A nurse notes late decelerations on the fetal monitor.

What priority actions should the

nurse take?
Suggested Maternal Newborn Learning Activity: Fetal Heart Monitoring and Interpretation
With late decels, this is a sign of hypoxia and fetal distress, due to the placental insufficiency/perfusion
during contractions. This is an urgent situation and the Pitocin should be turned off because it
stimulates contractions. Have patient to turn on left side and then apply up to 10 liters of oxygen, and
all the physician.
What are indications for amniotomy? Identify post-nursing interventions after this
procedure
An amniotomy is an artificial means of rupturing the membrane to induce labor by enhancing dilation
and effacement. Also, it is to access the amniotic fluid. An amniotomy is performed to hasten labor in
fetal distress or when gestation goes past 40 weeks.
The nurse will insure that there is no prolapse of the cord and that the fetus is at the proper station,
before the amniotomy is performed. Afterwards, the fetal heart rate must continue to be monitored
and be sure to assess for signs of infection by checking the color, odor and consistency of the amniotic
fluid. Lastly, the nurse should document the time of rupture and the temperature of the women should
be taken often, around Q2H.
A nurse is caring for a client in the postpartum phase. How should the nurse assess fundal
height following delivery? Suggested Maternal Newborn Learning Activity: Postpartum
Fundal Assessments
Assessing the fundal height is the U in the BUBBLEHEHE. The U is for uterine placement and
consistency. The nurse must check and assess for a boggy uterus and whether its midline. Normally,
the uterus or fundus should be midline and firm after delivery and should be at about the level of the
umbilicus.Q8H the fundus should be assessed. Every 24 hours the fundus should descend a littleabout 1 to 2 cm. and by the 10th day, the uterus should not be palpable.
To actually do the physical assessment with the patient, first explain the procedure to the patient, do
hand hygiene and then apply gloves, may need a perineal pad in case there is lochia flow upon
palpation.
Cup the hand above the symphysis pubis then take the other hand and feel for the uterus. The fundus
should be midline and firm, if not midline, have them to urinate or do a straight cath. If not firm, be
sure to massage in a circular motion and assess for the flow of lochia. Be sure to document fundal
height, whether its boggy, and if its deviated.
A nurse is caring for a newborn with fetal alcohol syndrome. What clinical findings should
the nurse anticipate?
Babies born with FAS have a distinctive look. The will be born with ptosis, poor sucking reflex, cleft lip
and palate, small teeth, strabismus, deaf, irregular hair, creases in their palms ill be irregular, heart
defects such as tetralogy of Fallot, problems sleeping, developmental and growth delays.
The nurse must still assess he infant. Look at the newborns behavior, reflexes, feeding ability,
fontanels, I & O, and do blood test, xrays to determine level of heart abnormalities, and will most
likely administer medications to control irritability and any seizure activity.

A nurse is providing information on injury prevention to the parents of a toddler. What

information should be discussed? Suggested Nursing Care of Children Learning Activity:
Developmental Stages & Transitions
Parents should be educated on the age appropriate activities of their children, to reduce the risk of
injury.
Parents should always ensure that their children have age appropriate toys, and wear proper
clothing that does not have lose buttons, and not to have small objects just lying around in reach of
small kids that may cause choking. Most parents do not think about certain candies becoming lodged
in the throat of toddlers, also, how they can swallow coins and become choked, and food such as
grapes and hotdogs causing choking. Grapes should be cut in half and hotdogs cut the length then cut
in pieces. Parents should know how to handle an emergency such as the heimlic maneuver or CPR for
their own children.
This is the time of year that is especially dangerous for kids at swimming pools. Parents
normally trust lifeguards to ensure the safety of their children. Children should not be left unattended
at the swimming pool. At home, a fence should be around the swimming pool just in case wondering
children happen upon it and drown. Also, bathroom doors should be left closed because children love
playing in the toilet and may fall over in it causing them to drown. Just in case someone forgets to
close the door, the lid to the toilet should be downboth of which should become habits in the home.
Firearms should be put away properly with the ammunition taken out of it and locked away. Knives
should be kept out of reach and sight of children. They should be taught stranger danger and not
unsupervised with animals.
In regards to the bathroom, toddlers should not be left in a tub of water, alone. also, the water
thermostat should be 120 degrees or lower to prohibit burns. Outlets should be covered. Pot handles
should be inward facing toward the back of the stove.
To prevent falls and other bodily harm from climbing and adventurous toddlers, doors and windows
should be locked, mattresses can be placed on the floor or in the lowest position with rails raised to
the highest position. Safety gates should be placed at the bottom and top of the stairs.
To prevent injury in a car accident, toddlers should be in a car seat until they reach 2y.o. and should
be rear facing until they reach a certain height. Children should always be in the back seat in cars with
airbags.
In regards to poisoning, each parent should know Poison Controls number. All cleaners should be out
of reach and locked away along with medications. Additionally, lead paint exposure should be avoided.
What should be kept in cribs is nothing. Children are known to suffocate from things that we do not
think about or think is okay such as blankets and pillows. Also, the crib slats should be less than 2.5
inches or 6cm apart. Also, do not allow toddlers to play with plastic.
A nurse is caring for a client who has recurrent urinary tract infections (UTIs). What are
risk factors for UTIs in children?
Children can get UTIs from stasis urine, anomalies of the urinary tract, constipation, inadequate
hygiene, potty training, and not wiping properly-from front to back.
A nurse is obtaining a rectal temperature. When should rectal temperatures be avoided?
(Review the Fundamentals Review Module) Suggested Nursing Care of Children Learning
Activity: Vital Signs in the Pediatric Population

Do not perform rectal temps when the infant has myelomeningocele due to irritation and possible
rectal prolapse. Also, avoid invasive rectal temps when the child is neutropenic, anemic, or
thrombocytopenic due to risk of bleeding and injury.
A nurse is caring for a 12-year-old anorexia nervosa. What are common laboratory and
diagnostic testing results commonly associated with anorexia nervosa? (Review the Mental
Health Review Module)
Anorexic clients should be tested for several things to include, electrolyte imbalances of potassiumabnormally low from purging; may cause abnormal EKG or abnormal beats of the heart.
May experience dehydration from aldosterone production which causes the body to retain sodium and
water but can cause the excretion of potassium.
Also the client should be checked for anemia and leukopenia, hypercholesteremia. ALT & AST should
be checked for liver impairment, check T3 for abnormal thyroid, DEXA scan for possible osteoporosis,
and blood sugar for elevation.

A nurse is providing education to the parents of an infant with gastroesophageal reflux

(GER). What information regarding feeding and positioning should the nurse include in this
education?
Suggested Nursing Care of Children Learning Activity: Gastrointestinal Disorders
GER is when gastric contents backup into the esophagus and over time this causes damage. This
ailment resolves around 1 year of age.
Have the child to sit up at least 30 degrees during and after eating to prevent symptoms of GER
the child should eat small meals and liquids thickened with rice cereal. Be sure the child is the
appropriate weight. No citrus fruit, mint, spicy food, greasy/fried foods, or caffeine.
If the diet regime is not followed, the child could end up with long term effects such as problems
swallowing, heartburn, and stomach pain.
A nurse is caring for a 1-year-old child with viral meningitis. Identify three (3)
manifestations the nurse should anticipate with viral meningitis.
Suggested Nursing Care of Children Learning Activity: Bacterial Meningitis
A toddler with viral meningitis has symptoms that are more pronounced to include: irritability, fever,
fontanels bulge, high pitched cry with seizure activity. They will vomit and will not eat and have nuchal
rigidity.
After performing a lumbar test, the spinal fluid will be clear but will have WBC elevations and proteins.
The CT scan will show increased intracranial pressure.

A nurse is caring for a child with moderate dehydration secondary to an acute

gastrointestinal infection. What manifestations should the nurse anticipate? Suggested

Nursing Care of Children Learning Activity: Gastrointestinal Disorders

A child with a gastric disorder will have a change in stool pattern which may cause diarrhea and
electrolyte losses, anorexia/weight loss, experience pain, malaise, tired, and have a change in
behavior.

Several tests will be performed to determine what the disorder is. A CBC is performed to determine
which infection along with a urinalysis and fecal occult blood test. A tape test is brought to the lab for
evaluation.
Fontanels are sunken or may appear normal
Dry mouth and mucus membranes and may be thirsty and irritable
Decreased skin turgor
Assess vitals for elevations in pulse and may have orthostatic blood pressure and have slight
tachypnea
Capillary refill may be sluggish at >3sec