Exam 2 Flashcards
is a hemorrhage of blood between the skull and the periosteum (outer layer of bone) of any age human, to rupture of blood vessels crossing the periosteum.
Or
is a traumatic subperiosteal haematoma that occurs underneath the skin, in the periosteum of the infant’s skull bone
A collection of blood between the periosteum of a skull bone and the bone itself
Cephalohematoma
One leg longer, extra skin folds on inner thigh , uneven gluteal folds, hip click maneuver
Congenital hip dysplasia
Cleft lip- what it is?
Feedings?
Education for parents ?
Safety precautions?
Fissure or opening in the upper lip
The result of failure of maxillary and medium nasal processes
Can be fixed with surgery - encourage them to fix it to improve speech, dental , feedings, positive self image
Feedings- by dropper until the wound is completely healed 1-2 weeks . Breast fed milk or formula as soon as clear liquids are tolerated
Safety- auctioning the mouth should be avoided in infants who have a cleft palate repair
What is presumptive pregnancy?
Signs?
Definite diagnoses of pregnancy.. can’t be made.. signs could be common during pregnancy but can indicate something else
Deepening pigmentation, urinary frequency, quickening(moving of baby), amenorrhea (late period) Period late, tired , breast are tender, nauseated.
Define primigravida ?
Someone who is pregnant for the first time
What is viability of fetus?
The gestational age at which a prematurely born fetus/ infant had 50% chance of long term survival outside the womb
24-25 weeks
How often should women make prenatal visits ?
Weeks 4-8: 1 prenatal visit a month
Weeks 28-36: 1 prenatal visit every two weeks
Weeks 36-40: 1 prenatal visit every week
Define supine hypotension ?
Signs/symptoms?
What to do/nursing intervention?
Feeling of sickness and low bp that Occurs when pregnant women lie on their back
May feel dizzy/weak, low bp, nausea, sweating, pallor (pale), tachycardia
Turn patient to left side to resolve
Teachings for pregnant women traveling far from home ?
Take plenty of rest breaks
Drink plenty fluids
Not recommended after third trimester
Check with airlines if they have cut off when pregnant women can fly
Prenatal records
Seatbelt below abdomen
Signs and symptoms of “true labor”?
With true labor contractions, they become stronger, closer together and more regular
Normal fetal heart tones ?
When to report?
110-160 bpm
Heard through Mother’s abdominal wall
Report anything under or higher heart rate
What is Gravita and Para status ?
Gravita - number of pregnancies
Para - number of births after 20 weeks
What makes up a normal umbilical cord?
AVA- Artery vein Artery
2 arteries and one vein
Nurses priority during labor and delivery?
Pg 183
Pg 197
? Preparing for delivery
Asses for abnormalities
Promote bonding
Fetal assessment/VS/HR Labor process Maternal and fetal tolerance to labor Pain management I and O Vitals Communication with MD Empty bladder Promote position changes Provide hygiene Support and encouragement Assist with breathing techniques
Normal location of zygote implantation ?
Upper section of the posterior uterine wall
How to figure out Nagels rule ?
First day of last normal period
Subtract 3 months
Plus 7 days
Correct the year if necessary
Interventions and education for nausea and vomiting during pregnancy ?
Dry carbs like saltine crackers , lemonade over ice , sea bands , small frequent , and non-greasy meals
Normal weight gain during pregnancy and education?
If under weight ?
If overweight ?
25-35 pounds
Healthy nutrition, take vitamins, exercise, watch weight
28-40
11-25
Intrauterine growth restriction
Causes
Treatment
A condition in which a baby doesn’t grow to normal weight during pregnancy
Problem with placenta (common cause)
or health problems such as diabetes , HTN, heart disease, infections, kidney/lung disease, anemia, malnutrition, smoking , alcohol, drugs , chromosomal defects
Regular dr apts , be aware of body movements, check meds , eat healthy nutrition, plenty of rest, stop smoking
How to measure frequency of normal contractions ?
Labor vs false labor?
Frequency: Time from the beginning of one contraction until the beginning of the next (minutes)
Duration: time from the beginning of a contraction until the end of the same contraction (seconds)
Braxton Hicks- false labor where contractions can be regular or irregular, practicing for labor , does not cause a change in cervix
Real labor - regular rhythmic contractions, cervix changes , bloody discharge, water breaks
Nursing interventions for back labor pain?
Put woman on hands and knees , lean forward , birthing ball
What is back labor ?
Pain or discomfort in lower back, just above tailbone , to a woman during childbirth
Progression of labor ?
What is normal and what can cause it to slow?
1st :
Latent phase - slow effacement of the cervix , longest phase , 0-3 cm
Active phase- best time for pain meds epidural, 4-8 cm
Transition phase- angry sweaty, 9-10 cm
2nd- pushing / deliver
3rd-delivery of placenta
4th- bonding-put on belly and breast feed
Can slow- Stress, worry, fear , full bladder
What is amniotomy ?
What is the reason it’s done ?
Breaking amniotic fluid/ water
Done to induce or expedite labor
Normal color of amniotic fluid?
What to report immediately?
Clear with flecks of white vernix
Green fluid is also normal and means that hey have passed meconium ( their first stool)
Report- cloudy or yellow fluid with a bad odor- it might indicate an infection.
Foods high in iron?
Fish, green leafy veggies , red meats
What is the fundus?
The upper part of the uterus
- which is broad and flat -where Fallopian tubes enter on each side
The distance from the pubic bone to the top of the uterus
Fundal height
After 20 weeks your fundal height should match the number of weeks you been pregnant in cm
Fundal height at each trimester ?
Assessment after delivery?
Possible reasons for abnormalities ?
3rd trimester grow 1 cm per week
Asses 1 hour after Delivery to check if fundus is firm and at the level of the umbilicus- massage
Pain/contractions to normal size, bleeding, Check for clots , boggy uterus can be a sign of hemorrhage that needs to be treated STAT
Nurses priority on the newborn?
?
Examine head for lacerations, abrasions , or bruising
Pain assessment after delivery ?
Vaginal hematoma
Pelvic or rectal pain
-Cold pack in area , analgesics
Security process between mom and newborn?
No one but mom can carry baby to and from nursey
Anyone carrying must have badge ID
Any not mom push in crib
Normal vitals of new born?
BP- 60-80/40-45. (64/41)
Resp- 40-60
Heart rate - 110-160
T-96.8-99.0
Assessment findings for post term infant (born after 42 weeks)?
Wrinkled skin
LGA (large macromonia) or long and thin
^Hypoglycemia
Meconium staining
Long nails
Peeling skin
What complications to look for with forceps delivery?
Trauma : laceration , hematoma, bruising
Newborn assessment to report?
Vs abnormalities
Apgar number
Gestational age
Anomalies or skin conditions or jandauce - report if any STAT
Reflexes
What are (pitocin) Oxytocin infusions used for?
When are they stopped ?
Assessment during infusion ?
Possible complications?
Oxy- strengthen contractions
To contract the uterus
Stop IV when it induces labor and notify provider - 2-3 min apart
Asses time of contraction and placenta -
Excessive bleeding , abnormal heart rate , HTN, seizures, shallow breathing, muscle cramps
Nursing intervention with a stillborn ?
Therapeutic communication (silence, sympathy, open ended statements, reflection)
Promote expression of grief by providing privacy, eliminating time restrictions, allow support visits , recognition of cultural norms for grief/loss
What is phototherapy used for ?
Nursing actions?
Used to treat jaundice - get rid of excess bilirubin
Keep eyes covered Hydrate Frequent feeding Expose skin as much as possible Reposition every two hours or more Monitor bilirubin levels in blood Involve parents
Swelling during pregnancy - what it indicates?
Education
Primary assessments?
Preeclampsia /edema
Teach the symptoms, mag sulfate May cause hot flash, keep room quit and dim to prevent seizure
watch BP, hourly vitals , urine output 30 ml or more , magnesium levels, 24 hour urine sample, CBC , respiration depression, DTR (deep tenden reflexes) , seizures
Gestational hypoglycemia-
Signs and symptoms ?
Priority assessment?
Linked to women taking insulin or medicine for bs
Shaking and tremors , immature lungs, macrosomnia in baby,
check for glucose and ketones
Kick count education?
After 28 weeks, it’s ok if no movement in 30 minutes
Needs to be 10 times in 2 hours
Difference between reactive and nonreactive stress test?
Reactive: Two or more fetal heart accelerations within 20 minute period with or without fetal movement. Baby’s heart rate above baseline 15x
Non reactive : fetal heart rate did not go up (nothing)
Enlarged , gnarled veins commonly in the legs and feet
Varicose veins
Signs and symptoms of varicose veins ?
Nursing education ?
Aches and pain , dark purple veins , burning , throbbing, muscle cramping and swelling in lower legs , itching , bleeding, color changes, hardening, inflammation of skin or ulcers near ankle
Avoid standing or sitting for long periods
Walk/ exercise
Rest with legs elevated
Compression stockings
Avoid tight knee highs
Relieve hemorrhoid swelling with warm sits bath, pain ointment
Functions of the placenta ?
Delivers nutrients to baby, removes CO2 and waste
Placenta previa - what is it?
signs and symptoms ?
When placenta covers the opening of the mothers cervix
Painless bright red bleeding
Abrupt decrease in fetal heart rate and decrease baseline? Can happen with umbilical cord is temporary compressed
Variable decelerations
Bonding after delivery ?
Out baby on mother’s chest
The newborn should breast feed with in the first hours when alert
Postpartum interferes
Immediately - postpone cream
Pre-eclampsia/Eclampsia- priority nursing interventions?
Preeclampsia- renal involvement leading to proteinuria . HTN , edema , and protein in urine during pregnancy
Eclampsia- CNS involvement causing seizures, liver and coagulation abnormalities dominate the clinical picture
Monitor urine protein (3+ may indicate proteinuria)
Monitor weight ,urine output less than 30 ml ,baseline vital signs , fetal hr , minimal stimulation, edema , fluid intake and output
Calcium gluconate reverses magnesium sulfate
Blood pressure and seizure meds
Treatment for perineal lacerations after delivery?
?
Assessed for normal healing and signs of complications
Cold packs before first 12 hours to reduce pain, bruising , edema
12-24 hours after- heat packs or sitz baths increase blood circulation for healing
Oral pain meds
Developmental milestones
Birth -3 months - cooing and interacting
4-6 months- interests in sounds - balance self, sit up , tripid
7-8 months - waving / gestures , sit alone
9months - walk by a year, fear of strangers
Probable signs of pregnancy ?
Goodelles sign, Chadwick’s sign , hegars sign, McDonald’s , abdominal enlargement , Braxton Hicks , ballotment , straie, positive pregnancy test
Positive signs of pregnancy?
Audible fetal heartbeat
Fetal movement felt by examiner
Ultrasound visualization of fetus
