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175 Cards in this Set
- Front
- Back
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State the objective signs that signify ovulation |
-abundant thin clear cervical mucus (spinnbarkeit) egg white stretchiness of cervical mucus -open cervical os -initial slight drop in basal body temp and then .5-1 degree -ferning under microscrope |
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3 ways to identify chronological age of a pregnancy |
-10 lunar months -9 calendar months consisting of 3 trimesters of 3 months each -40 wks -280 days |
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What maternal position provides optimum fetal and placental perfusion during pregnancy? |
the knee-chest position, but the ideal position of comfort for the mother, which supports fetal, maternal, and placental perfusion, is the side-lying position (removes pressure from the abdominal vessels (vena cava, aorta) |
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Name the major discomforts of the first trimester and one suggestion |
-nausea and vomiting: crackers before rising -fatigue: rest periods/naps and 7-8hrs of sleep at night |
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If the first day of a woman's last normal menstrual period was Feb 3, what is the EDB using the Nagele rule? |
count back 3 months and add 7 days : Nov 10 (always give Feb 28 days) |
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At 20 weeks gestation, the fundal height would be ___ ; the fetus would weigh approx ____ and would look like ____. |
-At the umbilicus: -300 to 400 g -with hair, lanugo, and vernix, but without any subcutaneous fat |
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State the normal psychosocial responses to pregnancy in the second trimester |
-Ambivilance wanes and acceptance of pregnancy occurs; -pregnancy becomes "real"; signs of maternal bonding occur |
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The hemodilution of pregnancy peaks at __ weeks and results in an __ in a woman's Hct |
28-32 weeks decrease |
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3 principles relative to the pattern of weight gain in pregnancy |
total gain should average 11340 and 15876 (25-35). Gain should be consistent throughout pregnancy. An average of 1 lb/week should be gained in the 2nd and 3rd trimester |
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During pregnancy, a woman should add __ calories to her diet and drink __ milk per day |
300 calories 236.5 ml (8oz) per day |
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FHR can be ausculatated by Doppler at __ weeks gestation |
10-12 weeks |
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Describe the schedule of prenatal visits for a low risk pregnant woman |
Once every 4 weeks until 28 weeks; every 2 weeks from 28-36 weeks; then once a week until delivery |
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Name 5 maternal variables associated with diagnosis of a high risk pregnancy |
-preeclampsia -DM -cardiac disease -<3 months between pregnancies -maternal age under 17, over 34 -parity over 5 |
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Is one ultrasound exam useful in determining the presence of IUGR (Intrauterine growth restriction)? |
no. serial measurements are needed to determine IUGR |
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What does the BPP determine? |
A biophysical profile (BPP) test fetal well being |
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List 3 necessary nursing actions before an ultrasound exam for a woman in the 1st trimester |
-have client fill bladder -don't allow client to void -position supine with a uterine wedge |
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State the advantage of CVS over amniocentesis |
can be done between 8 and 12 weeks gestation, with results returned within 1 week, which allows time for decision about termination while still in in first trimester |
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Why are serum or amniotic AFP levels done prenatally? |
to determine Alpha-fetoprotein (AFP)levels: -elevated AFP may indicate neural tube defects, -low AFP indicates trisomy 21 |
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What is the most imp determinant of fetal maturity for extrauterine survival? |
L/S ratio (lung maturity, lung surfactant develpmt) |
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Name 3 most common complications of amniocentesis |
spontaneous abortion fetal injury infection |
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Name the 4 periodic changes of the FHR, their causes, and one nursing treatment for each |
-accelerations are reassuring and require no treatment since they are caused by a burst of sympathetic activity -early decelerations are caused by head compression; they are benign and alert the nurse to monitor for labor progress and fetal descent -variable decelerations are caused by cord compression; change of position should be tried first -late decelerations are caused by UPI and should be treated by placing client on her side and admin oxygen |
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What is the most imp indicator of fetal ANS health |
FHR variability |
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Name 4 causes of decreased FHR variability |
hypoxia, acidosis, drugs, fetal sleep |
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State the most imp action to take when a cord prolapse is determined |
examiner should position mother to relieve pressure on the cord or push the presenting part off the cord with fingers until emergency delivery is accomplished |
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What is a reactive nonstress test |
FHR acceleration of 15 bmp for 15 sec in response to fetal mvmt |
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What are the dangers of the nipple-stimulation stress test? |
the inability to control oxytocin dosage and the chance of tetany/hyperstimulation |
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Normal fetal scalp pH in labor is ___ and values below __ indicate true acidosis |
7.25-7.35 7.25 |
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List 5 prodromal signs of labor the nurse might teach the client |
-Lightening -braxton hicks contractions -increased bloody show -loss of mucous plug -bursts of energy -nesting behaviors |
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How is true labor discriminated from false labor |
true labor: regular, rhythmic contractions that intensify with ambulation, pain in the abdomen sweeping around from the back, and cervical changes false: irregular, abdom pain (not in back) that decreases with ambulation |
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state 2 ways to determine whether the membranes have truly ruptured |
-nitrazine testing: paper turns blue/black -demonstration of fluid ferning under microscope |
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are psychoprophylactic breathing techniques prescribed for use according to the stage and phase of labor? |
No, clients should use these techniques according to their discomfort level and should change techniques when one is no longer working for relaxation |
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identify 2 reasons to withhold anesthesia and analgesia until the midactive phase of stage 1 labor |
If given too early, can retard labor If given too late, fetal distres |
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Hyperventilation often occurs in the laboring client. What results from hyperventilation, and what actions should the nurse take to relieve the conidtion? |
Resp alkalosis occurs; it is caused by blowing off CO2, and is relieved by breathing into a paper bag or cupped hands |
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Describe the maternal changes that characterize the transition phase of labor |
irritability and unwillingness to be touched, but does not want to be left alone; nausea, vomiting and hiccuping |
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When should a laboring client be examined vaginally? |
before analgesia and anesthesia to rule out cord prolapse, to determine labor progress if it is questioned, and to determine when pushing can begin |
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Define cervical effacement |
The taking up of the lower cervical segment into the upper segment; the shortening of the cervix expressed in percentages from 0% to 100% or complete effacement |
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Where is the FHR best heard |
Through the fetal back in vertex, OA positions |
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Normal FHR during labor is |
110-160 bpm |
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Normal maternal BP during labor is |
<140/90 |
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Normal maternal pulse during labor is |
<100 |
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Normal maternal temp during labor is |
38C |
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List 4 nursing actions for the 2nd stage of labor. |
-make sure cervix is completely dilated before pushing -assess FHR with each contraction -teach woman to hold breath for no longer than 10 sec -teach pushing technique |
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List 3 signs of placental seperation |
-gush of blood -lengthening of cord -globular shape of uterus |
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When should the postpartum dosage of oxytocin be administered? Why is it admin? |
give immediately after placenta is delivered to prevent postpartum hemorrage and atony |
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State one contraindication to the use of ergot drugs (methylergonovine) |
hypertension |
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State 5 symptoms of resp distress in the newborn |
tachypnea dusky color flaring nares retractions grunting |
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If meconium was passed in the utero, what action must the nurse take in the delivery room? |
arrange for immediate endotracheal tube observation to determine the presence of meconium below the vocal cords (prevents pneaumonitis and meconium aspiration syndrome) |
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What is considered a good Apgar score? |
7-10 |
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What is the purpose of eye prophylaxis in the newborn |
to prevent opthalmia neonatorum, which results from exposure to gonorrhea in the vagina |
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What is the danger assoc with regional blocks |
hypotension resulting from vasodilation elow the block, which pools blood in the periphery, reducing venous return |
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What is the major cause of maternal death when general anesthesia is admin |
aspiration of gastric contents |
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Why are PO meds avoided in labor |
gastric activity slows or stops in labor, decreasing absorption from PO route; it may cause vomiting |
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State the best way to admin IV drugs during labor |
at beginning of contraction, push a little medication in while uterine blood vessels are contricted, thereby reducing dose to fetus |
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When is it dangerous to admin butorphanol, an agonist/antagonist narcotic? |
when the client is an undiagnosed drug abuser of narcotics, it can cause immediate withdrawal symptoms |
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Hypotension commonly occurs after the laboring client receives a regional block. What is one of the first signs the nurse might observe |
nausea |
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State 3 actions the nurse should take when hypotension occurs in a laboring client |
turn client to left side admin o2 by mask at 10 L/min increase speed of IV infusion |
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How is the 4th stage of labor defined |
the first 1-4 hrs after delivery of placenta |
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What actions can the nurse take to assist in preventing postpartum hemorrage |
massage the fundus gently and keep bladder emptied |
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To promote comfort, what nursing interventions are used for a 3rd degree episiotomy that extends into the anal sphincter? |
ice pack, witch hazel compresses, and no rectal manipulation |
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What nursing interventions are used to enhance maternal-infant bonding during the 4th stage of labor |
withhold eye prophylaxis for up to 1 hr. perform newborn admission and routine procedures in room wtih parents. encourage early initiation of breastfeeding. darken room to encourage newborn to open eyes |
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List 3 nursing interventions to ease the discomfort of afterpains |
keep bladder empty. provide a warm blanket for abdomen. admin analgesics presecribed by HCP |
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List the symptoms of a full bladder that might occur in the 4th stage of labor |
fundus above umbilicus, dextroverted (to the right side of ab), increased bleeding (uterine atony) |
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What action should the nurse take first when a soft, boggy uterus is palpated |
perform fundal massage |
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What are the symptoms of hypovolemic shock |
pallor, clammy skin, tachycardia, lightheadedness, hypotension |
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How often should the nurse check the fundus during the 4th stage of labor |
every 15 min for 1 hr, every 30 min for 2 hrs if normal |
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A nurse discovers a postpartum client with a boggy uterus that is displaced above and to the right of the umbilicus. What nursing action is indicated? |
Perform immediate fundal massage. Ambulate to the bathroom or use bedpan to empty bladder because cardinal signs of bladder distention are prsent. |
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Which women experience afterpains more than others? |
Breastfeeding women, multiparas, and women who experienced overdistention of the uterus. |
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Upon admission to the postpartum room, 3 hrs after delivery, a client has a temp of 37.5C. What nursing actions are indicated? |
Temp is probably elevated due to dehydration and work of labor-force fluids and retake temp in an hour; notify HCP if above 38C |
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A client feels faint on the way to the bathroom. What nursing assessments should be made? |
Assess BP sitting and lying; assess hgb and hct for anemia |
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What factor places the postpartum client at risk for thromboembolism? |
increased clotting factors |
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A breastfeeding mother complains of very tender nipples. What nursing actions should be taken? |
have her demonstrate infant position on breast (incorrect positioning can cause tenderness) Leave bra open to air dry nipples for 15 min 3x daily. Express colostrum and rub on nipples |
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3 days postpartum, a lactating mother has full, warm, taut, tender breasts. What nursing actions should be taken? |
She is engorged; have newborn suckle freq; take measures to increase milk flow; warm water, breast massage, supportive bra |
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What info should be given to a client regarding resumption of sexual intercourse after delivery? |
Avoid until postpartum exam. Use water-soluble jelly. Expect slight discomfort due to vaginal changes |
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A woman has decided to take birth control pills as her contraceptive. What should she do if she misses taking the pill for 2 consecutive days? |
Take 2 pills for 2 days and use an alternative form of birth control |
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A woman asks why she is urinating so much in the postpartum period. The nurse bases the response on what info? |
up to 3000 ml per day can be voided because of the reduction in the 40% plasma volume increase during pregnancy |
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A woman's WBC count is 17,000; she is afebrile and has not symptoms of infection. What nursing action is indicated? |
Continue routine assessments; normal leukocytosis occurs during postpartal period because of placental site healing |
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What is the most common cause of uterine atony in the first 24 hrs postpartum? |
a full bladder |
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What is the purpose of giving docusate sodium in the postpartum client? |
to soften the stool in mothers with 3rd or 4th degree episiotomies, hemorrhoids, or csections |
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What should the fundal height be at 3 days postpartum for a vaginal delivery ? |
3 fingerbreadths/cm below the umbilicus |
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List 3 signs of positive bonding between parents and newborn |
calling infant by name, exploring newborn head to toe, using en face position |
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The newborn transitional period consists of the first __ of life |
6-8 hrs |
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The nurse anticipates the newborns that will be at greater risk for problems in the transitional period. State 3 factors that predispose to respiratory depression in the newborn |
-c section delivery, - magnesium sulfate given to mother in labor -asphyxia or fetal distress during labor |
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What is the danger to the newborn of heat loss in the first few hrs of life |
-leads to depletion of glucose (very little is stored in immature liver) -body begins to use brown fat for energy, producing ketones and causing ketoacidosis and shock |
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Normal newborn temp is ____. Normal newborn heart rate is _____. Normal newborn resp rate is _____. Normal newborn bp is ____ |
temp: 36.5-37.4C HR: 110-160 bpm RR: 30-60 Bp: 80/50 |
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The nurse records a temp below 36.1C on admission of the newborn. What nursing action should be taken? |
Place newborn in isolette or under radiant warmer, and attach a temp skin probe to regulate temp in isolette or radient warmer. -Double-wrap newborn if no isolette or warmer available, and put cap on head. Watch for signs of hypothermia and hypoglycemia. |
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True/False: the newborns head is usually smaller than the best |
False, the head is 2 cm larger unless severe molding occurs |
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During the physical exam of the newborn, the nurse notes the cry is shrill, high pitched, and weak. What are the possible causes? |
CNS anomalies, brain damage, hypoglycemia, drug withdrawal |
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The nurse notes a swelling over the back part of the newborn's head. Is this a normal newborn variation? |
If it crosses suture lines and is a caput (edema), it is normal. If it does not cross suture lines, it is a cephalohematoma with bleeding between the skull and periosteum. This could cause hyperbilirubinemia |
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What symptoms are common to most newborns with down syndrome? |
low set ears simian crease on palm portruding tongue brushfield spots in iris epicanthal folds |
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Identify 3 ways to determine the presence of congenital hip dislocation in the newborn. |
hip click determination asymmetric gluteal folds unequal limb lengths |
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Should the normal newborn have a positive or negative babinski reflex? |
positive, until 12-18 mo |
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A SGA newborn is identified as one who ___ |
has a weight below the 10th percentile |
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When suctioning the newborn with a bulb syringe, which should be suctioned first, the mouth or nose? |
mouth; stimulating the nares can initiate inspiration, which could cause aspiration of mucus in oral pharynx |
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A new mother asks the nurse whether circumcision is medically indicated in the newborn. How should the nurse respond? |
Controversy; it does cause pain/trauma and medical indications (prevention of penile/cervical cancer) are unfounded |
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Normal blood glucose in the term neonate is ____ |
40-80 |
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Why does the newborn need vit K in the first hour after birth? |
sterile gut at delivery lacks intestinal bacteria necessary for the synthesis of vit K; vit L is needed to prevent hemorrhagic disorders |
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Physiologic jaundice in the newborn occurs ____. It is caused by ____. |
2-3 days of life; caused by immature liver's inability to keep up with the bilirubin production resulting from normal RBC destruction |
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When is the screening test for the PKU done? |
2-3 days of life, after enough breast milk or formula, usually after 24 hrs is ingested to allow for determination of body's ability to metabolize amino acid phenylalanine |
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A term newborn needs to take in ___ calories per pound per day. After the initial weight loss is sustained, the newborn should gain ___ per day |
50 calories per lb a day newborn should gain 1 oz or 30 g |
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List 5 signs and symptoms new parents should be taught to report immediately to a doctor or clinic. |
lethargy temp over 37.7C vomiting green stools refusal of 2 feeds in a row |
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What instructions should the nurse give the woman with a threatened abortion? |
Maintain strict bed rest for 24-48 hrs. Avoid sex for 2 wks |
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Identify the nursing plans and interventions for a woman hospitalized with hyperemesis gravidarum. |
weight daily, check urine ketones 3 times daily, give progressive diet, check FHR every 8 hrs, monitor for electrolyte imbalances |
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Describe discharge counseling for a woman after hydatiform mole evacuation by D&C. |
Prevent pregnancy for 1 yr Return to clinic or doctor for monthly hCG levels for 1 year Postoperative D&C instructions: Call if bright red bleeding or foul smelling vag discharge occurs or temp spikes over 38C |
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What condition should the nurse suspect if a woman of childbearing age presents to the emergency room with bilateral or unilateral abdominal pain, with or without bleeding? |
ectopic pregnancy |
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List 3 symptoms of abruptio placentae and 3 symptoms of placenta previa. |
Abruptio placentae: fetal distress, rigid boardlike abdomen, pain, dark red or absent bleeding Placenta previa: pain free, bright red vag bleeding, normal FHR, soft uterus |
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What specific information should the nurse include when teaching about HPV detection and treatment? |
detection of dry, wartlike growths on vulva or rectum. Need for pap smear in the prenatal period. Treatment with laser ablation (cannot use podophyllin during pregnancy). Associated with cervical carcinoma in mother and resp papillomatosis in neonate. Teach about immunization for females 9-30 with Gardasil |
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State 3 principles pertinent to counseling and teaching a pregnant teen |
Nursing must establish trust and rapport before counseling and teaching begin. Adolescents do not respond to authoritarian approach. Consider the developmental tasks of identity and social and individual intimacy |
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What complications are pregnant teens particularly prone to developing |
preeclampsia, IUGR, CPD, STDs, anemia
Cephalopelvic disproportion (CPD) occurs when a baby's head or body is too large to fit through the mother's pelvis. |
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All pregnant women should be taught preterm recognition. Describe the warning symptoms of preterm labor. |
More than 5 contractions per hr, cramps, low dull backache, pelvic pressure, change in vag discharge |
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List the factors predisposing a woman to preterm labor. |
UTI, overdistention of uterus, diabetes, preeclampsia, cardiac disease, placenta previa, psychosocial factors such as stress |
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When is preterm labor to be arrested? |
cervix is <4cm dilated, <50% effacement and membranes intact and not bulging out of the cervical os |
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What is the major side effect of beta-adrenergic tocolytic drugs (terbutaline) |
tachycardia |
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What special actions should the nurse take during the intrapartum period if preterm labor is unable to be arrested? |
monitor the FHR continously and limit the drugs that cross placental barriers so as to prevent fetal depression or further compromise |
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A prolonged latent phase for a multipara is ___ and for a nullipara is ____. Multipara's average cervical dilation is ___ cm/hr in the active phase, and nulliparas' average cervical dilation is ___ cm/hr in the active phase. |
multipara: >14 hrs, avg cervical dilation 1.5 nullipara: >20 hrs, avg cervical dilation 1.2 |
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What are the major goals of nursing care related to pregnancy induced hypertension with preeclampsia? |
Maintenance of uteroplacental perfusion; prevention of seizure; prevention of complications such as HELLP syndrome, DIC, and abruption |
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Mag sulfate is used to treat preeclampsia. What is the purpose of admin mag sulfate? |
to prevent seizures by decreasing CNS irritability |
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What is the main action of mag sulfate? What is the antidote? |
CNS depression, seizure prevention antidote: calcium gluconate |
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List 3 main assessment findings indicating toxic effects of mag sulfate |
reduced UO, reduced resp rate, decreased reflexes |
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What are the major symptoms of preeclampsia |
Increase in BP of 30 mm Hg systolic and 13 mm Hg diastolic proteinuria, albuminuria CNS disturbances |
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What is the priority nursing action after spontaneous or AROM |
Assessment of fetal hR |
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What is the most common complication of oxytocin augmentation or induction of labor? List 3 actions the nurse should take if such a complication occurs. |
tetany=turn off oxytocin, turn pregnant woman to side, admin o2 via facemask |
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List the symptoms of water intoxication resulting from the effect of oxytocin on the ADH |
n/v, headache, hypotension |
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State 3 nursing interventions during forceps delivery |
-ensure empty bladder -auscultate FHR before application, during process, and between traction periods -observe for maternal lacerations and newborn cerebral or facial trauma |
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What is the cause of preeclampsia |
Generalized vasospasm with increased peripheral resistance and vascular damage this decreased perfusion results in damage to numerous organs |
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What interventions should the nurse implement to prevent further CNS irritability in the preeclampsia client? |
darken room, limit visitors, maintain close 1:1 nurse-to-client ratio, place in private room, plan nursing interventions all at the same time so client is disturbed as little as possible |
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A woman on the oral hyperglycemic tolbutamide asks the nurse if she can continue this medication during pregnancy. How should the nurse respond? |
no, oral hypoglycemic medications are teratogenic to the fetus; insulin will be used |
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Name 3 maternal and 3 fetal complications of gestational diabetes |
maternal: hypoglycemia, hyperglycemia, ketoacidosis fetal: macrosomia, hypoglycemia at birth, fetal anomalies |
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When should the nurse hold the dose of mag sulfate and call the HCP |
When client's respirations are <12/min, DTRs are absent, or UO is <100 ml/4hr |
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State 3 priority nursing actions in the postdelivery period for the client with preeclampsia |
monitor for signs of blood loss. Continue to assess BP and DTRs every 4 hrs. Monitor for uterine atony. |
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What are the 2 most difficult times for control in the pregnant diabetic |
late in 3rd trimester and in the postpartum period, when insulin needs drop sharply |
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Why is regular insulin used in labor? |
it is short acting, predictable, can be infused intravenously, and discontinued quickly |
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List 3 conditions clients with DM are more prone to developing |
-preeclampsia -hydramnios -infection |
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When is cardiac disease in pregnancy most dangerous |
at peak plasma volume increase, between 28-32 wks gestation, and during stage 2 labor |
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Does insulin cross the placenta-barrier? |
No, therefore insulin dependent women may breastfeed |
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The goal for diabetic management during labor is euglycemia. How is it defined? |
70-90 mg/dL |
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What contraceptive technique is recommended for diabetic women |
diagphragm with spermicide; clients should avoid birth control pills, which contain estrogen, and intrauterine devices which are an infection risk |
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List symptoms of cardiac compensation in a laboring client with cardiac disease |
tachycardia, tachypnea, dry cough, rales in lung bases, dyspnea, orthopnea |
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What interventions can the nurse implement to maintain cardiac perfusion in a laboring cardiac client? |
position client in a semi/high fowler position -prevent valsalva maneuvers -position client in side lying position for regional anesthesia -avoid stirrups because of possible popliteal vein compression and decreased venous return |
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Gentle counterpressure against the perineum during an emergency delivery prevents ___ and ___ |
maternal lacerations fetal cerebral trauma |
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When may a VBAC (vaginal delivery) be considered by a woman with a previous c-section |
if a low uterine transverse incision was performed and can be documented, and if the original complication does not recur, such as CPD |
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Before anesthesia for c-section delivery, the mother may be given an antacid or a gastric antisecretory drug (histamine receptor antagonist). State the reason the drugs are given |
antacid buffers alkalize the stomach secretions. If aspiration occurs, less lung damage ensues. An antisecretory drug reduces gastric acid, reducing the risk for gastric aspiration |
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Clients who have had a c-section are prone to what postop complication |
paralytic ileus, infection, thromboembolism, resp complications, and impaired maternal-infant bonding |
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May women with a positive HIV antibody try to breastfeed? |
No, HIV has been found in breastmilk. |
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What are the most common SE of antibiotics used to treat puerperal infection |
GI adverse reactions: N/V, diarrhea, cramping Hypersensitivity: rashes, urticaria, hives |
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How does the nurse differentiate the symptomatology of cystitis from that of pyelonephritis? |
pyelonephritis has teh same symptoms as cystitis (dysuria, freq, urgency) with the addition of flank pain, fever, adn pain at costovertebral angle |
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What are the signs of endometritis |
subinvolution (boggy, high uterus);lochia returning to rubra with possible foul smell, temp 38C or higher, unusual fundal tenderness
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What are the nursing actions for endometritis and parametritis? |
measures to promote lochial drainage, antipyretic measures (acetaminophen, cool cloths) admin of analgesics and antibiotics, increase of fluids, with attention to high protein and high vit C |
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State 4 risk factors for or predisposing factors to postpartum infection |
operative delivery, intrauterine manipulation, anemia, poor physical health, traumatic delivery, hemorrhage |
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state 4 risk factors or predisposing factors to postpartum hemorrhage |
dystocia or prolonged labor, overdistention of the uterus, abruptio placentae, and infection |
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what immediate nursing actions should be taken when a postpartum hemorrhage is detected |
fundal massage. Notify HCP if it doesn't firm fundus. count pads to estimate blood loss. Assess vital signs. Increase IV fluids and admin oxytocin infusion as prescribed |
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Must women diagnosed with mastitis stop breastfeeding? |
No, women who stop breastfeeding abruptly may make the situation worse by increasing congestion and engorgement and providing further media for bacterial growth. Pt may have to discontinue if pus is present or antibiotics are CI for neonate |
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List the major CNS danger signals that occur in the neonate |
lethargy, high pitched cry, jitterness, seizures, and bulging fontanels |
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A baby is delivered blue, limp, HR <100. The nurse dries the infant, suctions the oropharynx, and gently stimulates the infant while blowing O2 over the face. Infant still doesn't respond. What is the next nursing action |
begin oxy by bag and mask at 30-50 breaths per min. if heart rate is <60, start cardiac massage at 120 events per min (30 breaths and 90 compressions). Assist HCP in setting up intubation procedure |
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What does the Silverman Anderson Index measure |
resp difficulty |
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What are the 2 major complications of O2 toxicity |
RLF and BFD Bronchopulmonary dysplasia (BPD) retrolental fibroplasia (RLF) |
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NEC results from ___ and is manifested by __ Ischemia/hypoxia result in ___ |
ischemic hypoxia, abdom distention, sepsis, and a lack of absorption from intestines, injury to the intestinal mucosa
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IVH is more common in ___ and results in symptoms of ____ |
premature neonates and VLBW babies, increased ICP Very Low Birth Weight (VLBW) |
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What conditions make oxygenation of the newborn more difficult |
RDS: alverolar prematurity and lack of surfactant; anemia, and polycythemia RDS (respiratory distress syndrome) |
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In order to prevent problems with oxygenating the newborn, what parameters can the nurse observe |
po2 50-90 svo2 60-80 mmhg |
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What are the cardinal symptoms of sepsis in a newborn |
lethargy, temp instability, diff feeding, subtle color changes, subtle behavioral changes, and hyperbilirubinemia |
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A premature baby is born and develops hypothermia. State the major nursing interventions to treat hypothermia |
place under radiant warmer or in incubator with temp skin probe over liver. warm all items touching newborn. place plastic wrap over neonate |
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Nurses often weigh diapers in order to determine exact UO in the high risk neonate. Explain this procedure. |
diapers is weight in grams being being applied to infant. diaper is weighed after infant has wet it. Each gram of added weight it calculated and recorded as i ml of urine |
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What factors does a nurse look for in determining a newborn's ability to take in nourishment by nipple and mouth |
infant has a good suck, has coordinated suck-swallow, takes less than 20 min to feed, gains 20-30 g/day |
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What complications are associated with TPN |
hyperglcemia, electrolyte imbalance, dehy, and infection |
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In order to prevent rickets in the preterm newborn, what supp are given? |
calcium and vit d |
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List 4 nursing interventions to enhance family and parent adjustment to high risk newborn |
initiate early visitation at ICU. provide daily info to family. encourage parcipitation in support group for parents. encourage all attempts at caregiving (enhances bonding) |
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List the risk factors for hyperbilirubinemia |
rh incompatibility, ABO incompatibility, prematurity, sepsis, perinatal asphyxia |
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List the symptoms of hyperbilirubinemia in neonate |
bilirubin levels rising 5 mg/day, jaundice, dark urine, anemia, high reticuloycyte (RBC) count, dark stools |
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Write one nursing diagnosis generated from the data pertinent to hyperbilirubinemia |
risk for injury related to predisposition of bilirubin for fat cells in brain |
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List 3 nursing interventions for the neonate undergoing phototherapy |
apply opaque mask over eyes, leave diaper loose so stools and urine can be monitored but cover genitalia turn every 2 hrs, watch for dehyd |
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List the symptoms of neonatal narcotic withdrawal |
irritability, hyperactivity, high pitched cry, frantic sucking, coarse flapping tremors, poor feeding |
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Neonates who are sick are prone to receiving too much stimulation in the form of invasive procedures and handling , and too little dev appropriate stimulation and affection. How might such an infant respond? |
failure to thrive, absence of crying |
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How should a nurse determine the length of a tube needed for the oral gavage feeding of a newborn? |
measure from bridge of nose to earlobe and then to a point halfway between the xiphoid and the umbilicus |
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What are the 2 best ways to test for correct placement of the gavage tube in the infant's stomach? |
aspiration of stomach contents and ph testing |
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What characteristics would the nurse expect to see in a neonate with FAS |
microcephaly, strabismus, growth retardation, short palpebral fissures, maxillary hypoplasia, abnormal palmar creases, irregular hair, whorls, poor suck, cleft lip, cleft palate, small teeth |
