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