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NSG 314A

QuestionAnswer
BUBBLE Breast, Uterus, Bowel, Bladder, Lochia, Episiotomy/perineum
HEAVN Homan's Sign, Emotional bonding & baby, Abdomen, VS, Nutrition
Newborn VS; Pulse 120-160 bpm; sleeping as low as 100 bpm; crying up to 180 bpm; apical pulse counted for 1 full minute
Newborn VS; Respirations 30-60 resp/min; predominantly diaphragmatic but synchronous with abdominal movements; Count for 1 full minute
Newborn VS; Blood Pressure 80-60//45-40 mm Hg at birth; 100/50 mm Hg at day 10
Newborn VS; Temperature Normal Range: 36.5-37.5*C (97.7-99.4*F) Axillary: 36.4-37.2C (97.5-99F) Skin: 36-36.5C (96.8-97.7F) Rectal: 36.6-37.2C (97.8-99F)
Fetal bradycardia <110 bpm over a 10 minute segment
Fetal tachycardia >160 bpm over a 10 minute segment
Variability Represents intactness of fetal CNS. Most important indictaor of fetal well being. Visually detecable FHR iscillations in the baseline defined as absent, minimal, moderate, and marked (depending on amplitude of waves)
Early decelerations visually apparent gradual decrease in FHR below baseline. Onset nadir >30 sec and coincident with the onset, peak, and ending of CTX. Caused by fetal head compression
Late decelerations visually apparent gradual decrease in FHR below baseline. Onset to nadir >30sec and delayed in timing to peak of contraction with recovery after end of CTX. Caused by uteroplacental insuff., fetal hypoxia. TX: reposition, O2, IVF, notify MD, DC induction
Variable decelerations visually apparent abrupt decreases on FHR below baseline. Peak >15 bpm, Duration > 15 sec, but < 2min, most occur with CTX. Cause: cord compression. If severe, eliminate cord compress. and increase fetal O2
Prolonged decelerations visually apparent decrease in FHR below baseline. >15 bpm, > 2 min, and < 10min. Multiple causes: prolapsed cord, hyperstimulation, rapid decent, abruption, etc.
Latent Phase of Labor Nullipara: 8.6hr & Multipara: 5.3hr Dilated 0-3cm. CTX Q3-30min, Frequ: 20-40sec Duration and intensity: Mild prog. to moderate; 25-40 mm Hg IUPC
Active Phase of Labor Nulli: 4.6hr, Multi:2.4hr, Dilation: 4-7cm, CTX: Q2-5min, Frequ: 40-60sec. Duration: Moderate prog. to strong, Intensity: 50-70 mm Hg by IUPC
Transition Phase Nulli: 3.6hr, Multi: Variable. Dilation: 8-10cm, CTX Q1.5-2min, Frequ: 60-90 sec, Duration is strong by palpation, Intensity 70-90 mm Hg by IUPC
Second Stage Nulli: up to 3hr, Multi: 0-30 min. Dilation 10cm. Contractions Q1.5-2 min, Frequ 60-90 sec. Duration is strong by palpation and 70-100 mm Hg by IUPC
6 Rights Right drug, right dose, right route, right time, right patient, right documentation right purpose
REEDA Redness, edema, ecchymosis, discharge, approximated edges. Used to assess C-section site
Created by: rschoengold
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