4910 Exam 2
truncus arteriosus
1 big artery then branches, pulmonary artery and aorta are the same vessel
acetylcestine
Tylenol antidote
preschoolers
______ should start learning to check their own blood sugar
April 29, 2011
a client tells the nurse that the first day of her last menstrual period was July 22, 2010. What is the estimated date of birth? May 7, 2011 April 29, 2011 April 22, 2011 March 6, 2011
G5 T2 P1 A1 L4
a pregnant client is making her first antepartum visit. She has a 2-year-old son born at 40 week, a 5-year-old daughter born at 38 weeks and 7-year-old twin daughters born at 35 weeks. she had a spontaneous abortion 3 years ago at 10 weeks. using the GTPAL format, what does the nurse document about the client's obstetric history?
if my baby does not move I need to call my health care provider
a primigravid client at 16 weeks gestation has had an amniocentesis and has received teaching concerning signs and symptoms to report. Which statement indicates that the client needs further teaching? 1. I need to call if I start to leak fluid from my vagina 2. if I start bleeding, I will need to call back 3. if my baby does not move, I need to call my health care provider 4. if I start running a fever I should let the office know
hydrocele
abdominal fluid accumulates in scrotal sac may resolve on own with support if surgery - no tub baths, support scrotum, no straddle toys
transposition of great vessels
aorta and pulmonary artery are attached to wrong side of heart 2 closed loops MUST keep ductus open
TE fistula
connection between trachea and esophagus whatever you swallow ends up down esophagus
testicular torsion
emergency, only 6 hours of viability from onset of pain. must go to surgery to fix
croup
flu is the most common cause
blood pressure
four days after a vaginal delivery, the client visits the clinic stating she has excessive lochia rubra with clots. the physician prescribes methergine 0.2mg intramuscularly. before administering this drug the nurse should assess 1. blood pressure 2. pulse rate 3. breath sounds 4. bowel sounds
acute glomerulonephritis
hematuria, high blood pressure, dependent edema treated with ACE inhibitors and diuretics
ulcerative colitis
high calorie diet lactose free low fat low fiber low salt gluten free
celiac disease
no gluten (rye, cereals, grains, pasta, wheat, barley) can have meat and poultry, fish and seafood, vegetables and fruits, rice and potatoes, dairy, nuts, beans, and legumes
epiglottitis
not seen much anymore, medical emergency will close off airway completely all the time nothing in mouth at all
1:1 ex. pedialyte
oral rehydration solution ratio of sugar to salt
increased pulmonary blood flow
patent ductus arteriosus atrial septal defect ventricular septal defect atrioventricular canal
Brady-dysrhythmias
sudden hypoxia leads to_______ (first line treatment is oxygen)
hirschprung (megacolon)
treat constipation under surgical resection diet, bowel schedule, lots of stool softeners NOT an emergency
hypertrophic pyloric stenosis
watch for dehydration, hypoglycemia, failure to thrive (unable to absorb nutrients) start IV fluids and get to surgery
later school age
________ should be administering their own insulin
active genital herpes
a client in labor at 39 weeks gestation is told by the health care provider that she will need a cesarean birth. The nurse reviews the clients prenatal history. what preexisting condition is the most likely reason for cesarean birth? 1. gonorrhea 2. chlamydia 3. chronic hepatitis 4. active genital herpes
blue
a multigravid client at 34 weeks gestation visits the hospital because she suspects that her water has broken. after testing the leaking fluid with netrazine paper, the nurse confirms that the clients membranes have ruptured when the paper turns which of the following colors? 1. yellow 2. green 3. blue 4. red
PKU
autosomal recessive inborn error of metabolism missing enzyme to convert phenylalanine into tyrosine build up causes neurologic deficits
aspirin overdose
correct acidosis, electrolyte imbalance, give vitamin K if bleeding (platelets will be very slippery)
fever
increases metabolic rate, oxygen demand and insensible fluid loss
school age
tell about procedures/surgeries 1-2 days before
preschooler
tell about procedures/surgeries 1-2 hours before
adolescents
tell about procedures/surgeries 1-2 weeks before
toddler
tell about procedures/surgeries immediately before
large percentage of body is water kidneys dont concentrate urine effectively to conserve fluids and electrolytes
why child get dehydrated so quickly
4, 1, 5, 3, 2
A client has several tests during pregnancy. Place the tests in the order they should be performed during pregnancy 1. fetal movement test 2. sickle cell screening 3. group B streptococcus culture 4. serum glucose for gestational diabetes 5. alpha fetoprotein testing for neural tube defects
high protein, grains and diet sodas
PKU patients should avoid _________
development of rh-positive antibodies
Rho (D) immune globulin is prescribed for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which of the following? 1. development of a future rh-positive fetus 2. an antibody response to rh-negative blood 3. a future pregnancy resulting in abortion 4. development of rh-positive antibodies
respiratory rate every hour
a 16-year-old primigravida client admitted at 38 weeks gestation with severe preeclampsia given intravenous magnesium sulfate and lactated ringers solution. the nurse should obtain which of the following information? 1. urinary output every 8 hours 2. deep tendon reflected every 4 hours 3. respiratory rate every hour 4. blood pressure every 6 hours
the cord lengthens outside the vagina
a 24-year-old primigravida client who delivers a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered? 1. the cord lengthens outside the vagina 2. there is decreased vaginal bleeding 3. the uterus cannot be palpated 4. uterus changes to discoid shape
probable
a 30 year old multigravida client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. she is experiencing enlargement of her abdomen, a positive pregnancy test, and changes in the pigmentation on her face and abdomen. these assessment findings reflect this woman is experiencing a cluster of which signs of pregnancy? 1. positive 2. probable 3. presumptive 4. diagnostic
the neonate will be delivered with mature lungs
a client at 33 weeks gestation is admitted in preterm labor. she is given betamethasone 12mg IM every 24 hours x 2. what is the expected outcome of this drug therapy? 1. the contractions will end within 24 hours 2. the client will deliver a neonate without infection 3. the client will deliver a full term neonate 4. the neonate will be delivered with mature lungs
apply an electronic fetal monitor
a client at 37 weeks gestation is admitted to the birthing unit from the emergency department. she had arrived by ambulance following a motor vehicle accident. her vital signs are 90/60, 108, 24. she is reporting sharp abdominal pain. what is the priority nursing intervention at this time? 1. apply an electronic fetal monitor 2. prepare for a possible cesarean birth 3. draw blood for a type and crossmatch 4. assess the amount of vaginal bleeding
complete a vaginal examination to determine dilation, effacement, and station
a multigravid client is admitted at 4cm dilation and requesting pain medication. the nurse gives the client nubbin 15mg. within 5 minutes the client tells the nurse she feels like she needs to have a bowel movement. the nurse should first: 1. have narcan available in the delivery room 2. complete a vaginal examination to determine dilation, effacement and station 3. prepare for delivery 4. document the client's relief due to pain medication
multipara with a shoulder presentation
a nurse in the birthing suite has just admitted four clients. which client should the nurse anticipate will need to prepared for a cesarean birth? 1. multipara with a shoulder presentation 2. multipara with a documented station of floating 3. primigravida with a fetus presenting in the occiput posterior position 4. primigravida with a twin gestation with the lowermost in the vertex presentation
twin birth over distended bladder retained placental fragments
a nurse is assessing several postpartum clients. which clients are at risk for developing postpartum hemorrhage? select all that apply 1. twin birth 2. overdistended bladder 3. hypertonic uterine dystocia 4. retained placental fragments 5. mild gestational hypertension
2. I can hold my baby several different ways during feedings 4. if I breast-feed my uterus will return to pre-pregnancy size more quickly 6. I need to feed my baby when I see feeding cues and not wait until she is crying
a primigravida client at 32 weeks gestation is enrolled in a breast-feeding class. which of the following statements indicate that the client understands the breast-feeding education? select all that apply 1. my milk supply will be adequate since I have increased a whole bra size during pregnancy 2. I can hold my baby several different ways during feedings 3. if my infant latches on properly, I won't develop mastitis 4. if I breast-feed my uterus will return to pre-pregnancy size more quickly 5. breast milk can be expressed and stored at room temperature since it is natural 6. I need to feed my baby when I see feeding cues and not wait until she is crying
the maximum blood loss considered within normal limits is 500ml
a primigravida client in a preparation for parenting class asks how much blood is lost during an uncomplicated delivery. the nurse should tell the woman: 1. the maximum blood loss considered within normal limits is 500ml 2. the minimum blood loss considered within normal limits is 1000ml 3. blood loss during a delivery is rarely estimated unless there is a hemorrhage 4. it would be very unusual if you lost more than 100ml of blood during the delivery
multiple gestation
a primigravida client is admitted as an outpatient for an external cephalic version. the nurse should assess the client for which of the following contraindications for the procedure? 1. multiple gestation 2. breech presentation 3. maternal rh-negative blood type 4. history of gestational diabetes
provide firm pressure to the clients sacral area
a primigravida client whose cervix is 7cm dilated with the fetus at 0 station and in a left occipitoposterior position requests pain relief for severe back pain. the nurse should: 1. provide firm pressure to the clients sacral area 2. prepare the client for a cesarean delivery 3. prepare the client for precipitate delivery 4. maintain the client in a left side lying position
performs McRobert's maneuver
a primigravida is experiencing a prolonged second stage of labor with a fetus suspected of weighing over 4kg. which of the following interventions is most important? 1. preparing for a vacuum-assisted delivery 2. administering an IV fluid bolus 3. preparing for an emergency cesarean delivery 4. performing the McRobert's maneuver
although it varies, a gain of 25-35lb is about average
after instructing a primigravida client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client states which of the following? 1. a total weight gain of approximately 20lb is recommended 2. a weight gain of 6.6lb in the second and third trimesters is considered normal 3. a weight gain of about 12lb every trimester is recommended 4. although it varies, a gain of 25 to 35lb is about average
group b streptococcus
an antenatal primigravida client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during pregnancy. the nurse realizes the client needs further instruction when she indicates carrying twins puts her at risk for which of the following? 1. preterm labor 2. twin to twin transfusion 3. anemia 4. group b streptococcus
left sided heart failure
backup into the lungs crackles, SOB, orthopnea, crying
decreased pulmonary blood flow
backward effect is venous congestion; trickle of blood getting the lungs will have chronic hypoxia, know baseline sat polycythemic, dependent edema, low oxygen reserve, hyper cyanosis (knee chest, oxygen and meds) want to keep ductus open
oral rehydration
best way to cure dehydration in children
increased pulmonary blood flow
blood is getting pushed to the lungs causing fluid overload in the lungs looks like left sided heart failure sit them up, lasix, oxygen
right sided heart failure
body is swollen, backing up into venous circulation (whole body) dependent edema
omphalocele/gastroschisis
born with intestines on the outside treat like an evisceration cover with moist sterile saline cause and get to surgery
hypoplastic left heart syndrome
born with small left heart of no left ventricle at all must have open ductus until can get a shunt - give prostaglandin E
polycythemia
chronic hypoxia leads to
aortic stenosis
damage to aorta before the arch pale extremities, weak pulses all over volume overload in the lungs
right sided heart failure, hypercyanotic spells
defects with decreased pulmonary blood flow
left sided heart failure
defects with increased pulmonary blood flow
metabolic acidosis
dehydration leads to ______ in children
intussusception
emergency reduce with barium enema or surgery currant jelly stools (blood and mucus) bilious vomiting, lethargy, distention, sausage-like mass can cause bowel necrosis
cleft lip/palate
feed sitting upright, use wide based nipples/spoons, direct formula to side and back of the mouth prone to vasal regurge into the ears (prone to ear infections) position on side after feedings
knee chest positioning
first thing to do when child has hyper cyanotic spell
bronchiolitis
life threatening in babies try bronchodilator, then 3% saline ned (gargle the lungs with saltwater to try to draw some fluid out and decrease edema) if that doesn't work, nothing else to do. assess, suction, oxygen, keep upright
chrons disease
limit dairy products low fat (avoid margarine, butter, cream sauce and fried foods) limit fiber, spicy foods hot beverages, pre-workout drinks, alcohol and caffeine
epiglottitis
lots of stridor (seal barking), drooling, tripod positioning emergency intubation equipment ready give inhaled epi to decrease swelling
patent ductus arteriosus
low oxygen and high prostaglandins keep this open close with prostaglandin inhibitor such as indomethacin or ibuprofen
nephrotic syndrome
massive proteinuria, normal to low blood pressure, anasarca (severe generalized edema) treated with steroids, ACE inhibitors, diuretics and albumin
protect suture line
priority after cleft lip/palate repair surgery
decreased pulmonary blood flow
pulmonic stenosis (can't get out of right ventricle) tetralogy of fallot (pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, overriding of the aorta)
hypertrophic pyloric stenosis
pylorus is overgrown and clamps off exit to the stomach so stomach cannot empty, it stretches when overfilled and snaps back; will have horror movie vomit would expect to see metabolic alkalosis
aspirin
rheumatic heart disease and Kawasaki disease are treated with
TE fistula
right after birth will have frothy sputum and turn blue immediately NPO, sit them up, put on oxygen, will need to go to surgery ASAP
coarctation of the aorta
stricture of the aorta just past the arch trickle of blood to lower body, high pressure to upper body poor perfusion to body, cool pale weak pulses mottled skin bounding pulses in arm, high BP in arms, flushed face, volume overload in lungs
bladder status
the cervix of a primigravida client in active labor who received epidural anesthesia 4 hours ago is now completely dilated, and the client is ready to begin pushing. before the client begins to push, the nurse should assess: 1. fetal heart rate variability 2. cervical dilation again 3. status of membranes 4. bladder status
1. changing the perineal pad and reporting the drainage 4. reinforcing good hygiene while assisting the client with washing the perineum 6. assisting the client with ambulation shortly after delivery
the nurse assigns an unlicensed assistive personnel to care for a client who is 1 day postpartum. which of the following would be appropriate to delegate to this person? select all 1. changing the perineal pad and reporting the drainage 2. assisting the mother to latch the infant onto the breast 3. checking the location of the funds prior to ambulating the client 4. reinforcing good hygiene while assisting the client with washing the perineum 5. discussing postpartum depression with the client who is found crying 6. assisting the client with ambulation shortly after delivery
estimated date of delivery
the nurse in the labor and delivery area receives a telephone call from the emergency room announcing that a multigravida client in active labor is being transferred to the labor area. the client has had no prenatal care. when the client arrives by stretcher, she says I think the baby is coming help. the fetal skull is crowning. the nurse should obtain which of the following information first? 1. estimated date of delivery 2. amniotic fluid status 3. gravida and parity 4. prenatal history
hypoglycemia
the nurse is caring for a primiparous client and her neonate immediately after delivery. the neonate was born at 41 weeks gestation and weight 9lb. assessing for signs and symptoms of which of the following conditions should be a priority in this neonate? 1. anemia 2. hypoglycemia 3. delayed meconium 4. elevated bilirubin
multigravida who had a positive oxytocin challenge test
the nurse is reviewing results for clients who are having antenatal testing. the assessment data from which client warrants prompt notification of the health care provider and a further plan of care? 1. primigravida who reports fetal movement 6 times in 2 hours 2. multigravida who had a positive oxytocin challenge test 3. primigravida whose infant has a biophysical profile of 9 4. multigravida whose infant has a reactive non-stress test
a G2, P1 client with a history of hyperemesis gravidarum
the nurse is working on a busy labor and delivery unit with other nurses and a licensed practical nurse. which of the following labor clients would the nurse assign to the licensed practical nurse? 1. a G4, P3 client with a history of gestational diabetes 2. a G3, P1 A1 client at 35 weeks gestation 3. a G1, P0 client with leaking green amniotic fluid 4. a G2, P1 client with a history of hyperemesis gravidarum
to contract the mother's uterus
the nurse, while shopping in a local department store, heads a multiparous woman say loudly I think the baby's coming. after asking someone to call 911, the nurse assists the client to deliver a term neonate. while waiting for the ambulance, the nurse suggest that the mother initiate breast-feeding, primarily for which of the following reasons? 1. to begin the parental-infant bonding process 2. the prevent neonatal hypothermia 3. to provide glucose to the neonate 4. to contract the mothers uterus
hemorrhage
the physician prescribed an intramuscular injection of phytonadione for a term neonate. the nurse explains to the mother that this medication is used to prevent which of the following 1. hypoglycemia 2. hyperbilirubinemia 3. hemorrhage 4. polycythemia
softening of the cervix and beginning of effacement
the primary health care provider has prescribed prostaglandin gel to be administered vaginally to a newly admitted primigravida client. which of the following indicate that the client has had a therapeutic response to the medication? 1. resting period of 2 minutes between contractions 2. normal patellar and elbow reflexes for the past 2 hours 3. softening of the cervix and beginning of effacement 4. leaking of clear amniotic fluid in small amounts
assess the fetal heart rate for 1 full minute
the primary health care provider plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks gestation for labor induction. after the amniotomy, the nurse should first 1. monitor the clients contraction pattern 2. assess the fetal heart rate for 1 full minute 3. assess the clients temperature and pulse 4. document the color of the amniotic fluid
to decrease the frequency and severity of variable decelerations
the primary health care provider prescribed an amnioinfusion for a primigravida client at term who is diagnosed with oligohydramnios. Which of the following should the nurse include in the client's teaching plan about the purpose of this procedure? 1. to decrease the frequency and severity of variable decelerations 2. to minimize the possibility of fetal metabolic alkalosis 3. to increase the fetal heart rate accelerations during a contraction 4. to raise the amniotic fluid index to more than 15cm
at about the level of the clients umbilicus
when measuring fundal height of a primigravida client at 20 weeks gestation, the nurse will locate the fundal height at which of the following points? 1. halfway between the clients symphysis pubis and umbilicus 2. at about the level of the clients umbilicus 3. between the clients umbilicus and xiphoid process 4. near the clients xiphoid process and diaphragm
sometimes baby girls have this from hormones received from the mother
while changing the neonates diaper, the client asks the nurse about some red tinged drainage from the neonates vagina. which of the following responses would be most appropriate? 1. its of no concern because it is such a small amount 2. the cause is usually related to swallowing blood during the delivery 3. sometimes baby girls have this from hormones received from the mother 4. this vaginal spotting is caused by hemorrhagic disease of the newborn
