NURS 131 exam 1 notes

jasmine's version from 2016-05-11 01:32

Section 1

Question Answer
Vertex Most common (chin to chest, occiput-back to head presenting)
Military Top of head, baby looking straight ahead
Brow Fetal head partially extended (sniffing)
Face Fetal head hyper extended, face is presenting part
Gynecoid Pelvis most favorable for vaginal birth, inlet rounded with all inlet diameters adequate
Android Male type pelvis, too narrow. Not favorable for vaginal birth. Descent to pelvis is slow, HEART shaped
Platypelloid Not favorable pelvis, baby can't engage. Oval shaped, least desirable
Late deceleration Decreased HR, after contraction means baby is running out of steam. NOT okay
FHR 110-160 bpm Over or under could mean fetal distress
Nursing intervention for cord compressionAssessment is initially made by decrease in FHR and/or decelerations, place trendelenberg or knee-chest position, push presenting part away from cord, EMERGENT delivery, some cases saline injected into the bladder, without complete dilation of the cervix: usually C-section
Anesthesia Numbing-local/regional (ex: epidural block, continuous epidural infusion, spinal block, pudental block, general anesthesia)
AnalgesicPain relief (ex: stadal, nubain, morphine, sublimaze, demerol)
Amniotomy Artificial rupture of membranes, done with amnihook to jumpstart labor, must be 2 cm, more effective in multipara, manipulates hormones, allows presenting part to descend and place direct pressure on cervix to accelerate dilation, FHR before and after, water inspected, temperature monitored ever 2hr, exams to a minimum. Must deliver in 24 hours
Cervical edema Caused by bearing down if the cervix is not completely dilated which retards dilation
Involution Rapid reduction in size and return to non-pregnant uterus. Uterus should be contract and be firm to clamp blood vessels and stop bleeding
Nursing care for perineal bruising, episiotomy, hemorrhoids Periobottle (squeeze bottle with sprayer head), pad changes, ice pack/glove/ sitz bath, analgesics or topical anesthetics, side lying for infection or dehiscence, assess for REEDA (redness, edema, ecchymosis/bruising, discharge, approximation)
Taking in 1-2 days after birth woman tends to be passive and dependent. Follows suggestions, hesitates to make decisions. May frequently talk about labor
Taking hold phase 2nd-3rd day new mother is usually ready to resume control of her body, mothering and life. she requires assurance. Assess for post partum blues. (manifested by mood swings, anger, weepiness, anorexia, difficulty sleeping and a feeling of let down. Assess for social support
Before delivery full bladder Ultrasound, abdominal discomfort
After deliver full bladder Risk for over distention, displaced uterus, abdominal distention/ pain

Section 2

Question Answer
Post C-section nursing care Cough and deep breath every 3-4 hours first 4 days, assess pain and promote comfort through positioning, encourage breathing, relaxation and distraction techniques, incision assessment and care, encourage family presence, administer analgesics, listen for the return of bowel sounds, assess consistency of abdoment, assess IV site/flow rate/patency, monitor the condition of surgical dressing or incision site to REDDA and skin temp around site, encourage ambulation/leg exercises
When can sex resume? When lochia has stopped, when perineum has healed and lochial flow has stopped. This may occure by the end of the 3rd week. May experience dryness and decreased libido
Newborn injections following delivery Vitamin K-within 1 hour of birth given vastus lateralis; Hep B-as ordered by physician 2 hours after birth before delivery; eye drops-prophylactic ophthalmic ointment in both eyes after baby makes eye contact and with 1 hour of birth
Newborn vital signs BP 60-80/40-45; Pulse 120-160bpm; Resp. 30-60/min (count full minute); Crying-strong and listy, moderate tone and pitch, varies 3-7 minutes after consoling; T: 97.5-99 (bigger newborn higher temp); Weight- 2500g-4000g (5.8-8.3 lbs) normal loss 5%; Length-18-22 inches; Posture-fixed
General care immediately following delivery for newborn Assess immediately after birth, suction and provide patent airway. Infant is initially placed on mother's abdomen or radiant heat unit; infant dried; wrapped in warm blankets or under warmer. Then APGAR scoring, umbilical cord care, abbreviated assessment
Resting posture The more flexed, the higher gestational age
Skin-preterm Is thin and transparent
Lanugo Fine hair covering decrease as gestational age increases
Sole creases the more prominent, the higher gestational age
Breast tissue As gestational age increases, this and areola enlarge
Ear form and cartilage distribution Thinner and less formed in preterm
Testes decent Below 36 weeks, less rugae (series of ridges produced by folding of the wall of an organ; commonly applied to the internal surface of the stomach)
Head circumference 32-37 cm (12.5-14.5 in) approximately 2 inches longer than chest
Chest circumference 30-35 cm (1214 in)
Breast swelling May occur on 3rd day caused from hormones
Lochia Pseudo-menstruation caused by withdrawal of maternal hormones
Mottling Caused from circulation fluctuation
Cold hands (newborn) Body shuts to core
Care of circumcision Assess every 30 minutes for about 3 hours, observe for first voiding after circumcision and evaluate for urinary obstruction. Petroleum ointment and gauze may be applied. Teaching, clean with warm water after each diaper change and apply ointment next few. If bleeding occurs apply with light pressure and contact physician if doesn't stop. Report any signs of infection. Ensure diaper not rubbing
APGAR Activity, Pulse, Grimace, Appearance (skin color), Respiration
True labor Contractions are at regular intervals, gradually shorten, contraction increase in duration and intensity, discomfort starts in back and around to abdomen and doesn't ease up with walking, cervical dilation and effacement are progressive
False labor Contractions are irregular, usually no change, discomfort is usually in abdomen, walking has no effect or lessens the contractions, no cervical change
Alternative methods for pain management Ambulation or change position, hypnotherapy, provide guided imagery, hydrotherapy, massage, music, acupressure/acupuncture
Best time to initiate breastfeeding Assess for active bowel sounds, absence of abdominal distention and lust cry and is replaced with rooting or sucking behavior when a stimulus is placed near lips. Signal hunger and ready to tolerate. Throughout first 2 hours of birth and especially during first hour infant usually alert and ready to breastfeed
After-pain is more common in ______ than in primaparas and are caused by intermittent uterine contractions due to decreased uterine tone and may cause discomfort for 2-3 days after birth. Multiparas
Care for after birth pain Warm bottle against lower abdomen may reduce discomfort, mild analgesic, breast feeding

Section 3

Question Answer
Effects of Pitocin on labor Speeds up labor-promotes uterine contraction. Synthetic oxytocin. Contractions may be more frequent and more painful with fewer rest periods
Safest time to give a systemic analgesic In active labor but prior to late stages of labor. If given late, it may induce neonatal respiratory depression
Engrossment Preoccupation, interest, involvement
Where does epidural go in spinal column? Injection of an anesthetic agent into the epidural space to provide pain relief throughout labor. This space is between the dura mater and the ligamentum flavum and is accessed through the lumbar spine
Pudential block Administered by transvaginal method, intercepts signals to the pudental nerve, provides perineal anesthesia for the latter part of the first stage of labor and the second, the birth and the episiotomy repair. Does not alter FHR or maternal vital signs. Additional assessments are not necessary. Disadvantages include possible broad ligament hematoma, perforation of the rectum and trauma to sciatic nerve. Urge to push could decrease
Newborn Zoe's temperature drops when she is placed on the cool plastic surface of the weight scales. This is an example of heat loss via Conduction
Describe teaching for physiologic jaundice Appears after first 24 hours of birth, yellow color seen in newborn skin and eyes. Comes from normal breakdown of RBC's and livers decreased ability to produce and excrete bilirubin which causes temporary build up of bilirubin in blood and fatty tissue. Peaks between 3 and 5 days. Time is important, if noticed in first 24 hours means pathological
Which time frame is most appropriate for the nursery nurse to initiate breastfeeding? The first period of reactivity
A primary nursing intervention appropriate to the second period of reactivity would be to Auscultate the abdomen for the presence of bowel sounds
Why is it important to determine the gestational age of all newborns? The anticipate possible physiological problems and establish individual plan of care for baby and family
The average weight is __________. Usual weight loss within the first 3-4 days of life for a full-term newborn is _____%. 2500-4000g; 5-10
Why does the newborn commonly exhibit a "physiologic weight loss"? Small fluid intake, increased volume of meconium, stooling fluid shifts and increased urination
An infant weighs 9 lbs, 3 oz a birth. The nurse plans to make a home visit to the mother and infant when the infant is 7 days old. What is the lowest acceptable weight the infant should be at this age? 8 lbs, 2 oz ( 10% of 9 =0.9. 9-0.9=8.1)
A newborn's head circumference is 34 cm (13.6 in.) and chest circumference is 32 cm (12.5 in). Which nursing action would be appropriate? Measure the occipitofrontal circumference daily
Normal length of newborn 50 cm (20 in)
Mons pubis Protects pelvic bones, especially during coitus
Paraurethral (Skene's) glands Secretions that lubricate the vaginal vestibule to facilitate sexual intercourse
Vulvovaginal (Bartholin's) glands Secretes clear, thick mucus that enhances sperm viability and motility
Labia monora Rich in sebaceous glands that lubricate and provide bactericidal secretions
Clitoris Produces smegma that has a sexually stimulating odor
Perineal body Site of episiotomy and lacerations
False pelvis Portion above the pelvic brim or linea terminalis, support the pregnant uterus; directs the presenting fetal part into the true pelvis below
True pelvis Lies below the pelvic brim linea terminalis, its shape and size determine the adequacy of the birth passage
Pelvic inlet Upper border of the true pelvis; usually rounded, determines whether engagement can occur
Pelvic outlet Lower border of the true pelvis; if too narrow the baby's head may be pushed backward, making extension difficult and causing shoulder dystocia for large babies
What factors can alter the vagina's pH and decrease its self-cleansing action? Antibiotic therapy, douching and use of perineal sprays or deodorants

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