FINAL 250 Flashcards
Fundus at 15 hr should be..
at the U, midline, bladder should be empty, with moderate rubra
Cardio changes during pregnancy
CO increase, BP decreases, stroke volume increases, physiologic anemia, after delivery the HR decreases
what to do when a fundus is boggy..
have them empty bladder, massage fundus, gice oxytocin, check bp
no methergine for cardiac mom
thermoregulation of newborn
prevent heat loss by evaporation- dry baby completely, put hat on them, dont give bath until stable temp at 97 degrees.
Rubin stages
taking in- mom focused on self
taking hold- regaining control and taking interest in baby
letting go- bonding with baby
capat succedaneum
swelling crosses the sutures line
happens immediately, resolves in few days.
cephalhematoma
bleeding between peritineum and skull - buldging fontanels
doesnt happen immediately, longer to heal.
what to do for pre term labor
hydrate
meds to stop labor - (tocolytics) trabutaline, mag sulfate, calcium channel blockers
look for infections - UA (urine analysis)
Risks for a prolapsed cord
and what to do
baby malpositioned - breech, baby not engaged - head not down low
Get mom in knee chest position, ER c-section (sometimes nurse or person doing exam that notices this, goes into surgery hold the head off the cord), 100% 02 by mask
s/s and tx for abruptio
dark blood, hard rigid abd, pain
ER- c-section
can cause DIC or fetal demise
s/s and tx of placenta previa
bright blood, soft abd, no pain
pad cont, contractions, fetal heart tone, no vag exam (do US), risk for PPH (especially if mag sulfate used)
Uterine atony
most common cause of PPH
massage fundus, empty bladder, oxytocin then methergine- cn cause hypotension, 02
Augmenting labor
massage the nipples (releases oxytocin), walk, change positions, give oxytocin
Resp distress syndrom (RDS)
number 1 complication of preterm or diabetic baby
lack of surfactant
grunting, cyanosis
Atraumatic care
explain on childs level of development
pain not a reason to stop care
health people 2010
easy access to health care, nutrition, decrease health disparities
Care in pediatric is..
family centered, open system
manifestations of pyloric stenosis
projectile vomiting after eating - no bile, dehydration - sunken fontanels, lytes imblances, in metabolic akalosis
Rheumatic fever tx
PCN for up to 5 years and with and surgery, ASA
cultures done for any sore throat
wilms tumor
monitor for HTN, DO NOT palpate abd, treat with chemo with or without radiation
TEF
coughing, chocking, cyanosis
regurge/ aspiration - suction !
NPO - straight to surgery
Hemophilia
factor VIII - most common
RICE
bleeding in joints - ROM and PT after, can give replacement factor VIII
non-contact sports
PKU diet
no protein, no milk - lolfenac for infants
unlimited fruits and veggies
serpation anxiety beings around
6 months, can last until about 2
car seats
must be used for all children
middle back seat, rear facing
Med admin
add 5ml of sweetener
no mixing with formula or primary foods
along side of mouth, upright, not when crying, if put syringe in infant mouth they will tend to stop crying and suck on syringe.
oral syringe
injections - 25 gauge, 5/8 in needle, vastus lateralis
check IV site every hour
Accidental poison..what to do..
call poison control
dont induce vomiting
take EVERYTHING with you (what was ingested, urine, vomit, etc)
Go to ER
have meds locked and up high.
Management of nephrotic syndrome
prednisone - usually high doses
albumin
protect from injection - room with non infectious child
check urine for protein
s/s pf sepsis
behavioral changes, feeding problems, elevated temp
asthma triggers
mold, pets, carpets, upholstered furniture, smoking in household
Kawasaki’s
tx with ASA high doses and IVIG
autoimmune
can lead to coronary artery aneurysm
s/s- strawberry tongue, red hands and feet, cracked lips
post op cleft lip and palate
LIP- elbow restraints, position supine or side lying, logans bar to decrease manipulation, cuddle to soothe baby- dont want to cry and put strain on sutures, NO utensils, feed upright - formula and soft foods only, allow breaks - have difficulty adjusting to nose breathing.
PALATE- position prone to promote drainage, can have hearing and speech problems
complications of leukemia
infection, fractures, bone pain, bleeding, anemia
AGN complcations, at risk for
acute renal failure- check bun, cr, I&O, daily weight, VS
stroke - give no added salt diet, diuretics, and HTN meds
s/s of bact meningitis
increase temp, increase WBCs, HA, nuchal rigidity
newborn - poor sucking, high pitched cry, lethargy
CP goals of care
to function as normally as possible
Tetralogy of fallot
4 defects: VSD, pulmonic stenosis, overring aorta, hypertrophy of right ventricle
may have tet spells
risk for emboli, seizures, loss of consciousness or sudden death following anoxic spell
home care pre op cardio surgery
teach parents to watch for tachycardia, tachypnea
most teaching abour surgery is done out of hosp
Coarcatation of the aorta
Assess BP - higher in upper extermities, lower in lower exterm
EKG, MRI will show - left sided heart enlargement due to bac pressure and also notching of the ribs from the enlarged collateral vessels
DM type 1 are at risk for what..
DKA - kussmaul resp, ketonuria, polyuria, excessive thirst, dry mucous membranes, acetone breath, are in metabolic acidosis.
Common cause of death in infants (0-12 months)
suffocation - most common
dall down stairs, pick things up and eat them, can burn easily
injury in toddlers (1-3 yr)
and preschoolers (3-5yr(
Poisons, dart into streets, can drown in even 2 in of water, can open doors while driving, will put anything in their mouths.
injury in school age (6-12yrs)
Motor vehicle accidents, sport injuries, drugs, firearms, walking to school - avoid unsafe areas
injury of adolescents (13-18yrs)
motor vehicle, firearm, drugs, alcohol, suicides
sources of lead poisoning
older cities - lead based paint used in houses, peels off and children eat it
can also be inhaled
trust vs mistrust
birth to 1 year
infants need consisten, loving care by a mothering person
mistrust results when their is deficient or lacking of trust in the infants life, or their basic needs are not met.
autonomy vs shame and doubt
1 to 3 years
autonomy- the child is able to control their new physical abilities as well as mental abitilies
shame and doubt happens when they are made to feel small, forced to be dependent in ares they capable of being in control
initative vs guilt
3 to 6 years
initative- children are able to have their own mind and control their actions with being aware of threats
If they are made to feel their actions are bad, they will start to feel a sense of guilt
industry vs inferiority
6 to 12 yrs
industry- feel the need to work, want to carry out activities that they can finish or complete. Start to compete and cooperate with others and learn rules
if too much is expected of them or they feel they cant measure up they have feelings of inferiority
identity vs role confusion
12 to 18 yrs
start to become very concerned with their apperances and discovering their role in life
if they have trouble discovering their rold they end up in role confusion
normal VS for newborn
BP - not taken on a newborn
P 120-160, apical for 1 min, 110-160 for fetal HR
R 30 -60, periods of apnea less then 20 sec is normal
T 97.7 - 99.1 (F) 36.5 - 37.2 , anything lower than 97.7 or 36.5, intervene, could be infection
normal assessment of newborn
flexed, with some vernix and lanugo, newborn rash (sometimes seen), milia, iris-deep blue, sclera white, ears should recoil, small white dots on palate, breast engorgement is common and will subside, labia majora cover minora and clit - white or blood tinged fluid normal, closer the creases come to heel more mature they are, testes should be descended.
LGA
90th precentile, above 8 lbs
at risk for hypoglycemia and birth trauma
Problems: more likely to go thru a longer labor, suffer injury at birth, or need to be delivered by C-section, shoulder dystocia, fx of clavicle, damage to cervical or brachial plexus, or facial or phrenic nerves, cephalhematoma, subdural hematoma, bruising , congenital heart defects, higher mortality rate
ductus venosus
shunts 20-30% of blood f/umbilical vein to inferior vena cava & away f/immature liver; closes by 7-14 days after birth
Foramen Ovale
provides opening btwn RA & LA so blood can bypass nonfunctioning lungs & go directly to LV & aorta; opens only in R-to-L direction b/c of high RA pressure & low LA pressure; closed by 3rd month
ductus arteriosus
widely dilated to carry blood f/PA to aorta & avoid nonfunctioning lungs; functional closure by 10-96 hrs. & permanent closure within 2-3 mos.
physiologic changes in pregnancy
Uterus increases in size and the walls thin, vaginal secretions increase and ph decreases, breasts and nipples increase in size - colostrum is produced, hyperpigmentation, hair grows, resp are faster and deeper, N&V due to high hcg levels first 6-12weeks, frequent urination in 1st and 3rd trimester, kindeys enlarge, center of gravity changes.
SGA
problems- fetal distress, asphyxia, higher morbidity & mortality rates, low Apgar scores, meconium aspiration, polycythemia, hypoglycemia (b/c of inadequate storage of glycogen by liver), inadequate thermoregulation
first prenatal first
Comprehensive Health History
Reasons for seeking care
History-OB, Menstrual, Contraceptive, Med/Surg
Physical Exam- Head to Toe
Pelvic Exam-external, internal, shape and measurements
Lab Tests
prenatal blood work
Initial
Blood type and RH, Antibody screen, CBC-H&H, VDRL or RPR, HIV, Hep B Surf antigen, Tb, Rubella
15-16 weeks
MSAFP or triple or quad screen, Ultrasound
**24-28 weeks** Glucose challenge test or glucose tolerance, CBC, Rhogam if indicated
36 weeks
GBS
Follow up prenatal visits
**Maternal assessment **
Vital signs, weight, urine-glucose, protein, ketones
Common discomforts, nutrition
Warning signs
Appropriate lab tests, u/s etc
Fetal assessment
Fetal heart tones
Fetal movement
Fundal height measurement
Leopold’s
Stages of labor
1ST STAGE: Onset of Labor → 10cm
Latent- 0-3 cm, Active 4-7 cm, Transition 8-10cm
2nd STAGE: 10cm→Birth
3rd Stage: Birth of Baby →Delivery of Placenta
4th Stage: Delivery of Placenta →1-4hours post-partum
True labor
CONTRACTIONS:
REGULAR, STRONGER, LONGER, MORE INTENSE, Back to Front
CERVIX:
PROGRESSIVE CERVICAL DILATATION, MORE ANTERIOR
LABOR: MAY BEGIN WITH ROM
False labor
Contractions: Inconsistent in frequency, duration & intensity, Don’t change or may decrease w/activity (such as walking)
Pain: Felt in abd. & groin
May be more annoying than painful
Cervix Doesn’t significantly change in effacement or dilation
maternal physiologic responses to labor
with contractions- increase BP and P
WBC: 14,000-25,000 cells/mm³
Resp rate nd 02 consumption increase
increase metabolism
increase temp
may have N&V,
muscle cramps and aches
Fetal heart rate variablities
Baseline variability: we like to see some variability, its reassuring ex. Goes from 115, 120, 122, 130 etc.
Absent-no variability
Minimal-less than, equal to 5bpm
****Moderate-6-25 bpm(we love this!!)
Marked-over 25 bpm
Long term: Fluctuations of 6-10bpm
Short term: One beat to the next. Must have internal monitor.
No variability: Fetal sleep pattern or distress
2nd stage of labor - fully dialated- interventions
Check labor progress to see if shes completely dilated
Continue to monitor mom and baby: FHT’s, Vital Signs, Contractions
Support for mom and dad
Turn radiant warmer on, have O2, ambu bag, (if resp depression)
Put bed in delivery position if needed
Perineal prep if requested (vag delivery is clean technique)
Assist nurse-midwife or MD as needed
Call NICU if required – if thick meconium, or a pre-me, or resp. depression,
2nd stage - the birth
Crowning
Nurse Midwife or Physician will:push baby a lil to Control speed of delivery of head. (face down LOA, ROA)
Watch perineum
Episiotomy: only if needed
Check for nuchal cord
Clear mucous from baby’s mouth then nose
Deliver shoulders: light traction down and
then up
Clamp cord. Usually significant other cuts cord, ONCE THE BABY IS OUT
Stage 3 of labor - birth of baby has happened - ends with delievery of placenta
Bonding taking place: Place warmed blanket over mom’s abdomen so baby may be given to mom
Assess baby
Apgar score at 1 and 5 minutes, color, breathing, even if moms holding baby
Weight, length, head circumference of baby in the warmer
Footprints
Identification bands, HUGS security band , 2 on baby 1 on mom 1 on dad
3rd stage - expolsion of placenta
Nurse-midwife or MD will usually hold slight traction on cord, Too much traction could result in tearing of the cord.
Inspect placenta
Check for lacerations after delivery
Nursing Interventions: Administer Oxytocin after delivery of placenta if ordered Fundus, watch for excessive bleeding, Massage it Vital Signs Assist with laceration/episiotomy repair
DIRTY DUNCAN= MATERNAL, Shiny Shultz- fetal (baby)
4th stage of labor - placenta is delievered to 4 hours post partum
VS q 15 minutes x 1 hour
Fundus: location in relation to umbilicus. One hour after delivery right at umbilicus (back up from the 3 cm down @ delivery) One sonometer down q day!! (3 days post partum= 3; 2 days =2)
Bladder - have them void
Lochia: Rubra (Red) first bleeding they have
Perineum- put ice on everyones perineum that gives birth first 24 hr
Pain management-ibuprofen! or Motrin
Bonding
signs of an ectopic preg
Classic signs
Missed period****
Vaginal bleeding****
Abdominal pain****
Shock s/s are possible
Exam
+ pregnancy test
Adnexal fullness or tenderness or both on ovaries
+ Champaign sign (cervical motion tenderness)
Medical management of ectopic
Labs:
B Hcg and Serum Progesterone
Transvaginal u/s
Surgical removal (Ruptured Ectopic, Tube ruptured) Taking tube out is salpingectomy
methotrexate - for a intact ectopic the tube has not yet ruptured, this is a chemp drug it’s a folic acid that makes cells stop growing
pre and post of care of surgical removal of ectopic preg
Have blood products available
Pre-op labs generally include CBC, Type & Rh, Serum quantitative B Hcg
Post-op Care:
Verify Rh and antibody status
Rhogam if indicated
Grief counseling
Fertility counseling
mild preeclampsia
BP 140/90
proteinuria- +1 or +2
edema- dependent, eyes, face, fingers
reflexes- normal +2
urine output- 30ml/hr
severe preeclampsia
bp 160/110
proteinruria - +3 or +4
edema- generalized with pulmonary
hyperreflexia - +3 or +4 -clonus
urine - >20ml/hr
headache
blurred vision
irritability
hyperemesis gravidarum
Monitor:
Wt & VS’s, Urine dipstick for ketones, Labs as ordered
liver function, electrolytes
Environment: quiet, dark, no odors
Medications: Phenergan, Benedryl, Zantac, Pepcid, Prilosec, Reglan, Zofran, Methyprednisolone
Diet progresses slowly
Must have no N/V for 48Hrs
IV fluids and may need TPN
Psychosocial Assessment
Emotional support
risk for cardiac moms
miscarriage & PTL & PTD (preterm)
IUGR
risk of congenital heart lesions in NB
maternal mortality rate (in some cases 50% or >)
DM mom post part care
Check BS q 2hr
Insulin requirements substantially decrease after delivery so BS values are tracked closely, lower insulin med given
IV of D5W initiated
Risks of preeclampsia/eclampsia, PPH (b/c a big baby their uterus cant contract as much), and infection exist
Breastfeeding is advised and encouraged
it decreases insulin needs significantly
problems with the passenger
Anomalies = gross ascities, lg tumor, open neural tube deficits Excessive Size (diabetics)= cephlo-pelvic disproportion (CPD), usually \>4000 gms Associated with maternal DM, obesity, multiparity, lg wt gain, lg parents Malposition = 25% have persistent occiput posterior (back labor) \*\*\*Reposition her on all fours\*\*\* Malpresentation = breech is most common Frank = thigh flexed, knees extended Complete = thigh and knees flexed Incomplete breech =foot extends below buttocks and knee extends below buttocks Multifetal pregnancy = overdistention of uterus leading to dysfunctional patterns
Prolapse cord tx
Carefully assess during/after ROM
Immediate identification since fetal hypoxia can result & even death can occur w/o tx
SVE to lift presenting part
Maternal position changes****
Emotional support and information
O2 & IV fluids
Prepare for emergency delivery
hypotonic uterine dysfunction
Definition: Normal progress is made initially then changes in the active phase of labor
ctx’s become weak & inefficient or stop altogether
Common causes-CPD cephalopelvic disproportions & malpresentations
Tx- assess fetal size and status
if normal-ambulation, hydrotherapy, an enema, stripping membranes, nipple stim, and oxytocin or ptocin-can be used
if abnormal -c/section
**Hypotonic uterine dysfunction is more common than hypertonic.
Bishop score
Means to predict inducibility of the cx
Score includes-Cx dilation, effacement, fetal station, cx consistency, & cx position
Each category is scored 0-3
A score > or = to 8- means a successful induction is likely
augmentation/induction of labor
Oxytocin - produced in posterior pituitary gland
It stimulates uterine ctxs
It is given IVPB as a 2nd line on a pump to induce or augment labor
Indications- IUGR, PROM, dysfunctional ctxs, postterm pregnancy, chorioamnionitis, maternal medical conditions (DM, pulmonary Dx), PIH, Fetal demise, Hx precipitous delivery
GEST DM post part care
After delivery:
>90% of these women return to normal glucose levels
6 weeks PP/ After BF stop
75 gm 2hr glucose challenge test is done to assure a return to normal
***The infants of these women are at greater risk of obesity & DM in childhood or adolescence***
puerperal infections
Bacterial infection after childbirth
Temp of 100.4 of ↑ after the 1st 24 hrs. & occurring on at least 2 of the 1st 10 days following childbirth
Endometritis care
Goal: confine infectious process to uterus & prevent spread of infection throughout body
Abx until afebrile & asymptomatic for 24-48 hrs.
Prophylactic dose of Abx IV to any woman having a C/S
Comfort measures: warm blankets, cool compresses, cold/warm drinks, heating pad
Foods high in Vit. C & protein to aid healing
endometritis s/s
Temp of 100.4 or higher within 36 hrs. of birth, chills, malaise, anorexia
Abd. pain & cramping, uterine tenderness, purulent, foul-smelling lochia
Tachycardia, subinvolution
Elevation in leukocytes
wound infection care
Cultured & broad-spectrum Abx
Analgesics
Warm compresses or sitz baths may provide comfort & promote healting by increasing circulation to area
Surgical debridement for necrotizing fasciitis
wound infection s.s
Edema, warmth, redness, tenderness, pain
Edges of wound may pull apart, seropurulent drainage
Fever & malaise
UTI care
ABX - Pt. instructed to take med for entire time prescribed & not to stop when symptoms subside
2500-3000mL fluid/day
UTI s/s
Begin on 1st or 2nd PP day
Dysuria frequency, urgency, suprapubic pain
Hematuria, low-grade fever
Pyelonephritis: chills, spiking fever, costovertebral angle tenderness, flank pain, N&V
mastitis care
Supportive measures: moist heat or ice packs, breast support, bed rest, analgesics
Measures to prevent mastitis: position infant correctly & avoid nipple trauma & milk stasis, breastfeed q2-3h & avoid formula supps, nsg pads changed as soon as wet, avoid continuous pressure on breasts f/tight bras or infant carriers
Breast should be completely emptied at each feeding to prevent stasis, which can result in abscess
Massage over affected area before & during feeding helps ensure complete emptying
mastitis s/s
May think she has flu b/c of fatigue & aching MM
Temp of 102.2 of higher, chills, malaise, HA
Characterized by localized lump or wedge-shaped area of pain, redness, heat, inflammation, & enlarged axillary Lymph node
Hard, tender area may be palpated
Septic Pelvic Thrombophlebitis care
Readmission to hospital
Anticoagulation therapy w/IV heparin & IV abx
Warfarin may be given when heparin is d/c
septic pelvic thrombophebitis s.s
Occurs when infection spreads along venous system & thrombophlebitis develops
Clinical S/S
Ovarian vein syndrome: pain in groin, abd., or flank
Fever, tachycardia, N, V, bloating, decreased or absent bowel sounds
effects of substance abuse
Tobacco-↓O2, LBW vasoconstriction
Alcohol-IUGR, CNS, Facial Features
marijuana-Tremors, ↑Moro Reflex
Cocaine-Abruptio, low birth weight
Amphetamines-Vasoconstriction
Anti-depressants-unknown long-term
animism
Ascribing lifelike attributes to inanimate objects.
Fear a toilet because in a cartoon it ate a child.
Shaken baby syndrome
Characteristic injuries: intracranial bleeding, retinal hemorrhages, fx of ribs/long bones
Severe forms: seizures, posturing, alterations in LOC, apnea, bradycardia, death
Long-term outcomes: seizure, blindness, developmental delays, hearing loss, cerebral palsy, mild to profound mental, cognitive, motor impairments
signs of abuse
Conflicting stories about “accident” or injury
Cause of injury blamed on sibling/other party
Injury inconsistent w/hx (concussion & broken arm f/falling off bed)
Inappropriate response of caregiver (exaggerated/absent emotional response, refusal to sign for added tests or agree to necessary treatment, excessive delay in seeking treatment, absence of parents for questioning)
Inappropriate response of child (little/no response to pain, fear of being touched, excessive/lack of separation anxiety, indiscriminate friendliness to strangers)
prevention of otitis media
pneumococcal conjugate vaccine (PCV); reduce RF (breastfeed for 1st 6 mos., avoid propping bottle, ↓ or D/C pacifier, prevent exposure to tobacco smoke)
