to the local ED.There she is evaluated and attached to the electronic fetal monitor (EFM).

Matching:
Match the correct term describing uterine contractions (UCs) in Column A with the descriptions in Column B:

Match: uterine contractions
Match: uterine contractions

Ava is in labor.

Fill in the blanks.

Fill in the blanks using these external fetal monitor strips:

External Fetal Monitor Strips
External Fetal Monitor Strips

What is the frequency of Ava’s contractions? ________
What is the duration of Ava’s contractions? ________
What is the interval of Ava’s contractions? ________
What is the intensity of Ava’s contractions? ________

Ava is admitted to the L&D suite.


Mirabel comes into the ED approximately the same time as Ava. She is a 27-year-old G2, T0, P0, A1, L0. Mirabel states that she missed her period last month but was waiting to see whether it returned this month. Her primary complaint is pain in her left lower abdomen that radiates down her leg. On a pain scale of 0 to 10 she rates it a 6, and is visibly uncomfortable.

Multiple-choice:

The nurse should anticipate that the primary care provider (PCP) will order:
A. A computerized axial tomography (CAT) scan and human chorionic gonadotropin (hCG) level
B. An MRI and ultrasound
C. An ultrasound and CAT scan
D. An hCG level and ultrasound

These tests confi rm that she is pregnant, but it is an unruptured ectopic pregnancy

Hot spot:

Place an X on the diagram the portion of the female anatomy where you believe the implantation is most
likely to occur.

Implantation
Implantation

Mirabel is given methotrexate, which is an antimetabolite drug that will stop rapidly dividing cells, such as an embryo, in order to save the fallopian tube. She is extremely lucky that the ectopic pregnancy did not rupture. Therefore, Mirabel has a better chance of becoming pregnant in the future.


Sara comes to the ED while Ava is waiting to be taken to the L&D suite. Sara is pregnant and experiencing vaginal bleeding. She is in her fi rst trimester. An ultrasound that was done 2 weeks ago dated the pregnancy at 9 weeks gestation, which is consistent with Sara’s dates. Sara is G4, T1, P0, A2, L1. Since her son was born 6 years ago, she has experienced two spontaneous abortions.

One was a complete abortion and the second one was an incomplete abortion, for which she had to be admitted to the hospital for a dilation and evacuation (D&E) at 7 weeks gestation. She is now under a threatened abortion and is
placed on bed rest in the ED, after which she is transferred to the perinatal unit. During the next 2 hours of observation, the bleeding increases and an ultrasound shows no FHR. Sara is diagnosed with an inevitable abortion, which will be extremely difficult for her. She will need to be referred to the outpatient perinatal center for genetic studies because she is a habitual aborter.

Matching:

Match the terms in Column A with the defi nitions in Column B:

Definitions
Definitions

Select all that apply:

Choose the appropriate nursing interventions for Sara.
A. Tell her she can get pregnant again
B. Tell her to adopt a child
C. Encourage her to verbalize about the loss
D. Give her a special memento, such as a silk rose, to remember the loss
E. Include her husband in the discussion


Ava is attached to the EFM. The FHR shows good variability or push and pull of the sympathetic and parasympathetic nervous system of the fetus. There are FHR accelerations with UCs and fetal movement. Therefore, the pattern is reassuring.

Ava is allowed to walk around, off the monitor, for 40 minutes out of every hour and placed on the monitor for 20 minutes. The nurse evaluates the monitor for basic patterns every hour and uses the acronym VEAL CHOP

VEAL CHOP Mnemonic
VEAL CHOP Mnemonic

After 3 hours, Ava is 4-cm dilated and the PCP has decided that Ava will receive labor augmentation. Artificial rupture of membranes (AROM) is done with an amniohook to augment Ava’s labor process.

Multiple-choice:

The expert nurse understands that after artifi cial rupture of membranes (AROM), her fi rst intervention will be:
A. Clean the patient’s bed
B. Observe the fl uid’s color
C. Count the fetal heart rate (FHR)
D. Palpate the maternal pulse

After the AROM, Ava’s UCs become stronger and she receives butorphanol 1 mg.

Multiple-choice:

The nurse understands that once a labor patient receives a narcotic, a priority intervention is:
A. Assist when out of bed (OOB)
B. Monitor the labor contractions, which may decrease in intensity
C. Provide oral hygiene to reduce dry mouth
D. Have naloxone (Narcan) available

Calculation:

Order: Give butorphanol 1 mg intravenous (IV) push, stat
On hand: Butorphanol 2 mg in 1 mL
How much do you give? ______________

Calculation:

Order: Have neonatal naloxone (Narcan) 0.1 mg/kg intramuscular (IM) on hand
On hand: Naloxone (Narcan) 0.4 mg /mL
How much would you give if you suspect a 7-lb baby? ______________

Ava is now in bed and she is 5-cm dilated (Table 4.5). Ava is very uncomfortable and requests an epidural. The nurse increases her IV fluid rate, as ordered, to increase the vascular volume to offset the hypotensive effect of the epidural, which is produced by the vasodilation.

Stages and Phases of Labor
Stages and Phases of Labor

Calculation:
Order: Increase Ringer’s lactate (RL) to 500 mL bolus in 30 minutes.
On hand: 1,000-mL bag of RL on a pump that delivers mL/hr
What would the pump setting be for this bolus? ____________________

Ava receives a continuous epidural infusion and the nurse checks her BP every minute for 5 minutes, then every 15 minutes for 1 hour to make sure it does not drop too low. A low blood pressure can severely affect placental perfusion of blood and therefore fetal oxygenation. The baby is continuously monitored and Ava rests in between UCs.

Select all that apply:

Check all the appropriate nursing interventions for the fi rst stage of the second phase of labor:
A. Catheterize or void every 4 hours
B. Change blue pads every 30 minutes
C. Allow her to order a regular full lunch
D. Turn lights on so she is alert
E. Take off the fetal monitor

Ava’s UCs slow down and oxytocin (Pitocin) stimulation or augmentation is given via IV.

Calculation:

Calculate the correct dose if the primary care provider (PCP) orders a Pitocin intravenous (IV) to start at
2 mU/min.
On hand: 500-mL bag of Ringer’s lactate (RL) with 30 units of Pitocin and a pump that delivers mL/hr
What is the correct pump setting? __________________________________________________________

Ava wakes up and is starting to feel the UCs again. She is short tempered with her mother and irritable with the nurse, but the nurse knows this is normal and reviews the stages and phases of labor with Ava’s mother, so she understands Ava’s behavior. The professional nurse notes early decelerations on the fetal monitor but the FHR
remains at 130 to 140 in between contractions, which is the baseline.

Fill in the blanks:

What is the normal fetal heart rate (FHR) range? The normal range is______ to _______ beats/min.

The nurse has Ava checked internally and she is fully dilated (10 cm). The nurse repositions
Ava so she can push. Ava pushes effectively for approximately an hour, and when
rechecked the baby is + 3 station. The delivery table is brought into the room and the
PCP is called. The baby is crowning and Ava feels the “ring of fi re” sensation around
her perineum.

The PCP massages her perineum in an attempt to decreases perineal
lacerations. The baby turns in external restitution and the nurse reviews the six cardinal
processes of childbirth (Exhibit 4.1) with the graduate nurse who is being oriented and
is observing the delivery. A right medial lateral (RML) episiotomy is made to prevent
perineal tearing.

The baby is bigger than expected and the anterior shoulder gets caught under the
symphysis pubis. An RML episiotomy is made. The PCP immediately puts on the call
bell to alert the L&D team that there is shoulder dystocia. The McRobert’s maneuver is
performed. Ava’s legs are fl exed as far as possible to open the pelvic arch, and subrapubic
pressure is applied to dislodge the fetal shoulder. The McRobert’s maneuver is successful,
anesthesia is not needed, and the baby is delivered.

Six Cardinal Processes of Labor
Six Cardinal Processes of Labor

Select all that apply:

The nurse understands that the baby is at high risk for:
A. Broken clavicle
B. Cephalhematoma
C. Caput succedaneum
D. Brachial plexus
E. Fractured humerus
F. Hydrocele

Multiple-choice:

The nurse understands that the proper interventions to expect at the delivery include:
A. Ritgen’s maneuver, suction the infant’s nose and then mouth
B. Suction the infant’s nose, Ritgen’s maneuver, and then suction the infant’s mouth
C. Externally rotate the infant, Ritgen’s maneuver, and suction the infant’s mouth
D. Ritgen’s maneuver, suction the infant’s mouth and then nose


The PCP places the baby on Ava’s abdomen and cuts the cord.

Fill in the blanks:
The umbilical cord should contain ___ vessels; there are two ________ and one _________.

Ava’s nurse remembers the important interventions for the baby after the delivery.

Fill in the blanks:

One letter simply stands for a letter of the alphabet. See if you can break the code.
Y M N – A H W W D N O J O T Y M J C J G I
ONE— _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ O N B _ _ _
W C Y – B G T
TWO— _ _ _
W D G N N – Z Y Q K W K Y M W D N D N J B
THREE— _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Z Y U G – Q H E W K Y M
FOUR— _ _ _ _ _ _ _
Z K X N – Q W K I H S J W N W Y O G N J W D N
FIVE— _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Matching:

Match the type of heat loss in Column A to the appropriate sentence in the neutral thermal environment
(NTE) story in Column B:

Neutral thermal environment
Neutral thermal environment

Benjamin is 6 lb 4 ounces. He has central cyanosis and is hypotonic with poor refl exes. His respirations are gasping and he has a HR of 110 bpm. The nurse suctions him with the bulb syringe (mouth then nose) and provides him with free-flow or blow-by oxygen; the baby responds by crying.

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