N344 Review for ATI &

Final

When does the embryos

heart start to beat?
When can we hear the heart
beat with a doppler?
4 weeks after fertilization (6
weeks LMP)
9-12 weeks from LMP.
2

When is the developing

embryo most susceptible to
teratogens?
3-8 weeks after fertilization.

M.L.s Last Normal

Menstrual Period (LNMP)
was Feb 12-16, 2016.
Calculate her EDD?
November 19, 2016

DQ is 8 weeks pregnant. Her OB

history is:
--SVD of twins at 34 weeks
--1 induced abortion
--1 ectopic pregnancy
--2 living children
What is her G/TPAL?

4/0122
5

What hormone does a

pregnancy test detect?

Human chorionic
gonadotropin = hCG

Name the functions of the

placenta.
1. Transports nutrients and oxygen to
fetus.
2. Stores carbohydrates, proteins,
calcium & iron for fetal use.
3. Removes fetal waste.
4. Produces hormones: estrogen,
progesterone, hPL, hCG
7

Name the functions of

amniotic fluid.
1. Maintains fetal temperature.
2. Cushions fetus & cord from trauma.
3. Prevents amniotic bands, congenital
amputations and other deformities.
4. Fetal hydration when fetus swallows
fluid.
5. Eliminates waste when fetus urinates.
6. Allows movement for musculoskeletal
development.
8

Name the 3 shunts in fetal

circulation. What do they
bypass/connect)?
1. Foramen ovale connects Rt atrium to
Lt atrium, bypassing lungs
2. Ductus arteriosus connects pulmonary
artery to aorta, bypassing lungs.
3. Ductus venosus: connects umbilical
vein (coming from placenta) to inferior
vena cava.
9

Where should the fundus

be at:
a) 12 weeks gestation
b) 20 weeks gestation
c) 30 weeks gestation
a) At the pubic symphysis.
b) At the umbilicus.
c) 30 cm (28-32) from symphysis to
fundus.

10

How much weight should

a woman with a normal
BMI gain in a healthy,
singleton pregnancy?
25-35 pounds

11

1. Who needs RhoGam

during pregnancy and
when?
2. Who needs RhoGam
after
pregnancy
1. Rh negative
mother: atand
28 weeks
gestation, and if she has vaginal
when?
bleeding/spotting including
miscarriage, induced abortion, or other
pregnancy loss.
2. Rh negative mother with an Rh
positive baby. Within 72 hours of birth.
12

Name 4 self-care
measures for nausea and
vomiting in early
pregnancy.
1.
2.
3.
4.
5.
6.
7.
8.

Small frequent meals.

Eat something bland before rising.
Drink in between meals.
Avoid strong smells.
Avoid spicy or acidic foods.
Sea bands.
Ginger.
Acupuncture.
13

Name 3 medications for

vomiting in pregnancy.
1.
2.
3.
4.
5.

Zofran (ondansetron)
Pyridoxine (vit B6) + Doxylamine
(antihistamine)
Reglan (Metoclopramide)
Phenergan (promethazine)
Antihistamines: Benadryl
(diphenhydramine), Meclizine
14

When would you expect

quickening in a:
a) primip
b) multip
a) 20 weeks
b) 16-18 weeks

15

Describe 3 changes in the

maternal cardiovascular
system during pregnancy.
Blood

volume increases 40-50%.

Cardiac output increases 30-50%.
HR increases 10-15 bpm starting at 14-20
weeks gestation.
Respiratory rate increases 1-2 breaths/min.
WBCs increase near term (and
postpartum).
16

What is physiologic
anemia of pregnancy?
A normal decrease in hemoglobin
and hematocrit from the
hemodilution of pregnancy. (A
woman makes ~50% more blood
during pregnancy.)
Peaks at 28 weeks of pregnancy.
17

What is pica?
Eating non-food substances like dirt,
ice or laundry starch.
It may be dangerous if the substances
contain lead or other toxins.
It may fill the woman up so her diet
lacks nutritious foods.
18

List 3 foods that pregnant

women should avoid.
Alcohol.
Unpasteurized

dairy products (milk and

soft cheeses).
Fish with mercury: shark, swordfish, ahi
tuna. (Max. 6 oz per week of canned
tuna.)
Raw or undercooked meat, fish or eggs.
Caution with deli meatsreheat until
steaming.
19

What would you

recommend for heartburn
(reflux)?
Avoid

spicy or acidic foods

Eat small meals & drink in between
meals.
Sit up for 30 min. after eating.
Tilt up head of bed.
AntacidsRolaids, Tums, Maalox OK
H2 receptor blockersZantac
(ranitidine) or Pepcid (famotidine)
20

A 25-year-old woman plans to

get pregnant. Her brother has
cystic fibrosis. Which genetic
test would be recommended
for her?

Carrier testing.

21

If both the patient and her

partner test positive as cystic
fibrosis carriers, what is the
babys risk of having cystic
fibrosis (an autosomal
recessive disorder).

1 in 4.
(1 in 2 risk of being a carrier)
22

What prenatal test(s) could

they have to diagnose cystic
fibrosis in the fetus?

Chorionic villus sampling.

Amniocentesis.

23

What are the risks and benefits

of maternal serum Quad screen
versus an amniocentesis?
Quad screening: screening test (not diagnostic,
more false positives and false negatives).
Blood draw onlyno physical risks.
Amnio: diagnostic, very accurate, tests for a
wider range of chromosomal disorders. Risks:
SAB, infection, accidental damage to fetal
limbs, ROM.
24

When is the most

accurate time to have an
ultrasound for pregnancy
dating?
First trimester. The earliest
ultrasounds are most accurate for
dating. (Embryo can be seen on
ultrasound by 5-6 weeks.)

25

What instructions should

you give a woman
undergoing
amniocentesis?
1. Empty her bladder to prevent accidental
puncture.
2. She will feel pressure as needle goes in.
3. Keep breathing to avoid lowering the
diaphragm and shifting the uterus down.
4. Rest & drink for next 24 hours.
5. Call if: fever, chills, leaking or bleeding from
insertion site or from vagina, contractions, or
decreased fetal movement (for late amnio).
26

At 8 weeks gestation, a
woman develops light
vaginal bleeding. What are
the possible pregnancy
1. Threatened
SAB
related
causes?
2. Ectopic pregnancy
3. Molar pregnancy

27

How would you assess

vaginal bleeding at 8
weeks gestation?
1. Detailed history: pain vs.
cramping, location of pain, color,
amount bleeding, associated
symptoms, last intercourse?
2. Ultrasound
3. Serial quantitative hCG levels

28

Define:
a) Threatened SAB
b) Inevitable SAB
c) Incomplete SAB
a) Threatened: bleeding but cervix closed. May
go on to SAB or not. (Expectant
management.)
b) Inevitable: bleeding, cervix dilating, will
miscarry.
c) Incomplete: products of conception remain in
uterus, will continue to bleed until complete.
(May need D&C.)
29

Define:
a) Missed SAB
b) Septic SAB
c) Recurrent SAB

a) Missed: embryo nonviable (no FHR) but

no bleeding or cramping. (Expectant
management vs. D&C vs. misoprostol.)
b) Septic: SAB + infection.
c) Recurrent: 3 SABs in a row. (Needs
work-up to ID cause.)
30

What are risk factors for

ectopic pregnancy?
PID:

Pelvic Inflammatory Disease

Recurrent or prolonged chlamydia,
gonorrhea
Endometriosis
h/o ectopic pregnancy
h/o female infertility, tubal scarring or tubal
surgery
Copper wrapped IUD
31

What are classic signs &

symptoms of ectopic
pregnancy?
Pregnancy with:
Abdominal pain often unilateral
Vaginal bleeding

32

What occurs with hCG levels in:

a) Normal pregnancy
b) Ectopic pregnancy
c) SAB
d)
Molarevery
pregnancy
a) Double
48 hours in 1 trimester
st

b)
c)
d)

Plateau or rise slowly

Decrease
Are extremely high

33

What are classic signs &

symptoms of hydatidiform
mole?
Severe

N/V
Spotting or bleeding (usually brownish)
Uterus large for gestation
Very high hCG levels
No FHR

34

What serious complication is

gestational trophoblastic
Choriocarcinoma
disease
associated with, and
D&C to remove mole and all placental/
how
do
we
protect
against
it?
trophoblastic fragments.
If

woman has completed her childbearing, or

if excessive bleeding, hysterectomy may be
done.
Follow hCG levels x 1 year--plateau or
increase suggests malignant transformation.
Avoid pregnancy x 1 year (or hCG rise will
be obscured).
35

At her initial prenatal exam, TRs labs are:

H&H 12.5/37.4
A negative blood type
HBsAg negative
RPR NR
HIV NR
Toxoplasmosis antibody negative
ppd 12 mm

Rhogam.
What follow up will she need?
Teach: avoid changing kitty litter, cook
meat thoroughly.
Assess for s/s TB, CXR.
36

TRs 28 week labs show:

H&H 11.5/35.4
A negative blood type
1 hour GTT 148
What follow up will she need?

Rhogam.
3 hour GTT.

37

TRs 36 week labs show:

Chlamydia positive
Gonorrhea negative
GBS positive
What follow up will she need?

Treat for chlamydia (patient & partner),

with test of cure 3 weeks later. Urge
condoms!
IV PCN every 4 hours in labor, starting with
labor onset or SROM, whichever is first.
38

What is the difference between

gestational hypertension and
pre-eclampsia?
Gestational

HTN: elevated BP after 20

weeks without proteinuria or s/s endorgan damage
Preeclampsia: elevated BP +
proteinuria (+/- s/s end-organ
damage)

39

ND has a BP of 148/88 at 35
weeks gestation. What other
s/s will you assess for?
Proteinuria
Edema

(especially hand, face)

Headache
N/V
Epigastric or RUQ pain
Visual changes
40

ND is admitted for
preeclampsia and started on
magnesium sulfate. What s/s
of magnesium toxicity will you
RR <12
monitor her for?
Loss

of DTRs
Urine output <30 ml/hr
Decreased level of consciousness

41

NDs respiratory rate is 10

breaths per minute and her
DTRs are 0. What are your
nursing interventions?
1.
2.
3.
4.

Discontinue Magnesium.
Notify MD.
Prepare antidote: calcium gluconate (for
MD to administer).
Supportive care: monitor VS, administer
oxygen prn, continue to monitor s/s
toxicity.
42

What complication would you be

concerned about if NDs labs come
back:
H&H 9.8/28.0
Platelets 110,000
Elevated AST or ALT.
HELLP syndrome.

43

What are signs and symptoms of

maternal hypoglycemia?
Hunger
Irritability,

shakiness
Fatigue or weakness
Headache
Blurred vision
Tingling of mouth or extremities
44

A multigravida presents at 34
weeks with vaginal bleeding
and abdominal pain. Whats
the most likely cause?
Abruptio

placenta

45

A multigravida presents at 34
weeks with painless vaginal
bleeding. Whats the most likely
cause and what would your nursing
actions be?
Placenta previa.
Monitor for FHR & contractions.
Monitor bleeding.
Monitor maternal VS.
Notify Provider.
If bleeding heavy or fetal distress, administer
oxygen & IV fluids prn (as ordered).
Check ultrasound results in prenatal chart before
vaginal exam for cervical dilation.
46

A primigravida presents at 30
weeks c/o contractions. If she
is in preterm labor (5 cm/80%),
what medications would you
expect to be prescribed?
Tocolytic,

such as Terbutaline.
Corticosteroid to mature fetal
lungs.
PCN for GBS prophylaxis.
Possibly: magnesium sulfate to
decrease risk of CP.

47

A client presents in preterm

labor. Which test requires
delaying a cervical exam
until the test specimen has
been
obtained?
A) GBS
B)

Transvaginal ultrasound
C) Fetal fibronectin
D) Nitrazine testing
Fetal

fibronectin (fFN.)
48

A woman at 30 weeks
gestation calls c/o decreased
fetal movement. What testing
is most appropriate?
Nonstress

test (NST).
If nonreactive, she will need a
biophysical profile (BPP).

49

What is a reactive
nonstress test (NST)?
At

least 2 accelerations with fetal

movement in a 20 minutes period.
An acceleration = rise in FHR of
>15 beats above baseline for >15
seconds.
A reactive NST is a sign of fetal
wellbeing and is reassuring for 3-4
days.
50

What is the significance of a

4/10 biophysical profile
score?
Scores

below 6/10 indicate fetal

compromise.
4/10 would suggest the fetus
needs to be delivered. Induction
would be considered.

51

GG is a G3P1 being induced at 41 weeks

gestation. She is admitted with a Bishops
score of 3, and orders for cytotec
(misoprostol) pv.
What does the Bishops score mean?
Why is she getting cytotec? What is a risk of
cytotec?
Bishops score indicates whether the cervix is
ripei.e. ready for labor. A score below 6 in a
multip or below 8-9 in a primip indicates a need
for ripening first. Cytotec is a ripening agent.
Cytotec can cause tachysystole. In a scarred
uterus it can cause uterine rupture

52

After 12 hours of cervical ripening, GGs

cervix is 3/80/0. The midwife orders
pitocin. What potential risks of pitocin
will you monitor for?
Uterine

hyperstimulation:
tachysystole, tetanic contraction,
increased resting tone. (Rarely:
uterine rupture)
Fetal distress.

53

A woman arrives in triage stating, I

think my water broke. What will you
want to know right away?
What can cause a false positive pH
(nitrazine)
test? amount, color,
TACO: timing,

odor
Check FHR to r/o cord prolapse.
False positive nitrazine: blood,
semen, cervical mucus.
54

Many infections are associated

with preterm labor (PTL). If the
woman is not
immunocompromised and has
not ruptured her membranes,
A) Bacterial
which
of the vaginosis
following is not
B) Group Bwith
StrepPTL
associated
C)

Periodontal disease
D) Urinary tract infections

55

A multip at 5/90/0 requests pain

medication, but isnt sure what she
wants. What are the risks and
benefits of an epidural?
What are the risks and benefits of
Epidural: most effective pain relief, requires
opioids?
insertion through back, decreases maternal
mobility, SE may include: longer labor (especially
pushing), need for pitocin augmentation, maternal
fever, maternal hypotension leading to fetal
distress.
Opioids: takes the edge off but still feel
contractions, lasts 1-2 hours, SE may include:
dizziness, N/V, somnolence, newborn respiratory
distress if given within 1-2 hours of birth.
56

If she chooses Stadol, what

newborn med will you need to have
on hand?
Narcan (naloxone), in case the newborn has
respiratory depression from the Stadol.

57

What causes early

decelerations of the fetal heart
rate and how would you
respond?
Head compression.
Check

cervix to see if mother is

fully dilated and fetal head
descending.

58

What is this fetus position

and presentation?

LOP/Vertex or Occiput

59

What causes late decelerations

of the fetal heart rate and what
intervention do they require?
Placental

insufficiency

Reposition

mother to left lateral or hands &

knees.
Turn off pitocin.
Administer oxygen.
Take Blood pressure.
Administer IV bolus.
Notify clinician if no improvement with
interventions.

60

A multipara pushes for 2 hours

and then has a slow delivery of the
babys head. You then note the
turtle sign. What complication
should you prepare for?
Shoulder

dystocia

61

At 60 seconds after a delivery, a

newborn without meconium is
warmed, dried, suctioned and
positioned, but her HR is only 80.
What would the next step be?
Positive-pressure

ventilation.

62

On day 1 postpartum, a mother c/o

that last night she was sweating
and urinating frequently. How
should you respond?
This

is normal. The body is

getting rid of extra fluid from the
pregnancy.

63

A breastfeeding mother c/o her

breasts are tender, hard and very
full on day 3 postpartum. Her
temperature is 100.0. What is this
and what will you recommend?
Engorgement.
She

should breastfeed the baby

frequently, wear a supportive bra,
may apply warm compresses, take
Tylenol or Motrin.
It will improve in the next 1-2 days.
64

A bottlefeeding mother asks her

first day postpartum how often she
should feed her newborn and how
much. How much will the baby take
at 2 weeks?
Every 3-4 hours.
Up to -1 oz (10-30 ml).
4-5

oz (up to 150 ml)

65

Name 3 infant sleep safety

instructions.
Firm

mattress with nothing in crib

(no pillow, use sleeper pajamas, not
blanket).
New crib (older cribs may have slats
too far apart, elevated corner posts,
side rails that open out).
Sleep in same room as parents but
not in same bed.
Put baby to sleep on his or her back.
66

Describe umbilical cord

care.
Keep

cord dry (fold diaper below

it).
Some hospitals apply alcohol or
triple dye.
Monitor for s/s infection: redness
or edema around base.
Will fall off spontaneously ~day
5-10.
67

What are your first 2 nursing

interventions for a jittery baby at 2
hours of age?
Check

babys temperature.
Check babys blood glucose (with
a heel stick).

68

What is newborn metabolic

screening (PKU test)
How
it done?
is
Inborn
errors of metabolism (eg.
PKU)
Thyroid disorders.
Infectious & congenital illnesses
(SSA, HIV).
A heel stick after 24 hours of age.
Fill 4-5 circles on testing card.
Allow blood to dry completely.
Card sent to state lab.
69

What will you teach a pregnant

mother to prevent
toxoplasmosis infection?
Avoid

changing the kitty litter.

Cook all meat and fish
thoroughly.
Wash chopping surfaces well,
with bleach solution.

70

Your client in labor has hepatitis B

infection. How should the
pregnancy, labor, birth and
newborn care be adapted to
decrease the risk of transmission to
Universal precautions.
the baby?
Prenatal:

avoid amniocentesis, CVS.

L&D: avoid AROM, fetal scalp
electrode, foreceps, vacuum,
episiotomy.
Newborn: give HBIG as well as Hep
B vaccine.

71

List 4 contraindications for

combined OCPs.
Age

>35 + smoker
Migraines with aura
h/o DVT, PE or stroke
HTN
Breast cancer
Caution with some meds (antiseizures,
antibiotics, protease inhibitors)

72

List 3 side effects of DepoProvera

Weight

gain
Worsening depression
Bone density loss
Delay in return of fertility
Irregular Bleeding

73

What should you do the

night before the ATI?
a)Stay

up all night studying.

b)Stay NPO so you dont feel
nauseous during the test.
c)Take ativan to calm yourself down.
d)Review your homework worksheets
and remind yourself how much
youve learned this semester!
d
74

Good luck on the ATI!

75