QB 6 Flashcards
What is augmentation of labor ?
Augmentation of labor is the process of stimulating the uterus to increase the frequency, duration and intensity of contractions after the onset of spontaneous labour.
What to remember about fetal decelerations …
late decelerations indicate a reduction in heart rate, usually after a uterine contraction. Once deceleration starts, it takes about 20 to 30 seconds to reach its lowest point. When the timing of deceleration is delayed, it means that the lowest point is occurring past the peak of your uterine contraction.
late decelerations could be considered dangerous. They’re a sign of hampered blood flow to your placenta, which might trigger imminent fetal hypoxia (or a lack of oxygen for fetal tissues).
When persistent late decelerations are noted, further assessment is not needed prior to taking action. Interventions include re-positioning the client to the left side or to the knee-chest position to increase uterine blood flow, administering oxygen and fluid to increase oxygenation and cardiac output, and correcting the stimulus of the late decelerations. Late decelerations may stem from excessive contractions or maternal hypotension. Late decelerations are caused by decreases in fetal oxygenation and subsequent fetal hypertension. If allowed to continue, fetal hypoxia results in sustained fetal bradycardia.
Nurse Empowerment
Characterized by innovating in solving problems, resulting in a sense of accomplishment and feeling of worth
Feeling empowered is critical in nursing practice. The lack of empowerment will lead the staff to rely heavily on rigid bureaucratic structures rather than their own professional power to guide, practice, or create a solution.
How to help a clinet in a situational crisis ?
When caring for a client in a situational crisis, the nurse should: Evaluate current and prior coping strategies, and provide support and encouragement. It is most important for the nurse to assess for signs the client is a risk to self or others; the nurse needs to initiate safeguards for client or others in crisis as needed. Therapeutic communication techniques will assist in identification of coping mechanisms and assist client to decide on a course of action. The nurse should also help identify available support systems and community resources.
Remember signs of lithium toxicity
EARLY SIGNS - diarrhea, muscle weakness,
LATE SIGNS - Coarse hand tremors, ataxia,
Diarrhea is a sign of lithium toxicity, along with oversedation, ataxia, tinnitus, slurred speech, and muscle weakness/twitching.
muscle weakness, diarrhea, oversedation, ataxia, tinnitus, slurred speech, tremors, fever, mental confusion, seizures, coma, and death.
What to remember about bronchiolitis and RSV?
What do we need to remember about care for infants with RSV?
Bronchiolitis is an infection of the lower respiratory tract causing inflammation and obstruction of the bronchioles.
It may be of viral or bacterial origin and the most frequent causative organism is the respiratory syncytial virus (RSV). Treatment includes respiratory assessments to monitor changes in the infant/child’s condition, maintaining elevation of the head of bed, and suctioning to facilitate breathing. Administer oxygen and medications as prescribed to dilate bronchioles and improve gas exchange at the alveolar level. Address hydration and provide fluids via oral and intravenous routes as prescribed.
Infants with these infections can have nasopharyngeal secretions that block airway passages so a bulb syringe is required for airway management. An infant is unable to clear the airway and would need to have secretions removed through the use of a bulb syringe.Young infants are obligatory nose breathers. Parents should be instructed on how to use the syringe before feedings and as necessary.
When are arterial blood gases drawn ?
Arterial blood gases (ABGs)are drawn whenever a client is at risk for respiratory failure. They are also used to detect a metabolic disorder. Trends in respiratory status can be assessed using pulse oximetry and periodic ABG analysis. Arterial blood gases are used to detect impaired gas exchange (SaO 2 <92% to 95%; PaO 2 <80 mm Hg) or a metabolic problem (HCO 3 <22 or >26 mEq/L).
Altered level of consciousness, visual disturbances, headache, and slurred speech are associated with conditions including
hypoglycemia, transient ischemic attack (TIA), or stroke (cerebrovascular accident [CVA]). A bedside blood glucose assessment is quick, simple, and noninvasive and is one of the nurse ’s initial actions. While ruling out hypoglycemia or TIA, the nurse continues to anticipate treatment of the client for the most serious of the suspected diagnoses, which is stroke.
Stroke is an interruption of blood flow in the brain as a result of hemorrhage or thrombus. Strokes are classified as hemorrhagic or ischemic. The phrase “time is brain ” has been used to demonstrate the importance of stroke recognition and seeking medical treatment quickly. Prepare the client for emergent CT scan of the brain to assess for hemorrhage, carotid Doppler to assess blood flow, magnetic resonance angiography (MRA) to visualize blood flow, magnetic resonance imaging (MRI) to assess damage if an ischemic stroke is diagnosed, and ECG if atrial fibrillation is present. Laboratory blood work includes a complete blood count, blood chemistry, and coagulation studies.
What to remember about UTI’s and pregnancy ?
Pregnancy is a risk factor for urinary tract infection (UTI) partly because hormonal changes make the tissues of the urinary tract vulnerable to infection. To prevent and manage UTI, the client should drink at least eight glasses of water a day. Common antibiotics such as amoxicillin, erythromycin, and penicillin, are considered safe for pregnant women. The nurse should teach the client that the majority of urinary symptoms are due to pregnancy-related changes in the urinary system. Past history of UTI, sexual activity, lower socioeconomic group, and multi-parity are significant risk factors for UTI.
Content Refresher
During pregnancy, a mother will experience physiological changes in all systems of the body. Distention and dilation of the renal pelvis due to the increased progesterone level may lead to urinary stasis and development of a urinary tract infection . The nurse should review methods to reduce urinary tract infections, such as increasing fluid intake.
Which form of therapy is commonly offered for survivors of intimate partner violence ?
What is psychodrama?
Group therapy
Psychodrama is a form of dramatic play in which a client acts out emotional problems and examines subjective experiences to develop new perspectives. It is used with groups of verbal children and adolescents.
The nurse is assigned to provide care to four clients on the medical-surgical unit. After receiving change-of-shift report, which client does the nurse assess first?
- A client admitted 3 hours ago with a gunshot wound and 1.5 cm area of dark red drainage noted on the dressing.
- A client who underwent a mastectomy 2 days ago with 23 mL of serosanguinous fluid noted in the bulb-suction drain.
- A client with a collapsed lung due to an accident and no drainage noted from the chest tube in last 8 hours.
- A client who underwent an abdominal perineal resection 3 days ago and who reports chills.
1) INCORRECT— The client appears to be stable and is not the highest priority for assessment. Acute bleeding typically is bright red in color. The presence of dark red drainage is suggestive of old blood. The amount of drainage on the dressing is minimal.
2) INCORRECT— The client is not the highest priority for assessment. The client’s assessment findings are reflective of an expected outcome. Drainage of serosanguinous fluid is a normal finding for a client who underwent a mastectomy 48 hours earlier.
3) INCORRECT— The client is not the highest priority for assessment. The client’s assessment findings indicate resolution of a health alteration. Absence of drainage from a chest tube suggests healing is likely occurring.
4) CORRECT— This client is the highest priority for assessment. The client’s assessment findings indicate a potential complication may be developing. The client who undergoes abdominal perineal resection is at risk for developing peritonitis. Because chills may indicate infection, immediate assessment of the client is indicated.
As a physical sign, chills almost always signify an acute change in the client’s physical condition. Chills are usually a marker of an infection. The nurse should look for the source of infection and other findings such as an increase in white blood cell count, low or high temperature, and hemodynamic changes. An abdominal infection should be explored for this client.
What to remember about apnea and infants
It is normal for a neonate to have periods of apnea. Apnea lasting longer than 20 seconds should be reported to the health care provider.
Infant apnea is diagnosed for any unexplained episode of the cessation of breathing that lasts 20 seconds or longer or when a shorter respiratory pause is associated with other symptoms (e.g. bradycardia, cyanosis, pallor, and the occurrence of marked hypotonia). While apnea is fairly common in preterm infants, it is rare among full-term healthy infants. When apnea occurs for full-term infants, it is usually an indication of an underlying pathology. The nurse should offer reassurance to parents by explaining the difference between true apnea and periodic breathing (pauses in respiration that last less than 10 seconds). Periodic breathing is not dangerous and no intervention is required.
What are contraindications associated with breastfeeding ?
clients who are HIV positive or have varicella, active tuberculosis that is untreated, or active herpes to the breast. In addition, clients who take certain medications (e.g., chemotherapy or radioactive isotopes), use illicit drugs, or smoke should avoid breastfeeding. Finally, an infant diagnosed with galactosemia should not be breastfed.
During any “ordinary” illness such as a cold, sore throat, flu, or mastitis, the client should continue to breastfeed. Wearing a surgical mask will prevent transmission of respiratory infectious agents to the newborn.
TRUE OR FALSE
TRUE
What to remember about when not to give vaccines to children
After birth, the newborn is protected for a short period of time by the mother’s immunity, which is provided while in utero. For future immunity, the newborn needs to receive vaccinations in order to prevent the development or contraction of certain illnesses. A schedule of immunizations has been created, which identifies the appropriate times when vaccination should be provided. Reasons to withhold the vaccine would be evidence of immunosuppression or allergy to the vaccine.
The Centers for Disease Control and Prevention recommend that children receive vaccinations on schedule, even if they have an ear infection, mild diarrhea, cold symptoms or a cough, or a fever of less than 101° F. Though vaccines may cause mild side effects such as a slight fever or pain and swelling at the injection site, the vaccines are not likely to make a child more ill. Mild illness also does not impair the body’s ability to mobilize a response to vaccines. A child taking an antibiotic may receive vaccines as scheduled, but vaccines should be delayed if a child is taking an antiviral medication.
Provide education to parents regarding newborn care and additional signs and symptoms to report to the health care provider (e.g. ____________________________________________). Instruct parents to monitor for ___ to ________wet diapers per day and that stools will transition to thin green-brown by day 3.
increased respiratory rate, grunting, nasal flaring, intercostal retractions, sunken or bulging fontanelles, fever, hypothermia, or severe hypo- or hyperactivity
6 to 10
What to remember about peptic ulcers ……
How do they develop?
What is the client at risk for ?
What is a telltale sign of peritonitis ?
We know the stomach is the organ where food begins the digestive process. At times, an excess amount of hydrochloric acid in the stomach injures the tissue wall. If left untreated, the injury enlarges, erodes through the tissue, and can progress to a perforation. The body’s immediate response to tissue injury is bleeding, swelling, and pain. Bleeding will be present within the stomach, but also throughout the abdominal cavity. Bleeding into this area will cause the abdominal tissues, organs, and muscles to cramp. The abdomen becomes hard and extremely painful.
Peptic ulcer disease (PUD) is caused by the erosion of the mucosa of the gastrointestinal (GI) tract by hydrochloric acid (HCL) and pepsin. Peptic ulcers can develop in any segment of the GI tract exposed to HCL and pepsin. The most common areas are stomach, lower esophagus, and duodenum. They are categorized as acute or chronic. Erosion of the mucosa may be deeper with prolonged, chronic PUD. When erosion of the mucosa occurs, the client is at risk for hemorrhage (blood in stool, dizziness, and hypovolemic shock), perforation that leads to peritonitis (severe abdominal pain that radiates, rigid abdomen, and fever), and gastric outlet obstruction (epigastric fullness, nausea, and vomiting). They are all emergent situations requiring rapid assessment and treatment.
RSV requires what kind of precautions
contact
Assessment of Peritonitis
Severe Abdominal Pain
Abdominal Rigidity/Rebound Tenderness
Nausea/Vomiting
Abdominal Distension -Ascites
Fever/Leukocytosis
Decreased bowel sounds - possible paralytic ileus
Complications:
Hypovolemic shock (from all the fluid shifts), sepsis, abscess
What is Losartan ?
Losartan, an angiotensin II receptor blocker (ARB), causes dilation of blood vessels, decreases release of aldosterone, and increases renal excretion of sodium and water.
Losartan lowers blood pressure and can cause orthostatic hypotension.
A low dose of this medication is initially prescribed and then increased or changed according to the status of the client’s heart failure
What is Cyclosporine ?
immunosuppressant medication used for anti-rejection in organ transplants
AE: hypertension, nephrotoxicity, infections
some causes of dehydration and S/S
Dehydration is caused by a variety of disorders including inadequate fluid intake, diarrhea, vomiting, and disorders that result in fluid losses (diabetes mellitus, diabetes insipidus, fluid shifts, burns, hemorrhage, and certain medications such as diuretics). Thirst, decreased urine output, dry mucous membranes, poor skin turgor, weight loss, hypotension, tachycardia, and lethargy are clinical manifestations of dehydration.
The home health nurse visits a client diagnosed with heart failure who is prescribed a diuretic. Which client statement causes the nurse to assess the client further? (Select all that apply.)
- “I’m hardly making urine, but I haven’t been drinking well”
- “I take my water pill in the morning because I urinate so much.”
- “I have a bowel movement every other day.”
- “I’ve been dizzy, and I almost passed out yesterday.”
- “I’m noticing that I bruise really easily.”
1) CORRECT — Failure to make urine, especially while on a diuretic, may indicate kidney insufficiency due to lack of perfusion.
2) INCORRECT— Taking diuretics in the morning is advised because an expected side effect of diuretics is frequent urination.
3) INCORRECT— Constipation is a minor side effect of diuretics caused by dehydration. Having a bowel movement every other day indicates adequate hydration. Although daily bowel movements are ideal, this is not typical for every person.
4) CORRECT — Dizziness and near syncope indicate dehydration and decreased perfusion. The client may require a dose adjustment, alteration in activities or activity level, or further instruction about hydration and safety while on diuretics.
5) CORRECT — Bruising indicates a potential coagulation issue, possibly due to liver insufficiency secondary to decreased perfusion or medication toxicity.
Heart failure is a complex disease. Both the condition and the treatment pose challenges. The nurse should monitor the client closely for impending decompensation, end organ damage, and respiratory distress. Signs of low cardiac output, such as oliguria and fainting, should be addressed immediately. Prevention of heart failure exacerbation includes maintaining normal blood pressure, diuretic and inotropic therapy, and controlling diabetes and coronary artery disease. The nurse should also suggest to the provider to obtain a brain natriuretic peptide (BNP) level.
What is basal cell carcinoma ?
Basal cell carcinoma is a type of skin cancer that most often develops on areas of skin exposed to the sun.
Exposure to the sun increases the risk of skin cancer. The nurse should urge the client to use sunscreen with SPF (solar protection factor) to block harmful rays and reapply sunscreen every 2 hours or after swimming. The client should also use lip balm with sunscreen protection and avoid sun exposure during peak sun hours.