Health Promotion And Maintenance Flashcards
Growth and development characteristics: 1 month
Head sags (neck muscles not strong enough)
Growth and development characteristics: 2 months
- closure of posterior fontanelle
- infant can turn from side to back
- infant develops social smile
- infant’s eye will begin to follow a moving object
Growth and development characteristics: 3 months
- infant brings objects to mouth
- infant can hold head erect, smile at mother, and laugh
Growth and development characteristics: 4 months
- thumb apposition, drools
- absent tonic neck reflex/moro reflex
- pleasure in social contact
Growth and development characteristics: 5 months
- birth weight doubled
- infant takes objects presented to him/her
Growth and development characteristics: 6 months
- weight gain 4 oz/week in second 6 months
- begins teething
- infant can turn from back to stomach
Growth and development characteristics: 7 months
- sits for short periods
- grasps toys with one hand
- fear of stranger begins to appear
- abrupt mood shifts
Growth and development characteristics: 8 months
- anxiety with strangers
- separation anxiety
Growth and development characteristics: 9 months
- elevates self to sitting position
- says “Dada”
- responds to parental anger
Growth and development characteristics: 10 months
- crawls well
- pulls self to standing position
- vocalize one or two words
Growth and development characteristics: 11 months
Infant can stand erect with support
Growth and development characteristics: 12 months
- birth weight tripled
- needs help while walking
- sits from standing position
- eat with fingers
- may say words other than “mama” and “dada”
Age-appropriate toys for infants from birth to 2 months
Mobiles
Age-appropriate toys for infants 2-4 months
Rattles, cradle gyms
Age-appropriate toys for infants 4-6 months
Brightly colored toys to grasp
Age-appropriate toys for infants 6-9 months
Large toys with bright colors, movable parts, noise makers
Age-appropriate toys for infants 9-12 months
Books with large pictures, push pull toys, teddy bears
At what age is solid food typically introduced to infants?
4-6 months
Solid food introduction considerations
- introduce one food at a time each 2-week period
- introduce least allergenic foods first half of first year, and more allergenic foods last half of first year
Usual order to introduction of solid foods
Cereal, vegetables & fruits (non-citrus), potatoes, meats, eggs, orange juice*
NOTE: * indicates allergenic foods
Growth and development characteristics: 15 months
- walks alone
- throws objects
- holds spoon
- names commonplace objects
Growth and development characteristics: 18 months
- anterior fontanelle closure
- walks backward
- climbs stairs
- hold crayon and scribble
- 10 word vocabulary
- thumb sucking
Growth and development characteristics: 24 months
- 300-word vocabulary
- obeys easy commands
- jumping
Growth and development characteristics: 30 months
- walks on tiptoe
- stands on one foot
- sphincter control fully developed for toilet training
Age-appropriate toys for toddlers (12-36 months)
- push-pull toys
- stuffed animals
- dolls
- low rocking horse
NOTE: avoid toys with small pieces to prevent airway obstruction; PARALLEL play develops at this age and these children often play through imitation
Growth and development characteristics: 3 years
- copies a circle
- decrease in tantrums
- rides a tricycle
- walks downstairs without assistance
- undresses without help
- 300-word vocabulary
- may invent imaginary friend
Growth and development characteristics: 4 years
- climbs and jumps wells
- laces shoes
- brushes teeth
- 1,500-word vocabulary
- skips and hops on one foot
- can throw ball or object overhead
Growth and development characteristics: 5 years
- runs well
- jumps rope
- dresses without help
- 2,100-word vocabulary
- tolerates increasing periods of separation from parents
- beginning of COOPERATIVE play
- learns how to tie shoes
Age-appropriate toys for preschool children (ages 36 months-6 years)
- playground materials
- housekeeping toys
- coloring books
- tricycle with helmet
Growth and development characteristics: 6 years
- self centered, show off
- Sensitive to criticism
- begins losing temporary teeth
Growth and development characteristics: 7 years
- participates in team games/sports
- develops concept of time
- plays with other children of same sex
Growth and development characteristics: 10-12 years
- remainder of teeth (except wisdom) erupt
- begins to develop interest in opposite sex
Play characteristics age 0-1 year
Holding toys
Play characteristics ages 1-7 years
Imitation
Play characteristics ages 8-12 years
Games and hobbies
Type of play exhibited throughout infancy
Solitary play
Type of play exhibited by toddlers
Parallel play
Type of play exhibited by preschoolers
Associative play
Type of play exhibited by school-age children
Cooperative play
Erikson’s trust v.mistrust stage of development
- Age: birth-1 year
- positive outcome: trusts self and others
- negative outcome: withdrawn, isolated
Erikson’s autonomy v. Shame and doubt stage of development
- Age: 1-3 years
- positive outcome: exercises self control
- negative outcome: defiant and negative
Erikson’s initiative v. Guilt stage of development
- Age: 3-6 years
- positive outcome: learns limits
- negative outcome: fearful, pessimistic
Erikson’s industry v. Inferiority stage of development
- Age: 6-12 years
- positive outcome: sense of confidence
- negative outcome: self doubt and feelings of inadequacy
Erikson’s identity v. Role diffusion stage of development
- age: 12-20 years
- positive outcome: coherent sense of self and plans for education, work, and future
- negative outcome: lack of personal or vocational identity
Erikson’s intimacy v. Isolation stage of development
- age: 20-35 years
- positive outcome: intimate relationship
- negative outcome: avoidance of intimacy
Erikson’s generatively v. Stagnation stage of development
- age: 35-65 years
- positive outcome: creative and productive
- negative outcome: self-centered
Erikson’s integrity v. Despair stage of development
- age: 65+
- positive outcome: sees life as meaningful
- negative outcome: fear of death and life lacking meaning
Mild intellectual delay
- IQ 55-70
- slow to walk, feed self, and talk
- may be able to learn reading and math for 3rd-6th grade level
Moderate intellectual delay
- IQ 40-55
- delay in motor movement
- able to perform some self-help activities
- will respond to training
- will NOT progress with reading or math skills
- communication skills will be poor
Severe intellectual delay
- IQ 24-40
- marked delay in development
- may not be able to perform self-care activities
- will profit from habit training
- will have some understanding of speech
Profound intellectual delay
- IQ <25
- significant delay
- minimal capacity to function
- may respond to skill training
- show basic emotions
Fundal height is above the symphysis at ___-___ weeks gestation
12-24
Fundal height is at the umbilicus or 20 cm at ___ weeks gestation
20
Fundal height rises ___ cm/week until 36 weeks
1
Total number of pregnancies regardless of duration (including present)
Gravida
Number of pregnancies beyond period of viability (20 weeks or 500 g)
Para
Quickening is maternal perception of fetal movement occurring between ___ and ___ weeks gestation
16; 20
Total recommended weight gain throughout pregnancy
24-28 lbs
Recommended weight gain during first trimester
2-4 lbs
Recommended weight gain during second trimester
12-14 lbs
Recommended weight gain during third trimester
8-12 lbs
Presumptive signs of pregnancy
- amenorrhea
- morning sickness
- breast sensitivity
- fatigue
- quickening
- urinary frequency
Probable signs of pregnancy
- uterine enlargement
- positive urine test
- hegar’s sign: softening of isthmus of uterus
- Chadwick’s sign: bluish discoloration of cervix
Positive (definitive) signs of pregnancy
- fetal heartbeat: 12 weeks by ultrasound, and 18-20 weeks by auscultation
- palpation of fetal movement
- visualization of fetus by ultrasound
Normal FHR
120-160 bpm
Normal fetal movement
Regular pattern of 10 movements in 20 minutes to 2 hours twice/day
NOTE: report less than 3 movements/hour
Maternal alpha-fetoprotein test (AFT)
- predicts neural tube defects (spinal bifida)
- decreased levels may predict Down syndrome
- done at 16-18 weeks gestation
Ultrasound nursing consideration
Full bladder assists in clarity of image
Favorable non-stress test (NST) result
2+ FHR accelerations of 15 bpm lasting 15 sec over a 20 min period
Positive contraction stress test
Late decelerations with at least 50% of contractions; potential risk to fetus; C-section may be indicated
Negative contraction stress test
No late decelerations with minimum of 3 contractions lasting 40-60 sec in 10 min period
Danger signs of pregnancy
- gush of fluid or bleeding from vagina
- regular uterine contractions
- severe headaches, visual disturbances, abdominal pain, persistent vomiting
- fever or chills
- swelling in face and fingers
- decrease in fetal movement
Latent phase of labor
- 0-3 cm dilated
- contractions 10-30 sec long, 5-30 min apart
- mild to moderate intensity
Active phase of labor
- 4-7 cm dilated
- contractions 30-40 sec long, 3-5 min apart
- moderate to strong intensity
Transition phase of labor
- 8-10 cm dilated
- contractions 45-90 sec long, 2-3 min apart
- strong intensity
Postpartum fundal height
- at level of umbilicus for first 12 hours
- descends by 1 fingerbreadth each day
Postpartum lochia
Day 1-3: rubra (bloody)
Day 4-9: serosa (pink-brown)
Day 10+: alba (yellow-white)
Abruptio placentae assessment
- Painful vaginal bleeding
- tender, painful abdomen
It is important to test all women with average risk for diabetes at ___-___ weeks gestations
24-28
Ectopic pregnancy assessment
- unilateral lower quadrant pain
- rigid, tender abdomen
- referred shoulder pain
- low Hct and hCG levels in blood and urine
- bleeding
Hydatidiform mole assessment
- elevated hCG
- uterine size larger than expected for dates
- no fetal heart tones
- minimal dark red/brown vaginal bleeding with grape-like clusters**
- N/V
Hydatidiform mole client education
Monitor hCG levels for 1 year, pregnancy discouraged for 1 year
Mild preeclampsia
- begins past 20th week
- BP > 140/90 mm Hg
- 2+ to 3+ proteinuria
- slight generalized edema
Severe preeclampsia
- BP > 160/110 mm Hg
- 4+ proteinuria
- headache
- epigastric pain
- may develop pulmonary edema
- hyperreflexia
Eclampsia assessment
- hypertension
- proteinuria
- tonic-clonic seizures
- coma
Placenta previa assessment
- first and second trimester spotting
- third trimester — painless, profuse bleeding
Postpartum hemorrhage is defined as blood loss greater than _____ mL after a vaginal birth or _____ mL after a cesarean birth
500; 1000
Postpartum blood loss is measured by weight perineal pads and is considered large if it exceeds ___ inches to saturated in _____
6; 1 hr
Moderate postpartum blood loss
Greater than 4 inches but less than 6 inches in 1 hr
Apgar score criteria
- color
- HR
- reflexes
- muscle tone
- respirations
NOTE: each category scored from 0-2
Apgar scoring
< 3: critical
4-6: fair
7-10: normal
Normal newborn respirations
30-60 breaths/min with short periods of apnea (<15 sec)
Normal newborn blood pressure
65/40 in arm and calf
Umbilical cord care
Keep it dry and exposed to air (will fall off after 1-2 weeks)
Prevention of cold stress in newborns
- delivery room set at 22 degrees Celsius (71 degrees Fahrenheit)
- infant dried with pre-warmed towels and given a cap
- skin to skin contact with mom
Hypoglycemia in the infant is when the blood sugar is less than ___ mg/dL
35
NOTE: normal blood sugar is 40-80 mg/dL
Breast self-examination
- perform 1 week after onset of menstrual period OR on a designated day (first of month)
- inspect breasts in mirror
- examine with arms at sides, with arms above head, and with hands on hips
- use pads of 3 middle fingers
- assess for dimpling, discharge, changes
Testicular self-examination
- support testes in palm of hand
- palpate between thumb and forefinger
- perform during warm shower
- perform monthly
Diaphragm contraception patient education
- fitted by HCP
- do NOT insert > 6 hrs prior to sex
- remove at least every 24 hours
- higher risk of UTI and TSS
Cranial nerve I
- Olfactory
- test this by having client smell an nonirritating substance with eyes closed; test each nostril separately
Cranial nerve II
- optic
- test with snellen chart and ophthalmoscopic exam
Cranial nerve III
- oculomotor: controls pupil constriction and raising of eyelids
- test by having client look up, down, and open eyes; shine penlight and assess PERRLA
Cranial nerve IV
- trochlear: controls downward and inward movement of eyes
- test by having client look down and watch finger as moved towards client’s face
Cranial nerve V
- trigeminal: controls jaw movement, sensation on face and neck
- test by touching both sides of face with pin and cotton; have client open jaw and bite down
Cranial nerve VI
- abducens: controls lateral movement of eyes
- test by having client look up, down, and inward; have client watch finger go towards their face
Cranial nerve VII
- facial: controls facial movement and taste on anterior 2/3 of tongue
- to test, have client frown, smile, and raise eyebrows; place sweet, sour, bitter, salty substances on tongue to assess taste
Cranial nerve VIII
- acoustic: controls sense of hearing and balance
- to test, have client listen to ticking watch; have client stand with eyes closed to assess balance
Cranial nerve IX
- glossopharyngeal: controls swallowing and taste on posterior of tongue
- assess by placing sweet, sour, bitter, salty substance on tongue; elicit gag reflex
Cranial nerve X
- vagus: controls swallowing and speech
- instruct client to say “ahh” to assess soft palate and uvula; have client speak to assess quality of voice
Cranial nerve XI
- spinal accessory: controls flexion and rotation of head, shrugging of shoulders
- assess by having client shrug shoulders against resistance, and move head side to side against resistance
Cranial nerve XII
- hypoglossal: controls tongue movement
- assess by asking client to stick out tongue and move it quickly side to side
The nurse performs a caloric test as part of the neurological assessment. Which information does the client need to know before the caloric test?
Vertigo and dizziness may occur during the examination
NOTE: this assesses cranial nerve 8
Hep B vaccination schedule
1) birth - 3 mo.
2) 1-4 mo.
3) 6-18 mo.
DTaP vaccination schedule
1) 2 months
2) 4 months
3) 6 months
4) 15-18 months
5) 4-6 years
6) Td (booster) 11-16 years
Hib vaccination schedule
1) 2 months
2) 4 months
3) 6 months
4) 12-15 months
Inactivated polio (IPV) vaccination schedule
1) 2 months
2) 4 months
3) 6-18 months
4) 4-6 years
MMR vaccination schedule
1) 12-15 months
2) 4-6 years
Varicella vaccination schedule
12-15 months
Pneumococcal (PCV) vaccination schedule
1) 2 months
2) 4 months
3) 6 months
4) 12-15 months
Sequence for assessment of abdomen
Inspection, auscultation, percussion, palpation
Sequence for physical assessment
Inspection, palpation, percussion, auscultation
The _________ of the stethoscope should be used to auscultate high-pitched sounds such as lung, bowel, and heart
Diaphragm
The _________ of the stethoscope should be used to auscultate low-pitched sounds such as murmurs
Bell
