Blue Book 2 Flashcards
When the terminology “the 3 phases of labor” is used, what does it mean?
If the statement refers to PHASES of labor, it means the 3-step process of latency, followed by active and transitional. (LAT order - just as its spelled in LATency)
Normal length of pregnancy is ____ to ____ days
240, 300
Pregnancy is divided into ____ trimesters
3
During the 1st trimester the woman experiences decreased or increased vaginal secretions?
increased
When are urine pregnancy tests positive?
At the time of the first missed period
Pregnancy tests test for the presence of what hormone?
HCG (human chorionic gonadotropin hormone)
Urine and blood pregnancy tests are enough evidence to be certain of pregnancy (T/F)?
false, these tests only suggest pregnancy
What is Hegar’s sign?
Uterine softening
What is Chadwick’s sign?
Blue-tint to the cervix
The first trimester goes from week ___ to week __
1-13
The second trimester goes from week ___ to week ___
14-27
Which week can mother first feel the fetus move?
16th-20th week, (the end of the 4th month into the 5th month)
What is the word used to ID the feeling that the mother experiences when the fetus moves?
quickening
The 3rd trimester goes from week ___ to week ___
28-40
In which trimester does the women most feel backache?
3rd
Which trimester is the fetus most susceptible to effects of outside agents?
1st
What is the name of the process in which outside agents cause birth defects in the fetus?
Teratogenesis
Which trimester is N&V most common?
1st
Which trimester do Braxton-Hicks contractions begin?
3rd
What are Braxton-Hicks?
Usually painless contractions that strengthen the uterus for labor
Which trimester does quickening occur?
2nd
Which trimester does venous congestion in the legs occur?
3rd
Which trimester does linea nigra appear?
2nd
What is linea nigra?
Single dark vertical line on the abdomen
Which trimester do striations occur?
2nd
What is chloasma?
Mask of pregnancy- pigmented area on face
Which trimester is constipation most common?
3rd
In addition to the nares, where else should the nurse assess for skin irritation when nasal cannulae are in use?
Behind and on top of the ears
What are two signs of hypoxia?
Restlessness and tachycardia
What is the highest flow rate appropriate for nasal cannulae?
6 L/min
How often should the nares of a client with O2 by nasal cannulae be assessed for skin breakdown?
Q 6-8hrs
What is the maximal O2 flow rate for the client with COPD?
2L/min
What are the signs of O2 toxicity?
confusion, HA
What can happen if the client with COPD is given a high flow rate of O2
they may stop breathing
respiratory depression
What is the problem with giving high flow rates of O2 by nasal cannulae?
dires mucous membranes
Can a client smoke in the room when the O2 is turned off?
No, the O2 delivery device must be removed from the wall or the tank out of the room before a client can smoke
When O2 is administered, it must be …
humidified
Masks deliver higher or lower concentrations of O2 than nasal cannulae?
higher
How often should the nurse check the flow rate of the O2?
at least once per shift
O2 is an explosive (T/F)?
False, it does not explode- it supports combustion
What structures in the brain are most affected in Parkinson’s
basal ganglia
The neurotransmitter imbalance that causes Parkinson’s is a ___ in _____ ______
Decrease, dopamine activity
What drugs can cause a Parkinson-like syndrome?
Haldol, major tranquilizers - drugs that end in “-azine”
What is the classic motor manifestation of Parkinson’s?
pill-rolling and tremors
What type of rigidity is typical of Parkinson’s?
Cogwheel - Cogwheel’ rigidity is a combination of leadpipe rigidity and tremor which presents as a jerky resistance to passive movement as muscles tense and relax
Parkinson’s patients move fast or slow?
slow
What type of gait is seen in Parkinson’s?
shuffling, slow
Patients with Parkinson’s have ___ speech
monotone
Patients with Parkinon’s tend to have constipation or diarrhea?
constipation
Name 4 drugs used to treat Parkinson’s
Levodopa, Sinement, Symmetrol, Cogentin, Artane, Parlodel
In what type of chair should Parkinson’s patients sit?
firm, hard backed
What time of day can be particularly dangerous for the Parkinson’s patient?
Mealtime, d/t choking
When a patient is taking Levodopa he should have assistance getting out of bed because…
Of orthostatic hypotension
What vitamin should patients on Levodopa avoid?
B6, pyridoxine - Vitamin B6 reduces the effectiveness of levodopa
Levodopa should be given with or without food?
with food
What might Levodopa do to patients urine?
make it very dark
The tremors of Parkinson’s will get better or worse when they purposefully move or perform a task?
Better, they tremor more when not performing an action
The client on a PCA pump is less likely to have post-op complications than the client w/o a PCA pump (T/F)?
True, b/c the comfortable pt moves around more and is less likely to get thrombophlebitis, pulmonary embolus, fatigue, ileus and pneumonia
Clients with COPD are not good candidates for PCA pumps (T/F)?
True, d/t the effects of narcotics on central respiratory control
Name the 3 most common uses of PCA techniques
Post-op pain, cancer pain, sickle-cell crisis pain
PCA pumps allow a more constant level of serum drug than conventional analgesia (T/F)?
ture
A major disadvantage of PCA pump is that the client can take too much medication (T/F)?
False. It is not possible for a client to OD d/t the lock-out feature
Clients on PCA pumps use more medication than those receiving IM injections (T/F)
False, they use less
A disadvantage of PCA pumps is that the client does not ambulate as early d/t the machine (T/F)
False, PCA clients ambulate earlier and they pull their machine with them
When d/c a PCA infusion it is acceptable to discard the drug cartridge (T/F)
False, the whole cartridge system must be returned to the pharmacy d/t federal narcotic control laws
Comfort range of relative humidity is…
30-60%
Which patients should be forbidden to smoke? Smoke alone?
Those with oxygen in the room, confused, sleepy, drugged patients
When applying restraints remember to…
Avoid bruising the skin, cutting off circulation, and accidental entangling
List ways to ensure privacy…
Use drapes and screens during care in semi-private rooms
Plastic pillow cases are _____ (disadvantage)
Hot and slippery
When using restraints with clients who object, dont forget about ____ ______
False imprisonment
Individuals who are ill are ____ sensitive to noise than individuals who are well
more
When you are not at the bedside the bed should always be…
In the lowest position
Can nurses be held liable for an accident resulting from a client not being told how to use the call light?
yes
Dangers associated with drafts are…
Circulation of micro-organisms on air currents
The first thing a nurse should do when a client objects to side rails is…
Explain why they are being used
The comfort range of temperature is …
68-74
Is having the client verbally ID himself considered adequate for safety?
No, only ID bands are acceptable
Bed side rails should be up for the following individuals…
Elderly clients, unconscious, babies, young children, restless, confused
The S&S of sensory overload and sensory deprivation are…
Fear, panic, depression, inability to concentrate, restlessness, agitation
If a family member asks to have the side rails down while they are in the room you should…
Remember that you are responsible for the client’s safety - not his family, it might be unwise to permit this
Pillows are sterilized between uses (T/F)
false
What is the common name for pediculosis?
lice
What is a common finding with pediculosis pubis?
Reddish-brown dust in the underwear
What common household solution is used to remove nits?
Vinegar. Nits are the eggs of lice that adhere to the hair shaft
What shampoo is used for lice?
kwell
Where are head lice most commonly found?
At the back of the head and behind the ears
On what do lice feed?
blood
After tx how long do you have to inspect for lice?
Inspect for 2 weeks to be sure that they are all gone
What is the most common symptom of lice?
itching
What is the most dangerous toxicity of Kwell?
CNS toxicity
What is the typical of the lesions of pemphigus
Foul-smelling, blisters break easily, seen in the elderly, cause is unknown
What is the characteristic lesion of pemphigus?
Large vesicular bullae
What are bullae?
large blisters
What chemical is added to the bath water of a client with pemphigus?
Potassium permanganate
What precaution must be taken with potassium permanganate?
Be careful that no undissolved crystals touch the client; it will burn the skin
What is the typical skin care of pemphigus?
Cool, wet dressings
What unusual nursing dx is high priority in pemphigus?
Alteration in F&E balances - Because you may have lost bodily fluids due to oozing of the sores, you may receive fluids through a vein (intravenously), as well as electrolytes — minerals such as sodium, potassium and calcium that maintain the balance of fluids in your body — and protei
What are the top 3 nursing interventions in pemphigus?
Oral care, protection from infection, encouraging high fluid intake
What kinds of fluids will clients with pemphigus drink best?
cold fluids
What drugs are most commonly used?
steroids
Should steroids be given with meals?
always
What is the #1 cause of death of pemphigus?
overwhelming infection
Define pemphigus
An acute or chronic disease of adults, characterized by occurrence of successive crops of bullae that appear suddenly on apparently normal skin and disappear, leaving pigmented spots. It may be attended by itching and burning and constitutional disturbance. The disease if untreated is usually fatal. A characteristic finding is a positive Nikolsky sign: When pressure is applied tangential to the surface of affected skin, the outer layer of epidermis will detach from the lower layer (probably autoimmune)
Define peritoneal dialysis
The removal of wastes, electrolytes and fluids from the body using the peritoneum as a dialyzing membrane
When PD is being used the client must be on heparin (T/F)
False, you don’t need to be heparinized for peritoneal, but you do need to be heparinized for hemodialysis
How long does one episode /course of PD last?
Could be 10 hours
With PD there is a high/low risk of peritonitis?
high
When fluid accumulates in the abd during PD what problem does the client experience first?
Dyspnea- SOB or difficulty breathing, d/t the inability of the diaphragm to descend
What nutrient is lost in highest amounts during PD?
protein
Can a client who had recent bowel surgery get PD?
no
Should a client who is having breathing problems receive PD?
no
What body surface must be punctured to administer PD?
the abd
The solution introduced into the peritoneum during PD is called…
dialysate
Before allowing the dialysate to flow into the peritoneal cavity it must be ___ to ____ temperature
warmed, body
Before PD it is important the client be…
Weighed, to assess water loss or gain
Before PD it is important the client be…
Weighed, to assess water loss or gainWhat force is used to introduce the dialysate into the peritoneum
What force is used to introduce the dialysate into the peritoneum
Gravity only, no pumps
How fast does the dialysate usually flow into the peritoneum?
in 10 mins
How long is the dialysate allowed to remain in the peritoneum before it is drained out?
15-30 mins
How long does it usually take for the dialysate to drain out of the perineum?
10 minutes (10 minutes flow in, 30 minutes in abd cavity, 10 minutes out = total of 50 minutes)
If the dialysate does not drain out well, you would first…
Have them turn side to side
What color is the dialysate when it comes out?
Straw colored- clear
Should you raise the HOB to increase drainage of the dialysate?
yes
How often do you measure vital signs during PD?
Q15min during the first cycle and qhour thereafter
Can a client on PD: Sit in a chair? Eat? Urinate? Defecate?
yes to all
If too much fluid is removed during PD, the client will experience…
decreased BP
If the client absorbs too much of the dialysate the client will experience…
increased BP (circulatory overload)
If the client complains of dyspnea during PD you would first ___, then ____
Slow the flow, elevate HOB
Cloudy drainage in the dialysate most commonly means…
Peritonitis, (Not good, call MD)
What would you do if you noticed a small amount of blood come out in the first few bottles that were infused?
Nothing, this is normal; the blood is due to the initial puncture of the abd
What precautions are important in the care of the client receiving PD?
Safety, bc they get dizzy
Is it I&O important to record during PD?
yes
How high should the diasylate bag be when its being infused?
shoulder height
What factor do clients with pernicious anemia lack?
Intrinsic factor. It has no other name
What vitamin is not absorbed in a patient with pernicious anemia?
vitamin B12
What is another name for Vitamin B-12
extrinsic factor
Why isn’t Vitamin B-12 (extrinsic factor) absorbed in pernicious anemia?
Bc these patients lack intrinsic factor
What happens when patients with pernicious anemia don’t absorb Vitamin B- 12?
Their RBC’s do not mature and they become seriously anemic
What other disease can be confused with pernicious anemia?
Angina pectoris
What are some classic and unique signs of pernicious anemia?
Beefy red tongue, numbness, and tingling of the hands, sores in the mouth, chest pain
What is the medical treatment for pernicious anemia?
IM injections of Vitamin B-12
How long must the client receive this medical treatment?
For the rest of their life
Can we cure pernicious anemia?
No, just treat the symptoms
What unique urine test is done to diagnose pernicious anemia?
The Schilling test
Is it okay to give B-12 orally to a client with pernicious anemia?
No, it will never be absorbed d/t a lack of intrinsic factor
What neurologic test do they do for this anemia?
The Romberg test (a test for balance); in normal people this test is negative, in the client with pernicious anemia this test becomes positive (A loss of balance is interpreted as a positive Romberg’s test)
What is conservation? In what stage does it develop?
When the child realizes that number, weight, volume remain the same even when outward appearances change; Concrete Operational
What is the age range of formal operation thinking?
12-15
What is the sensori-motor stage of intellectual development?
It is the intellectual stage of children from birth to 2 years
What is the age range of concrete operational thinking?
7-11
What is the age range of pre-operational thinking?
3-6
What is the classic pattern in formal operational thinking?
Abstract reasoning
What is egocentricity? In what stage is it found?
The child views everything from his frame of reference, common in pre-operational thinking
In Placenta Previa the placenta is implanted ___ than it should be and lays over the ____ ____.
Lower, cervical os
What is the classic symptom of Placenta Previa?
Painless 3rd trimester bleeding (hint: Painless Placenta Previa)
In whom is Placenta Previa most likely to occur? Prima or multi
mltigravidas
What is meant when the physician/nurse use the terms total (complete) or partial (incomplete) in reference to placenta previa?
Total or complete: placenta covers whole cervical opening
Partial or incomplete: placenta covers only part of the cervical opening
What are 3 complications of placenta previa?
Shock, maternal death, fetal death
What is the best and safest way to confirm placenta previa?
ultrasound
Should a woman with placenta previa be hospitalized?
Yes, always if bleeding
If a surgeon delays doing a C-section for placenta previa it is d/t: (reason for delay)
Immaturity of the fetus (they will want the child to mature)
As soon as placenta previa is diagnosed, most pregnancies will be terminated via C- section if the fetus is mature (T/F)
ture
If a woman is admitted with active bleeding with Placenta Previa you should monitor fetal heart tones ____
Continuously via fetal monitor
It is not necessary to use electronic fetal monitoring when there is active bleeding in Placenta Previa (T/F)?
False, infant must always be monitored
Will a woman with active bleeding in Placenta Previa be given any systemic pain relief during labor?
No, they don’t want to suppress the fetus
If you were told to start the IV on the woman admitted for Placenta Previa, what gauge need would you use?
18 gauge, or any other one large enough to administer blood
Pneumonia is an ____ in the ____ __ ____
Infection, alveoli of lungs
Which blood gas disorder is most common in pneumonia?
Respiratory alkalosis, bc the hyperventilation blows off more CO2, than the consolidation traps in the blood
What is polycythemia vera
A blood disease in which there is an increase in erythrocytes, leukocytes, and platelets
What is the typical complexion of a client with polycythemia vera?
Ruddy red, almost purple
What procedure is done to relieve S&S in polycythemia vera?
Phlebotomy
What is phlebotomy?
Drain off 200-500 cc of blood from body (opposite of transfusion)
What type of diet will ppl with polycythemia vera be on?
low iron
What are the 3 signs of polycythemia vera?
HA, weakness, itching
Is hemoglobin inc. or dec. in this disease?
increased
What oral problem will people with polycythemia vera have?
Bleeding mucous membranes
What organ will be enlarged in polycythemia vera?
The spleen, bc it is destroying the excessive RBCs
D/t enlarged destruction of RBCs seen in polycythemia vera what blood level will be increased?
Uric acid levels will be high (remember- uric acid levels are always high when cells are being destroyed as in hemolysis, chemotherapy or radiation therapy)
What drug is most commonly used in polycythemia vera?
Myleran (this is usually used for bone marrow cancer)
How often should the client cough and deep breath post-op
q2hr
How often should the post-op patient turn?
q2h
How often should the pt use the incentive spirometer?
q1-2hr
How often should the nurse auscultate the lung sounds post-op?
q4hr
How often should the bedridden post-op patient do leg exercises?
q2hr
The post-op pt should void by ___ hours post-op or you must call the MD
6-7hrs
Will the typical post-op client have lung sounds? Bowel sounds? Increased temp?
Lung-yes; bowel sounds- no; Low grade temp- yes
Unless contraindicated the pt should be out of bed no later than ___ hours post-op
24hr
DVT is most common in what kinda surgery?
low abd or pelvic
The most common complication of DVT is ____ ______
PE
The best way to prevent thrombophlebitis is TED hose (T/F)
False, ambulation /exercise are the best way
What is a paralytic ileus?
Paralysis of the bowel d/t surgery (common- especially in abd surgery)
If a post-op pt complains of gas and cramping you should first ____ then ____
Assess then ambulate
The onset of post-op infection is on the ___ or ____ day post-op day
2nd or 3rd, never before that (remember elevated temperatures earlier than the 2nd post-op is NOT an infection)
Define dehiscence
Separation of the incisional edges
Define evisceration
Protrusion of abd contents through a dehiscence
What do you do for dehiscence?
Dec HOB (but not flat; can steri strip, then call MD
What do you do, in order, for evisceration?
Dec HOB (but not flat); cover with sterile gauze moistened with sterile saline, call MD
Pregnancy (dec/inc) the body’s insulin requirements
increases
Can pregnancy convert a non-diabetic woman into a diabetic?
yes
What name is given to diabetes that is brought on by pregnancy?
Gestational diabetes
Diabetes with pregnancy is (more/less) common as the woman ages
more
What is the #1 cause of infant illnesses when the mother has diabetes?
hypoglycemia
When is infant hypoglycemia most likely to occur during L&D?
In the hours immediately following delivery
Hormones of pregnancy work against insulin (T/F)
true
A sign of gestational diabetes is excessive weight (loss/gain)
weight gain
(Obese/ very thin) women are most likely to become diabetic during pregnancy
obese
In gestational diabetes the client experiences a (dec/inc) in thirst
increase (polydipsia)
In gestational diabetes the client experiences a (dec/inc) in urine output
increased (polyuria)
Gestational diabetes is ass w/ (htn/hypotension)
HTN
Gestational diabetes is ass w/ what OB history?
Prev. large baby (over 9lb.), unexplained stillbirth, miscarriage, congenital anomalies
Women who have gestational diabetes tend to deliver infants who are (small/large)
Large for gestational age
Gestational diabetics tend to get ____ infections
Monilial (yeast) infections
What test confirms the diagnoses of gestational diabetes?
3 hr glucose tolerance test A blood sample will be collected when you arrive. This is your fasting blood glucose value. It provides a baseline for comparing other glucose values.
You will be asked to drink a sweet liquid containing a measured amount of glucose. It is best to drink the liquid quickly. For the standard glucose tolerance test, you will drink 75 grams or 100 grams.
Blood samples will be collected at timed intervals of 1, 2, and sometimes 3 hours after you drink the glucose. Blood samples may also be taken as soon as 30 minutes to more than 3 hours after you drink the glucose.
What are the 2 main tx methods in gestational diabetes?
diet, insulin
How often should a woman visit the doctor prenatally if diabetes is present?
Twice a month, then once per week in the 3rd trimester
How many lbs/week is the diabetic allowed to gain the 2nd and 3rd trimesters?
1 lb a week (same as non-diabetic)
Is severe carbs restriction required in gestational diabetes?
No, it could lead to ketosis
