exam 1
Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?
"When is the last time you ate or drank?": Consumption of food and fluids near to the time of surgery places the client at increased risk for aspiration.
primiparous clinet who underwent a caesarean delivery 30 minutes ago is a candidate for Rho(D) immune globulin. nurse anticipates administering this ordered medication within which time frame after delivery? a. 8 hours b. 24 hours c. 72 hours d. 96 hours
72 hours most Rh negative clients also receive RhoGAM during the prenatal period at 28 weeks gestation and then again after delivery. its given to Rh-negative mothers who have a delivered Rh-positive neonate
Following diagnostic testing, a patient requires a cholecystectomy. This surgical procedure would be categorized as which of the following?
Urgent;Acute gallbladder infection would be categorized as an urgent surgery. Emergent surgeries include severe bleeding, bladder or intestinal obstruction, and a fractured skull. Required surgeries include thyroid disorders and cataracts. Elective surgeries include repair of scars, simple hernia, and vaginal repair.
while performing a complete assessment of a term neonate, which of the following findings would alert the nuirse to notify the pediatrician? a. red reflect in the eyes b. expiratory grunt c. respiratory rate of 45 breaths/ minute d. prominent xiphoid process
expiratory grunt
factors that increase postpartum complications
infection:
while making a home visit to a postpartum client on day 11, nurse would anticipate client's lochia would be which color? a. dark red b. pink c. brown d. white
white
stages of lochia
rubra (1-3 days): bloody flesh odor serosa (4-9 days): pink /brown alba (10+days): yellow /white
What intervention by the nurse is most effective for reducing hospital-acquired infections?
Proper hand-washing techniques: Efforts to prevent wound infection are directed at reducing risks, such as thorough hand washing. (Preoperative and intraoperative risks and interventions are discussed in Chapters 17 and 18.) Postoperative care of the wound centers on assessing the wound, preventing contamination and infection before wound edges have sealed, and enhancing healing
how to check for jaundice
look at whites of eyes for yellow color depresson forhead and nose then sternum (if its a more severe jaundice it will be present on the soles of the feet baby is more sleepy and may not eat as well if lights are working stool will turn dark as bilirubin leaves the baby. encourage eating to pass bilirubin in severe cases blood transfusions may be needed can cause mental retardation, deafness and cerebral palsy if elevated for prolonged periods
A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?
"I will support my incision with my hands when I cough and do my deep breathing exercises.": Splinting of the incision provides support to the incision and helps to control pain, so this client statement is correct. Clients should take pain medication routinely and frequently after surgery. Pain medications for postoperative clients are given orally at home. Pain is a subjective feeling, so comparison is difficult.
In which instance may a surgeon operate without informed consent?
Emergency situations: In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the client's informed consent.
a viable female neonate delivered vaginally at term has an APGAR score of 9 at 1 minutes and 10 at 5 minutes after birth. immediately postpartum the nurse keeps the infant under a radiant warmer away from the cooling ducts in the room to prevent heat loss by which of the following mechanisms a. evaporation b. convection c. conduction d. radiation
convetion with evaproation heat is lossed through the drying of skin with convection heat is drawn from the body to the cooler surrounding air with conduction body heat is transferred to a cooler solid object with contact to the skin with radiation heat is transferred to a cooler object not in direct contact as the baby like a window
while the nurse is preparing to assist a prim parous client to the bathroom to void 6 hours after vaginal delivery under epidural anesthesia, client says she feels dizzy when sitting up on the side of the bed. nurse explains this is most likely caused by whick of the following? a. effects of the anesthetic during labor b. hemorrage during delivery process c. effects of the analgesics used during labor d. decreased blood volume in the vascular system
decreased blood volume in the vascular system
a 38 yr old woman is 36 weeks pregnant presents with HTN since age 34 witch requires antihypertensice drugs. prior to pregnancy BP 130/70. during frist trimester BP 120/60; has risen in recent weeks to 150/95. complaining of worsening lower extremity edema. 24 hr urine shows 1500 mg protein. lab values for electrolytes, liver function and platelets are normal. what is the patients diagnosis? a. chronic essential hypertension b. eclampsia c. HELLP sydrome d. preeclampsia
preeclampsia *patients with chronic HTN have 5x higher risk of preeclampsia preexisting HTN also increases risk of intrauterine growth restriction. placental abruption and mid trimester fetal death
mrs jones asks "this hurt a lot. I don't want to have another baby for a long time. If i continue to breast feed I won't have to worry about it right? you respond a. that's right b. that may or may not be correct c. odds are you will get pregnant d. what wrong with you jordan needs a sibling
that may or may not be correct ovulation and menstruation occurs approx. 6 weeks after childbirth if not breastfeeding. if breastfeeding at least 3 months after childbirth but for some menstruation may not return until breastfeeding stops
Which is the least important issue concerning safety for the perioperative team before proceeding to the operating room?
Client's ambulatory aids: It is imperative that the entire perioperative team participates in verifying the client's identity, the correct surgical procedure, and the appropriate surgical site before preceding to the OR. The client's ambulatory aids are not an important safety concern before proceeding to the OR.
A fractured skull would be classified under which category of surgery based on urgency?
Emergent: Emergent surgery occurs when the client requires immediate attention. An elective surgery is classified as a surgery that the client should have. A required surgery means that the client needs to have surgery. An urgent surgery occurs when the client requires prompt attention.
During the admission history the client reports to the nurse of taking the usual dose of warfarin the previous day. What is an appropriate nursing action?
Notify the surgeon that the client took warfarin the day before surgery.: Warfarin (Coumadin), an anticoagulant, places the client at risk for excessive bleeding during the intraoperative and postoperative periods.
nurse is assessing a cesarean section client who delivered 12 hours ago. findings include: distended abdomen with faint bowels sounds x1 quadrant, fundus firm at umbilicus, lochia scant rubra, and pain rated 4 on a scale of 1-10. IV and foley catheter have been discontinued; client medicated 3 hours ago for pain. when planning care for this client, what should the nurse identify as the highest priority interventions? a. medicate the client b. incentive spirometry c. ambulate the client d. encourage caring for infant
ambulate the client
which of the following locations would the nurse expect to palpate the fundus of a prim parous client 12 hrs after delivery of a neonate? a. halfway between the umbilicus and the symphysis pubis b. at the level of the umbilicus c. just below the level of the umbilicus d. above the level of the umbilicus
at the level of the umbilicus *by the 9th or 10th day the fundus should no longer be palpable
two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. after voiding, the nurse assesses the clients bladder, finding it distended. the nurse interprets this finding based on understanding the client's bladder distention is most likely caused by which of the following? a. prolonged first stage of labor b. urinary tract infection c. pressure of the uterus on the bladder d. edema in the lower urinary tract area
edema in the lower urinary tract area *
HELLP
hemolysis, elevated liver enzymes, low platelets occurs between 28-36 weeks gestation but may occur postpartum S/S headache, nausea, vomiting; indigestion with pain after eating. abdominal or chest tenderness and upper right side pain (from liver distention) shoulder pain or pain when breathing deeply, bleeding, changes in vision, swelling
the physician orders an intramuscular injection of phytonadione vitamin k for a term neonate. the nurse explains to the mother this medication is used to prevent which of the following a. hypoglycemia b. hyperbilirubinemia c. hemorrhage d. polycythemia
hemorrhage vitamin k is given in the middle third of the vastus lateralus
36 week pregnant woman presents complaining of mid-epigastric tenderness, nausea and comiting. looks unwell. BP is 146/100; lab test show normal renal function, low platelet count, AST level of 80 IU/L (elevated liver enzymes, and hemolysis with a microangiopathic blood smear. Diagnosied with HELLP) which of the following is the most important initial therapeutic intervention for this patient. a. bedrest until fetus reaches 40 weeks b. immediate delivery c. platelet infusion to prevent bleeding d. right upper quadrant ultrasound
immediate delivery *platelet infusion should only be given to patients with severely low platelet counts, or have significant bleeding right upper quadrant ultrasound may showhepatic infarction of subscapular hematoma but has no role in acute management of the patient most infant deaths occur do to abruption of the placenta or placental failure
27 year old female 30 weeks pregnant presents to her MD for routine follow-up: BP 150/105 Hg; previously normotensive. UA reveals 1+ proteinuria. Serum uric acid lever 5.0mg/dl. Platelet count and liver function tests are normal. 24 hr urine collection 1.1 g protein. which of the following does this patient most likely have? a. chronic hypertension b. gestational hypertension c. normal blood pressure for pregnancy d. preelcampsia
preeclampsia *bp is abnormally high for pregnancy. 140/90 and greater, 300mg protein in 24 hr collection and edema=preeclampsia occurs in the geriatric pregnancies, young pregnancies, those with multiple births, DM, preexisting renal disease, HTN family history monitor mom and baby, BP control, IV magnesium for seizures, early delivery may be needed
A presurgical client asks, "Why will I go to the PACU instead of just going straight up to the postsurgical unit?" What is the nurse's best response?
"The PACU allows you to recover from the effects of anesthesia, and you'll stay in the PACU until you're oriented, have stable vital signs, and are without complications." The PACU provides care for the client while he or she recovers from the effects of anesthesia. The client must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. Clients will sometimes recover in the ICU, but this is considered an extension of the PACU. The PACU does allow the client to recover from anesthesia, but the environment is calm and quiet as clients are initially disoriented and confused as they begin to awaken and reorient. Clients are not usually placed in the medical-surgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for client triage. Incisions are very rarely modified in the immediate postoperative period.
The nurse is starting preoperative teaching. What is the best response by the nurse when the client states, "I'm so nervous about my surgery"?
"Would you like to discuss the concerns that you have?": People express fear in different ways. Some clients may ask repeated questions, regardless of information already shared with them. Others may withdraw, deliberately avoiding communication by reading, watching television, or talking about trivialities. Consequently, the nurse must be empathetic, listen well, and provide information that helps alleviate concerns. "Would you like to discuss the concerns" focuses on the client. "Relax and stop worrying" provide false reassurance. Asking the client to revoke the consent is premature until more discussion has happened.
the infant has entered the sleep phase and second reactive phase in the nursery. identify the assessments or tasks the nurse needs to do during the transitional care period
1. check for excessive mucus use a bulb syringe as needed to assist 2. observe for apnea 3. take vital signs with temperature 4. weigh and measure if not done include head circumference 5. check blood glucose. give initial swallow of glucose to assess swallowing adequacy then give formula or breast to maintain blood glucose 6. give vitamin K in the vastus lateralus muscle. 7. physical assessment to determine gestational age 8. bath baby to remove vaginal and amniotic fluids/vernix is often present 9. check labs for PKU testing and hct. 10. give hep B vaccine 11. position on back or side 12. keep wrapped with a hat on to maintain warmth
Ive heard that breast feeding is the best but i'm all thumbs, this seems to take so much coordination, can you help me get the hang of it? Identify important points to include in your teaching plan
1. wash hands after every diaper change 2. change your peri pad before touching your breasts because stimulation can cause cramping 3. choose a comforitable position for yourself and the infant, ensuring that the infants head is slightly elevated. could place a pillow under your arm for support, show football hold 4. compress the breast behind the areola and have the baby directly in front of the nipple so he can latch on easily. 5. baby needs to be awake and alert to feed. stimulate if necessary 6.colostrum is produced initially very nutritious and loaded with antibodies to help babies immunity. 7. feed the infant every 2-3 hours during the day and as the baby awakens at night. milk production works as a supply and demand. babies need to nurse 8-10 times a day and for at least 7-9 minutes on each side initially then increase to 20 minutes each side. 8. breast fed babies do not ingest as much air as bottle fed babies, but still need to be burped. 9. breast milk is 80% water so the infant does not need extra water 10 discuss the benefits breast feeding/nutrition ect.
You are caring for a client preoperatively who is very anxious and fearful about their surgery. You know that this client's anxiety can cause problems with the surgical experience. What type of problems can this client have because of their anxiety and fear?
Anxious clients have a poor response to surgery and are prone to complications.: Anxiety and fear, if extreme, can affect a client's condition during and after surgery. Anxious clients have a poor response to surgery and are prone to complications. The scenario does not indicate an increased need for anesthesia or postoperative medications in the anxious and fearful client. Anxious clients do not generally need psychological counseling after surgery. Anxiety and fear do not affect a client positively during and after surgery.
The nurse is providing preoperative care to a client who is anxious about total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father!" What are some ways the nurse might help alleviate the client's anxiety? Select all that apply.
Ask the client if he would like to speak with a clergyperson. Listen empathetically to the client's concerns about the procedure. Make sure the client understands what will happen during surgery. Review the client's postoperative goals following the procedure. Preparing the client emotionally and spiritually is as important as doing so physically. Anxiety and fear, if extreme, can affect a client's condition during and after surgery. Careful preoperative teaching and listening by the nurse about what will happen and what to expect can help allay some of these fears and anxieties.
The surgical nurse is preparing to send a client from the presurgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply.
Consent must be freely given. Consent must normally be obtained by a physician. Signature must be witnessed by a professional staff member. Valid consent must be freely given, without coercion. Consent must be obtained by a physician and the client's signature must be witnessed by a professional staff member. It does not need to be signed on the same day as the surgery and it does not need to be notarized.
The nurse is caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?
Encourage the client to move legs frequently and do leg exercises.: The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless ordered and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone surgery.
Mrs Jones notes that her daughter's eyelids move rapidly when she is asleep. describe to Mrs Jones the cause for these movements
In the active sleep state the infant has rapid eye movement the baby has irregular respiration, closed eyes with rapid eye movements visible through the lids. irregular sucking motions and minimal activity, and irregular but smooth movement of extremities environmental and internal stimuli can initiate a startle reaction and a change of state
A nurse is planning preoperative teaching for an older client. Which structural or functional changes in the older adult impact the surgical experience? Select all that apply.
Increased fatty tissue prolongs elimination of anesthesia. Decreased ability to compensate for hypoxia increases the risk of an embolism. Loss of collagen increases the risk of skin complications. Reduced tactile sensitivity can lead to assessment and communication problems. The older adult has increased fatty tissue which prolongs elimination of anesthesia, decreased ability to compensate for hypoxia increases the risk of an embolism, loss of collagen increases the risk of skin complications, and reduced tactile sensitivity can lead to assessment and communication problems. The older adult has decreased plasma proteins, and no enlarged liver unless there is an underlying disease.
The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate?
Reinforce the importance of early mobility in preventing complications.: The client may be refusing to ambulate because of fear or pain. Educating the client on the importance of mobility in preventing complications may encourage the client to ambulate. The nurse should try all reasonable measures (e.g., pain control, education) before documenting the client's refusal to ambulate. If the client is already refusing to ambulate, delegating the task to the unlicensed assistive personnel is not an appropriate action. The client should not be forcefully removed from the bed.
a client delivered vaginally two hours ago and has a 3rd degree laceration. Ice in place on her perineum. her perineum is slightly edematous and client is complaining of pain rated 6 on a scale of 1-10. which nursing intervention would be the most appropriate at this time? a. begin sitz baths b. administer pain medication per dr order c. replace ice packs on perineum d. initiate anesthetic sprays to the perineum
administer pain medication per dr order *
The parent of a 16-year-old client asks the nurse, "How could the surgeon operate without my consent?" What is the best response by the nurse?
"Your child had life-threatening injuries that required immediate surgery.": In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the client's or parent's informed consent. Informed consent must be obtained before any invasive procedure. A minor cannot consent to a surgical procedure. The opinions of two doctors do not overrule the need to obtain informed consent.
What are the newborn ccharacteristics that affect newborn temperature regulation and the establishment of a neutral thermal environment? what should Mrs Jones be taught to keep Jordan warm?
-The newborn has decreased subcutaneous fat and a thin epidermis. so more heat can escape -blood vessels are closer to the skin that in an adult therefore, changes in environmental temperature influence the circulating blood and in turn influence the hypothalamic temperature regulating center -the flexed posture of the term newborn decreases the surface area exposed to the environment, thereby reducing heat loss -size and age also can affect the establishment of an NTE. for example, the preterm or small for gestational age newborn has less adipose tissue and is hypoflexed and therefore requires higher environmental temperatures to achieve a thermal neutral environment. larger well insulated newborns might be able to cope with lower environmental temperatures -larger body surface, head in proportion to body allows for more heat to escape -keep him bundled up in a blanket, and a cap for his head. keep him away from drafty areas
my niece turned yellow and had to have special lights at home, it totally ruined her newborn pictures. is it going to happen to jordan too? should i reschedule his photo shoot just in case he turns yellow? discuss with mrs jones the different types of jaundice nad the etiology behind it
-jaundice appearing before 24 hours old: pathological- baby has possible serious birth defects -jaundice appearing within 24 hours old: heolytic: Rh ABO group incompatibility. moms antibodies attack babies red blood cells causing increased bili levels -jaunice appearing around 24-72 hours old: physiological or normal jaundice-elevated biliruben from the normal breakdown of red blood cells.caused by immature liver. concealed hemorrhages polucythemia, sepsis neonatorum -appearing after 72 hours old: breast feeding jaundice- occurs less often. happens when babies don'e get enough breast milk. delayed or difficulty feeding breast milk jaundice- happens to 1-2% of breast fed babies. causes problems with excretion of bilirubin through the intestines. slowly improves over 3-12 weeks
In preparing the client for transfer to the operating room, which of the following actions by the nurse is inappropriate?
Allow the client to wear dentures.: Dentures, jewelry, glasses, and prosthetic devices are removed prior to surgery.
A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?
Allow the client to wear the ring and cover it with tape.: Most facilities will allow a client to wear a wedding band during a surgical procedure. The nurse must secure the ring with tape. Although it is appropriate to discuss the risk for infection, the client has already refused to remove the ring. The surgery should not be canceled and the ring should not be removed without permission.
The nurse has just admitted a 12-year-old client who is going to have an above-the-knee amputation of their left leg due to osteosarcoma. The nurse knows that adequate preoperative teaching and learning is important for what reason?
Client will have a shorter recovery period.: The purpose of adequate preoperative teaching/learning is for the client to have an uncomplicated and shorter recovery period. He or she will be more likely to deep breathe and cough, move as directed, and require less pain medication. Options B, C, and D are incorrect because preoperative teaching does not ensure that a 12-year-old client understands they are losing their leg or understand that they will have cancer. Preoperative teaching also does not ensure the client's family understands the child will lose their leg. This is the responsibility of the physicians who are treating the child and their family.
Eclampsia s/s:
HTN+protein in urine+seizures
stages of eclampsia
HTN, Preeclampsia, eclampsia, HELLP
after instructin a primiparous client about episiotomy care, which of the following client statements indicates successful teaching? a. i'll use hot, sudsy water to clean the episiotomy area. b. I wipe the area from frount to back using a blotting motion c. before bedtime, i'Il use a cold water sitz bath d. I can use ice packs for 3-4 days after delivery
I wipe the ara from front to back using a blotting motion. cleanse the area with warm water and wipe front to back with a blotting motion. after the first 24 hours warm water sitz baths may be taken 3-4 times a day for 20 minutes this increases circulation to the area. ice packs are only helpful the first 24 hours as they decrease blood flow
after instructing a primiparous client who is bottle-feeding, which of the following client statements indicates client needs further teaching? a. I'll burp him after 15 minutes of feeding him formula b. after he takes one-half ounce of formula, I'll burp him c. i'll burp him while he is in an upright position d. I'll gently pat his back to get him to burp
I'll burp him after 15 minutes of feeding him formula *the entire feeding should take about 15-20 minutes. during initial feedings, burping should be done after each half-ounce of formula with the neonate in an upright position, patting the neonate gently on the back
The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and increased body mass index mean that she is at increased risk for what complication in the postoperative period?
Infection: Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative client who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls.
An OR nurse will be participating in the intraoperative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care?
Monitoring the client's physiologic status: During the intraoperative phase, the nurse is responsible for physiologic monitoring. The intraoperative nurse cannot support the family at this time and the nurse is not responsible for maintaining the client's cognitive status. The intraoperative nurse maintains an aseptic, not clean, environment.
An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults?
Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients.: The underlying principle that guides preoperative assessment, surgical care, and postoperative care is that elderly clients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than younger clients. The hazards of surgery for the elderly are proportional to the number and severity of coexisting health problems and the nature and duration of the operative procedure. Respiratory and cardiac complications are the leading causes of postoperative morbidity and mortality in older adults.
The nurse has administered preanesthetic medication. What action should the nurse take next?
Place the client on bed rest with the side rails up.: Preanesthetic medication can make the client lightheaded and dizzy. Safety is a priority, so the client should remain in bed with the side rails up. The consent form should be signed before the client is medicated. Consents signed after the client is medicated are not legal. Reviewing the home medications and educating the client should take place before the client is medicated.
When is the ideal time to discuss preoperative teaching
Preadmission visit: The ideal timing for preoperative teaching is not on the day of surgery but during the preadmission visit, when diagnostic tests are performed. Teaching should be done long before the patient enters the preop area. Preoperative teaching should not be done when the patient is sedated.
What is the major purpose of withholding food and fluid before surgery?
Prevent aspiration: The major purpose of withholding food and fluid before surgery is to prevent aspiration. Decreasing overhydration, decreasing urine output, and decreasing constipation are not major purposes of withholding food and fluid before surgery. Until recently, fluid and food were restricted preoperatively overnight and often longer. Currently, specific recommendations depend on the age of the client and the type of food eaten.
The nurse recognizes which symptom as a clinical manifestation of shock?
Rapid, weak, thready pulse: The client's pulse increases as the body tries to compensate for the effects of shock. Pallor is an indicator of shock. The skin is generally cool and moist in shock. Usually, a low blood pressure and concentrated urine are observed in clients who are in shock.
Mrs, Jones has just delivered her first baby boy. The nurse assesses the newborn immediately and hears an audible murmur upon examination. "What's a murmur, cries Mrs. Jones tearfully, is he going to die?" Mrs Jones's daughter also has a temperature noted at 36.2 C axillary. The nurse relays the information to the physician. What would be the explination for the murmur? the physician has ruled out any cardiac defectss. how do you respond to Mrs. Jones?
The doctor has ruled out any heart problems, it if normal for Jordan to have a murmur. Murmurs are produced by turbulent blood flow. In newborns 90% of all murmurs are transient and not associated with anomalies. function murmurs can occur because the special structures of fetal circulation do not close completely immediately after birth
approximately 90 minutes after birth the nurse encourages the mother of a term neonate to do which of the following? a. feed the neonate b. allow the neonate to sleep c. get to know the neonate d. change the neonate's diaper
allow the neonate to sleep
Mrs. Jones puts on her call light ans says "what's wrong with Hordan Jr, he lust lies there and won't eat. I can't get him to wake up at all" you not the baby is lethargic and not feeding well what should your next action be?
check the babies glucose level and notify the PCP
I just couldn't decide on circumcision, but i decided to go ahead with it. now it just looks so messy, maybe i made the wrong decision. how will i handle this mess at home. and the cord looks kind of gross what should you tell mrs jones about cord and circumcision care?
circumcision care: keep it clean with warm water and pat dry. apply vaseline to the circumcision to keep if from sticking to the diaper and to facilitate healing. explain that its normal to see yellow tissue as the skin heals. observe for bleeding, pus or S&S of infection Cord care: per facility protocol. keep the stump dry wash with warm water and pat dry if soiled. watch for signs of infection: redness, swelling at the base and purulent drainage. the cord will fall off after 7-10 days don't pick at it. when it falls off there will be a "raw" spot keep the area clean and dry
stages of breastmilk content
colostrum 1-3 days: creamy, yellow. protein, minerals, vitamins and immunoglobulins transitional milk 2-4 days: breast milk with some colostrum mature milk 7+ days: 90% water, 10% carbs, proteins and fats
the nurse makes a home visit to a 3-day old full tem neonate who weighed 3,912 g at birth. today the neonate who is being bottle fed weighs 3,512. which of the following instructions would the nurse most likely give to the mother. a. continue feeding every 3-4 hours since the weight loss is normal b. contact the physician if the weight loss continues over the next few days c. switch to a soy based formula because the current one seems inadequate d. change to a higher -calorie formula to prevent further weight loss
continue feeding every 3-4 hours since the weight loss is normal full term neonates tend to lose 5-10% of their weight during the first few days . most likely because of minimal nutrition intake. with bottle feeding the neonates intake varies from one feednig to another. additionally the neonate experiences a loss of extracellular fluid. typically neonates regain any weight loss by 7-10 days of life. if weight loss continues after this time physician should be called
A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse:
continuously monitors the sedated client.: Intraoperative care includes the entire surgical procedure. During sedation, the nurse continuously evaluates the client. Assessment of heart rate, respiratory rate, BP, oxygen saturation, and level of consciousness occurs during all phases of perioperative care. Obtaining consent would occur during the preoperative phase of perioperative care. During the postoperative phase the nurse would assess how the client is recovering from anesthesia.
uterine atony
inability of the uterus to contract effectively. the most common cause of postpartum hemorrhage
While making a home visit to a primiparous client and her 4 day old daughter, the nurse observes the mother changing the infant's diaper. Before putting the new diaper on, the mother begins to apply baby powder to the infant's buttocks. Which statement about baby powder would the nurse make? a. it may cause pneumonia to develop b. it helps prevent diaper rash c. it keeps the diaper from adhering to the skin d. it can result in allergies late in life
it may cause pneumonia to develop baby powder can enter the neonates lungs and result in pneumonia secondary to aspiration of the particles. best prevention of diaper rash is to change diaper often and keep the skin dry
a prim parous client who is bottle feeding her neonate at 12 hours after birth asks the nurse "when will my menstrual cycle return?" which of the following responses by the nurse would be most appropriate? a. your menstrual cycle with return in 3-4 weeks b. it will probably be 6-10 weeks before it starts again c. you can expect your menses to start in 12-14 weeks d. you menses will return in 16-18 weeks
it will probably be 6-10 weeks before it starts again. for bottle feeding mothers menstrual flow should return 6-10 weeks after a rise in FSH. non lactating mothers rarely ovulate before 4-6 weeks post partum. breast feeding women may not have a menstrual flow return for 3-4 months or even for the entire period of lactation because ovulation is suppressed
Newborns' and Mothers' Health Protection Act of 1996
mandates that insurance companies pay for at least 48 hours of hospital stay for vaginal births and 96 hours for caesarean births after delivery
A nurse is caring for a postpartum client who delivered vaginally 4 hours ago and has not voided since delivery: feeling has returned to her perineal area; she ambulated to the bathroom and attempted to void twice. Ice is on her edematous perineum. Uterus is 3 finger breadths above the umbilicus, to the right of midline firm only with massage. what would the priority nursing actions? a. Evaluate the client with a bladder scan b. insert a foley catheter c. medicate the client with a nonsteroidal anti-inflammatory drug d. massage the fundus until it is firm and perform a one-time catheterization
massage the fundus until it is firm and perform a one-time catheterization
a client is in the first hour of her recovery after a vaginal delivery. during an assessment, the lochia is moderate, bright red and trickling from the vagina. nurse locates fundus at the umbilicus: firm and midline with no palpable bladder. client vital signs remain at their baseline. based on this information, the nurse would implement which of the following actions? a. increase the IV rate b. recheck the admission H&H levels c. report the finding to the healthcare provider d. document the findings as normal
report the finding to the health care provider. *lochia should never be bright red and should not be trickling or running out of the vagina. because the fundus findings are normal the bleeding is likely coming from a cervical or vaginal laceration and connot be stopped by the nurse.
"it's been 24 hours isn't jordan supposed to poo by now?" what information would the nurse discuss with Mrs Jones related to her sons stool patterns
term newborns usually pass meconium within 8-24 hours of life, and almost always within 48 hours. explain what maconium looks like the nurse should evaluate the newborn's feeding pattern and hydration status. Stool will turn golden brown when lactation is established newborns should urinate at least 6 times a day.
when developing a plan of care for a prim parous client during the first 12 hours after vaginal delivery, which of the following concerns of the client should be the nurse's primary focus of care? a. the neonate b. the family c. the client's own comfort d. the client's significant other
the clients own comfort *first 12 hours after delivery are part of the Taking in Phase of maternal postpartum adjustment which typically lasts 1-3 days. this is when the client focuses on her own needs after the first 1-3 days postpartum is taking hold phase where she'll focus on the needs of the neonate.
A perioperative nurse is assigned to complete a preoperative assessment on a client who is scheduled for surgery for kidney stones the next day. What category of surgery does this procedure fall into?
urgent: Surgery for kidney or urethral stones is considered urgent; it is usually performed the next day. Emergent surgery is performed without delay. Required surgery is performed within a few weeks or months. Elective surgery refers to procedures that the client plans in advance.
a 26 year old primiparous client is seen in the urgent care clinic 2 weeks after delivering a viable female neonate. client, who is breast-feeding, is diagnosed with infectious mastitis of the right breast. client asks the nurse "can i continue breast feeding?" which of the following responses would be the most appropriate? a. you can continue to breast-feed, feeding your baby more frequently b. you can contiue once your symptoms begin to decrease c. you must discontinue breast-feeding until antibiotic therapy is completed d. you must stop breast-feeding because the breast is contaminated
you can continue to breast-feed, feeding your baby more frequently feeding should occur every 2-3 hours. continually emptying breasts decreases the risk of engorgement or breast abscess. treatment also includes bed rest, increased fluid intake, local heat application, analgesics and antibiotic therapy.
