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mark k Flashcards

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1
Q

If the pH and bicarb are in the same direction, the problem is ___

A

metabolic

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2
Q

What kind of imbalance is DKA?

A

met. acidosis

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3
Q

What is the problem when over ventilating?

A

alkalosis

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4
Q

What is the problem when under ventilating?

A

acidosis

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5
Q

When is the prob usually met alkalosis?

A

prolonged gastric suctioning or vomiting

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6
Q

What do high pressure alarms mean?

A

resistance
1. kinked tube
2. water condensing in tube
3. secretions

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7
Q

What are some interventions for high pressure alarms?

A

fix tubing, change position (turn, cough, deep breath)

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8
Q

What does low pressure alarm mean?

A

decreased resistance to airflow, disconnection

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9
Q

Wernicke-Korsakoff syndrome tx?

A

give vitamin b1, redirect when making up stories

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10
Q

Disulfuram teaching ?

A

onset: 2 weeks
duration: 2 weeks
-avoid all forms of alcohol (mouthwash, perfume, aftershave, uncooked icing, insect repellent, OTC elixir)

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11
Q

What are upper drugs?

A

caffeine, cocaine, PCP/LSD, methamphetamines, adderall

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12
Q

What is the greatest risk in upper OD/downer withdrawal?

A

seizure

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13
Q

What is the greatest risk in downer OD/ upper withdrawal?

A

resp arrest

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14
Q

Difference between alcohol withdrawal vs delirium tremens?

A

-alc withdrawal: always occurs after 24 hrs
-delirium tremens: progresses after 72 hrs

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15
Q

What are the tx for both alc withdrawal and delirium tremens?

A

HTN pill
tranquilizer
multivitamin B1

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16
Q

What do aminoglycosides tx?

A

TB, septic peritonitis, fulminating pyelonephritis, septic shock, third degree burns

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17
Q

What do aminoglycosides end in?

A

-mycin (ones w/ “-thro-“ in middle are not aminoglycocides)

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18
Q

Toxic effects of a mean old mycins?

A

monitor hearing (mice), tinnitus, nephrotoxic (ear shaped like kidney), CN8 toxicity (figure 8 drawn outside of ear)

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19
Q

When can mycins given PO?

A

bowel sterlization pre op and hepatic encephalopathy

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20
Q

Who can sterlize the bowel?

A

NEO KAN
neomycin & kanamycin

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21
Q

What is the #1 producer of ammonia?

A

e. coli

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22
Q

When to draw trough?

A

30 mins before next dose

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23
Q

When is peak for sublingual?

A

5-10 min after dissolved

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24
Q

When is peak IV?

A

15-30 mins after bag finished

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25
Q

when is peak IM?

A

30-60 mins

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26
Q

What do Calcium Channel Blockers do?

A

calm down heart, like valium for the heart

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27
Q

When to use CCBs?

A

Antihypertensive, Anti-anginal, anti atrial arrythmia

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28
Q

S/E of CCBs?

A

headache and hypotension (H&H)

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29
Q

What do CCBs end in?

A

-dipine (dipping into calcium channel)
-verapimil
-cardizem (given continuous IV drip)

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30
Q

If question mentions QRS depolarization?

A

ventricular

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31
Q

If question mentions P wave?

A

atrial

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32
Q

What are the lethal arrythmias?

A

v fib and asystole

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33
Q

What are beta blockers used for?

A

antihypertensive
anti-anginal
anti atrial arrythmia

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34
Q

S/e of beta blockers?

A

headache, hypotension, and bronchoconstriction

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35
Q

What do beta blockers end in?

A

-lol (funny asf)

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36
Q

What is the treatment for v fib?

A

defibrillation

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37
Q

Tx for asystole?

A

atropine and epi

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38
Q

What is removed by chest tube in pneumothorax?

A

air

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39
Q

What is removed by chest tube in hemothorax?

A

blood

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40
Q

What is removed by chest tube in hemopneumothorax?

A

air and blood

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41
Q

What does an Apical chest tube remove?

A

Air = (A)pical

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42
Q

What does a Basilar position chest tube remove?

A

Blood = (B)asilar

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43
Q

Nursing action if seal of chest tube breaks?

A
  1. Clamp <15 seconds
  2. cut the airway
  3. submerge stick the end of tube under sterile water
  4. unclamp
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44
Q

Interventions if chest tube is pulled out?`

A
  1. take gloved hand and cover opening
  2. sterilze vaseline and tape 3 sides
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45
Q

What do all the trouble congenital heart defects start with, what is the exception?

A

T, except left ventricular hypoplastic syndrome

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46
Q

What will all children have with CHD?

A

-murmur
-echocardiogram done to determine cause of murmur

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47
Q

What are the 4 defects that are within ToF?

A

think “PROVe”
P-pulmonary artery stenosis
R-right ventricular hypertrophy
O-Overriding aorta
V-Ventricular septal defect

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48
Q

What type of diseases are usually put into contact precautions?

A

GI or fecal/oral
c diff, hep a, e coli, cholera, dysentery, staph, rsv, herpes

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49
Q

What type of diseases usually go into droplet precautions?

A

meningitis, influenza, epiglottitis (bugs traveling through cough, sneezing)

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50
Q

What type of diseases usually go into airborne precautions?

A

mmr, tb, varicella mtv

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51
Q

order of putting ppe on?

A

(g’s in reverse alphabet order)
1. gown
2. mask
3. goggles
4. gloves

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52
Q

Take off PPE order?

A

alphabetical order
1. gloves
2. goggles,
3. gown
4. mask

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53
Q

What is a 2 point gait for crutches?

A

crutch and opposite foot and crutch with other foot move together mid bilateral weakness

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54
Q

What is a 3 point crutch gait?

A

move 2 crutches and bad leg together followed by unaffected leg

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55
Q

What is a 4 point gait?

A

move everything separately
crutch-opposite foot-crutch-opposite foot

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56
Q

When to use 2 and 4 point gait?

A

When weakness is EVENLY distributed (both even #s)
-2 pt for mild probs
-4 pt for severe

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57
Q

Up the stairs w crutches?

A

when going up, good foot moves up first, crutch always move with bad leg

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58
Q

Down stairs w crutches?

A

bad foot move down last

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59
Q

Teaching for canes?

A

-hold on strong side
-advance w opposite side for wider suppport
-handgrip @ level with wrist

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60
Q

Teaching for walker?

A

-walker on side of patient
-hold onto chair, stand up, grab onto walker
-tie belongings to side

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61
Q

What are delusions?

A

false, fixed belief or idea or thought with no sensory component

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62
Q

Example of paranoid delusion?

A

“people are out to kill me”

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63
Q

Example of somatic delusion?

A

“I have xray vision”

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64
Q

What is the difference between an illusion and delusion?

A

Real things are happening that are being misinterpreted in illusions, whereas with delusions nothing is reality

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65
Q

What are most common delusions in order?

A
  1. auditory
  2. visual
  3. Tactile
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66
Q

What are the steps for nursing interventions in functional psychosis?

A
  1. Acknowledge feelings
  2. Present reality
  3. Set limits
  4. enforce limit
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67
Q

What are the disorders that experience functional psychosis?

A

skeezo (schizo), skeezo (schizo-affective), major, manic (bipolar only during mania)

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68
Q

What are the 3 types of psychosis?

A
  1. functional
  2. dementia
  3. psychotic delirium (secondary to illness)
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69
Q

What are the steps of nursing intervention when dealing with psychotic delirium?

A
  1. Acknowledge feelings
  2. Reassure safety and reminder of temporariness of condition
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70
Q

What is Diabetes Insipidus?

A

FVD, polyuria & polydypsia leading to dehydration due to low ADH, high urine output (low urine Specific gravity)

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71
Q

What is SIADH?

A

FVE, oliguria, decreased urine output, decreased serum specific gravity, high urine SG

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72
Q

What is. DM2 diet usually?

A

-caloric restriction
-1200, 1400, 1600
-6 small frequent feedings per day

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73
Q

What is the onset, peak, and duration of reg insulin?

A

-1 hour
-2 hours
-4 hrs

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74
Q

What is onset, peak, and duration of NPH insulin?

A

-6 hrs
-8-10 hrs
-12 hrs

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75
Q

What is the onset, peak, and duration of Lispro insulin?

A

-15 mins
-30 mins
-3 hours

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76
Q

What is the onset, peak, and duration of Glargine insulin?

A

-no peak
-12-24 hours

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77
Q

What is the #1 cause of DKA?

A

upper resp infection within last 2 weeks

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78
Q

What are S/Sx of DKA?

A

(D): dehydration
(K): high K+, Ketones in urine, Kussumauls
(A): Acidosis, Acetone breath, Anorexia

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79
Q

What is HHS and what is the tx?

A

hyperglycemia in DM2
dehydration!!!!!!!
rehydration is tx, successful tx= increased Urine output and moist mucous membranes

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80
Q

What is a normal HbA1c value?

A

<6

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81
Q

What is uncontrolled A1c?

A

> 8

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82
Q

What is borderline A1c?

A

7

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83
Q

What is lithium and what are the toxic values?

A

-used for bipolar
- greater than or equal to 2 is toxic

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84
Q

What is Lanoxin/Digoxin and what are the toxic values?

A

-A fib and CHF
-greater than or equal to 2 is toxic

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85
Q

What is aminophylline and what are the toxic values?

A

-muscle spasms airway relaxer, compound of bronchodilator theophylline
-greater than or equal to 20 is toxic
-non-therapeutic level is <10

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86
Q

What is dilantin (phenytoin) and what are the toxic values?

A

-seizure med
-greater than 20 is toxic

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87
Q

What is bilirubin and what are the toxic values?

A

-breakdown product of RBCs
- in newborn over 20 is elevated (usually admit newborn to hospital with levels around 14-15)

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88
Q

What disorder can happen when jaundice level gets >20?

A

Kernicterus
can cause aseptic meningitis or encephalopathy

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89
Q

What is the position a newborn may assume when irritated meninges from Kernicterus?

A

hyperextended posture
tx: put newborn on side

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90
Q

What is hiatial hernia?

A

-regurg of gastric acic upward or backward into esophagus
-contents go in wrong direction at correct rate

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91
Q

What are the s/sx of hiatial hernia?

A

same as GERD; heartburn, indigestion on lying down after eating

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92
Q

What is tx for hiatial hernia?

A

raise HOB, increase fluid with meals, increase carb content

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93
Q

What is dumping syndrome?

A

gastic contents dumped too quickly into duodenum (right direction, wrong rate). low proetin

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94
Q

S/Sx of dumping syndrome?

A

DRUNK: staggering gait, impaired judgement, labile, hypolgycemia
Acute abd distress: diarrhea, cramping, guarding, borborygmi, bloating, distention

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95
Q

Tx of dumping syndrome?

A

-lower HOB during meals and put pt on side
-decrease amnt of fluid 1-2 hrs before meals
-decrease carb intake
-high protein

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96
Q

What direction do patients with hypo/hyperkalemia present with?

A

same as prefix except HR and urine output

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97
Q

What direction do calcemias go with patient presentation?

A

opposite direction as prefixes
hypocalcmia: chvostek and troussau signs, TETANY, pick muscle/bone related

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98
Q

What direction does mag go with patient presentation?

A

opposite

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99
Q

Patient presentaiton w/ hyponatria?

A

FVO

100
Q

Patient presentation w/ hypernatremia?

A

dehydratin

101
Q

What are the first signs of electrolyte imbalance?

A
  1. parasthesia (numbness and tingling in limbs)
  2. paresis (muscle weakness)
102
Q

Tx for hyperkalemia?

A

give d5w, reg insulin, and kayexelate at same time (rapid repsonse, requires many healthcare members in room at once)

103
Q

Hyperthyroidism s/sx?

A

-weight loss
-tachy
-elevated BP
-hyperpersonality
-heat intolerance
-expothalmos (run yourself into the GRAVES disease)

104
Q

Hypothyroidism s/sx?

A

-weight gain
-brady
-low bp
-flat, boring
-cold intolerance

105
Q

Tx for hyperthyroidism?

A

-radioactive iodine
-PTU (propylthiouracil)
-Thyroidectomy

106
Q

Teaching for radioactive iodine?

A

-priv room for 24 hours
-flush toilet three times (call hazmat if urine spills)
-visitor restriction in hospital and @ home for first 24 hrs

107
Q

What to monitor for PTU tx?

A

immunosuppression (PTU=Puts Thyroid Under)

108
Q

What are total thyroidectomy patients at risk for?

A

hypocalcemia due to difficulty spare parathyroid gland

109
Q

What are subthyroidectomy pts at risk for?

A

thyroid storm

110
Q

Thyroid strom s/sx?

A

-temps of >105
-high BP, stroke level(210/180)
-severe tachy
-psychotically delirious

111
Q

Tx of thyroid storm?

A

-lower temp
-increase O2
-ice pack, cooling blanket, oxygen at 10L

112
Q

What are the priority risks for sub and total thyroidectomy in first 12 hrs?

A
  1. airway (edema)
  2. hemorrhage
113
Q

What are the priority risks for sub and total thyroidectomy in next 12-48 hrs?

A

-total: tetany (hypocal)
-sub: thyroid STORM

114
Q

What is the priority risk for sub and total thyroidectomy after 48 hrs?

A

infection for both

115
Q

What is myexedema?

A

when pt with hypothyroidism presents with skin involvement

116
Q

Tx for hypothyroidism?

A

-levothyroxine (synthroid)
taken in morning 1/2 to 1 hour before breakfast on empty stomach w water

117
Q

Should you sedate hypothyroidism pts?

A

NOOOO

118
Q

What is Addison’s disease?

A

-under secretion of steroids
-addisonian crisis=hypoglycemic episode
-pts hyperpigmented
-do not adapt to stress
-in addisons, you “add a -sone” (steroid therapy)

119
Q

Cushing disease s/sx? `

A

-moon face
-hirsutism
-truncal or central obsesity
-muscle atrophy
-gynecomastia
-buffalo hump
-sodium and water retention
-losing K+ out back
-High glucose
-easy bruising
-grouchy
-immunosuppression

120
Q

Tx for cushings diseae?

A

adrenalectomy (takes abt a year of steroids for them to look normal, now have Addisons diseae)

121
Q

What are best toys for 0-6 months?

A

-sensorimotor
-musical mobile or something soft and large

122
Q

What are the best toys for 6-9 months?

A

-object permanence
-cover/uncover (jack in box, peek a boo)
-large but firm toys

123
Q

What are the best toys for 9-12 months?

A

-vocalization (tickle me elmo, woody cowboy)
-purposeful play: build, sort, stack, make, construct

124
Q

Best toys for 1-3 years?

A

-gross motor skills (running, jumping)
-push/pull toys, paint, parallel play, lawn mowers, wagon

125
Q

Best toys for 3-6 y/o?

A

-fine motor skills (write, draw, scissors, dance, ice skate, highly imagineable)

126
Q

best toys for 7-11 y/o?

A

creative, collective, and competitive

127
Q

Why is laminectomy performed?

A

relax nerve root compression, cut bony prominences to give nerves more room

128
Q

S/Sx of nerve root compression?

A

1.pain
2. paresthesia
3. paresis

129
Q

Cervical laminectomy nursing priorities?

A

-preop: assess for breating and functions of arms and hands
-postop complication:pneumonia

130
Q

Thoracic laminectomy nursing priorities?

A

-assess cough and bowel preop
-pneumonia and paralytic ileus postop complication

131
Q

Lumbar laminectomy nursing priorities?

A

-preop: urinary retention assessment (last void/ bladder empty)
-postop: urinary retention and leg function

132
Q

Mobilization with laminectomy pts?

A

-do not dangle
-log roll
-supine-> walking ASAP
-no sitting > 30 mins
-walk, stand, lie down

133
Q

What is laminectomy w/fusion?

A

-takes bone graft from iliac crest and the spine
-hip will have more pain & bleeding
-spine will have risk of rejection
-equal chance for infxW

134
Q

What is temporary teaching after fusion/laminectomy?

A

(6 weeks)
-do not sit > 30 mins
-lie flat, log roll
-do not drive
-do not life > 5 weeks

135
Q

What is permanent teaching after fusion/laminectomy?

A

-not allowed to bend at waist
-not allowed to lift over head
-no horseback riding, off trail biking, rollercoasters

136
Q

What is creatinine? Normal value?

A

-best indicator of kidney function
-0.6 to 1.2
-Level A or B if procedure with dye is involved

137
Q

What is INR normal?

A

2-3

138
Q

When is INR level C & action?

A

-greater than or equal to 4
actions:
1. hold coumadin
2. focused bleeding assessment
3. prepare to give K+
4. Call hcp

139
Q

When is K+ a level C?

A

if low or high (5.3-5.9)

140
Q

When is K+ level D and action?

A

> 6
-hold K+
-asess heart
-prepare to give insulin/kayexelate
-call hcp
-STAY WITH PT

141
Q

What to do when K+ is low?

A

-assess heart
-prepare to give K+
-call hcp

142
Q

When is pH level D and actions to take?

A

-if in 6s
-assess VS
-call HCP

143
Q

When is hemoglobin level C and actions to take?

A

<8
-assess for bleeding/anemia/malnutrition
-prepare blood
-call HCP

144
Q

When is bicarb level C and actions?

A

in 50s
-assess breathing
-ask pt to perform pursed lip breathing
-call hcp

145
Q

When is bicarb level D and actions?

A

60<
-Prepare to intubate/ventilate
-call resp then hcp
-DO NOT LEAVE PT

146
Q

When is 02 or Pa02 level c and action?

A

70-77
-assess for resp difficulty & dyspnea
-prepare to give 02
-call hcp

147
Q

When is 02 or Pa02 level d and action?

A

60s or lower
-prepare to intubate/vent
-call resp then hcp

148
Q

in coronary care what are the two most common episofic causes of tachy and what is the action?

A

hypoxia and dehydration (give 02 and increase fluid rate)

149
Q

When is 02 sat a level C and action?

A

-<93%
-give patient 02

150
Q

What can invalidate a 02 sat reading?

A

-anemia
-dye procedure

151
Q

When is sodium level C and actions to take?

A

-abnormal AND change in LOC
-assess for fluid volume overload or dehydration
-prepare furosemide or IV fluid
-call hcp

152
Q

When is WBC level C and action to take?

A

<4,000
-assess and put on neutropenic precautions

153
Q

When is ANC a level C and what action to take?

A

<500
-assess and put on neutropenic precautions

154
Q

When is CD4 count indicative of HIV?

A

<500

155
Q

When is CD4 count indicative of AIDS?

A

<200

156
Q

When is platelet level C?

A

<90000

157
Q

When is platelet level D?

A

<40000

158
Q

What are the five deadly D drugs?

A

-K+ >6
-pH in 6s
-CO2 in 60s
-PO2 <60
-platelets <40,000

159
Q

What do all psych drugs cause?

A

low bp and weight changes (usually weight gain)

160
Q

What are phenothiazines?

A

-major tranquilizer
-end in -zine
-use zine for the zany (crazyyy)
-may be antiemetic in small doses

161
Q

S/S of phenothiazines?

A

(A)nticholinergic (dry mouth)
(B)lurred vision
(C)onstipation
(D)rowsiness
(E)PS
-(F)oto sensitivity
a(G)ranulocytosis (low wbc, immunosupressed, teach pt to recognized and report and s/sx of infection)

162
Q

What do the tricyclic antidepressants do?

A

-reuptake inhibitors
-mood elevators

163
Q

What are the tricyclic antidepressants?

A

Elavil, Trofranil, Aventyl, Desyrel

164
Q

S/E of tricyclic antidepressants?

A

(A)nticholinergic
(B)lurred vision
(C)onstipation
(D)rowsiness
(E)UPHORIA

165
Q

What are the benzos?

A

-anti-anxiety, minor tranquilizers
-usually have zep in name and many end with “pam” or “lam”

166
Q

What is the caution with benzos?

A

do not take >2-4 weeks, work while waiting for major tranquilizers to kick in. take both at same time

167
Q

S/E of benzos?

A

(A)nticholinergic
(B)lurred vision
(C)onstipation
(D)rowsiness

168
Q

What are the MAOIs and how to spot them on exam?

A

-antidepressant
-MARplan, NARdil, PARnate (beginnings rhyme)

169
Q

S/E of MAOIs?

A

A
B
C
D

170
Q

What does lithium do?

A

treat bipolar disorder, mania

171
Q

S/E of lithium?

A

3 P’s
-peeing (polyuria)
-pooping (diarrhea)
-paresthesia (numbness and tingling)

172
Q

Toxic side effects of lithium?

A

-tremors
-metallic taste
-severe dirrhea

173
Q

What is the #1 nursing intervention for pts on lithium?

A

INCREASE FLUIDS
monitor Na+ levels

174
Q

What does Prozac (fluoxetine) do?

A

SSRI, mood stabilizer

175
Q

S/E of prozac

A

A
B
C
D
EUPHORIA

176
Q

Things to watch out for when admin for prozac?

A

-give before noon, can cause insomnia
-when changing dose for young adults and adolescents, watch for suicidal ideation

177
Q

What is Haldol?

A

tranquilizer

178
Q

S/E of Haldol?

A

A
B
C
D
E
F
G

179
Q

What to monitor when pt on Haldol?

A

-development of neurolyptic malignant syndrome from OD
-fever >105

180
Q

What does Clozaril (clozapine) do?

A

atypical antipsychotic
-2nd g4n antipsychotics end in -zapine)

181
Q

S/e of clozapine (clozaril)q

A

agranulocytosis (worse than cancer drug, can trash pt bone marrow

182
Q

What is zoloft (sertraline) used for?

A

antidepressant

183
Q

What can sertraline (zoloft) interact with?

A

st johns wart
warfarin

184
Q

S/E of serotonin syndrome?

A

(S)weating
(A)pprehensive
(D)izziness
HEADache
(sad head)

185
Q

What should nurse do if pt on st johns wort or warfarin w sertraline?

A

lower dose

186
Q

How to do Naegels rule for EDD?

A

take 1st day of last menstrual period, add 7 days & subtract 3 months

187
Q

How much weight is expected to gain each week for 1st, 2nd and 3rd trimester?

A

-1st: 1 lb/month (3 lbs total)
-2nd/&3rd: 1 lb/week
28 + or - 3

188
Q

What to do if mom has gained + or - 3 lbs than expected?

A

assess her

189
Q

What to do if mom has gained - or + 4 lbs than expected?

A

perform BPP on fetus

189
Q

When can fundal heigh be palpated?

A

12 weeks (should be midway between umbilicus and pubic symphysis)

190
Q

What can a much bigger than normal fundus indicate?

A

molar pregnancy

191
Q

Positive signs of pregnancy?

A
  1. fetal skelton on x-ray
  2. presence of fetus on US
  3. auscultation of fetal heart
  4. examiner palpates fetal movement
192
Q

When would you FIRST vs MOST LIKELY find fetal heart?

A

8 weeks
10 weeks

193
Q

When would you FIRST vs MOST LIEKLY have quickening?

A

16 weeks
18 weeks

194
Q

MAYBE s/sx of pregnancy?

A

(occur chronologically in alphabetical order)
1. urine blood/preg tests
2. Chadwick- cervical color changes to Cyanosis
3. Goodelll- good and soft soothening of cervix
4. Hegar sign- uterine softening

195
Q

When should prenantal visits be?

A

-1x a month until week 28
-Every other week between 28-36
-Every week after week 36 until delivery or week 42
-delivery induction or c section at week 42

196
Q

What is the abnormal lab that is normal in pregnancy?

A

low Hemoglobin
-1st trimester: 11
-2nd: 10.5
-3rd: 10

197
Q

When is urinary incontinence seen in pregnancy and how to treat it?

A

-1st and 3rd trimester
-void at least every 2 hrs until 6 weeks pp

198
Q

What is the most valid sign that a woman is in labor?

A

onset of regular/progressive contractions

199
Q

What is fetal lie?

A

relationship between spine of mother and baby (you want vertical line)

200
Q

What are the most common fetal presentations?

A

ROA or LOA, pick ROA before LOA

201
Q

What are the names with the first stage of labor?

A
  1. Latent
  2. Active
  3. transition
202
Q

Characteristics in latent stage of labor?

A

-cervical dilation from 0-4 cm
-contractions 5-30 mins apart lasting 15-30 seconds
-mild intensity

203
Q

Characteristics of active stage of labor?

A

-cervical dilation 5-7 cm
-contractions 3-5 mins apart
-60-90 seconds

204
Q

Characteristics of transition stage of labor?

A

-8-10 cms
-contractions 2-3 mins apart lasting 60-90 seconds
-strong intensity

205
Q

What is stage 2 of labor?

A

delivery of baby

206
Q

What is stage 3 of labor?

A

delivery of placenta

207
Q

What is stage 4 of labor?

A

2 hours, until bleeding stops

208
Q

What are the parameters for normal contractions?

A

90 seconds and no closer than 2 mins apart

209
Q

What can be the prob if contractions are greater than parameters?

A
  1. uterine atony
  2. stop pitocin
  3. uterine hyperstimulation
210
Q

Interventions for painful back pain?

A

-position and push
-knee chest position
-push with fist into sacrum to use counter pressure

211
Q

Prolapsed chord interventions?

A

-push head in off chord and position knee chest or trendelenburg
-prep for c section

212
Q

Interventions for all other labor complications?

A

(L)eft side
(I)V
(O)xygen
(N)otify HCP
stop pitocin before everything else

213
Q

What to keep in mind with pain med admin during labor?

A

do not give med if baby is likely to be born when med peaks

214
Q

What to do with fetal monitoring patterns that start with “L” (late, low baseline variablity, low fetal HR)

A

LION

215
Q

What to do with high FHR?

A

> 160
-document acceleration
-take moms temp
-baby WNL

216
Q

What happens in second stage of labor?

A
  1. deliver head, stop pushing
  2. suction baby mouth then nose
  3. check for nuchal chord around neck
  4. deliver shoulders and body
  5. ID band before leaving delivery area
217
Q

What to check in third stage of labor?

A
  1. placenta complete and intact
  2. check 3 vessel cord and 2 arteries 1 vein AVA
218
Q

What to do in 4th stage of labor?

A

(4x an hour, every 15 mins)
1. vital signs (assess s/sx of shock, decrease bp, rates increased, cold, pale, clammy)
2. Fundus (massage if boggy, catheterize if misplaced)
3. Perineal bads (excessive: saturated in 15 mins or less)
4. Roll patient over and check for bleeding underneath

219
Q

What to assess in post-partum stage?

A

(assess every 4-8 hrs)
-Uterine fundus
-lochia (rubra red, serosa pink, alba white, moderate amount 4-6 inches in hour)
-extremities

220
Q

What should the height of the fundus be after delivery?

A

@ umbilicus

221
Q

How to check for thrombophlebitis?

A

measure calf circumference

222
Q

What do tocolytics do and what are the med names?

A

mag sulfate and terbutaline
stop premature labor

223
Q

S/E of terbutaline (Brethine)

A

maternal tachy

224
Q

S/E of mag sulfate, what to monitor?

A

brady, hypotension, decreased reflexes, decreased RR and LOC

225
Q

What do oxytocics do and what are med examples?

A

stimulate and strengthen labor
pitocin and methergine

226
Q

S/E of oxytocin?

A

uterine hyperstimulation

227
Q

S/E of methergine?

A

causes HTN d/t contraction of blood vesssels

228
Q

What are the fetal/neonate lung meds and what are the examples?

A

help mature lungs
betamethasone (Steroid)
surfactant (survanta)

229
Q

S/e of betamethasone?

A

-hyperglycemia
(given to mother IM before baby born)

230
Q

When is surfactant given?

A

given to baby transtracheal after birth

231
Q

What to think with subq injection questions?

A

“5s”
-pick answer that has 5
-25 gauge, 0.5 inch

232
Q

Heparin tips and tricks?

A

-IV or subq
-works immediately but cannot take more than 3 weeks (exccept lovenox)
-protamine sulfate antidote
-CAN be used during pregnancy

233
Q

Coumadin (warfarin) tips n tricks?

A

-given PO
-pts can be on it for life but can take few days to a week to work
-vit k antidote
-lab: PT/INR
-CANNOT be used during preg

234
Q

What is the only tranquilizer antipsychotic safe for preg?

A

haldol

235
Q

What is piaget stage for 0-2 years?

A

sensorimotor
-do not understand play
-think present tense, just tell them

236
Q

What is the piaget stage for 3-6 yeares?

A

preoperational (preschool)
-fantasy-oriented, imaginative, illogical
-understand future & past

237
Q

What is the piaget stage for 7 to 11?

A

concrete operational “7/11 grocery stores surrounded by concrete?
-rule oriented
-teach a day or two ahead of time
-teach what you’re going to do

238
Q

What is the piaget stage for 12 to 15 years?

A

formal operations
-abstract and think cause and effect
-teach like adult

239
Q

What are the 4 phases of psych nursing principles?

A
  1. pre-interaction
  2. orientation
  3. working
  4. termination
240
Q

Anatomical location of aortic valve?

A

2nd intercostal, right of sternal border

241
Q

Anatomical location of pulmonic valve?

A

2nd intercostal left of sternal border

242
Q

Where is erb point auscultation?

A

3rd intercostal (between pulmonic and tricuspid)

243
Q

Anatomical location of tricuspid valve?

A

4th intercostal, left of sternal border

244
Q

Anatomical location of mitral valve?

A

5th intercostal at midclavicular line

NCLEX!! (2 decks)

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