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PHCC 2004 Mc Nursing
test 2
| Question | Answer |
|---|---|
| Describe triple screen. | For the screening, a sample of blood is drawn from the mother to measure three basic things: the levels of hCG (human chorionic gonadotropin) and estriol, which are produced by the placenta, and the level of alpha-fetoprotein (AFP), which is produced by t |
| Uterine Atony | Most common cause of postpartum hemorrhage |
| Signs/Symptoms Uterine Involution | Uterus is difficult to feel, and when found feels soft or boggy |
| Predisposing Factors Uterine Involution | Over distended uterus due to large infant |
| When the uterus is boggy the nurse should________it until it is firm but be careful not to overstimulate it | massage |
| Lochia: | Vaginal discharge that persists throughout most of the postpartum period |
| Lochia rubra: | Bright red lasts about 3 days |
| Lochia serosa: | Pinkish or brownish from day 3 to 14 |
| *Lochia alba: | yellow-white, thin cream like, from day 10-14 to 3-4 weeks, last up to 6 weeks. |
| Non Breastfeeding mother: Menses returns | within 6-8 weeks, ovulation is unpredictable |
| Nursing mother: Varieswith when menses | returns, may or may not menstruate during lactation period or may occur 2-18 months after delivery. |
| Vital Signs: | Taken every 15 minutes for the first hour, if within normal limits then every 30 minutes during the second hour |
| Temperature: 1st 24 hours | may be increased to 100.4 due to results of dehydrating effect of labor. |
| Puerperal fever: | Temperature of 38C or 100.4F or higher after the first 24 hours and occuring on at least 2 days during the first 10 days postpartum. |
| Low B/P: Indicates | inrease uterine bleeding |
| Orthostatic hypotension: . | Common 1st 48 hours r/t internal organ engorgement |
| Fundus (top of uterus) | palpated for location and firmness. Should feel firm upon palpation |
| location of fundus immediately after delivery of placenta | 2cm below the umbilicus |
| location of fundus 1 hour after delivery | at or 1cm below umbilicus, then descends ata rate of 1-2 fingerbreadths each day |
| T or F the fundus is Not palpable after 9th day postpartum | true |
| Perineum | Edematous after childbirth, more pronounced within 24 hours after delivery |
| Usually returns to pre-pregnant Circulatory System level when | within 2-3 weeks but can stay elevated up to a year |
| Cardiac output: peaks 30-60 minutes after delivery as uterine blood does what | supply is returned to general circulation |
| Blood loss average with vaginal delivery | 200-500cc |
| Blood loss with cesarean., | 700-1000cc |
| Diuresis: begins within when | 12 hours after delivery as the extra cellular fluid is mobilized into the circulation |
| Bladder fills quickly r/t what | lactose forming in mammary glands |
| Factors that can depress urge to void | Trauma: Can occur to the urethra & bladder as infant passes through the pelvisUrethra and urinary meatus may be edematousEffects of anesthesiaPelvic soreness & episiotomy/laceration |
| Approximately 12lb weight loss after svd | = fetus, placenta, amniotic fluid |
| Homan's Sign: | (complaint of pain in calf muscle when foot is dorsiflexed)Warmth, redness, tenderness in suspected leg |
| Rubin's Psychological ChangesPhase 1: Taking in | Mother is passive, willing to let others do for her |
| Rubin's Psychological ChangesPhase 2: Taking hold | Mother begins to initiate action and becomes interested in caring for the infant |
| Rubin's Psychological ChangesPhase 3: Letting go | Mothers and fathers work through giving up their previous lifestyle and family arrangements to incorporate their new infant |
| Postpartum depression | Nonpsychotic depressive illness usually manifested within 2 weeks after delivery |
| Postpartum psychosis | Much less common than postpartum depression*Woman has an impaired sense of reality*Can involve any psychiatric disorder *In many cases involves bipolar disorder and major depression* |
| t or f Feelings of ambivalence by mother/father are abnormal | false |
| Midway through the pregnancy, breasts begin to secrete _______ the precursor of actual milk, a yellowish colored to watery clear discharge | colostrum |
| Colostrum continues to be secreted in small amounts until | lactation begins 3rd or 4th day lactation begins 3rd or 4th day |
| The stimulus of sucking is the most important and is directly related to | frequency intensity and duration |
| Prolactin: | Secreted by anterior pituitary stimulates milk production |
| Frequent and complete emptying of the breast is necessary for what | for milk secretion to continue |
| Mastitis: | Infection of the breast |
| Mastitis s/s | Redness and heat in the breastsRedness and heat in the breastsRedness and heat in the breastsTenderness*Edema and breast heaviness*Purulent drainage |
| Monolial infection: | Milk duct clogged causing red tender area or lump in the breast which may or may not be tender |
| Methergine: | *Action: Contraction of the uterus*Side Effect: HTN, nausea/vomiting, headache*Contraindications: HTN, cardiac disease*Dosage and Route: 0.2mg IM q 2-4 hours up to 5 doses 0.2mg IV only for emergencies* |
| Nursing Considerations for Methergine:: | Check B/P prior to administration, do not give if >140/90*Monitor vaginal bleeding and uterine tone |
| Peri-Care: | Always wipe from front to back *May sit in warm tub bath to relieve discomfort*May have moderate amts of vaginal discharge *Discharge may last 4-6 weeks*Color may vary from dark brown, red to pink*May contain clots*Use sanitary pad instead of tampon* |
| Non-Stress Test: | Two of more accelerations with movement over 20minutes, normal baseline, long term variability 10/min |
| Non-Stress Test results: | Criteria met (accelerations)*Non-reactive: Criteria not met, after 40 minutes of continuous monitoring*No known contraindications |
| Hemorrhage: | greater than 500mL causes include laceration of birth canal, retained placental fragments and uterine atony. |
| Shock: | An emergency situation in which the perfusion of body organs may become severly compromised and death may occur. Activated in response to hemorrhage |
| Hemorrhagic Shock: Can occur rapidly, but classic signs may not appear until when | the woman has lost 30-40% of blood volume |
| Ectopic Pregnancy S/S: | Amenorrhea*Abnormal menstrual period followed by slight bleeding*Mass and cu-de-sac in/around adenxa*Unilateral pelvic pain over mass |
| Placenta previa s/s | Bright red bleeding *Increases as cervix effaces and dilates*Fetus is usually in abnormal presentation*Risk for hemorrhage, fetal hypoxia may occur |
| Marginal: Placenta previa | Reaches edges of cervix |
| Partial:Placenta previa | Partially covers cervical opening |
| Total:Placenta previa | Completely covers cervical opening |
| Abruptio Placenta S/S: | Painful*Partial*Total*Bleeding accompanied by abdominal/lower back pain*Dark red bleeding if it leaks past placenta*Uterus is tender and unusually firm*Continuous contractions |
| Abruptio Placenta Mild | Minimal external blood loss below 500mL *dark red blood/shock is rare*Pain, usually absent*Fetal heart rate normal |
| Abruptio Placenta Moderate | Absent or moderate external bleeding 1000-1500ml total*Dark red blood with mild shock*Pain is present *Fetal heart rate non-reassuring |
| Abruptio Placenta Severe | Absent to moderate external bleeding*Dark red, sudden profound shock*Pain persistent, uterus boardlike*Fetal heart rate non-reassuring or death |
| Rh sensitization: | Occurs when Rh- mother has an Rh+ fetus |
| Rhogam: | Commercial preparation of passive antibodies against the Rh factor |
| Rhogam drug info | *Action: Suppression of immune response*Indications: suppresses antibody formation in women with Rh- blood, after birth, miscarriage pregnancy*Dosage and Route: 1 vial 300ug IM in deltoid/gluteal muscle 1 vial 50ug IM in deltoid = micro dose |
| Heart Diseasein pregency | Leading cause of maternal mortality |
| Class 1: | ASD( Atrial septum defect) Asymptomatic at normal levels of activity Usually will have uncomplicated pregnancy. VSD (Ventricular septum defect) Left to right shunt, not common due to repair as child. Usually uncomplicated, risk for arrythmias, |
| Class 2/3 | :*Coarctation of the aorta: *Risk for hypertension, CHF, aortic rupture*Tx : rest, antihypertensives (beta adrenergic blockers)*Vaginal birth is possible with epidural/vacuum extraction*Antibiotics at birth*Tritilogy of Fallot: *VSD, Pulmonary stenosis |
| Class 3/4 | :*Mitral Valve stenosis: *May become symptomatic during pregnancy*S/S: a-fib, right sided heart failure, pulmonary edema Hemoptysis*tx: bed rest, restricted Na, medications such as digoxin and anticoagulants, epidural anesthes*Aortic Stenosis: MI |
| Pregnancy Induced Hypertension: | Onset of hypertension in a previously undiagnosed woman after 20 weeks gestation B/P 140/90 |
| Pre-eclampsia S/S Mild | B/P 140/90 x2 greater than 4-6 hours apart no greater than 1 week apart |
| Pre-eclampsia S/S Severe | B/P 160/110 x2 seperate occasions |
| Eclampsia | pih with seizures |
| when seizures occur mother is not breathing and fetus is not | oxygenating, insert airway if possible |
| Magnesium Sulfate Antidote | Calcium Gluconate |
| Magnesium Sulfate Therapeutic level | 4-8mg/dl |
| Family: | The sum of its individual members |
| Family as client approach | :*Family is focus of care*Focus on every individual member*Used in primary care settings, practitioner with each person in family is assessed, and relationship of family group is known to health care providers |
| Family as component of society approach* | Family is one of many societal institutions *Understood by some to be the basic or primary unit of society*Used by community health nurses*Family interacts with school, churches, legal bodies and economic institution |
| *Family as context approach | :*Individual is focus of care*Roots in pediatric and maternal child nursing*Deals with one client and family affecting the health, tx and management of the therapeutic regimen of the client |
| *Family as system approach: | *Family is more than sum of its parts*Assess both family and individual*Emotionally connected*Assess family members simultaneously*If significant event affects one member there is an impact on the others*Often used in mental health nursing |
| Parenting Styles | :*Authoritative*Authoritarian*Permissive |
| Authoritative:. | Parents use reason and explanation, encourage competence and exhibit warmth.*Children are more responsible, active, successful in school work and popular with peers |
| Authoritarian: " | Dominating, punitive and unrealistic.*"Do it because I say so"*"Children are to be seen not heard |
| Permissive: | Exhibits little control, no structure*Both Authoritarian and Permissive practices were found to shield the child from the opportunity to engage in vigourous interactions with people |
| Sources of Anxiety for Children: | Fear of abandonmentGuiltDenial of autonomy and statusFriction between parentsInterferes with physical activityDeath |
| Role: | Constellation of rules for behavior associated with a given status or position |
| Ascribed Role | A role in which a person formally assumes responsibility for carrying out and established set of norms |
| Achieved Role | Role which is assumed as a result of an accomplishment |
| Adopted Role | Role which is assumed for the achievment of a specific goal |
| Assumed Role | taken up or already posessed as an integral part of the personality. Especially important in childhood. Children continuously assume roles of people they observe in their environment |
| Watzlawick's Theory: | Communications Theory Axioms:*All behavior non verbal or verbal is communication*Communication defines a relationship*Verbal communication is content oriented*Non-Verbal is relationship oriented*Communication is symmetrical and complimentary |
| Genogram: | Depiction of a family tree |
| Placator: | Fixes problems |
| Blamer: | The accuser |
| Computer: | Non emotional |
| Minor Depression:. | Diagnosis has yet to be validated for inclusion in DSM, can be brief and associated with fewer than 5 symptoms required for major depression |
| Dysthmic Disorder: | Feels depressed nearly all the time for at least 2 years, must have at least 2 of the following:*Appetite disturbance*Sleep disturbance*Fatigue*Low self esteem*Poor concentration*Difficulty making decisions |
| Major Depression: | Requires 5 or more symptoms be present one symptom must be either depressed mood, or loss of interest in previously enjoyed activities |
| Bi-Polar: | Mood disorder characterized by cyclic experiences both mania an depression. Periods of normal mood and activity in between episodes, equally common in men and women |
| Bi-Polar:Contributing factors | Genetics*Situational crisis*Biochemical factors*Alienation of social support*Need for power and control*Low self estee*Anxiety |
| Bi-Polar: Criteria: | At least three of the following for at least 1 week*Grandiosity*Decrease need for sleep*Pressured speech*Flight of ideas*Distractibility*Psychomotor agitation |
| Milia: | Distended small white sebacious glands, may be noticeable on the nose and chin. |
| primary treatment for bipolar | lithium |
| Bilirubin:Direct: | Conjugated form of bilirubin that is excreted from liver cells as a constituant of bile. Excreted into biliary tract |
| Bilirubin Indirect: : | Unbound bilirubin can leave the vascular tissue and goes to the skin, sclera, oral mucosa membrane |
| *Hyperbilirubinemia: | Rh incompatibility, results in jaundice 12-24hours after birth |
| *Hyperbilirubinemia TX: | Bili-lioght or fiber optic blanket*Monitor skin temp.*Increase formula or breastfeeding to increase excretion of bilirubin in stool |
| Acrocyanosis: | Blue or purple mottled discoloration of the extremities*Due to capillary stasis, high hemoglobin*Normally occurs intermittently during the first seven to ten days |
| Circumcision: | Removal of the foreskin of the penis |
| Apgar Score: | Permits a rapid assessment for the need of resuscitation based on 5 signs ,Heart rate,Respiratory rate ,Muscle tone,Reflex,color |
| Score of 0= | absent heart rate,resps, flaccid, no reflex irritability and color is blue/pale |
| Score of 1= | slow heart rate <100BPM slow/weak cry, some flexion,grimace reflex, body pink and extremities blue |
| Score=2 | heart rate>100BPM good cry, well flexed, cry for reflexes,color pink |
| Scores of 0-3 indicate | severe distress |
| scores of 4-6 inicate | moderate difficulty |
| 7-10 indicate | infant should have no difficulty |
| *Sucking and Rooting: | Touch infants lip, cheek or corner of mouth*Infant turns head toward stimulus, opens mouth takes hold and sucks*If response weak or absent consider prematurity or neurologic defect |
| Swallowing: | Usually follows sucking and obtaining fluids*If response weak or absent consider prematurity or neurologic defect |
| Grasp | :*Palmar: Place finger in palm of hand, infant fingers curl around examiner finger*Lessens by 3-4 months*Plantar: Place finger at base of toes, toes curl downward around examine finger*Response lessens by 8 months |
| *Extursion: | Touch or depress tip of tongue*Newborn forces tongue outward*Response disappears 4th month of life |
| Glabellar (Myerson's) | Tap over forehead, bridge of nose, maxilla of newborn whose eyes are open*Newborn blinks for first 4-5 taps*If blinking continues with repeated taps is consistent with extrapyramidal disorder |
| Tonic Neck (Fencing) | With infant falling asleep or sleeping turn head quickly to one side*Extremities assume opposite postureDisappears by 3-4 months*After 6 weeks persistent response is sign of possible cerebral palsy |
| Babinski sign: | On sole of foot beginning at heel stroke upwards and move finger across ball of foot *All toes hyper extend with dorso flexion of big toe*Should disappear after one year of age |
| Moro: | Place infant on flat surface, strike surface to startle infant*Systematic symmetric abduction and extension of arms *Seen until 8weeks of age, body jerk 8-18 weeks*Absent by 6 months if neurologic maturation not delayed |
| Stepping: | Hold infant vertically allow one foot to touch table*Infant will simulate walking*Present 3-4 weeks |
| Spina Bifida: | Defect in closure of the vertebral column with or without varying degrees of tissue protrusion through bony cleft |
| Myelomeningocele: | Hernial protrusion of a sac like cyst of meninges, spinal fluid, and a portion of the spinal cord with its nerves through a bony defect in the vertebral column |
| Necrotizing Enterocolitis: | Severe damage to the intestinal mucosa of a preterm infant due to eschemia resulting from asphyxia or prolonged hypoxemia |
| Tracheoesophageal Fistula: | (TEF) Connection between esophagus and trachea excessive salivation and drooling. Stomach distended with air. |
| *Three C’s of TEF | *Choking *Coughing *Cyanosis |
| *Consequences of cold stress | :*Hypoxia*Metabolic acidosis*Hypoglycemia |
| Car Seat: | Right seat for height and weight*Positioned properly*Not all children fit in the same car seat*Cannot sit in front facing seat until at least 1 year of age and weigh 20 lbs*Never place infant in passenger seat with passenger side airbag* |
| Car Seat: | Cannot reuse car seat after has been involved in an accident*Safest place for all children in back seat, position in center if possible |
| Newborn Respiration:Characteristics | *Irregular*30-60respirations minute*Short periods of apnea |
| S/S Respiratory distress | Nasal flaring*Retraction*Grunting with expiration*<30 or >60 breaths/minute at rest*Apnea lasting >15seconds |
| Meconium: | Fetal or newborn bowel movement |
| The first elimination of urine and meconium is used to determine what | the patency of the urinary and intestinal tract |
| Cephalhematoma: | Collection of blood between a skull bone and its periosteum.*Blood*Usually corrects itself*Up to/ Past suture line |
| Pre-Term or premature: | Born before 37 weeks gestation regardless of weight |
| Term: | Born between 38 and 42 weeks regardless of weight |
| Post-Term: | Born after 42nd week regardless of weight |
| Post Mature: | Born after 42nd week and has experienced progressive placenta insufficiency |
| *Ballard/Dubowitz scale | *35-42 weeks*6 external physical signs*6 nuero-muscular signs*Each sign has a number score and correlates with a maturity rating of 26- 44 weeks gestation.*Can be used with an updated version on infants as young as 20 weeks gestatio |
| Hydrocephalus: | An excessive accumulation of cerebral spinal fluid within the ventricular system, resulting in passive dilation of the ventricles |
| Communicating hydrocephalus | *Impaired absorption of CSF within the sub arachnoid space |
| Non-CommunicatingHydrocephalus | Obstruction to the flow of CSF within the ventricles |
| Exstophy of the bladder: | Anterior wall of the bladder and the lower portion of the abdominal wall are absent causing the bladder to lie open and exposed on the lower abdomen. |
| Omphalocele | : Covered defect of the umbilical ring into which varying amounts of the abdominal organs may herniate |
| Phenylketonuria (PKU): | Inherited error in metabolism |
| Phenylketonuria (PKU) child can not have what | protein |
Created by:
jtcmedic
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