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Exam 2 nr 327 Questions & ANSWERS 100% Verified | Latest Update
- Know how to determine the newborn APGAR score based on the assessment information pro- vided. (review table 15.4 on page 425 of your required text- book)
- Apgar score 2 re- veals
- Common med- ication adminis- tered to new- borns at delivery and how to ad- minister them
- What is the treat- ment for new- born born to mother who is Hep B positive
A (Activity) limp P (pulse) absent G (Grimace/Reflex) no response A (apperance/color) pallor or cyanosis R (Respiration). No spontaneous
-Greater than 100 hr -spontaneous lust, strong cry -Flexed body posture -responds promptly -pink (white) -cyanosis (black) -pink mucous membranes.
- Vitamin K Phytonadione- intramuscular- vastus lateralis muscle.
- Erythromycin Ophthalmic Ointment- From inner to outer canthus 3)Hepatitis B immunization- the schedule is at birth, 1 month, and 6 months. ditterent site than vit k.
hepatitis B immunoglobulin and the hepatitis B vaccine is given within 12 hr of birth. (dif sites)
Exam 2 nr 327 Questions & ANSWERS 100% Verified | Latest Update
- Know priority in- terventions for immediate new- born care
- Know normal newborn assess- ments (review table 20.2 on pages 555- of your required textbook)
- Know normal newborn vital signs range
- Know care of the newborn umbili- cal cord stump
- Stabilize infant. cough reflex, then suction mouth then nose.
- 2 identification
- warm infant
Vitals length (19-21 inches) Head circumference (13-15 in) chest (12-14in) 2 less than head APGAR 3 vessels in cord
Temp: 97.7-99.5 F HR: 120- RR: 30- BP- 65/
Make sure it is clamped. 24-48 hours- comes ott when they go home. Use only water look for erythema, edema, and drainage with each diaper change.
and parent teach- cord falls ott 10-14 days ing Keep diaper folded down. do not submerge in water.
- Know normal ver- Normal sus abnormal - Yellowish scab or crust healing of the cir- - should be healed within 10 days cumcised penis
- Know the re-
quirements of
the newborn car seat
- Know how to perform the dif- ferent new- born measure- ments (see page 543 in required textbook)
- Know different methods of new- born heat loss and how to prevent them (review pages 520-523 of your required text- book)
rear-facing car seat in the back seat, preferably in the middle (away from air bags and side impact), to transport the newborn. Keep infants in rear-facing car seats until age 2
Head- measure around the fullest part of the head. Place around occiput and just above the eyebrows. Chest-Put tape at the level of the nipples. Length- from top of the head to the heel.- put one hand on babys head and stretch out legs.
Radiation- Transfer of heat to cooler object like keeping baby by the window. Evaporation- Air drying of the skin that results in cooling. Dry infant from head to toe as quickly as possible. Conduction- Direct contact with something cold. Use skin to skin. Convection- Drafts, air, open doors.
- Know how to elic- Ïsucking and rooting: turns head to side that is touched and it newborn reflex- begins to suck when cheek or edge of mouth is stroked. es and the impor- ÏPalmar grasp: Grasps object when placed in palm. tance of them ÏPlantar grasp: toes curl downward when sole of the foot is touched. Ïmoro reflex: Arms and legs symmetrically extend and then abduct while fingers spread to form a "C" when infant's head and trunk are allowed to fall backward to an angle of at least 30°. Ïtonic neck (fencer position): extends arm and leg on same side when head is turned to that side, and flexes arm and leg of opposite side. babinski: toes
fan upward and out when outer edge of
- Discharge teach- ing for postop- erative for c-sec- tion.
- Education to re- duce perineal in-
clients who have had a cesarean birth should wait until the 4- to 6-week follow-up visit before performing strenuous exercise, heavy lifting, or excessive stair climbing.
Cleanse the perineal area from front to back with warm water after each voiding and bowel movement.
fection for a vagi- ÏBlot perineal area from front to back. nal delivery
- Know s/s of mas- titis
- S/S of DVT, prevention,
ÏRemove and apply perineal pads from front to back
-Initial symptoms may be flulike with fatigue and aching muscles. -fever 102. -chills, malaise, headache -redness, heat -a sore nipple that has cracks and fissures fissure or crack in the nipple and progresses to chills and fever, plus localized pain, swelling, and redness.
s/s: Leg pain and swelling, Unilateral area of swelling, warmth, and redness
and non-pharma- ÏHardened vein over the thrombosis cological treat- ment
- What are the
signs and symp- toms pf placen-
ÏCalf tenderness
P r e v e n t i o n - f l u i d s
, evevate legs, walk treatment: Bed rest is prescribed for the woman with deep vein thrombosis to decrease swelling and to promote venous return from the leg.
PLACENTA PREVIA: Painless vaginal bleeding Assess for bleeding, leakage, or contractions. ÏAssess fundal height. ÏPerform Leopold maneuvers (fetal position
At 12 hours after delivery, the fundus is typically 1 cm above the umbilicus About a week after delivery, the fundus should be halfway between the umbilicus and the symphysis pubis. Every 24 hr, the fundus should descend approximately 1 to 2 cm. It should be halfway between the symphysis pubis and the umbilicus by the sixth postpartum day.
- Know signs and symptoms of hy- datidiform mole (gestational tro- phoblastic dis- ease)
- Know S/S of preeclampsia
- Know the s/s of magnesium tox- icity, treatment,
ÏAfter 2 weeks, the uterus should lie within the true pelvis and should not be palpable.
dark brown vaginal bleeding in the second trimester that is not accompanied by abdominal pain. increased fundal height that is inconsistent with the week of gestation, and excessive nausea and vomiting due to elevated hcg levels.
Occurring after 20 wk of pregnancy BP 1 e4 0 mm Hg systolic or 9 e 0 mm Hg diastolic or higher Proteinuria 0.3 g protein or higher in a 24-hour urine specimen or e+ 1 per dipstick or P/C ratio 0 e. 3 mg/dL .
s/s: Respiratory depression, with a rate of fewer than 12 breaths per minute
and priority nurs- • Decreasing maternal pulse oximeter values: ing assessment • Less than 95% during pregnancy
- Less than 92% during postpartum phase
- Absence of DTRs
- Blurred vision
- Altered sensorium (confused, lethargic, slurred speech, drowsy, disoriented)
- Oliguria
- Hypotension
- Serum magnesium value greater than 8 mg/dL
- Respiratory/cardiac arrest 3.5-
Treatment:
- after 3 months to determine whether immunity to rubella has been developed.
Know the pur- pose of Rho D Im- mune Globulin
- Know what the indirect coombs test detects
- Know who are and aren't candi- dates for a vagi- nal birth after ce- sarean (VBAC)
- Know patient teaching instruc- tions for natur-
Rh antibodies in the mother's blood
- A woman who has one previous low transverse uterine incision.
- A woman with two prior cesarean deliveries may have a low risk of uterine rupture with VBAC.
- Absence of other uterine scars (e.g., removal of fibroid tumors) or a previous uterine rupture.
- A pelvis that is clinically adequate for the estimated fetal size.
- Immediate availability of a physician during active labor if an emergency cesare- an is needed.
- Availability of anesthesia and personnel to perform an emergency cesarean.
NOT CANDIDATES
ïLarge for gestational age newborn ïMalpresentation ïCephalopelvic disproportion ïPrevious classical vertical uterine incision
Calandar: Accurately record the number of days in each cycle counting from the first day of menses for a period of at least six cycles.
al family planning ÏThe start of the fertile period is figured by subtracting 18 days from the number methods of days in the woman's shortest cycle. ÏThe end of the fertile period is established by subtracting 11 days from the number of days of the longest cycle.
They should
abetic regarding exercise
- Know s/s of en- dometritis
- Know non-phar- macological care of sore nipples
- Fundus becomes soft and un- contracted when massage is stopped.
What to do...
- Fundus is above umbilicus and/or displaced from midline.
What to do...
a tender uterus and foul-smelling lochia. Continued flow of lochia serosa or alba beyond the normal length of time can indicate endometritis, especially if it is accompanied by fever, pain, or abdominal tenderness Pelvic pain ÏChills ÏFatigue ÏLoss of appetite
Apply breast milk and air dry. after breast feeding. Use various positions
Still support lower uterine segment. Massage fundus until firm; then apply pres- sure to express clots. Notify health care provider, and begin oxytocin or other drug administration, as prescribed, to maintain a firm fundus.
Assess bladder elimination. Assist mother in urinating, or catheterize, if necessary, to empty bladder. Recheck the position and consistency of fundus after bladder is empty.
