Planning care for a patient who has cholelithiasis - ANSWER Inflammation of gall-bladder wall Most often caused by gall stones Give pain medications as prescribed Patients that would receive Rho(... D) immune globulin during pregnancy period - ANSWER Pregnant women who are RH negative and exposed to RH positive blood. Presumptive signs of pregnancy - ANSWER Amenorrhea, fatigue, nausea and vomiting, urinary frequency, breast changes, quickening, uterine enlargement Probable signs of pregnancy - ANSWER + pregnancy test, Abdominal enlargement, Hegars sign, Chadwicks sign, Goodell's sign, ballottement, Braxton Hicks, fetal outline felt Positive signs of pregnancy - ANSWER Fetal heart sound, visualization on ultrasound, fetal movement palpated by an experienced Examiner. Fetal heart rate (FHR) - ANSWER 110-160 Hegar's sign - ANSWER Softening in compressibility of lower uterus Chadwick sign - ANSWER Defend Violet bluish color of cervix and vaginal mucosa Goodell's sign - ANSWER Softening of cervical tip Ballottement - ANSWER Rebound of unengaged fetus Quickening - ANSWER Slight fluttering movements of the fetus felt by a woman usually between 16 to 20 weeks of gestation Chloasma - ANSWER Facial hyperpigmentation Striae gravidarum - ANSWER Stretch marks of abdomen and thighs 1st stage of Labor - ANSWER Last 12.5 hours Latent phase:0-3cm active phase:4-7cm transition:8-10cm 2nd stage of Labor - ANSWER The birth of the infant pushing stage contractions every 1 to 2 minutes 3rd stage of Labor - ANSWER Ends with the delivery of the placenta 4th stage of Labor - ANSWER Mother's recovery after birth of baby and placenta Tocolytic therapy/ Vifedipine used - ANSWER Premature labor Stop contractions in premature labor and decreases BP If late decelerations occur during labor - ANSWER Discontinue oxytocin, Pt sidelying position, administer 02 8-10L/min Nursing interventions for prolapsed umbilical cord - ANSWER Place gloved hand into vagina and hold the presenting part the umbilical cord until delivery. Lochia rubra - ANSWER Bright red color, bloody consistency, fluffy older, may contain small clots, transient flow increase during breastfeeding and upon Rising. 1-3days Lochia serosa - ANSWER Pinkish brown color, fleshy odor, last 11 to 6 weeks Lochia Alba - ANSWER Yellowish white creamy color, fleshy odor, 11 days to 6 weeks Oligohydraminos - ANSWER Decreased amniotic fluid Apgar scoring - ANSWER 7-10 =no distress 2 score: HR: >100 RR: good cry Muscle tone: well flexed Reflex: cry Color: completely pink Circumcision care - ANSWER Sponge bath until healed. Change diaper every 4 hours clean penis with warm water. Apply petroleum jelly to penis does not stick to diaper. Contraindications for CST - ANSWER 1. Placenta previa 2. Preterm labor 3. Multiple gestations Indications of true labor - ANSWER 1. Energy burst 2. Rupture of membranes 3. Bloody show Actions to take for preterm labor - ANSWER 1. Modified bed rest (not strict, may have adverse effects) 2. Encourage client to rest in left lateral position to increase blood flow to uterus and decrease uterine activity 3. Tell client to avoid sexual intercourse 4. Monitor FHR and contraction pattern Nursing Interventions for late decelerations in FHR - ANSWER 1. Place client in side-lying position 2. Discontinue oxytocin if being infused 3. Elevate client's legs Priority intervention for pt who has depression - ANSWER 1. Assess if pt has thoughts of hurting herself or her baby 2. Assess history of depression & level of support 3. Advise pt to take some time for herself each day 4. Provide support and counseling, as well as community resources (support groups) Care for a client who has cholelithiasis - ANSWER 1. Provide pain management - analgesics, warm or cold compress 2. Comfort measures for nausea and vomiting that may occur 3. Aspartate aminotransferase increase can indicate obstruction Candidates for induction of labor - ANSWER 1. Postterm pregnancy - >42 weeks gestation 2. Prolonged rupture of membranes - predisposes client and fetus to risk of infection 3. Dystocia (prolonged, difficult labor) due to inadequate uterine contractions Teaching about prenatal screenings - ANSWER 1. Dramatically reduced infant and maternal morbidity and mortality rates by early detection and treatment 2. Majority of birth defects occur between 2 and 8 weeks gestation. 3. Obtain medical history, current meds, family history, psychosocial history, abuse history, and additional risks. Findings of hypoglycemia - ANSWER 1. poor feeding 2. jitteriness/tremors 3. hypothermia 4. weak cry 5. lethargy 6. cyanosis 7. blood glucose less than 45mg/dl should be followed up with serum glucose. Teaching a client who has phenylketonuria - ANSWER 1. genetic disease in which high levels of phenylalanine - pose a danger to fetus 2. Resume PKU diet for at least 3 months prior to pregnancy and continue throughout pregnancy 3. Avoid foods high in protein (fish, poultry, meat, eggs, nuts, dairy) as well as aspartame Nursing Care During Stages of Labor: Nursing Interventions for Umbilical Cord Prolapse (Active Learning Template - Basic Concept, RM MN RN 10.0 Chp 14) - ANSWER -Umbilical cord appears to lengthen as placenta descends -When there is suspected rupture of membranes, the nurse should first assess the FHR to ensure there is no fetal distress from possible umbilical cord prolapse, which can occur with the gush of amniotic fluid -Encourage upright positions, application of warm/cold packs, ambulation, or hydrotherapy if not contraindicated to promote comfort Labor and Delivery Processes: Indications of True Labor (Active Learning Template - Basic Concept, RM MN RN 10.0 Chp 11) - ANSWER -Contractions: can begin irregularly but become regular, stronger, longer, more frequent, felt in lower back, walking can increase contraction intensity, continue despite comfort measure -Cervix: progressive change in dilation and effacement, moves to anterior position, bloody show -Fetus: presenting part engages in pelvis Complications Related to the Labor Process: Prioritize Care to the Client in Labor (Chapter 16-Basic learning concept - ANSWER -Call for assistance immediately -Notify provider -Using a sterile glove, insert 2 fingers into vagina and apply pressure on either side of cord to fetal presenting part to relieve pressure -Reposition in high Trendelenberg or side-lying poition with rolled towel -apply warm sterile saline-soaked towel to visible cord -provide continuous FHR monitoring, check for late decels Managing Client Care: Delegation to assistive personnel (Chapter 1)` - ANSWER -Clerical duties -Selected care tasks such as ambulation, feeding, mouth care, and bathing -Data gathering such as intake and output and vital signs Prioritizing Care for a Group of Antepartum Clients - ANSWER When a nurse has a patient who has multiple clients and needs to identify who should get highest priority in care, there are many factors that play into that decision. In antepartum testing, if a patient has had an indication (diabetes, chronic hypertension, preeclampsia, fetal growth restriction, multiple gestation, oligohydramnios, PPROM, late term or post term gestation, previous still birth, decreased fetal movement, renal disease) than they would have a higher priority than mothers who do not have one of the indications. Lowdermilk, 635 Providing Discharge Teaching to a Client Who Had Gestational Diabetes Mellitus - ANSWER insulin requirements may decrease because a major source of insulin resistance has been removed, it may take several days to reestablish carbohydrate homeostasis so monitor blood glucose levels, continue to breast feed, endometritis is more likely to occur in patients with diabetes, may need to talk about contraceptives with diabetes lowdermilk, 698 Evaluating Positive Parenting Behaviors - ANSWER Early eye contact, early skin to skin contact, extended contact, touching the baby, talking around the baby especially the mother, having a sense of smell that doesnt change for the baby, smiles, naming the infant lowdermilk 503-504 Ante/Intra/Postpartum and Newborn Care: Fetal assessment during labor - late decelerations - ANSWER -fetal heart monitoring can be done continuously with a transducer across the moms abdomen -heart rate is broken into a 3 tier system: ~catergory one which includes baseline HR of 110-160 bpm, moderate HR variability, present or absent accelerations or early decelerations, no late or variable decelerations ~catergory 2: baseline is tachy or bradycardia, variability is either marked, absent, or minimal, episodic or periodic decelerations are present, absense of induced accelerations after fetal stimulation ~catergory 3: sinusoidal pattern, absent baseline variabilitty, recurrent late decels, bradycardia -late decelerations can happen because of uteroplacental insufficiency, maternal hypotension, preeclampsia, placenta previa, abruptio placenta, late or post-term pregnancies, maternal diabetes mellitus -nursing interventions for late decels: place client in side lying position, increase IV fluid rate, discontinue oxytocin, administer oxygen by mask at 8-10 L/min via nonrebreather mask, elevate clients legs, notify provider, prepare for an assisted vag birth or cesarean birth Reference: Maternal Newborn Nursing Edition 10.0 ch. 13 Alterations in body systems: Nutrition During Pregnancy - ANSWER Client education: client needs increased calories (450-500) a day, client should increase protein intake, take iron supplements, calcium is important, increase fluid, limit caffeine, abstain from alcohol Dietary complications during pregnancy: Nausea and constipation, PKU in mom - presents danger to fetus, monitor clients blood PKU levels during pregnancy, Diabetes mellitus - monitor blood glucose levels Reference: Maternal Newborn Nursing Edition 10.0 Ch. 5 Evaluating client understanding of newborn safety - ANSWER Suction mouth then nose Newborn safety - ANSWER Check 2 identifiers (mom & baby) Umbilical cord care - ANSWER - Observe for any bleeding from cord - Ensure that the cord is clamped securely to prevent hemorrhage Provide postpartum care & education: perineal care - ANSWER - Cleanse front to back with warm water after each voiding & bm - Blot perineal area from front to back - Remove & apply perineal pads from front to back Provide postpartum care & education: Breast care for those lactating - ANSWER - Well fitting, supportive bra - Hand hygiene prior to breastfeeding - To relieve breast engorgement, have the pt completely empty her breasts at each feeding - Allow baby to nurse on demand, which would be about 10 times in 24 hours - Massage breast during feeding can help with emptying - Alternate breasts with each feeding - For breast engorgement, apply cool compress between feedings & warm compresses prior to - For flat or inverted nipples, suggest client roll the nipples between her fingers just before Provide postpartum care & education Provide postpartum care & education: Breast care for nonlactating - ANSWER - Well fitting, supportive bra continuously for 72 hours - Avoid breast stimulation & running warm water over breasts for prolonged time until no longer lactating - For breast engorgment (3-5th day), apply cold compress 15 min on & 45 min off (fresh cabbage leaves) Provide postpartum care & education: rest/sleep - ANSWER - Plan at least 1 daily rest period - Rest when the infant naps Provide postpartum care & education: activity - ANSWER - DONT perform housework w heavy lifting for at least 3 weeks. DONT lift anything heavier than the baby. - Avoid sitting for prolonged periods with legs crossed (to prevent thrombophlebitis) - Limit stair climbing for 1st few weeks - C-section clients wait until 4-6 week follow up visit before performing strenuous exercise, heavy lifting, or excessive stair climbing - DONT drive for 1st 2 weeks or while taking opioids for pain control Provide postpartum care & education: nutrition - ANSWER - Diet high in protein (tissue repair) - 2-3L of fluid each day Provide postpartum care & education: postpartum exercises - ANSWER - Kegel exercises (regain pelvic floor muscles) - Pelvic tilt exercises (strengthen back muscles & relieve strain on lower back) Provide postpartum care & education: sex - ANSWER - Avoid sex until laceration is healed & vaginal discharge has turned white (lochia alba) - Takes 2-4 weeks - OTC lubes may be needed during the 1st 6 weeks - Physiological reactions to sex may be slower & less intense for 1st 3 mo after birth Provide postpartum care & education: Contraception - ANSWER - Begin contraceptions upon resumption of sex - Pregnancy can occur with breastfeeding even though menses has not returned - Menses in nonlactating client- resumes in 4-10 wks - Menses in lactating client- resumes in 3 mo Provide postpartum care & education: danger signs to report to MD - ANSWER - Chills or fever > 100.4 for 2 or more days - Change in vaginal discharge with inc amount, large clots, change to a previous lochia color, & a foul odor - Episiotomy, laceration, or incision pain that doesn't resolve with analgesics, foul-smelling drainage, redness, and/or edema - Pain or tenderness in abdominal or pelvic aresa that does not resolve with analgesics - Breasts with localized areas of pain & tenderness w redness & swelling - Urination with burning, pain, frequency, urgency (urine that's cloudy or had blood) Normal lochia flow patterns - ANSWER Bright red: 2-3 days Blood tinged serous: day 4-10 White vaginal: day 11- 6 weeks Provide postpartum care & education: postpartum depression - ANSWER - Client feels apathy toward the infant - Cant provide self or infant care - Has feeling that she might hurt herself or her infant Provide postpartum care & education: follow up visit - ANSWER - Pt should be discharged with an appt set for a postpartum follow-up visit - Or a # to call & schedule an appt - Vaginal: in 4-6 weeks - C-section: in 2 weeks Prioritize care to a client in labor: prolapsed umbilical cord - ANSWER - Call for assistance stat & notify MD - Use sterile gloved hand, insert 2 fingers into vagina & apply finger pressure on either side of cord to the fetal presenting part to elevate it off of the cord - Reposition client in knee to chest, Trendelenburg, or a side-lying position w rolled towel under client's hip - Apply warm, sterile, saline soaked towel to visible cord (prevent drying & to maintain BF) - Provide CONTINUOUS electronic monitoring of FHR for variable decelerations (indicate fetal asphysia & hypoxia) - Administer O2 at 8-10L/min via face mask (improve fetal O2) - Initiate IV access & administer IV fluid bolus - Prepare for C-section (if other meas fail) - Educate client Prioritize care to a client in labor: meconium stained amniotic fluid - ANSWER - Document color & consistency of stained amniotic fluid - Notify neonatal resuscitation team to be present at birth - Gather equip needed - Follow designated suction protocol - Assess neonate's RR, muscle tone, & HR - Suction mouth & nose (if RR strong, muscle tone good, & HR > 100) - Suction below vocal cords (endotracheal tube before spontaneous breaths occur if RR depressed, muscle tone dec, HR<100) Prioritize care to a client in labor: Fetal distress present when - ANSWER - FHR < 110 or > 160 - FHR shows dec or no variability - Fetal hyperactivity or no fetal activity Prioritize care to a client in labor: fetal distress - ANSWER - Monitor VS & FHR - Left-side lying reclining position w legs elevated - 8-10 L/min O2 via face mask - DC oxytocin (Pitocin) - Inc IV fluid rate (tx hypotension) - Prepare for emergency C-section Prioritize care to a client in labor: Dystocia - ANSWER - Dysfunctional (difficult) labor - r/t 5 powers of labor (passenger, passageway, powers, position, & psychologic response) - Apply fetal scalp electrode &/or intrauterine pressure catheter - Amniotomy (artificial rupture of membranes) - Encourage pt to regular void to empty bladder - Encourage position changes to aid in fetal descent or to open up the pelvic outlet (pt on hands & knees to help fetus to rotate from a post to ant position) - Encourage pt to ambulate, hydrotherapy (enhance progression of labor) - Apply counterpressure on sacral area (alleviate discomfort) - Assist pt to beneficial position for pushing & coach her about how to bear down with contractions - Prepare for a possible forceps-assisted, vacuum assisted, or C-section - Continue to monitor FHR in response to labor Prioritize care to a client in labor: Precipitous labor - ANSWER - Labor lasting < 3 hr - Dont leave pt unattended - Encourage pt to pant btw contractions (control the urge to push) - Side lying position (optimize uteroplacental perfusion & fetal O2) - Prepare for ROM upon crowning (fetal head visible at perineum) if not already rupture - Do not attempt to stop delivery - Control rapid delivery by applying light pressure to perineal area & fetal head (gently press upward) - Suction mucus from mouth to nose - Deliver anterior should located under symphysis pubis. Next posterior shoulder. Then allow the rest to slip out - Assess for complications Prioritize care to a client in labor: Rupture of uterus - ANSWER - Client says "ripping", "tearing", sharp pain - IV fluids - Blood product transfusions - Prepare for C-section - Inform pt Prioritize care to a client in labor: amniotic fluid embolism - ANSWER - 8-10 L/min O2 - Intubate & mechanical ventilation - Cardiopulmonary resuscitiation - IV fluids - Side lying w pelvis tilted at a 30 degree angle (to displace uterus) - Blood products (correct coagulation failure) - Indwelling catheter (measure hourly output) - Monitor mom & baby status - Prepare for emergency C-section T/F: the membranes must be ruptured prior to insertion of an internal electrode or intrauterine pressure catheter - ANSWER T A fetus receives more oxygen when ______ appears on the tracing: - ANSWER Relaxation btw uterine contractions Client in labor & RN observes late decelerations on the electronic fetal monitor. 1st action of nurse: - ANSWER - Assist client in left-lateral position (inc uteroplacental perfusion) While performing Leopold maneuvers the nurse should use which technique to identify the fetal lie? - ANSWER Palpate the fundus of the uterus Labor and Delivery Process: Teaching Findings of False Labor - ANSWER -Painless, irregular frequency, and intermittent contractions -Contractions decrease in frequency, duration, and intensity with walking or position changes -Contractions are felt in lower back or abdomen above umbilicus -Contractions often stop with sleep or comfort measures such as oral hydration or emptying of the bladder -The cervix has no significant changes in dilation or effacement -The cervix often remains in posterior position -The cervix has no bloody show -The presenting part of the fetus is not engaged in the pelvis. Newborn Nutrition: Safe Handling of Breast Milk - ANSWER -Breast milk can be stored at room temperature under very clean conditions for up to 8hrs -It can be refrigerated in sterile bottles for use within 8 days, or can be frozen in fertile containers in the freezer compartment of fridge for up to 6 months. Can be stored in a deep freezer for 12 months. -Thawing the milk in the fridge for 24hrs in the best way to preserve the immunoglobulins present in it. It can also be thawed by running lukewarm water over it. -Do not thaw in microwave -Do not refreeze thawed milk -Used portions of breast milk must be discarded Nursing Care During Stages of Labor: Identifying the Need for Reassessment - ANSWER -If there are late declarations, if baby is tachycardic or bradycardia Complications Related to the Labor Process: Nursing Action for a Nuchal Cord - ANSWER Slip cord over baby's head if it is loose enough nursing care during stages of labor: identifying the needs for reassessment - ANSWER each different stage of labor calls for different assessments of the mom stage one should focus on rupture of membranes, bladder distention, temperature, and FHR stage two should focus on BP, HR, and RR every 5-30 minutes, uterine contractions, pushing efforts by client, increase in bloody show, shaking of extremities stage three is focused on BP, HR, and RR every 15 min, clinical findings of seperation of placenta, vaginal fullness exam stage four should focus on assessing maternal vital signs to a steady state Reference: RN Maternal Newborn Nursing Ch. 14 Nutrition During Pregnancy: Identify Signs of Potential Prenatal Complications - ANSWER Nausea, constipation, maternal phenylketonuria, diabetes mellitus [Show More]
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