NUR113 final

What do you assess for during contractions?

Frequency, duration, intensity

s/s of toxoplasmosis

body aches, swollen lymph nodes, headache, fever, fatigue

s/s of trichinosis

frothy, greenish-yellow vaginal discharge

s/s of HPV

genital warts

what do you want to avoid when trying to therapeutically communicate with a client that experienced a loss

minimizing, comparisons, and giving advice

amniocentesis post procedure care

rhogam for Rh negative mothers, assess FHR, monitor for bleeding, educate pt to call HCP if she has any amniotic fluid loss/bleeding/fever/abdominal pain/fetal hyperactivity/fetal lethargy

The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the eye medication?

"I will flush the eyes after instilling the ointment."

how do you test for a ruptured membranes

*Nitrazine test for pH, sterile speculum exam*, evaluation of amniotic fluid

genetic/risk factors for cystic fibrosis

*both parents must have the gene*, diabetes, infection, malnutrition, infertility/fertility complications

what reflexes do you need to assess and what do they look like on a new born

*sucking/rooting (turns toward stimulus around mouth), grasp (finger/toes curl around fingers)*, Myerson/extrusion glabellar (infant blinks when you tap the bridge of their nose), tonic neck or fencing (infant will roll head to one side), *Moro (startle reflex), Babinski (toes flare open when Babinski test is preformed)*

What is the normal fetal heart rate range?

110-160

What teachings should the nurse tell parents about protecting the baby regarding it's respiratory status?

1Avoid loose bedding, waterbeds, and beanbag chairs Keep the infant away from secondhand smoke Prevent exposure to people with upper respiratory tract infections

expected findings of a new born

1st period of reactivity: HR 160-180, RR 60-80, fine crackles, audible grunting, nasal flaring, retractions, infant alert, BS audible period of decreased responsiveness: infant pink, resp rapid & shallow, unlabored 2nd period of reactivity: brief periods of tachypnea/tachycardia, increased muscle tone, meconium passed

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process?

A chronic disability characterized by impaired muscle movement and posture

The nurse is educating a pregnant client about her amniocentesis. What instruction should the nurse provide?

An informed consent needs to be signed before the procedure

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?

Back rather than on the stomach

The nurse should assess for which probable signs of pregnancy?

Ballottement Chadwick's sign Uterine enlargement

A client diagnosed with placenta previa. Which assessment findings should the nurse expect to see?

Bright red vaginal bleeding Fundal height may be greater than expected for gestational age

PID treatment

Ceftriaxone plus doxycycline or Cefoxitin with doxycycline

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially?

Contact the obstetrician (OB) and inform him or her of this finding

s/s of hepatitis

Flu-like symptoms, fever, chills, body aches

The nurse thoroughly dries the newborn right after delivery to prevent heat loss by what mechanism?

Evaporation

s/s of candidiasis

Extremely pruritic excoriations in labia, vulva, Labia and cervix may be red and swollen, tenderness present

What are the characteristics of uterine contractions?

Increment, Acme, Decrement

Which purposes of placental functioning should the nurse include in a prenatal class?

It gives an exchange of nutrients and waste products btw the mom and fetus

s/s of herpes

Lesions will be small , multiple crusted over vesicles. Some may be painful, NSAIDS may be used for comfort

education of hormonal contraceptives

Monitor for- for ACHES; Adverse effects: photosensitivity, migraines/headaches, dizziness, intolerance to contact lenses, gallbladder disease, break-through bleeding, vaginal candidiasis, weight changes, breast tenderness, changes in libido

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care?

Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches.

s/s of syphilis

Non-pruritic skin rash, often on hands and feet. May go unnoticed by the patient, transmitted via kissing and sex

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

Notify the obstetrician (OB). X

complications of gonorrhea

Pelvic Inflammatory Disease (PID): may cause fallopian tube obstructions, may pass from mother to baby during pregnancy

Which of these statements are helpful and provide accurate nursing advice concerning bathing a new baby?

Powders are not recommended because the infant can inhale powder. Sponge baths before umbilical cord falls off and is healed are ok

A nurse is assessing a full-term newborns elicits the Babinski reflex. How is this reflex elicited?

Stroking the outer sole of the foot from the heel to the little toe

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery?

Support the mother in her reaction to the newborn infant

The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent?

The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment?

Urine output of 20 mL in an hour Respirations of 10 breaths per minute

What are some maternal causes of labor?

Uterine muscle stretching Oxytocin Stimulation Pressure on cervix

Which assessment finding should the nurse expect to note if patient is diagnosed with abruptio placentae?

Uterine tenderness

FHR changes (veal, chop, mine)

Variable-cord compression-move client early-head compression- ID labor progress acceleration-other/okay- no action needed late-placental insufficiency- execute actions immediately

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list?

Wear a supportive bra. Rest during the acute phase. Maintain a fluid intake of at least 3000 mL/day. Continue to breast-feed if the breasts are not too sore.

Which instructions would the nurse provide regarding umbilical cord care?

You need to do cord care until the cord dries up and falls off The cord needs to be kept clean and dry

s/s of cerebral palsy

abnormally stiff muscles, involuntary movements, twisting postures, poor coordination, poor balance, diplegia, hemiplegia, monoplegia, quadriplegia, failure to meet developmental mile stones, delayed gross motor development, abnormal motor performance, alterations in muscle tone, abnormal postures, reflex abnormalities

third stage of labor assessment data

assess how the fetus is lie-ing, fetal attitude, fetal presentation, breach, station

The nurse notes that the fundus is firm, two fingerbreadths above the umbilicus, and deviated to right. The nurse should

assist the woman to empty her bladder

interventions/teaching for tubal ligation

avoid tub baths for 48 hrs, avoid driving, lifting, and strenuous activity for a week

Preventative care measures for conjunctivitis

clean unused contact lenses, no or unused makeup, *good hand hygiene*, sanitize and disinfect contaminated items, avoid sharing contaminated items, avoid touching eyes, avoid irritants

factors affecting conception

diet, smoking, use of contraceptive, drug use, exercise, genetic disorders, immunization status, exposure to x-rays, age,

how do you pull the ear of a child when administering ear drops ?

down and back

PID interventions

educate to avoid STIs, acute PID bed rest in semi fowlers, comfort measures, educate on complying with medication therapy,

s/s of a postpartum hemorrhage

excessive bleeding, boggy uterus, slow trickle, oozing blood , frank hemorrhage, shock, prolonged lochial discharge, dizziness, hypotension, tachycardia

In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:

excessive uterine bleeding

s/s of hypermesis gravidarum

extreme vomiting that causes weight loss, electrolyte imbalance, nutritional deficiency, ketonuria, dehydration, decreased B/P, increased pulse, unable to keep liquids down

amniocentesis purpose

fetal maturity, sex of fetus, genetic abnormalities, fetal status after Rh isoimmunization, hereditary metabolic disorder, amniotic abnormalities, amniotic infection, fetal distress, pre-mature rupture of membranes

purpose of a non-stress test

fetal well being, fetal viability,

treatment for post partum hemorrhage

firm fundal massage, uterotonic meds, possible blood transfusion and crystalloid, uterine tamponade, bilateral uterine artery ligation, uterine compression suturing, hysterectomy, monitor for hypovolemic shock

intervention for menopause

hormone replacement therapies, refrain from caffeine/alcohol/spicy food/concentrated sugars, kegal exercises, water soluble lubricate, dress in layers, kee something to help keep you cool near by (water, fan, change of cloths), empty bladder frequently, weight bearing exercises 2-3x wk, aerobic exercise 4-5x wk,

s/s of menopause

hot flashes/night sweats, insomnia, weight gain/bloating, emotional lability, irregular menses, headaches, vaginal dryness, disappearance of rugae, smooth vaginal walls, relaxation of pelvic floor muscles, decreased bone mineral density, loss of bone mass

assessment for a precipitous delivery

hypertonic contractions, birth occurs 3 hours or less from time of contractions to time of birth

post procedure care for non stress test

if fetus is nonreactive provide client with education about Contraction stress test

complications of syphilis

infection, may affect neurological, cardiovascular, musculoskeletal, multiorgan complications

pre procedure care for non-stress test

let client eat before test, encourage pt to empty bladder

complications of hepatitis

liver damage, increased risk of spontaneous abortion,

complications of HPV

long latency period, if excessive growth C-section will be preformed

complications of herpes

may adversely affect fetus, cervical dysplasia, C-section recommended

procedure for a non stress test

measure FHR for 20 minutes and fetal movement for 20 minutes, if fetus is quiet for 20 minutes stimulate fetus to move and record fetal movement for 20 minutes

teaching/interventions for ADHD

methylphenidate or atomoxetine, behavior modification, psychological therapy, safety due to increased risk for injury, high protein low simple carbs high complex carbs omega-3 supplements, monitor medication compliance

preventative care measures for otitis media

no bottle propping, up right position when feeding, breast feed for at least 6 months, hand washing, discontinue pacifier use after 6 months

interventions/teaching for vasectomy

no driving immediately after procedure, rest with min activity for 48 hrs, avoid strenuous activity for one week, ice pack as needed, sterility no achieved until 4-6 wks

SIDS prevention

no soft bedding, no toys in crib, no co sleeping, firm bed, one more layer than what an adult needs, pacifier use for first 6 months, breast feeding, African Americans/Hispanics/native Americans more at risk

what do you need to educate a post partum client

nutrition, s/s of excessive bleeding, pain not relieved by medicine, 6 wk before intercourse, care of incision, kegel exercises, maternal follow up, s/s of PPD, SIDS

amniocentesis pre procedure care

obtain informed consent, empty bladder, if after 20 wks, evaluate mother b/p, and fetal HR before procedure

PID assessment

pelvic or abdominal pain, vaginal discharge, fever, chills, irregular bleeding and urinary tract infections

s/s of pregnancy

positive pregnancy test (hCG in urine), breast changes, amenorrhea, nausea vomiting, urinary frequency, fatigue, quickening, goodell sgin, chadwick sign, hegar sign, ballottement, visualization of fetus

s/s of pregnancy induced hypertentsion

proteinuria after 20th wk, headaches, hyperreflexia, positive clonus, seizures

how do you administer medication to the eye

pull conjunctival sac down and administer from inner campus to outer campus.

interventions for hypovolemic shock

reassess, establish 2 large bore IV access, improve or monitor tissue perfusion, fluid resuscitation, O2 administration

s/s of hypovolemic shock

seeing stars, dizziness, nausea, restlessness, confusion, headache, reacts slow to stimuli, oliguria, tired, decreased O2, Increased HR, decreased B/p, thirst, cool clammy skin, diaresis, shallow resp, cyanosis, anxiety, decreased skin turgor

complications of chlamydia

serious, permanent damage to a woman's reproductive system (especially fallopian tubes and uterus), making it difficult or impossible for her to become pregnant later in life. Ectopic pregnancy is more likely

s/s of bacterial vaginosis

strong, malodorous "fishy" smell, Vaginal discharge may be white, thin, copious

interventions for hospitalized children

talk to them at their level, when speaking get on their eye level, do not use medical terminology, use word appropriate for age, offer therapeutic play

amniocentesis procedure

under direct ultrasonic visualization a needle is inserted to retrieve a sample of amniotic fluid

how do you pull the ear of a adult when administering ear drops?

up and back

how do you assess fetal heart rate

use of a doppler, listening to the chest of the fetus through the mothers stomach for a full minute

causes of post partum hemorrhage

uterine atony, retained placenta, lacerations of genital tract, hematomas, inversion of the uterus, subinvolution of the uterus

s/s of gonorrhea

women: purulent vaginal discharge, dysuria, frequency and menstrual change men: asymptomatic for a time but will most likely will present with purulent urethral discharge with dysuria

s/s of chlamydia

women: urethritis, cervicitis and Pelvic Inflammatory Disease PID Men: dysuria, urethritis, epididymitis or proctitis

how do you test for jaundice in a new born

yellow skin color observed, press on a bony prominence lift your finger skill will appear yellow, yellow conjunctiva, blood test for bilirubin levels