Obstrical Notes

8/14/2019 Obstrical Notes

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UTERUSHollow, pear-shaped fibromuscular organ

Functions:Organ of menstruationSite of implantation

Retainment and nourishment of product of conception

Consists of 3 parts:CorpusIsthmusCervix

Composed of 3 muscle layers:PerimetriumMyometriumEndometrium

FALLOPIAN TUBES4 inches long from each side of the fundusPeristaltic 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

OVARIESSex glandsProduce and expel ova or egg per cycleProduce estrogen and progesterone

EstrogenInhibits production of FSH (Follicle Stimulating Hormone)Causes hypertrophy of MyometriumStimulates growth of the ductile structures in the BreastsIncreases quantity and pH of the cervical mucus causing it to become thin and watery

ProgesteroneInhibits 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 motilityDecreases 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 PHYSIOLOGYPELVIS STRUCTURES

made of 4 bones:Ilium iliac crest

Antero-posterior iliac spinesIschiumPubisSacrumCoccyx

True and False Pelvis

False Pelvisoffers landmark for pelvic measurementSupports the growing uterus during pregnancyDirects the fetus into the true pelvis at the latter part of the gestation.

True PelvisInlet Diameter:

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Antero-posteriorTransverse 13cmOblique 13cm

Mid Pelvis SIPSSSacral promontory accessible

Ischial spines are not prominentPelvic wall are not convergentSacrum is curvedSub pubic arch is wide

OutletAnteroposterior 9.5 to 11cmIntertubrous 11cmPosterior sagital 7cm

Pelvic Types or VariationsGynecoidAnthropoid

PlatypelloidAndroid

MENSTRUAL CYCLEAmenorrheaMenorrhagiaMetrorrhagiaPolymenorrheaOligomenorrhea

Menstrual cycleRegular occurance of ovulation throughout the reproductive life of a woman

It is divided into two phases:Follicular (proliferative)Luteal (secretory)

Menstrual CycleSTRUCTURES INVOLVEDHypothalamusAnterior Pituitary GlandOvaryUterus

Menstrual CycleTwo simultaneous cycles:ovarian cycle andFollicular,Ovulatory,Luteal phaseMenstrual phaseendometrial cycleProliferativeOvulationSecretoryMenstrual phase

NEUROENDOCRINOLOGY OF REPRODUCTIONHypothalumusGnRHIntermittent, pulsatile cyclic manner controls the release of gonadotropins by the anteriorlobe of the pituitary gland

HORMONES REGULATING MENSTRUAL CYCLEFSH (Follicle Stimulating Hormone)LH (Luteinizing Hormone)Gonadotrophins

Estrogen

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Inhibits production of FSH (Follicle Stimulating Hormone)Causes hypertrophy of MyometriumStimulates growth of the ductile structures in the BreastsIncreases 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 tubeIncreases endometrial tortousity.Inhibit uterine and gastrointestinal motility.Decreases muscle tone of the urinary tract

Increase musculoskeletal motilityDecreases 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 pregnancyOvumZygoteEmbryoConceptusFertilization of one ovum by one sperm resulting in a fertilized ovum (zygote).Usually occurs in the distal outer third of fallopian tube

ImplantationBlastocyst

TrophoblastEmbryoblast

THE PROCESS OF APPOSITION

EMBRYONIC STRUCTURES

The deciduaIt is the pregnant endometrium if fetilization occurs.

DeciduabasalisDeciduacapsularisDecidua Vera

Chorionic Villi

Serves as the anchor of the trophoblast on the deciduas

SyncytiotrophoblastCytotrophoblast

The Amniotic MembranesAmnionChorion

Amniotic FluidProduced by the amnion500ml to 1L clear yellowish fluidOligo- and poly- hydramnios

Embryonic structures

The placentaFrom trophoblastic layersWeighs 1/6th of the fetus (400-600Gm)Compesd to 30 cotelydonsHas circulatory and endocrine function

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Endocrine function of the placentahCGmaintains levels of estrogen and progesteroneSuppress immunologic responseEstrogen

ProgesteronehPL

The umbilical cordFormed from fetal membranesConnects fetus and placenta2 arteries and I veinProtected by the whartons Jelly

Origin and Development of Organ SystemsECTODERMMESODERMENDODERM

Origin and Development of Organ SystemsCephalocaudalImplantation : BLASTOCYST

Amniotic cavity (ectoderm) yolk sac ( Entoderm)Yolk sac :supply nourishment until implantationSource of RBC until about 12th week(mesoderm)

ORIGIN AND DEVELOPMENT OF ORGAN SYSTEMS

EMBRYONIC PERIOD: Prone to teratogenicsAt 8 weeks: the end of embryonic period, all organ systems complete

CARDIOVASCULAR SYSTEMFirst system to be functional in intrauterine life, forms as early as 16th day and beats asearly as the 24th dayDoppler: from 10th 12th weekFetal circulation

3 unique structures of the heart and of the fetus:DuctusvenosusForamen ovaleDuctusarteriosus

Fetal hemoglobinComposed 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 SYSTEM4TH Week septum begins to divide the esophagus to the trachea

6th week lung buds extend down into the abdomen and diaphragm becomes complete atthe 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 componentSphingomyelin: chief component at early formation of surfactant

NERVOUS SYSTEM3rd 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 intoNeural tube neural crest(CNS:brain and SC) (PNS)

DIGESTIVE SYSTEM4TH 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 newbornAt 36 weeks : GIT has ability to enzymesExcept AMYLASE : which is secreted 3 months after birth.MUSCULOSKELETAL SYSTEMCartilage forms as early as 2 weeks of fetal life which provides support and positionAt 12th week: ossification of bones begin and continue throughout fetal life until adulthood

REPRODUCTIVE SYSTEMDetermined at the moment of conception by the spermatozoon carrying an X or a YchromosomeAt about 6 weeks : gonads are formed

Can be determined as early as 8weeks

URINARY SYSTEMPresent as early as 4th weekUrine is formed by the 12th weekAt term : 500ml per day

INTEGUMENTARY SYSTEMThin and almost transparentCovered by vernixcaseosa

IMMUNE SYSTEMIgG maternal anibodies cross the placenta during the 3rd trimester

No immunity to herpes virus

MILESTONES OF FETAL GROWTH AND DEVELOPMENT

END OF 4 GESTATION WEEKSSpinal cord is formed, rudimentary heart appearsArms and legs are budlike structuresRudimentary eyes, ears and nose

END OF 8 GESTATION WEEKOrganogenesis is completeHeart is beating regularlyFacial features are discernibleExternal genitalia are present but indistinguishable by simple observation

END OF 12 WEEKSSex is distinguishable by outward appearanceSpontaneous movement are possible, but too faint to be felt by motherBone ossification centers are formingHeartbeat is audible by doppler

END OF 16 WEEKS

Fetal heart sounds are audible by ordinary stethoscopeLanugo is well formedSex can be determined by ultrasoundFetus actively swallows amniotic fluid

END OF 20WEEKSSpontaneous fetal movements felt by motherFetal heartbeat is strong to be audible

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Vernixcaseosa begins to formDefinite sleep and activity patterns

END OF 24 WEEKSActive production of lung surfactantPassive antibody transfer from mother to fetus

Pupils capable or reacting to lightHearing can be demonstrated by response to sudden sound

END OF 28 WEEKSLung alveoli begin to mature

Testes begin to descend into scrotal sacEyes openBlood vessels of etina are extremely sensitive to high levels of O2

END OF 32 WEEKSActive moro reflex is presentFetus is aware of sounds outside mothers womdBirth position may be assumed

END OF 36 GESTATION WEEKSBody stores of glycogen, iron, carbohydrate and calcium augmentedLanugo begins to diminishMost babies turn into a vertex presentation

END OF 40 WEEKSFetus kicks actively enough to cause discomfortFetal hemoglobin begins its conversion to adult hemoglobinVernix is fully formedCreases of the sole cover 2/3 of the surface

DIAGNOSIS OF PREGNANCY

PRESUMTPIVE SYMPTOMS OF PREGNANCY1. Nausea with or without vomiting2. Disturbance in urination3. Perception of fetal movement4. Breast tenderness and tingling sensation5. Amenorrhea6. Anatomic Breast changes7. Changes in vaginal mucosa8. Skin pigmentation9. Thermal signs : increased temp by 0.3 to 0.5 for > 3weeks

PROBABLE EVIDENCE OF PREGNANCY1. Enlargement of the abdomen2. Changes in the shape, and consistency of the uterus3. Anatomical changes in the cervix4. Braxton Hicks Contraction5. Ballottment6. Physical outlining of the fetus7. Positive pregnancy test : B HcG levels

POSITIVE EVIDENCE OF PREGNACY1. Identification of fetal heart tones separately from mother2. perception of active fetal movement by the examiner3. Ultrasound or radiologic evidence

THE BEGINNING OF PREGNANCY

GESTATIONAL (MENSTRUAL AGE) : measured from the 1st day of the last menstrualperiod, in completed days or weeks

OVULATION (POST CONCEPTION AGE):2 weeks less the gestational ageVIABILITY:

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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 weeksPOST TERM : 42 completed weeks or more

Eg : G7P6TPAL (5,0,1,5)

GRAVIDA : woman who is or has been pregnant irrespective of pregnancy outcomePrimigravidMultigravidaNulligravid

PARITY : number of pregnancies reaching viability. Parity is same whether a single ormultiple fetuses were born alive/ stillbornPrimiparaMultiparaNullipara

RUBINS FRAMEWORK FOR MATERNAL ROLE ASSUMPTIONPSYCHOSOCIAL ASSESSMENTFirst Trimester

AmbivalenceBaby is part of her

Second TrimesterFeels well, happyFocus is on selfFantasizes about babyQuickening feltPsychosocial Assessment

Third TrimesterNestingEnergy surge as due date

approachesDesire to get to the end of the

pregnancyFocus on baby, delivery

REPRODUCTIVE CHANGES DURING PREGNANCY

OvariesIncreased vascularity

Corpus luteum persists until the 12th week of pregnancy after which it is taken over by theplacenta.

UterusPear-shapedSize enlarges compatible with age of gestation

Braxton Hicks contractionsStructural changes include:Changes in the endometriumChanges in the myometriumIncreased blood supplyFormation of the lower uterine segment

With onset of labor, contractions are regular synchronous with fundal dominance.

CervixGOODELLS SIGNIncreased mucus secretion of the cervical glands.

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Mucus accumulates within cervical canal that provides a barrier against infections.

VaginaIncreased in length, distensibilityIncreased vascularityCHADWICKS SIGN

Increased shedding of the glycogen rich squamous cell resulting in increased whitish,creamy, highly acid vaginal secretion.

BreastsEnlargement, tenderness or pain on slight pressureDarkening of primary areola, fluid expressed from the nipple

Colostrum

CardiovascularChanges during pregnancyIncrease in heart rateIncrease in cardiac output about 30-50%4 periods where there is increase in cardiac output:On the 28th week of gestationDuring laborImmediately postpartumDuring 1st week of puerperium

Respiratory Changes during pregnancyIncreased estrogen causes increased vascularization of upper respiratory tract

Progesterone causes respiratory alkalosis compensated by mild metabolic acidosis.

Gastro-intestinal Changes during pregnancySmooth muscle atony and decreased tone of lower esophageal sphincter, causingesophageal regurgitation.

Renal Changes during pregnancyIncrease in renal pelvis and ureter called physiologic hydroureter of pregnancy more onthe right side.

Endocrine Changes during pregnancyAnterior Pituitary gland hypertrophies with increased activity, posterior lobe increasesproduction of oxytocin necessary for contraction next to term.

Normal ovarian function is suspended, corpus luteum activity exists only until 12th weekwhen 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 toprovide adequate amount of calcium to fetus and mother.HCGHPL

Hematologic Changes during pregnancyIncreased blood volume due to increased plasma volume gradually happening at the end offirst trimester and stays high throughout the pregnancy.

Increase in blood coagulation factors, increased fibrinogen levels, increase in plasminogenlevels and fibrin degradation products.

Increased plasma iron binding capacity. Total iron requirement for pregnancy is one gram or6-7mg per day.

Maternal Metabolism In PregnancyWeight gain of 25-35lbsFirst trimesterSecond trimesterThird 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 metabolismWater retention - 6.5 litersIncreased plasma volume - 1.5 litersSodium retention is 3 grams/week but in inactive form

PRENATAL CAREGen Data

ESTIMATION OF THE DURATION OF PREGNANCYEDCLEOPOLDs MANEUVER

PE and ROSPELVIC EXAMLAB TESTS

Frequency of visitsEvery 4 weeks until 28 weeksThen every 2 weeks until 36 weeksWeekly thereafter

Pre-Natal VisitsPersonal dataObstetrical data

GPTPALPast pregnancies

Method of delivery Place of delivery Risks or Problems experienced

Present Pregnancy Main concern Danger signals

Medical dataReview 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 ofpremature if anyA Number ofabortions or aborted pregnancies if anyL Number ofliving children

Pre-Natal VisitsFundal Heightused to assess gestational age and fetal growth.

SIGNIFICANT MEASUREMENTS AND ESTIMATES

Age of GestationNgele's Rule - estimates expected date of confinement (EDC). McDonalds Method AOG in months. Measure distance from symphysis pubis to the top

of uterine fundus designated as fundal height in centimeters (cm).

ESTIMATING FETAL GROWTHMC DONALDS RULE:Note fundic heightBetween 20 to 31st week of pregnancy: height (symphisis to fundus) in cms in equal to theAOG in weeksUsually inaccurate at the 3rd trimesterOver symphisispubis : 12th week

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Umbilicus: 20th weekXiphoid process: 36 weeks

Age of Gestation Bartholomews AOG is estimated by the position of uterus in theabdominal cavity. Done thru palpation.

Length of Fetus in Centimeters

Haases 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

Johnsons 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

LEOPOLDS MANEUVER

LM1 ( Fundal grip)What fetal pole or part occupies the fundus?BREECH : irregular, nodularCEPHALIC : round

LM2 ( Umbilical grip)Which side is the fetal back?Back : linear, convexSmall Parts : numerous nodulationLM3: (PAWLICs grip)

What fetal lies above the pelvic inlet?Head engaged or not.LM4 : (Pelvic Grip)

Which side is the cephalic prominence?

Cephalic prominenceFlexionExtension

IDENTIFICATION OF HIGH RISK PREGNANCYMaternal ageMaternal heightWeightSocial factors

OB HISTORY (high risk)

Multiparity thyroid disease

PROM, IUGR PTBPremature labor Previous CSMacrosomia Abnormal presentationsMultiple pregnancy Placental abn.AF abnormalitiesUTI, DM, HPNUterine/ ovarian diseases

URINE EXAMINATIONBiological TestsThe 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 ExaminationThe 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 SCREENINGPregnancy is diabetogenic due to impairment of peripheral insulin action as a consequence

of the action of PLACENTAL LACTOGENS, ESTROGENS and PROGESTERONEInsulin 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 METHODAverage normal finding: 2x every 10 minutes or average of 10 to 12x an hourCARDIFF METHOD: COUNT TO TEN METHODrecords time interval to feel 10 fetal movements; usually this occurs within 60 minutes

Fetal Heart Tonescan be assessed through Doppler ultrasound device or by fetoscoperanges from 120-160 beats per minute.

Rhythm strip testingSemi fowlers positionUsing external FHT and uterine contraction monitors attached abdominallyRecord FHT for 20 minutes

Non stress testingResults of non stress testMovement : FHT should increase to about 15 beats per minute and remain elevated for 15

secondsIf no increase in FHT on fetal movement: poor oxygen perfusion of the fetusDone for 10 to 20 minutesResults:

REACTIVE (good)NON REACTIVEIf 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 test2.BPS ( biophysical profile)

Contraction stress testingMeasure of uteroplacental functionFHT analyzed in conjunction with contractionsSource of OXYTOCIN : nipple stimulationSteps:

Attach monitor for FHT and uterine contractionsGet baseline FHTNipple 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 patternEarly decelerationsLate

VariableEarly DecelerationsLate DecelerationsVariable Decelerations

UltrasoundUses :1. diagnose pregnancy as early as 6 weeks

(gestational sac at 5 to 6 wks)(CRL )crown rump length at 12-14weeksBiparietal diameter (BDD)or femoral length(FL) onwards2. confirm presence ,size and location of placenta and amniotic fluidUltrasound3. establish that fetus is growing and has no gross defects4. establish presentation and position of fetus ( sex can be diagnosed if penis is revealed)5. Others : complications of pregnancy

Other Types of ultrasoundB mode scanning : gray scale, sonogramReal time scanning : multiple wave, allows screen picture to move

LAB TESTSRH incompatibilityRh : 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 sensitizationParenteral combination to worry about:

Mother Rh (-) andfatherRh(+)antibodies --cross placenta and attach fetal RBCs-fetal hemolysis

When does sensitization happen?RH (-) mother becomes sensitized during earlier pregnancy in which the child was Rh (+)ERYTHROBLASTOSIS FETALIS

RhoGAM : treatment for exposureIf Rh(-) mother is exposed to fetal blood, RhoGAM is givenRhoGAM is RhIgG

TRIPLE SCREENINGUses 3 indicators:

AFP;unconjugatedestriol, andHCG

Yields more reliable results (70-80% of Down syndrome cases)MATERNAL SERUM AFPAFP : (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 villiUsed for chromosomal analysis

COELOCENTESIS: transvaginal aspiration of fluid from the extraembryonic cavityAvoid isoimmunization

AMNIOCENTESISAspiration 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 yellowGreen colorLecithin/Sphingomyelin ratio

Ratio of 2:1 : lung maturity

Phosphatidyl Glycerol and desaturatedphosphatidylcholinepositive : 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

AMNIOCENTESISInborn errors of metabolism: presence of enzymes

Alpha fetoprotein

Acetyl cholinesterase

PERCUTANEOUS UMBILICAL CORD SAMPLINGCORDOCENTESIS/ FUNICENTESIS

Aspiration of blood from umbilical vein for analysis: usu to check blood dyscrasias

CRITICAL FACTORS IN LABORBirth Passageway

The true pelvis and soft tissues of the cervix, vagina, and the pelvic floor form the birthpassageway.

The true pelvis is divided into three sections: the inlet, the pelvic cavity (midpelvis), and theoutlet.Birth Passageway

The four classic types of pelvises areGynecoidAndroidArthropoidPlatypelloid

Birth Passenger (Fetus)The Fetal HeadFetal AttitudeFetal LieFetal PresentationFetal Position.

Fetal HeadThe fetal head is composed of bony parts, which can either hinder childbirth or make iteasier.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 facethe 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 thecranium is composed of the two temporal bones, each with a sphenoid bone and anethmoid bone.

The bones composing the vault are the two frontal bones, the two parietal bones, and theoccipital 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 MOLDINGThe intersection of several cranial sutures forms an irregular space that is enclosed by amembrane 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 AttitudeFetal attitude refers to the relation of the fetal body parts to one another.The normal attitude of the fetus is termed general flexion

Fetal LieRelationship of the long, or cephalocaudal, axis (spinal column) of the fetus to the long, orcephalocaudal, axis of the mother.The fetus may assume either a

longitudinal (vertical)transverse (horizontal)

Fetal PresentationRefers to the body part of the fetus that enters the maternal pelvis first determined by fetal lieFetal presentation may be:cephalic (head first)breech (buttocks or feet first)shoulder.

Fetal Presentation

The most common presentation is Cephalic.Malpresentations.Breech andshoulder presentationsFetal Presentation

CEPHALIC PRESENTATIONVertex Presentationwhen 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 PresentationThe 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 thematernal pelvis

Face presentationThe fetal head is hyperextended (complete extension).

The submentobregmatic diameter presents to the maternal pelvisThe face is the presenting part.

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Breech Presentationthe 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 feltwhen palpating) is the landmark.

Complete BreechThe 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 BreechThe fetal hips are flexed, and the knees are extended.The buttocks of the fetus present to the maternal pelvis.

Footling BreechThe 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 PresentationWhen the fetal shoulder is the presenting part, the fetus is in a transverse lie and theacromion process of the scapula is the landmark.

Relationship of Maternal Pelvis and Presenting PartEngagementEngagement of the presenting part occurs when the largest diameter of the presenting partreaches 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.

EngagementThe presenting part is said to be floating (or ballottable) when it is freely movable above theinlet.When the presenting part begins to descend into the inlet, before engagement has trulyoccurred, it is said to be dipping into the pelvis

StationRelationship of the presenting part to an imaginary line drawn between the ischial spines ofthe maternal pelvis.

In a normal pelvis the ischial spines mark the narrowest diameter through which the fetusmust 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 landmarksOcciput,Mentum,SacrumAcromion

Scapula.In summary, three notations are used to describe the fetal position:1. Right (R) or left (L) side of the maternal pelvis2. The landmark of the fetal presenting part: occiput (O), mentum (M), sacrum (S), oracromion (scapula[Sc]) process (A)3. Anterior (A), posterior (P), or transverse (T), depending on whether the landmark is in thefront, 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 LaborThe primary force is uterine muscular contractions,The secondary force is the use of abdominal muscles

CONTRACTIONSUterine contractions are rhythmic tightenings and shortenings of the uterine muscles duringlabor.Each contraction has three phases:(1) increment,(2) acme,(3) decrement,

When describing uterine contractions during labor,intensityFrequencyDuration

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 bemeasured 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 indentabilityof the uterine wall during the acme of acontraction.

Bearing down.The combined involuntary pressure of the uterine contractions and the voluntary musclecontractions 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 ismature and ready for birth.

PROGESTERONE WITHDRAWAL HYPOTHESISProgesterone produced by the placenta relaxes uterine smooth muscle by interfering withconduction of impulses from one cell to the next. (Challis, 2004).

PROSTAGLANDIN HYPOTHESISpreterm labor may be stopped by using an inhibitor of prostaglandin synthesis such asindomethacin (Challis, 2004).

CORTICOTROPIN-RELEASING HORMONE HYPOTHESISCRH 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 etal., 2005).

ROLE of ESTROGENEstrogen is known to stimulate uterine muscle contractions to permit softening, stretching,and eventual thinning of the cervix.

Myometrial ActivityIn true labor the uterus divides into two portions. This division is known as the physiologicretraction 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 asbrachystasis.

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 LaborLightening describes the effects that occur when the fetus begins to settle into the pelvicinlet (engagement)the woman may notice the followingLeg cramps or painsIncreased pelvic pressure

Increased venous stasis,Increased urinary frequencyIncreased vaginal secretions

BRAXTON HICKS CONTRACTIONSthe irregular, intermittent contractions that have beenoccurring throughout the pregnancy

CERVICAL CHANGES. This softening of the cervix, called ripening, is under the influence ofhormonal factors.

BLOODY SHOWWith softening and effacement of the cervix, the mucous plug is often expelleda sign of impending labor, usually within 24 to 48 hours.

RUPTURE OF MEMBRANESIf membranes rupture and labor does not begin spontaneously within 12 to 24 hours, labormay be induced to avoid infection.If engagement has not occurred, the danger exists that the umbilical cord may be expelledwith the fluid (prolapsed cord).

SUDDEN BURST OF ENERGYSome 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 BIRTHFirst Stage

The first stage begins with the beginning of true labor and ends when the cervix iscompletely dilated at 10 cm.

First stage (Latent phase)Begins with the onset of regular contractions.

Nullipara: averages 8.6 hours< 20 hours

Multiparas: averages 5.3 hours


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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 thematernal pelvis by certain positional changes. These changes are called cardinalmovements or mechanisms of labor.

DescentDescent 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 theabdominal muscles, and (4) extension and straightening of the fetal body.

FlexionFlexion occurs as the fetal head descends and meets resistance from the soft tissues of thepelvis, the musculature of the pelvic floor, and the cervix. As a result of the resistance, thefetal chin flexes downward onto the chest.

Internal RotationThe fetal head must rotate to fit the diameter of the pelvic cavity, which is widest in theanteroposterior diameter. As the occiput of the fetal head meets resistance from thelevatorani muscles and their fascia, the occiput rotates from left to right, and the sagittalsuture aligns in the anteroposterior pelvic diameter.

Extension The resistance of the pelvic floor and the mechanical movement of the vulva openinganteriorly and forward assist with extension of the fetal head as it passes under thesymphysis pubis. With this positional change the occiput, then brow and face, emerge fromthe vagina.

External RotationAs the shoulders rotate to the anteroposterior position in the pelvis, the head is turnedfarther to one side (external rotation).

ExpulsionAfter the external rotation and through expulsive efforts of the laboring woman, the anteriorshoulder meets the undersurface of the symphysis pubis and slips under it. As lateral flexionof the shoulder and head occurs, the anterior shoulder is born before the posterior shoulder.

The body follows quickly.

Third StageThe third stage of labor is defined as the period of time from the birth of the infant until thecompleted delivery of the placenta.

SIGNS OF PLACENTAL SEPARATIONThese signs area globular-shaped uterusa rise of the fundus in the abdomena sudden gush or trickle of bloodfurther protrusion of the umbilical cord out of the vagina.PLACENTAL DELIVERYA placenta is considered to be retained if more than 30 minutes have elapsed fromcompletion of the second stage of labor.

PLACENTAL SEPARATIONTypes of placental deliverySchultze mechanismDuncan mechanism

The NewbornPhysiologic Response of the Newborn

The newborn periodNeonatal transitionDuring this period, the newborn adjusts from intrauterine to extrauterine life.

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RESPIRATORY ADAPTATIONS

FETAL LUNG DEVELOPMENTAt 20 to 24 weeks, alveolar ducts begin to appear, followed by primitive alveoli at 24 to 28weeks.

Type I cells (structures necessary for respiratory gas exchange) andType II cells (structures that provide for the synthesis and storage of surfactant)

RESPIRATORY ADAPTATIONSAt 28 to 32 weeks of gestationthe number of type II cells increases further, and peaks at about 35paralleling late fetal lung development.

The peak production of lecithin corresponds closely to the marked decrease in incidence ofidiopathic respiratory distress syndrome

RESPIRATORY ADAPTATIONSInitiation 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 EVENTSApprox 80 to 110 mL of fluid remains in the respiratory passages of a normal term fetus atthe time of birth.

Thoracic squeeze the process of labor is primarily responsible for the initial movement oflung fluid out of the lungs (Polin et al., 2004).

RESPIRATORY ADAPTATIONSNewborns may have problems clearing the fluid in the lungs and beginning respiration fora variety of reasons: The lymphatic system may be underdeveloped, thus decreasing the rate at which the fluidis absorbed from the lungs. Complications that occur before or during labor and birth can interfere with adequate lungexpansion, causing failure to decrease pulmonary vascular resistance, resulting indecreased pulmonary blood flow.

RESPIRATORY ADAPTATIONS

CHEMICAL STIMULIThe first breath is the natural result of normal vaginal birth with cessation of placental gasexchange when the cord is clamped.

THERMAL STIMULIExcessive cooling may result in profound respiratory depression and evidence of cold stress.

SENSORY STIMULIA number of physical and sensory influences help respiration begin. They include thenumerous tactile, auditory, and visual stimuli of birth.

RESPIRATORY ADAPTATIONSFactors Opposing the First Breath

(1) alveolar surface tension;(2) viscosity of lung fluid within the respiratory tract(3) lung compliance.

RESPIRATORY ADAPTATIONSObligate nose breather.Respiratory rates of 60 to 70 bpmWatch-out for dyspnea, cyanosis, or nasal flaring and expiratory grunting occur or anyincreased use of the intercostal muscle

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CARDIOVASCULAR ADAPTATIONSFive major areas of change in cardiopulmonary adaptation are:1. Increased aortic pressure and decreased venous pressure.2. Increased systemic pressure and decreased pulmonary artery pressure.

3. Closure of the foramen ovale.4. Closure of the ductusarteriosus.5. Closure of the ductusvenosus.

HEART RATEThe 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 extremitiesCapillary refill should be less than 2 to 3 secs

BLOOD PRESSUREThe 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 meanblood pressure is 5 to 55 mm Hg (Thureen et al., 2005)

HEMATOPOIETIC ADAPTATIONSAfter 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 levelsplacental transfusion,low oral fluid intake, anddiminished extracellular fluid volume

HEMATOPOIETIC ADAPTATIONSphysiologic anemia of infancy.Neonatal RBCs have a lifespan of 80 to 100 daysLeukocytosis is a normal finding because the stress of birth stimulates increased productionBlood 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 REGULATIONNewborn requires higher environmental temperatures to maintain a neutral thermalenvironment.

Temperature regulation is the maintenance of thermal balance by losing heat to theenvironment 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 fatBlood vessels of the newborn are closer to the skin

The flexed posture of the term infant decreases the surface area exposedSize and age affect the establishment of an NTE

Heat LossTwo major routes of heat loss:

1. from the internal core of the body to the body surface and2.from the external body surface to the environment.

The transfer is accomplished through anincrease in oxygen consumption,

depletion of glycogen stores, andmetabolizing of brown fat.Heat loss from the body surface to the environment takes place by four avenuesConvectionRadiationEvaporationConduction

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Heat Production (Thermogenesis)increased basal metabolic rate,muscular activity, andchemicalthermogenesis (also called nonshiveringthermogenesis [NST]) (Polin et al., 2004).

HEPATIC ADAPTATION

Iron Storage and Red Blood Cell ProductionTotal body Hgb content and length of gestation last until 5 months of age.Carbohydrate MetabolismAt 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 BilirubinTotal serum biliconjugated (direct) and unconjugated (indirect) bilirubin.

Unconjugated (indirect) bilirubinnot 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 metabolicand enzymatic activitydecreases the liver's ability to conjugate bilirubinincreases susceptibility to jaundice.

Physiologic JaundiceMaisels (2005) describes six factorsseveral of which can also be related to pathologiceventswhose 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 bilirubin4. Defect in bilirubin excretion5. 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 aboutthe 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 betweendays 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 stressresults in acidosis.Monitor stool for amount and characteristics.Encourage early feedings to promote intestinal elimination and bacterial colonization and toprovide 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, whenphysiologic jaundice is waning.

The level peaks at 5 to 10 mg/dL at 2 to 3 weeks of age and declines over the first severalmonths of life (Maisels, 2005).

The absence of normal intestinal flora needed to synthesize vitamin K in the newborn gutresults in low levels of vitamin K and creates a transient blood coagulation alteration

GASTROINTESTINAL ADAPTATIONSThe full-term newborn has adequate intestinal and pancreatic enzymes to digest mostsimple carbohydrates, fat, and proteins.

Lactose is the primary carbohydrate in the breastfeeding newborn and is generally easilydigested 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 the5% to 10% weight loss.

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Term newborns normally pass meconium within 8 to 24 hours of lifeand almost alwayswithin 48 hours.

MeconiumTransitionalStool of breastfeeding

URINARY ADAPTATIONSKidney Development and FunctionCertain physiologic features of the newborn's kidneys

1. The term newborn's kidneys have a full complement of functioning nephrons by 34 to 36weeks of gestation.2. The glomerular filtration rate of the newborn's kidneys is low3. The juxtamedullary portion of the nephron has limited capacity to reabsorb HCO3 and Hand concentrate urine.

The ability to concentrate urine fully is attained by 3 months of ageConcentrating and dilutional limitations of renal function are important considerations inmonitoring fluid therapy to avoid dehydration and overhydration.

IMMUNOLOGIC ADAPTATIONSThree major types of immunoglobulinsIgG,IgA, andIgM.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 ADAPTATIONSElevated levels of IgM at birth may indicate placental leaks or, more commonly, fetalantigenic stimulation in utero. Syphilis

TORCH syndrome (toxoplasmosis, rubella, cytomegalovirus, or herpes virus hominis type 2infection).

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 CareThe 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 assessmentDone in the birthing area immediately after birth to determine the need for resuscitation orother interventionsDone by the nursery nurse as part of the routine admission procedure.

estimate gestational age andevaluate the newborn's adaptation to extrauterine lifeDone before discharge behavioral assessment and a complete physical examination todetect any emerging or potential problems.

Nursing Assessment and DiagnosisReviews of prenatal record and risk factors assessment for the infant and review of deliveryinfectious disease screening results, drug or alcohol use by the mother, gestationaldiabetes, prolonged rupture of membranes,

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instrument or vacuum delivery, use of narcotic analgesia,presence of meconium

Nursing DiagnosisNursing 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, andconvective heat lossesAltered Peripheral Tissue Perfusion related to ineffective thermoregulationAcute 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 traumaAPGAR 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 withcloth.

Perform complete physical and neurologic exam when temperature stabilizes.Administer medications as ordered.

0.5% erythromycin or 1% tetracycline into conjunctival sac to preventophthalmianeonatorum.

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 Kdeficiency 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 1mg given in the birthing area or within 1 hour of birth (Wilson et al., 2007.used as prophylactic treatment of ophthalmianeonatorum and ophthalmic chlamydialinfections.Ophthalmic ointment (0.5%) is instilled as a narrow ribbon or strand, 0.5 to 1 cm long, alongthe lower conjunctival surface of each eye

Psychological InterventionsProperly identify mother and infant with matching bands.

Allow parents to hold infant, or place in warmed area in Trendelenburgs position tofacilitate 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 ScreeningRA 9288Perform screening tests before discharge.

Phenylketonuria (PKU)GalactosemiaCongenital HypothyroidismHomocystinuria

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Sickle cell anemia.

REVIEW QUESTIONS

Contains FSH to stimulate the ovaries to perform oogenesis or gametogenesis?

a. MOM c. Syntocinonb. Clomid d. Methergin

2. This is given to contract uterus and remove retained secundines to prevent bleeding andinfection?a. Yutopar c. Prednisoneb. Methylergonovine maleate d. Tamoxifen

3. One of this medication counteracts oxytocin to stop preterm labor?a. Pitocin c. Metherginb. Syntocinon d. Terbutaline

4. Anti-estrogen helps suppress growth of breast tumor that is supported by estrogen?

a. Teslac c. Nolvadexb. Halostiten d. Methergix

5. Helps relieve severe labor pain, best given at 6-7 cm cervical dilatation or at active phaseof the 1st stage of labor?a. Allopurinol c. Dolfenalb. Demerol d. Indomethacin

6. Sims Hunher test is ordered after a normal semen analysis. Which two of the followingresults are normal?I. 15-20 live motile sperm per hpfII. Mucus stretches 8-10 cms per hpfIII. Less than 15 live motile sperm per hpf

IV. Mucus stretches 5-7 cmsa. II and IIIb. I and IIc. I and IVd. II and IV

7. What method of delivery is based on the theory of stimulus-response conditioning toreduce pain sensation during labor?a. Lamaze c. Leboyerb. 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 ceasesc. Neonate is placed immediately on the mothers abdomend. 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 ofthe following is not a sign overdose?a. Absence of deep tendon reflexesb. Respiration rate slower than 12 per minutec. Urinary output less than 30 cc per hourd. Decrease BP

10. Ritodrine hydrochloride has been infusing IV for several hours to stop Janes pretermlabor. Since there are no contraindications for inhibiting labor and Jane is 30 weeksgestation, what other standard tocolytic therapy might the nurse use in place of ritodrine?a. Indomethacinb. Demerol and Vistaril IMc. 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. Hercervical cultures for the last 2 months were negative. She delivers vaginally. The day afterdelivery, Pat has lesion on her labia majora. What medication can the nurse use to helpalleviate the pain.

a. Acyclovirb. T-stat (erythromycin lotion)c. Hydrocortisone creamd. Ampicillin

12. During labor a client who has been receiving epidural anesthesia has a sudden episodeof severe nausea and her skin becomes pale and clammy. The nurses immediate reactionis to:a. Notify the physicianb. Elevate the clients legsc. Check for vaginal bleedingd. 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 hercontractions. The most important aspect of nursing at this time is to:a. Monitor the FHRb. Check the perineum for bulgingc. Time and record length of contractionsd. 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 anesthesiab. Act as preliminary anestheticsc. Induce sleep until the time of deliveryd. Increase the clients pain threshold, resulting in relaxation

15. Overstretching of perineal supporting tissues as a result of childbirth can bring about arectocele. The most common symptom is:a. Crampy abdominal painb. A bearing down sensationc. Urinary stress incontinenced. Recurrent urinary tract infection

16. During pregnancy, the uterine musculature hypertrophies and is greatly stretched asthe fetus grows. This stretching:a. By itself inhibits uterine contraction until oxytocin stimulates the birth processb. Is prevented from stimulating uterine contraction by high levels of estrogen during latepregnancy

c. Inhibits uterine contraction along with combined inhibitory effects of estrogen andprogesteroned. Would ordinarily stimulate contraction but is prevented by high levels of progesteroneduring pregnancy

17. The nurse would suspect an ectopic pregnancy if the client complained of:a. An adherent painful ovarian massb. Sharp lower left abdominal pain radiating to the shoulderc. Leukorrhea and dysuria a few days after the first missed periodd. Sharp lower left or right abdominal pain radiating to the shoulder

18. When obtaining the nursing history from a client with diagnosis of ruptured tubalpregnancy, 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 pregnancyb. At the beginning of the last trimesterc. Midway through the second trimesterd. Immediately after implantation19. A client is on magnesium sulfate therapy for severe preeclampsia. The nurse must bealert 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 headachec. Epigastric paind. 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 clients care should include:

a. A suggestion to find a housekeeperb. An explanation as to why bed rest is necessaryc. A warning of the risks involved in non-complianced. 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 Coumadintherapy. The nurse knows the client understands teaching about Coumadin when shestates: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, Ill 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 listedbelow. Which of the following medications should the nurse question before administeringthe drug?a. Ascorbic acid (Vitamin C) c. Cimetidineb. Secobarbital (Seconal) d. Psyllium

23. Which nursing care measure is not appropriate for client with thrombophlebitis?a. Careful leg massages c. Elevating the legsb. Elastic stockings d. Leg exercises

24. Which of the following the postpartum mother with diagnosis of thrombophlebitis shouldavoid?a. Helping the client avoid straining at stoolb. Telling the client to avoid sudden movementsc. Assisting the client to dangle on the side of the bed 3 times a dayd. 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 actionis not indicated during heparin administration?a. Having vitamin K available if bleeding occursb. Observing for hematoma at IV puncture sitec. Suggesting that the client use a soft bristled toothbrushd. Using an IV control device for drug administration

26. A client has thrombophlebitis. Heparin SC q 8hrs is prescribed. Nursing interventionsrelated to the administration of heparin include:a. Monitoring the clients UO

b. Checking the clients INR before administrationc. Checking the client for ecchymosisd. Informing the client that NSAIDS may be taken for discomfort

27. The patient who has a deep vein thrombosis has been receiving heparin sodium. Whichof these findings will evidence the desired effect of heparin therapy?a. A reduction of pedal edemab. A rapid capillary refill after squeezing the big toec. An increase in blood sedimentation rated. An elevation of the prothrombin time

28. Which statement by the client with thrombophlebitis indicates a need for furtherinstructions?

a. I can cross my legs at the knee but not the ankleb. I need to elevate the foot of the bed during sleepc. I need to avoid prolonged sitting or standingd. 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 previais being admitted to the labor room except:

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a. Auscultating the FHT with a fetoscopeb. Performing Leopold maneuversc. Determined cervical dilatationd. 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 cant 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. Ill 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 stripb. Elevated BP 155/98c. 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 havewhich of the following drugs available to counteract the potential adverse effect?a. Oxytocin (Pitocin)b. Sodium bicarbonatec. Phenytoin sodium (Dilantin)d. Calcium gluconate

33. Which of the following position is best indicated in woman with diagnosis of PIH?a. Semi-fowlers, alternating sidesb. Left lateral positionc. Supine with head elevated on a small pillowd. Right lateral Sims

34. A woman with diagnosis of PIH tells the nurse that she has severe headache and asksfor medication to relieve it. The nurse should:a. Notify the physician immediatelyb. Explain that headaches are common in PIHc. Offer some tea and toastd. Administer prescribed prn pain medications

35. Twenty-fours after delivery the woman with history of PIH has BP of 150/100mmhg. Thenurse should recognize that:a. PIH can continue for 48 hours after deliveryb. This may be precursor of chronic hypertensionc. Kidney damage has probably occurredd. 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 ishaving the desired effect?a. Reduction in patellar reflex response from +4 to +2b. Decreased in urine output from 100ml/hr to 50 ml/hrc. Increase in frequency of contractions from every 5 minutes to every 3 minutesd. 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 leftlower quadrant pain. She tells the nurse that she performed a home pregnancy test andbelieves that she is 8 weeks pregnant. On the admission the patients v/s are: pulse 90, BP110/70, respirations 20. a half hour later her v/s are pulse 120, BP 85/50, respirations 26.

The nurse interprets the change in the patients v/s to mean that:a. The patients pain may have increased

b. The patient may be bleeding internallyc. The patient may be frightenedd. The patient may have an infection

38. A 23 year old woman comes to the clinic at 32 weeks gestation. A diagnosis of PIH ismade. The nurse performs teaching. Which of the following statements made by the patientindicates 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 thefollowing findings is indicative of this condition?

a. The woman has been getting short of breath when climbing the second flight of stairs inthe familys apartmentb. The woman has a craving for salty foods latelyc. The woman has a BP of 124/80mmhg, compared with 90/60mmhg a month agod. 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 thehospital because her condition has not improved. She is placed on bed rest and started onmagnesium sulfate therapy. Which of the following assessment is essential for the nurse tomake?a. Obtaining the womans weight dailyb. Assessing the womans abdominal circumference dailyc. Observing the woman for jaundiced. Checking the equality of the womans femoral pulse

41. A patient with history of abruptio placenta bleeds continuously after delivery. Adiagnosis 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 curettagec. Add 10U of oxytocin (Pitocin) to the IV infusiond. Ask the client to sign consent for a hysterectomy

42. While in the recovery room a patient with history of abruptio placenta begins tohemorrhage after delivery. Which is the most likely cause of hemorrhage?a. Her uterus was not massaged adequatelyb. She developed hypofibrinogenemia, a coagulation defectc. Her rigid abdomen resulted in atony of the uterine musclesd. Placental fragments remained in her uterus

43. A 34 yearl old G4P2 is admitted in active labor. She complains of severe pain that doesnot subside between contractions and her abdomen has become rigid. A diagnosis ofabruption placenta is made. The priority nursing actions for the patient is/are to prepare fora blood transfusion and:a. Observe for changes in her v/s and skin colorb. Obtain a clean catch urine specimen for culture and sensitivityc. Prepare a solution of calcium gluconate for IV infusiond. Maintain her in supine position

44. A woman who is hospitalized because of abruptio placenta would be carefully monitoredfor which of the following complications?

a. Toxic shock syndromeb. Pulmonary embolismc. Cerebrovascular accidentd. Disseminated intravascular coagulation

45. In which type of high risk pregnancy would abruptio placenta most likely occur?a. Cardiac disease c. Drug addictionb. Chronic hypertension d. Hyperthyroidism

46. The fetal monitoring strip shows an FHR deceleration occurring midway duringcontraction; the FHR return to baseline midway between contractions. With this type ofdeceleration; the nurses first action should be to:a. Place the woman in trendelenburg or knee-chest position

b. Call the physicianc. Position the woman in labor on the left sided. Stop infusion of oxytocin47. 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 shestops pushing. This sudden change is probably the result of:a. Maternal positionb. Decreased utero-placental perfusion

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c. Fetal distressd. Umbilical cord compression

48. The fetal monitor strips shows an FHR deceleration occurring during the increment of acontraction, reaching its lowest point at the acme of the contraction, and returning tobaseline during the decrement of the contraction. This type of deceleration indicates:

a. Fetal distressb. Uteroplacental perfusionc. Fetal vagal nerve stimulationd. Umbilical cord compression

49. The fetal monitor strips shows an FHR deceleration occurring during the increment ofcontraction, reaching its lowest point at the acme of the contraction, and returning tobaseline during the decrement of the contraction. This type of deceleration indicates:a. Maternal hypoxia c. Fetal movementb. Fetal lung maturity d. Fetal well-being

50. The electric monitor tracing shows the FHR is not smooth and straight betweencontractions. This indicates that:a. The monitor cannot record the FHR accuratelyb. The fetus is jumpy between contractionsc. The healthy FHR has beat to beat variability and should be not smoothd. Application of internal monitor is necessary

51. Which of the following FHR patterns would indicate to the nurse that the fetus may beexperiencing distress?a. A baseline rate of 140-150 between contractions with moderate variability.b. Consistent heart rate accelerations that coincide with the fetal movementsc. A heart rate that slows midway during contraction and returns to baseline 30 secondsafter the contraction endsd. Gradual slowing of the heart rate that begins with the onset of the contraction and returnquickly to the baseline

52. An electronic fetal monitor is attached. The fetal monitoring strip shows an FHRdeceleration occurring about 30 seconds after each contraction begins and the FHR returnto baseline after the contraction is over. This type of deceleration is caused by:a. Fetal head compressionb. Umbilical cord compressionc. Uteroplacental insufficiencyd. Cardiac anomalies

53. Which one would clue the nurse to suspect pregnancy in a woman with history ofdiabetes mellitus since she was 10 years old and hospitalization for DKA?a. Nausea and vomiting c. Listless and fatigueb. Urinary frequency d. Breast sensitivity

54. A woman who is 20 weeks pregnant has history IDDM. The nurse understands that herinsulin dosage has been increased to her prepregnant dose and will probably be furtherincreased as her pregnancy progresses in order to:a. Utilize the increase caloric intake of the second half of pregnancyb. Limit the total pregnancy weight gain to 12.5 kg (27.5 lbs)c. Meet the increasing glucose demands of the rapidly growing fetusd. Counteract the effects of insulin antagonists produced by the placenta

55. When discussing diet with a newly diagnosed pregnant woman who is diabetic andtaking insulin, the nurse should:a. Emphasize the normalcy of pregnancy and the fact that her prescribed pregnancy dietwill be suitableb. Explain that pregnancy increases the need for protein and calcium but that will be the

only needed diet adjustmentc. Confirm that dietary and insulin needs may vary throughout the pregnancy thus requiringclose follow-upd. Instruct her to self-regulate her diet and insulin based on daily urine tests for glucose56. The woman is 6 weeks pregnant. She has history of IDDM. Her insulin dosage has beenlowered at this time because:a. Fetal insulin crosses the immature placent and enters maternal circulationb. Increasing fetal demands deplete maternal blood glucose levels

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c. Diabetic dietary needs decrease and less insulin is requiredd. 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. Amniographyb. 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 procedureb. Ingestion of 8 glasses of water 2 hours before the procedurec. An enema on the morning of the procedured. Emptying the bladder just before the procedure

59. The woman is admitted with diagnosis of placenta previa. She is taken to the deliveryroom for a double set-up examination. Nursing responsibilities include preparing the womanfor regional or inhalation anesthesia and:a. vaginal or rectal examinationb. vaginal delivery or ceasarian sectionc. ceasarian sectiond. hysterectomy

60. Which ultrasound finding helped confirm the diagnosis of H-mole?a. Multiple gestation of at least 4 fetusesb. No discernible fetal skeleton or soft partsc. Fetal anencephaly with hydrocephalusd. Large fetal meningomyelocele

61. After removal of H-mole by D&C, which of the following finding would indicate that itwould be safe to start another pregnancy?a. Albumin/globulin ratio of 2:1b. Negative HCGc. Blood urea nitrogen of 18 mg/dld. Negative-C reactive protein

62. Fifteen minutes after the administration of epidural anesthesia the nurse observesdecelerations of the FHR midway during contractions. The nurse should first:a. Notify the physicianb. Administer O2c. Record the findings q 5minsd. Assess the maternal BP

63. In the patients chart, the nurse notes doctors order of Ergonovine maleate (Ergotrate)0.4mg 4 x a day. The primary reason for the nurse to question the order of Ergonovinemaleate to the post partum with history of RHD is that Ergotrate:a. Can be administered either by oral or IM routeb. 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 dayd. Is usually contraindicated for cardiac clients

64. A teenager who is 4 months pregnant verbalizes that she has herpes genitalis. She asksif 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 protectedb. That is one of the few vaginal diseases that does no affect the baby before, during orafter deliveryc. If she has an active infection at term, a CS will probably protect her babyd. Her baby will be protected by vaccine that will be administered immediately afterdelivery

65. A woman with diagnosis of PIH is placed on bed rest. An IV of LR has been started. Thenurse has started an indwelling catheter to measure urine output because:a. Incontinence may occur if preeclampsia progresses to eclampsiab. Some urine may be lost when voiding on a bedpanc. 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 requirephysicians notification?a. Diuresis of 100ml/hrb. Maternal tachycardia of over 120 bpm

c. Nausea followed by projectile vomitingd. Fetal bradycardia of 110 bpm

67. Betamethasone (Celestone) a glucocorticoid is ordered to patient with premature laborbecause this medication:a. Acts as mild tranquilizer during pregnancy and will enhance uterine relaxationb. Promotes fetal lung maturity, which can prevent respiratory distress syndrome in apremature infantc. Is an anti-inflammatory agent and will decrease the irritability of her uterine musclesd. Elevates maternal blood glucose levels, which could lessen hypoglycemia in thepremature infant

68. Which of the following responses would a nurse expect to find in a reactive non-stresstest?a. Acceleration of the fetal heart rate with fetal movementb. Deceleration of the FHR without fetal movementc. No change in the FHR with fetal movementd. No change in FHR without fetal movement

69. Which of the following symptoms would be most significant when assessing a womanwho has PIH?a. Severe headacheb. Urine output of 200ml in the last 4 hoursc. Dependent edemad. Patellar reflex of +2

70. A woman who is at 34 weeks pregnant is experiencing a sudden painless bright redvaginal bleeding. A nurse observes a colleague taking all of the following measures with thewoman. Which one would the nurse question?a. Palpating uterine firmnessb. Performing Leopold maneuversc. Preparing a vaginal examd. 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 cordb. A woman with twin gestationc. A woman who has meconium-stained amniotic fluidd. A woman who has a non-reactive non-stress test

Mrs. Dantes, gravida 2 para 1 is admitted to the labor unit by ambulance anddeliver is imminent. She keeps bearing down and after two contractions thebabys head is crowning.

72. The nurse should:a. Tell her to breathe through her mouth and pant during contractionsb. Tell her to breathe through her mouth the not to bear downc. Transfer her immediately by stretcher to the delivery roomd. 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. Thenurses initial action should be:a. Ascertain the condition of the fundus

b. Establish airway for the babyc. Quickly tie and cut the umbilical codd. 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, anoxytocic drug, is administered IM. Since Mrs. Dantes has had a precipitous delivery, it isimportant to observe for:a. Bleedingb. Sudden chillingc. Elevation of RR

d. Respiratory insufficiency in the baby

75. If involution is progressing normally, few hours after birth the nurse should expect thefundus to be located:a. Three cm above the umbilicusb. At the level of the umbilicusc. 2 cm below the umbilicusd. 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 distressb. Call the physician immediately and await the ordersc. Turn Mrs. Roldan on her left side to increase venous returnd. Record this normal fetal response to contractions in the chart.

77. The patient begins to experience contractions 2-3 minutes apart that last about 45seconds. Between contractions, the nurse records a fetal heart rate of 100 bpm. The nurseshould:a. Closely monitor maternal vital signsb. Chart the rate as a normal response to contractionsc. Notify the physician immediatelyd. Continue to monitor the fetal heart rate

78. During delivery, episiotomy was performed. When caring for the patient during the postpartum period, the nurse encourages sitz bath TID for 15 mins. Sitz baths primarily aid thehealing process by:a. Softening the incision siteb. Promoting vasodilationc. Cleansing the perineal aread. Tightening the perineal sphincter

79. When preparing Mrs. Roldan to care for her episiotomy after discharge, the nurse shouldinclude, as a priority, instructions to:a. Continue the Sitz bath TID if it provides comfortb. Discontinue the sitz bath once she is at homec. continue perineal care after toileting until healing occursd. avoid stair climbing for at least a few days after discharge

Mrs. Walang, a 32 year old G3P2, spontaneously delivers a 4082g baby boy inroute 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 hipb. Intracranial hemorrhage d. Fractured clavicle

81. Perineal laceration is a common complication of precipitate delivery. In addition toregular perineal care, Mrs. Walangs nursing care should include:a. Encouraging early and frequent ambulationb. Encouraging perineal exercises to strengthen the musclesc. 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 intracranialbleeding. The nurse should expect the baby to display:a. Extreme lethargyb. Weak, timorous cryc. Abnormal respirationsd. Generalized purpura

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83. Nursing care of Baby Walang should include:a. Stimulating frequently to monitor level of consciousnessb. Elevating his head higher than his hipsc. 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 aswell. 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 wayc. Showing by example how to care for the infant and satisfy her own needsd. 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. Whiletaking the history, the nurse notes the following: gravida 8, para 7, 41 weeksAOG, membranes ruptures at 10:00 am that day, contractions occur every 3minutes; strong intensity with a duration of 60seconds.

85. What nursing action would take the highest priority at this time?a. Get blood and urine samplesb. Do perineal prep and give enemac. Attach monitor to the clientd. Determine extent of cervical dilation

86. Mercedes has just been given epidural anesthesia. What is the most importantassessment at this time?a. Maternal blood pressureb. Fetal heart ratec. Maternal level of consciousnessd. Fetal position

87. Mercedes had a normal spontaneous delivery. Why would she be considered at risk fordevelopment of postpartal hemorrhage?a. Grand multiparityb. Premature rupture of membranesc. Post term deliveryd. Anesthesia

Sylvia Mariano has just delivered a 10-lb girl.

88. In assessing Sylvia immediately after delivery, which of the following would the nursemost likely to find?a. Fundus located halfway between the symphysis pubis and umbilicus, lochia rubrab. Fundus displaced to the right and 3 cm above the umbilicus, lochia serosa

c. Fundus located at the umbilicus, lochia rubrad. 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 fromthe vagina. Her fundus is firm and in the midline. What is the most likely cause of thisbleeding?a. Lacerationsb. Subinvolutionc. Uterine atonyd. Retained placental fragment

90. Which of the following conditions predispose a client to postpartal hemorrhage?a. Twin pregnancy

b. Breech presentationc. Premature rupture of membranesd. Ceasarian section

91. After 24 hours, Sylvia has a temperature of 38 degrees Celsius, has voided 2,000mlsince delivery, and her skin is diaphoretic. Nursing actions should include which of thefollowing?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 feverc. Explain to Sylvia that these symptoms are very normal for a woman who has justdeliveredd. Suspect a postpartal infection and isolate the mother and the newborn

92. Sylvias sister warned her to suspect afterpains. The nurses teaching is based on the

knowledge that the most likely candidate for afterpains is the:a. Primipara who is bottle-feedingb. Grand multipara who is breast feeding twin boysc. Primipara who delivered prematurely and who is pumping her breastsd. Adolescent primipara who is breastfeeding

93. Sylvia is using bottlefeeding for her baby and asks when she should expect her firstmenses. The appropriate response would be:a. It usually takes at least 3 months before menstruation resumes after deliveryb. As you arent breastfeeding, it should occur in 4-6 weeks.c. Two weeks is the average time for menses to returnd. Ask your doctor. Im sure that after doing a pelvic exam, she can tell you.

Sheila, 32 weeks AOG, enters the emergency room complaining of prematurelabor.

94. Which of the following nursing actions is appropriate when caring for Sheila?a. Prepare for an oxytocin challenge test to determine fetal statusb. Prepare for application of an internal monitorc. Give frequent analgesia to relieve anxiety and promote comfortd. 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 cervixb. May stop the labor by decreasing uterine irritabilityc. Will promote and reduce anxietyd. Will reduce fetal activity

96. A tocolytic agent is administered to suppress her labor. Which of the following nursingactions would be most appropriate in preventing side effects from this type of drug?a. Side lying, anitembolic stockings, adequate hydrationb. Reduction in extraneous stimuli, frequent assessment of FHTc. Use of side rails, frequent monitoring of uterine contractionsd. Frequent monitoring of BP and pulse

97. Which of the following drugs is considered a tocolytic agent?a. Levallorphan c. Phenobarbitalb. 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 40weeks?a. Small amounts of lanugo and vernix, testes descended, palmar and plantar creasesb. Parchment-like skin, no lanugo, full areola in breastc. Upper pinna of ear well curbed with instant recoil, small amounts of lanugo, pink in colord. Dark red skin, testes undescended with few rugae, abundant lanugo

99. Which of the following is an important difference between a premature and a terminfant?a. Owing to size, a premature infant will have a more efficient metabolic rate for heatproductions and maintenanceb. In proportion to size, the premature infant will have more lanugo, and more vernix than afull-term infant

c. GI motility is decreased in preterm infant. Stools may be infrequent resulting inabdominal distentiond. Heat production is low in premature infant because of the greater boy surface related toweight and lack of subcutaneous fat

Situation: Susan delivered her first child, a boy, 24 hours ago. She had a normalvaginal 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 thefollowing?a. Separate the labia while cleansingb. Cleanse the perineum with soap and water after eliminationc. Pour sterile water over the perineum after eliminationd. Perform perineal care only if an episiotomy is performed

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