Contractions 3 minutes apart = what phase of labor?
Variable decelerations = what? Intervention?
Cord compression! Prep for emergency c-section or inducing labor. Also can change position, d/c oxytocin, O2 8-10L/min per mask, perform/assist with vaginal exam, assist with amnioinfusion if ordered
Which of the following is the initial nursing action the nurse should take when late decelerations appear on the fetal monitor? A. Reposition the client in to left-lateral position B. Apply a fetal scalp electrode C. Increase the IV fluid rate D. Perform a vaginal exam to assess dilation
Reposition client left-lateral position
Best pain management for 8-10 post open cholecystectomy: Demerol, hydromorphone, fentanyl, morphine
Demerol, NOT morphine or others. Morphine can cause biliary spasms.
Fontanels close when?
Posterior 2-3 months, anterior 12-18 months
Do you report chlamydia, do you need consent, etc.
Mandated reporting to CDC, without verbal or written consent
Empty JP drain when? Clean how?
Before half full, or every 8-12 hours, NOT 24 hours. Clean with soap and water, NOT antimicrobials or Dakin's etc.
If JP drainage has doubled in last two hours, possible cause?
Hemorrhage. So assess, stat CBC, notify physician.
What do bananas, avocado and spinach have in common? If patient on what med, these are good foods?
^ K+, so good for hypokalemic patients. If patients on thiazide diuretics (Diuril, Enduron), may be HYPOkalemic, so give these
MAOI's/Nardil, avoid what?
Cheese is not good with what? Cheese is good for what and why?
Nardil/MAOI's! Good for hyponatremia because high in sodium, high in protein
Is drainage at pin sites ok with bucks traction?
Drainage ok, note the type, odor, color and amount. Leave crust as a barrier, pin care 3x/day
Treats postpartum hemorrhage by inducing uterine contractions, reducing hemorrhage. HYPERTENSION is a risk, so CHECK BP prior to administration, watch for n/v, headache,
High pressure alarm, do what?
Assess for kinks, client biting, excess secretions (suction), pulmonary edema, etc. Notify provider
Low pressure alarm, do what?
Assess for leaks, displacement. If can't find anything wrong, MANUALLY VENTILATE AND CALL RESPIRATORY STAT, do NOT LEAVE ALONE
2 years of age, presentation of arms longer than torso, or round and soft abdomen?
Round and soft abdomen, NOT arms longer than torso
3 years of age normals; immunizations?
2-3kg/yr, 2.5-3in./yr., picky eater, initiative vs. guilt, imaginary friends, ride tricycle, jump off bottom step, stand on one foot for few seconds. DTaP, IPV, MMR, varicella, influenza
First thing to do with a newborn: Take temperature, weigh, dry...
Terminally ill patient only wants family, not friends with them. Type of grief?
Anticipatory, not dysfunctional, normal, or disenfranchised.
A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which IV solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume, and increase BP? 1. 5% dextrose in lactated Ringer's 2. 0.33% sodium chloride (1/3 normal saline) 3. 0.225% sodium chloride (1/4 normal saline) 4. 0.45% sodium chloride (1/2 normal saline)
5% dextrose in LR
Give what for hypovolemic shock
5% dextrose in LR
Client's family asks you to pray with them. Response?
Refer to spiritual services
After a blood infusion, will you look at hub, hct, BP, or HR for changes?
Hgb! 1-2 point increase per unit of blood.
Can you give an antibiotic in a TPN infusion line? What can you add to a TPN infusion line?
Change a TPN infusion line every 24 hours, or how often?
Yes! Every 24 hours
Can client's family change dressing daily? Tie tubing to neck?
No, every 8 hours! Yes, square knot with 1-2 finger widths,
TPN, slow down infusion before ending, d/c until new bag ready?
No, don't d/c or change rate, don't change flow rate!
Hip arthroplasty, what to watch out for?
Peripheral pulses! So cool and weak, 1+ peripheral pulses, sign to call provider.
Mom engorged, don't do what?
Don't self express milk! Ice packs, support bra all ok.
Rifampin, isoniazid, phenytoin, what's up?
INH/Isoniazid increases phenytoin toxicity, meaning ataxia and hallucinations may present. Decrease phenytoin dosage. Hepatotoxicity possible with rifampin.
Palpate fontanels by 2-3 years?
No! Bulging fontanels could mean ^ ICP, meningitis.