vn 34 final study guide Flashcards
- Cesarean section infant complications (pg.267):
Respiratory complications
A newborn delivered by c-section does not always have the benefit of the pressure squeezing the chest from the birth canal. This newborn often has more fluid in their lungs, making respiratory adaptation more challenging.
- Jaundice nursing actions and need to know in first 24 hours and after (pg.270):
Physiological Jaundice: is characterized by jaundice that occurs AFTER the first 24hrs.
Pathologic Jaundice: occurs within the first 24 hours (EMERGENCY)
Nursing actions: anytime jaundice is present, document and report it.
- Signs of respiratory distress (pg.267):
Tachypnea (sustained respiratory rate greater than 60 breaths per minutes)
Central cyanosis
Unequal movement of the chest and abdomen during breathing efforts
Intercostal or xiphoid retraction
Nasal flaring
Grunting (noted by stethoscope or audible to the ear)
- Nursing actions for admitted OB patient with sever hyperemesis (SG. 2):
Medication as order: B6, Phenergan, Reglan, and Zofran
Decrease trigger factors.
Carbohydrates can decrease nausea (cracker in AM)
Assist the woman with regaining fluid balance.
If admitted priority will be IV fluid and electrolyte replacement
- Risks to ectopic pregnancy (PG.360 & SG 2):
STIs
Tubal Ligation
IUD
Pelvic inflammatory disease
Hx of prior ectopic pregnancy/ Multiple abortion
Endometriosis and Salpingitis (infection of the fallopian tube)
- Know the circulatory flow between mother and fetus (pg.94):
In the cord are two arteries that bring deoxygenated blood from the fetus to the placenta and one vein that carries oxygenated and nourished blood from the placenta to the fetus.
- At what stage of labor does cardiac output increase 80%? (pg.161)
Immediately after birth, it may peak at 80% above the prelabor level.
- What is the least common presentation of baby(pg.153)?
Shoulder presentation are the least common, occurring in less than 0.3% of all term
pregnancies. Associated with a transverse lie.
- What are the four Ps?
Passageway- The passageway consists of the woman’s bony pelvis and the soft tissues of the cervix and vagina.
Passenger- The “passenger” refers to the fetus. The size of the fetal skull and the way the fetus is situated.
Powers- The primary force of labor comes from involuntary muscular contractions; the labor process is enhanced.
Psyche- When the woman feels confident in her ability to cope and finds ways to work with the contractions, the labor process is enhanced.
- What is the best indicator for induction? (SG 4)
Sign: burst of energy
True labor results in progressive effacement and dilation of the cervix
- What is the priority for overstimulation after oxytocin? (S.G 4)
Put on left side, give O2 & d/c oxytocin
Continuous fetal monitoring
- Give examples of gate control theory. (S.G 4)
Distracting client & mind focused on something else
Massage & deep breathing
- What symptoms does the nurse prioritize with a deep-pelvic hematoma? (S.G 5)
Deep pain unrelieved by comfort measures/meds that are accompanied by VS instability
Low HGB & HCT
- Laceration manifestations: (S.G 5)
Bright red bleeding can be steady or a trickle
- Risks for pp hemorrhage. (S.G 5)
Multiparty
Precipitous birth
Previous uterine surgery
Tocolytics
LGA- macrosomia
Polyhydraminos
- Cleft palate nursing actions: (S.G 6)
Suction & position to facilitate drainage, gentle w/bulb syringe as needed
Encourage parental attachment
Assist w/feeding techniques
Monitor weight & for dehydration
Elbow restraints (because they want to touch & pull)
NPO 2hr post op, then liquid 3-4 days
- Safety in ID in the hospital: (S.G 6)
Verify ID bands on both mom & baby
Verify gender
Verify DOB
Verify mom’s medical record #
Verify any health care worker ID badges
- Manifestations of trisomy 18: (S. G 6)
Brachycephaly (deformity in skull), short stature, flattened bridge of nose
Thick hypotonic muscles, protruding tongue, dry cracked, fissure skin that may be mottled
Small hands w/short broad fingers & curved 5th finger, single deep crease on palm of hand, wide space between 1st & 2nd toes
Lax muscle tone
Heart & eye anomalies, upward slanted eyes
Greater susceptibility to leukemia
- Expected birth weight for newborn. (pg.272)
5lb 8oz – 8lb 13oz (2,500-4,000g)
- Post term manifestations: (S.G 7)
Born @ greater than 42 weeks
Skin: leathery, cracked & wrinkled
Ear: cartilage thick, pinna stiff
- Proximodistal; You know this. (CLO 2)
Proximodistal- growth starts in the center and progresses outward
- Nursing actions when weighing an infant (ch.28 pg.273).
use appropriate equipment & technique
record as grams & kilograms or pounds & ounces
Always have one hand near the child, don’t walk away from child
Set the scale to zero.
Remove the newborn’s clothes, including diapers & blankets & place the newborn on the scale.
To avoid inaccurate results, do not leave clothes, including diaper, on the newborn while weighing.
Hold one hand just above the newborn’s body (Avoid touching the newborn.) Never turn your back away from the newborn while they are on the scale.
- Objective data (pg.595)
Information you observe directly
Includes height, weight, temperature, pulse, respiration, BP; physical examination
Usually does not proceed in head-to-toe manner as an adult
- subjective data (pg.595)
Information spoken by child or family is subjective
-review of body systems
Private, quiet setting; allow for questions from family and child
Include child in process
Use age-appropriate questions for child
Always evaluate child’s developmental status
Child can choose to have caregiver present
- Glomerulonephritis acute manifestations:
Appear 1-3 wks after the onset of a Strep infection
Periorbital edema may accompany or precede hematuria
Hematuria (smoky or bloody)
Headache
HTN (priority!)
- Client education for med used to treat Tinea cruris (ATI pg.192, Pg.877)
Tinea cruris, more commonly known as jock itch or ringworm of the inner thighs and inguinal area
Topical antifungal agents: clotrimazole, tolnaftate
Oral agents: griseofulvin, terbinafine
Clotrimazole or ciclopirox 2x/day for 2-4 weeks
Cotton underwear is recommended, sitz bath/wet compresses may be soothing.
Wear light colored socks & well ventilated shoes
Use appropriate hand hygiene
Avoid sharing clothing, hats, combs, brushes or towels
Keep child from touching or scratching the affected area by using distraction
Don’t squeeze vesicles!
Take meds as prescribed
- Early Hypoglycemia manifestations (pg.269)
Weak
High-pitched cry
Hypotonia
Irritability
Poor feeding
Listlessness
Low temperature
Jitteriness
- Late signs hypoglycemia manifestations (pg.269)
Seizures
Coma
Apnea
Respiratory distress
- What are pulmonary functions tests used to diagnose (pg.749)?
Pulmonary function tests are valuable diagnostic tools and indicate the amount of obstruction in the bronchial airways, especially in the smallest airways of the lungs.
A definitive diagnosis of asthma is made when the obstruction in the airways is reversed with bronchodilators.
- Priority when assessing a child in a mist tent for bacterial pneumonia (pg.638)?
-Assess that child doesn’t become cyanotic due to poor visibility in tent
The infant often receives oxygen while in an isolette or incubator.
High concentrations of oxygen can be dangerous to children, so close monitoring is needed. High concentrations of O2 is dangerous to small infants & children w/respiratory diseases.
Oxygen safety measures are taught to family caregivers and followed by healthcare personnel
Difficult to see child in tent/Difficult for child to see out
only used water based lubrication for nasal passageways
Child feels isolated
Change clothing & linen often
Keep side rails up
-Check equipment frequently to ensure proper functioning, cleanliness, and correct oxygen flow rate.
