NCLEX Hurst Maternity Nursing-unco – Flashcards
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What are probable signs of pregnancy?
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A positive pregnancy test Goodell's sign Chadwick sign Hegar sign Uterine enlargement Braxton hicks contractions Pigmentation/changes of skin: linea nigra, abdominal striae, facial chloasma (mask of pregnancy), darkening of the areola (around the nipple)
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What levels is a pregnancy test based off?
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The presence of hCG levels
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What other conditions can increase hCG levels?
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-hydatidiform mole (rare mass or growth that forms inside the womb (uterus) at the beginning of a pregnancy.) -drugs
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What is Chadwick's sign and when does it happen?
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Bluish color of vaginal mucosa and cervix first month
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What is the Goodell's sign and when does it happen?
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softening of cervix; in the second month
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What is the Hegar's sign and when does it happen?
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softening of the lower uterine segment; 2nd/3rd month
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Describe Braxton Hicks contractions?
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throughout pregnancy; move blood through the placenta
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Changes in skin of the linea nigra is?
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darkline down abdomin
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Changes in skin of abdominal striae is?
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Stretch marks
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Changes in Facial chloasma is?
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Mask of pregnancy-changes in facial pigmentation of mother
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When can you hear fetal heart rate with a doppler?
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10-12 weeks
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When can you hear fetal heart rate with fetoscope? (its a weird stethoscope)
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17-20 weeks
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What are positive signs of pregnancy?
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Fetal heart rate-doppler Fetoscope Fetal movement Ultrasound
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What is Gravidity?
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number of times someone has been pregnant
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What is parity?
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the number of pregnancies in which the fetus reaches 20 weeks
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What/when is viability?
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At 24 weeks. Infant has the ability to live outside the uterus.
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What age is considered not viable
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a 20 week baby is not considered viable
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TPAL describe the acronym?
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Gives further information on parity. T=term P=preterm A=abortion-this includes spontaneous and elective abortions. L=living children
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Describe Naegele's rule for the due date estimation?
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-Find the day of the last menstrual period. -Add 7 days -Subtract 3 months -Add 1 year
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What teaching do you need to teach when client in the first trimester regarding diet? (calories, protien and food groups?)
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Eat the 4 food groups Increase calories by 300 per day after the first trimester. Increase protein to 60 grams per day
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How much does adolescents clients need to increase their calories?
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Increase calories by 500 after first trimester
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How much weight is the client suppose to gain in the first trimester?
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Expect to gain 4 pounds in the first trimester.
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Why don't women like to take iron?
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It causes constipation and GI upset
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What should iron be taken with to increase absorption?
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Take iron with vitamin C to enhance absorption
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How much folic acid recommended daily and why?
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Folic acid prevent neural tube defects. Daily dose 400 mcg/day
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What exercises should be done when pregnant?
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Walking and swimming
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What should you not do pertaining to exercise and being pregnant? (temp, intensity)
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No high impact No heavy or unaccustomed exercise program No over heating (no hot tubs or electric blanket either).
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Why no over heating when pregnant?
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Increase body temperature= birth defect
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What is an exercise rule when pregnant and why?
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Don't let your heart rate get above 140. If the heart rate goes over 140bpm= cardiac output and uterine perfusion will drop.
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What are danger signs in pregnancy? (freak out)
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Sudden gush of vaginal fluid Bleeding Persistent vomiting Severe headache Abdominal pain Increased temps Edema No fetal movements
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What are common discomfort when pregnant?
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Nausea and vomiting, breast tenderness, urinary frequency, tender gums, fatigue, heartburn, increased vaginal secretions, nasal stuffiness, varicose veins, ankle edema, hemorrhoids, constipation, backache, leg cramps
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What are you going to tell the pregnant person about taking medications?
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Dont unless you ask your doctor
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Pregnant women what are you going to tell them about smoking?
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They should stop.
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How often should a pregnant client visit the physician?
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First 28 weeks: once per month 28-36 weeks: every 2 weeks At 36 weeks: weekly until delivery
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Before an ultrasound, what will you ask the client to do? and why?
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Drink water To distend the bladder causing to push uterus to abdominal surface
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What should you make sure the client does when getting an ultrasound prior to a procedure such as an amniocentesis?
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void
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What is the second trimester?
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Week 14 through Week 26
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Expected weight gain per week in second trimester?
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4 pounds a month-so 12
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In the second trimester should the client still be experiencing nausea and vomiting?
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No
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In the second trimester should the client still be experiencing breast tenderness?
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yes
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In the second trimester should the client still be experiencing urinary frequency?
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No uterus large and raise up in the abdomin
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What is quickening?
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Fetal movement
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What should the fetal heart rate be during the second trimester?
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120-160 bpm
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What is normal fetal heart rate?
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120-160 bpm
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What fetal heart rate should you be worried about?
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110-120 bpm
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What fetal heart rate should you panic about?
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less than 110 bpm
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Why are kegal exercises important?
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Exercise to strength the pubococcygeal muscle. These muscles help stop urine flow help prevent uterine prolapse.
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Pregnancy is considered full term if?
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It advances to 37 to 40 weeks.
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What is the third trimester?
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Week 27 through week 40
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Expected weight gain per week in third trimester?
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no more then 1 pound a week
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Monitor BP in third trimester should report if?
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Increase from the baseline
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What should fetal heart rate in third trimester?
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120-160 bpm
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How is fetal position/presentation determined by the doc?
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Leopold maneuvers
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What should the client do before Leopold maneuvers?
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Void
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If the client is having contractions, should leopolds maneuvers be done during or between contractions?
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Between
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What are the signs of labor
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Lightening-baby moving down the canal Engagement-largest presenting part is in the pelvic inlet Fetal stations Braxton Hicks contractions Softening of the cervix Bloody show Sudden burst of energy Diarrhea rupture of the membranes
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Describe Lightening?
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Usually occurs 2 weeks before term When the presenting part of the fetus (usually the head) descends into the pelvis. The client will feel less congested and breath easier, but urinary frequency is a problem (again)
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Describe Engagement?
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The largest presenting part is in the pelvic inlet. Hopefully, the fetal head is presenting first
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Describe fetal stations?
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Measured in cm; measures the relationship of the presenting part of the fetus to the ischial spines of the mother.
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What is the name of the sudden burst of energy in signs of labor?
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Nesting
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When should the client go to the hospital?
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When the contractions are 5 minutes apart or when the membranes rupture.
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What are we worried about when the membrane rupture?
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Prolapsed cord
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what do we want to see Non-stress tests and describe what we want the results to be? (non-reactive or reactive?)
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Want to see two or more accelerations of 15 beats/minute (or more) with fetal movement. Each increase should last for 15 seconds (but should come back down to baseline after 2 mins) and recorded for 20 minute. we want the results to be reactive.
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Describe Acceleration?
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Is when the fetal heart rate has a abrupt increase from the baseline. This is visualized on the fetal heart monitor. The increase is greater then or equal to 15 beats/min. above the baseline and lasts at least 15 seconds, but the heart rate should come back to baseline within 2 min.
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Do you want the non-stress test to be reactive or non-reactive?
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Reactive
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When is a biophysical profile test (BPP) done and why?
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Done in the last trimester, but can be done at 32-34 weeks in high risk pregnany.
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High risk pregnancy may have biophysical profile test (BPP) how often and what time frame?
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May have a BPP every week or twice a week in 3rd trimester.
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Measurements of biophysical profile test (BPP) is done with what machine, and explain scoring?
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Measurements are done by ultrasound; each parameter counts 2. 10/10 is great.
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What do biophysical profile test measure? and what are the parameters that must be met in the time period? (HMMBA)
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1. Heart rate-was Non-stress test (NST) reactive? 2. Muscle Tone-does baby have at least 1 flexion-extension movement in 30 minutes? 3. Movement-does the baby move at least 3 times in 30 minutes. 4. Breathing-does the baby have breathing movements at least once in 30 minutes? 5. Amniotic fluid-is there enough fluid around the baby?
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How long does biophysical profile test observation take?
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Observation time is 30 minutes.
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What are the result groups for biophysical profile test (BPP) and they mean?
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8-10 good 6 worrisome <4 ominous
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What is the Contraction Stress Test (CST) also called?
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Oxytocin Challenge Test
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When is the Contraction Stress Test (CST) done?
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Done when the NST is non reactive
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what kind of pregnancies is the Contraction Stress Test (CST) performed on and examples?
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Performed on high risk pregnancies: preeclampsia, maternal diabetes, and any condition in which placental insufficiency is suspected.
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What does the Contraction Stress Test (CST) determine?
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This determines if the baby can handle the stress of uterine contraction
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Why is the Contraction Stress Test (CST) done in regards to patho of contractions?
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Because uterine contractions decrease blood flow to the uterus and to the placenta. If the blood flow decreases enough to cause hypoxia in the fetus, the fetal heart rate will decrease from the baseline HR. This is called decelerations.
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What do you not want to see in Contraction Stress Test (CST) and why? and positive or negative test?
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Do not want to see late decelerations, this means uteroplacental insufficiency. Want a negative test
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Contraction Stress Test (CST) is rarely performed before how many weeks?
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28 weeks.
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How long are the Contraction Stress Test (CST) results good for?
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One week
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What are the three types of decelerations?
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Early decelerations. Late decelerations. Variable decelerations.
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Describe Early decelerations?
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(not bad) benign-caused by physiological hypoxia from fetal head compression (HC)
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Describe Late decelerations?
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(bad) caused by uteroplacental insufficiency (UPI)
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Describe Variable decelerations?
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(bad) caused by umbilical cord compression (CC)
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What does VEAL CHOP stand for?
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Variablility Cord compression Early decels Head compression Accelerations (are) Okay Late delelerations Placental insufficiency
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Describe True labor?
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Contractions are regular. Contractions increase in frequency and duration. Discomfort in back and radiates to abdomen.
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What happens to pain level with change in activity in true labor?
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Increase
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Describe false labor?
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Contractions irregular. Discomfort in abdomen.
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What happens to the pain with a change in activity in false labor?
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Decrease
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Position you need to be in for epidural anesthesia?
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Lie on left side, legs flexed, not as arched as with lumbar puncture.
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When is epidural anesthesia given?
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In stage 1 at 3-4 cm dilation
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Major complication of epidural anesthesia and what to monitor?
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Hypotension Monitor BP
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How should it be treated if epidural anesthesia causes hypotension?
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IV fluids: Bolus with 1000 mL of NS or LR to fight hypotension.
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What position should the mom be in for an epidural anesthesia to prevent hypotension and why?
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Put in semi-fowlers on side to prevent vena cava compression. If the vena cava is compressed, it will decrease venous return, reduce cardiac output and blood pressure and decrease placental perfusion. OR Alternate position from side to side hourly.
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What complications can occur with patient receiving oxytocin (Pitocin R)?
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Hypertonic Labor Fetal Distress Uterine rupture -Complete uterine rupture -Incomplete uterine rupture
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Describe complete uterine rupture?
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A tear in the uterus Through the uterine wall into the peritoneal cavity (there is a direct communication between the inside of the uterus and the peritoneal cavity).
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What are signs and symptoms of complete uterine rupture?
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Sudden, sharp, shooting pain (something gave away); if in labor the contractions may stop ad the pain will be relieved; signs of hypovolemic shock due to hemorrhage; if the placenta separates, the fetal heart tone will be absent.
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Describe Incomplete uterine rupture?
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Through the uterine wall but stops in the peritoneum. The peritoneal cavity is still intact.
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What are signs and symptoms of Incomplete uterine rupture?
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Internal bleeding, pain may not be present, fetus may or may not have late decels, client may vomit, faint, have hypotonic uterine contractions and lack of progress, and fetal heart tones may be lost.
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Describe complications that could occur with vaginal birth after C-section (VBAC)?
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Clients are at high risk for uterine rupture. The scar from the c-section is prone to open when under stress. Those at highest risk are that that are receiving oxytocin (Pitocin R).
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When receiving oxytocin you want contractions to be how far apart and how often?
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Contraction rate of 1 every 2-3 minutes, with each lasting 60 seconds.
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Discontinue oxytocin if?
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The contractions are too often. The contactions last to long. Fetal distress.
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How is Oxytocin given IV and what do you need to remember when discontinuing Oxytocin?
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Oxytocin (Pitocin R) is piggy backed into a main IV fluid, so when you discontinue the Oxytocin (Pitocin R), make sure you do not turn off your main IV fluid.
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What position should the client receiving Oxytocin (Pitocin R) be placed?
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Any position except flat on their back. Now, if the client has any unreassuring fetal heart tones (like fetal bradycardia),then we will put the client on her left side to enhance uterine perfusion.
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What should be done with the infusion if late decelerations occur?
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Turn it off.
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What needs to happen during/prior to emergency delivery?
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Tell client to pant/blow to decrease urge to push during contractions. the client should ONLY push during contractions. Wash hands Elevate HOB Place something clean under buttocks Minimize touching of vaginal area. As head crowns, the tear amniotic sac (only if it has not ruptured already) Place hand on fetal head and apply gentle pressure to prevent baby from coming out too fast When head is out, feel for cord around neck. Ease each shoulder out-do not pull on baby. The rest will deliver fast.
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What should be done to the baby during emergency delivery?
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Keep baby's head down. Dry Baby Keep baby at level of uterus. Place on mother abdomen Cover baby
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What should be done after birth of baby during emergency delivery?
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Wait for placenta to separate/deliver. Can push to deliver placenta Inspect placenta for intactness. Tie the cord off with a piece of cloth or shoestring.-Place one knot about 4 inches from the baby's naval and the second know about 8 inches from the baby's navel. Check firmness of uterus.
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What do you need to remember when telling the client to pant/blow to decrease urge to push?
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The client should not push between contractions. The mother should only push during contractions.
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As the head crowns, the tear amniotic sac you might have to?
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You will only have to tear the amniotic sac if it has not already ruptured.
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What does placing a hand on fetal head and apply gentle pressure?
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This will prevent the baby from coming out too fast
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What should the vital signs be like after Post-partal period?
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Temperature may increase to 100.4 F (38.0 C) during 1st 4hours. BP is stable Heart rate 50 to 70 common for 6-10 days.
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(Test Strategy) Tachycardia + postpartum think?
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HEMORRHAGE
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What should the breast be like during postpartum period?
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Soft for 2 to 3 days, then engorgement
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What should the abdomen be like during postpartum period?
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Soft/loose; diastasis recti (belly sticks out because the space between your left and right belly muscles has widened.)
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Is hunger common in postpartum period?
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yes
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Immediately after birth, the fundus is?
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Is midline 2 to 3 finger breadths below umbilicus.
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A few hours after birth the fundus does?
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It rises to level of umbilicus or one FB above.
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Want fundus to be?
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Firm
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What is the first thing you do if the fundus is boggy?
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Message the fundus until it is firm and then check for bladder distention.
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Bladder distention is suspected when? what does it cause?
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When the uterus is above the expected level or is not the midline. (Usually moved to the right). A distended bladder will not allow the uterus to contract normally which increases the chance of hemorrhage.
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Fundal height will descend how many FB's/day?
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one FB/day
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What is the proper term used when the fundus descends and the uterus returns to its pre-pregnancy size?
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Involution.
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Afterpains are common for the first 2-3 days and will continue to be common if the mother chooses to what?
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Breastfeed.
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What is lochia?
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the normal discharge from the uterus after childbirth.
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What should the lochia be right after birth and for how many days?
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Rubra: 3-4 days: Color dark red
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What is the lochia that comes after rubra and how many days after?
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Serosa: 4-10 days: Color pink/brown
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What is the lochia that comes after serosa and what days?
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Alba:10-28 days (can be as long as 6 weeks): Color: whitish yellow
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Clots are okay in lochia as long?
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as they are no larger than a nickle
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When should diuresis occur postpartum?
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Should begin 24 hours after delivery
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Is dehydration possible postpartum?
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Yes
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Why should the legs be inspected closely?
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DVTs
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What can be done for perineal care? (do what 5 things and report 2 things?)
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Ice packs intermittently for first 6-12 hours to decrease edema. Warm water rinses. Sitz baths 2-4 times per day Anesthetic sprays Change pads frequently Teach to report foul smell. Report lochia changes
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Warm water rinses, sitz baths 2-4 times per day, and anesthetic spray indicated in?
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These are indicated if the client has an episotomy, lacerations, or hemorrhoids.
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What is the peripad rule?
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We do not want the client to saturate more than 1 peripad/1 hour
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Describe bonding?
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Bonding between mother and baby and father and baby develops trust. In the infant, trust is not only an emotional need but a physical need
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How does the newborn benefit physiologically from bonding? (think of babys vital signs)
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Stabilize HR Improves O2 sats Regulates the infant temperature. Conserves calories Breast can change in temperature to warm or cool the infant.
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What is kangaroo care and how often should it be done?
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Mom or Dad places baby "skin to skin" on their chest. The baby is wrapped inside the parent's shirt or covers and held for 1 hour at least 4 times a week.
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What can be done to help breasts when breast feeding?
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Cleanse with warm water after each feedings; let air dry. Support bra. Ointment for soreness of express some colostrum and let it air dry. Breast pads to absorb moisture.
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Mother needs to initiate breast feeding?
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ASAP after birth
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what can mom do if she is unable to breast feed to help keep milk production going?
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Pump
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A breast feeding mother should increase her calorie intake by how much?
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Increase caloric intake by 500 calories
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Mother breast feeding fluid/milk intake should be?
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8-10 8oz glasses of fluid a day
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What should Non-breast feeding mothers do to their breast?
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Ice packs, breast binders, chilled cabbage leaves. Chilled cabbage leaves decrease inflammation and decrease engorgement. No stimulation for the breast.
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What are postpartum complications? (3 things)
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Postpartum infection. Postpartum hemorrhage. Mastitis
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What cause Postpartum infection? What should be done? (time period, type of bacteria, teach what and do what regarding cultures and meds?)
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Infection within 10 days after birth; E coli/Beta hemolytic strep. Teach proper hygiene (front and back cleansing) and hand washing. Usually get culture and antibiotics
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Definition of Early Postpartum hemorrhage, timeline and criteria that must be met to be considered pph?
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More than 500ml blood lost in first 24 hours and a 10% drop from admission hematocrit. You must have both to be true.
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Definition of Late Postpartum hemorrhage and timeline?
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After 24 hours, up to 6 weeks postpartum
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What are 4 things that can cause Postpartum hemorrhage?
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Uterine atony, lacerations, retained fragments, and forceps delivery.
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What are the medications used to halt excessive postpartum hemorrhage?
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Oxytocin (Pitocin R) Methylergonovine Maleate (Methergine R) Carboprost Tromethamine (Hemabate R)
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What cause Mastitis? when does it occur?
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Staphylococcus Usually occurs around 2-4 weeks
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Treatment for Mastitis?
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Bed rest Support Bra Binding (compression) can cause more stagnation Chilled cabbage leaves Initiate breast feeding frequently or pumping. Penicillin (ok with breastfeeding) Pain medication Heat Feed baby frequently and always offer the affected breast first
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What treatment for Mastitis should only be used when breastfeeding is discontinued permanently?
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Binding can cause more stagnation Chilled cabbage leaves
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What breast do you offer first when breastfeeding and have Mastitis?
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Always offer the affected breast first
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What is the immediate care for Newborns?
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Suction Clamp and cut the cord Maintain body temperature Apgar Erythromycin Phytonadione-vitamin k injections
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What is Apgar? What does it look like? What score do you want?
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Done at 1 and 5 minutes Looks at HR, Resp Rate, muscle tone, reflex irritability, color. Want at least 8-10
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Why Erythromycin to newborns?
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(gtts or ointment) for eye prophylaxis for neisseria gonococcus.
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What else does Erythromycin kill?
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Also kill the most rapidly growing STD:Chlamydia
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Why Phytonadione to newborns?
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Phytonadione (Aquamephyton R) vitamin k promotes formation of clotting factors.
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How should you care for the cord?
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Dries, and falls off in 10 to 14 days. Cleanse with each diaper change using alcohol or NS. Fold diaper below cord. No immersion until cord falls off; watch for infection
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What are complications of the newborn? (3things)
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Hypoglycemia Pathologic Jaundice Physiological Jaundice
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Why do babies sometimes experience hypoglycemia after birth?
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Because they are not getting glucose from mom.
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What babies are greatest risk for hypoglycemia?
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Include that are large for gestational age, small for gestational age, preterm, and babies of diabetic moms.
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When does pathologic jaundice occur and why?
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First 24 hours . Usually means Rh/ABO incompatibility.
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When does physiological jaundice occur and why?
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After 24 hours Due to normal hemolysis of excess RBC releasing bilirubin, or liver immaturity.
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Another name for physiological jaundice?
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Hyperbilirubinemia
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Rh sensitization occurs when?
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Rh- mother with an Rh+ fetus
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What cause the Rh sensitization in first pregnancy?
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Rh+ blood from baby comes in contact with mother's Rh- blood.
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When is the most likely time that the mom and babys blood will mix that will cause problems with RH sensitization?
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Mom's blood is most likely to come in contact with baby's blood when the placenta separates at birth
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When else can Rh sensitization occur?
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It can also happen during miscarriage, amniocentesis, or when there is trauma to mom's abdomen.
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What is the mom body doing in Rh sensitization?
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Mothers body looks at the Rh+ blood as a foreign body, (an antigen). Mother produces antibodies against the baby's Rh+ blood.
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Is the first offspring affect by the antibodies in Rh sensitization?
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The first offspring is not affected by the antibodies
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What happens when an Rh- sensitized mom gets pregnant again?
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She got these antibodies waiting for the Rh+ blood to come around so she can attack it.
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What increase the chances of Rh- mom having antibodies?
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The chances of an Rh- mom having antibodies to Rh+ blood increases with each pregnancy and each exposure to Rh+ blood because once you have these antibodies they never go away.
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The antibodies the mother has made enters where?
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the baby thru the placenta causing hemolysis in baby
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What is erythroblastosis fetalis?
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The increase of immature RBCs in the fetal circulation
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Erythroblastosis fetalis can result in?
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Hyperbilirubinemia Anemia Hypoxia Heart Failure Neurologic Damage Hydrops Fetalis (water buildup in baby's head-severe form of erythroblastosis fetalis)
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What is indirect Coombs and is it done on mom or baby?
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Done on mother measures number of antibodies in blood.
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What is direct coombs?
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Done on baby tells you if there are any antibodies stuck to the RBCs
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What do you do if you have a Rh+ fetus and a sensitized mother?
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1. Frequent ultrasounds 2. Early Birth
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When is Rho(D) immune globulin (RhoGam R) given?
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Rho (D) immune globulin (RhoGAM R) is given with any bleeding episode, before 72 hours of birth, and at 28 weeks.
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How does RhoGAM works?
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Destroys fetal cells that got in mother's blood; it has to do this before antibodies can be formed.
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What is the Rho (D) immune globulin (RhoGAM R) rule? (Test Strategy)
answer
Once antibodies are formed, the women has them for life. In Nclex world: Rho(D) immune globulin (RhoGAM) must be given before the antibodies form. In real world: a titer will be drawn to see the number of antibodies the woman has developed.
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An obstetrician already has three clients on the labor until receiving Oxytocin (Pitocin R) for induction of labor. All of the women are 38 weeks gestation. This labor unit has 6 beds and hour nurses are on duty: 3 RN staff members and 1 RN nurse manager. The primary healthcare provider calls from the office to inform the nurse manager that fourth client is en-route to the labor unit with orders to start Oxytocin (Pitocin R) induction. Which next action by the nurse manager is priority? 1. Assign yourself to monitor one client receiving Oxytocin (Pitocin R) 2. Request for delay of induction until one client delivers. 3. Call nursing supervisor, requesting float nurse from another floor. 4. Report the primary healthcare provider to PRO review committee for indiscriminate inductions.
answer
2. Request for delay of induction until one client delivers.
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