VN 34 Final Exam

Question 1

1. Cesarean section infant complications(pg.267)

Answer 1

 Respiratory complications
 A newborn delivered by c-section does not always have the benefit of the pressure squeezing the chest from the birth canal. This newborn often has more fluid in their lungs, making respiratory adaption more challenging.

Question 2

2. Jaundice nursing actions and need to know in first 24 hours and after(pg. 270)

Answer 2

 Physiological Jaundice: is characterized by jaundice that occurs AFTER the first 24 hours.
 Pathologic Jaundice: occurs within the first 24 hours (EMERGENCY)
 Nursing actions: anytime jaundice is present, document and report it.

Question 3

3. Signs of respiratory distress(pg.267)

Answer 3

 Tachypnea (sustained respiratory rate greater than 60 breaths per minutes)
 Nasal flaring
 Grunting (noted by stethoscope or audible to the ear)
 Intercostal or xiphoid retraction
 Unequal movement of the chest and abdomen during breathing efforts
 Central cyanosis

Question 4

4. Nursing actions for admitted OB patient with sever hyperemesis(Study guide T2)

Answer 4

 Medication as order: B6, Phenergan, Reglan, and Zofran
 Decrease trigger factors.
 Carbohydrates can decrease nausea (cracker in AM)
 Assist the woman with regaining fluid balance.
 If admitted priority will be IV fluid and electrolyte replacement

Question 5

5. Risks to ectopic pregnancy(Study Guide T2 & pg.360)

Answer 5

 STIs
 Tubal Ligation
 IUD
 Pelvic inflammatory disease
 Hx of prior ectopic pregnancy/ Multiple abortion
 Endometriosis and Salpingitis (infection of the fallopian tube)

Question 6

6. Know the circulatory flow between mother and fetus(pg.91)

Answer 6

 Two arteries and one vein

Question 7

7. At what stage of labor does cardiac output increase 80%(pg.161)

Answer 7

 Immediately after birth, it may peak at 80% above the prelabor level.

Question 8

8. What is the least common presentation of baby(pg.153)

Answer 8

 Shoulder presentation are the least common, occurring in less than 0.3% of all term pregnancies. Associated with a transverse lie.

Question 9

9. What are the four Ps? (Study Guide FB)

Answer 9

 Passageway- The passageway consists of the woman’s bony pelvis and the soft tissues of the cervix and vagina.
 Passenger- The “passenger” refers to the fetus. The size of the fetal skull and the way the fetus is situated.
 Powers- The primary force of labor comes from involuntary muscular contractions; the labor process is enhanced.
 Psyche- When the woman feels confident in her ability to cope and finds ways to work with the contractions, the labor process is enhanced.

Question 10

10. What is the best indicator for induction(Study Guide T4)

Answer 10

 Sign: burst of energy
 True labor results in progressive effacement and dilation of the cervix

Question 11

11. What is the priority for overstimulation after oxytocin?

Answer 11

 Put on left side
- give O2 & d/c oxytocin.
 Continuous fetal monitoring

Question 12

12. Give examples of gate control theory.

Answer 12

 Distracting client & mind focused on something else.
 Massage & deep breathing

Question 13

13. What symptoms does the nurse prioritize with a deep-pelvic hematoma?

Answer 13

 Deep pain unrelieved by comfort measures/meds that are accompanied by VS instability.
 Low HGB & HCT

Question 14

14. Laceration manifestations:

Answer 14

 Bright red bleeding can be steady or a trickle.

Question 15

15. Risks for pp hemorrhage.

Answer 15

 Multiparty
 Precipitous birth
 Previous uterine surgery
 Tocolytics
 LGA- macrosomia
 Polyhydramnios

Question 16

16. Cleft palate nursing actions:

Answer 16

 Suction & position to facilitate drainage, gentle w/bulb syringe as needed.
 Encourage parental attachment.
 Assist w/feeding techniques.
 Monitor weight & for dehydration.
 Elbow restraints (because they want to touch & pull)
 NPO 2hr post op, then liquid 3-4 days

Question 17

17. Safety in ID in the hospital:

Answer 17

 Verify ID bands on both mom & baby.
 Verify gender.
 Verify DOB
 Verify mom’s medical record #
 Verify any health care worker ID badges.

Question 18

18. Manifestations of trisomy 18:

Answer 18

 Brachycephaly (deformity in skull), short stature, flattened bridge of nose
 Thick hypotonic muscles, protruding tongue, dry cracked, fissure skin that may be mottled.
 Small hands w/short broad fingers & curved 5th fingers, single deep crease on palm of hand, wide space between 1st & 2nd toes
 Lax muscle tone
 Heart & eye anomalies, upward slanted eyes
 Greater susceptibility to leukemia

Question 19

19. Expected birth weight for newborn.

Answer 19

 5lb 8oz – 8lb 13oz (2,500-4,000g)

Question 20

20. Post term manifestations:

Answer 20

 Born greater than 42 weeks.
 Skin: leathery, cracked & wrinkled
 Ear: cartilage thick, pinna stiff

Question 21

21. Proximodistal; You know this.

Answer 21

 Proximodistal- growth starts in the center and progresses outward.

Question 22

24. Nursing actions when weighing an infant.

Answer 22

 Use appropriate equipment and technique.
 record as grams and kilograms or pounds and ounces
 Always have one hand near the child
 Thoroughly wash your hands.
 Put on a pair of clean gloves.
 Place a paper or other designated covering on the scale to prevent direct contact of the newborn’s skin with the scale.
 Set the scale to zero.
 Remove the newborn’s clothes, including diapers and blankets, and place the newborn on the scale.
 To avoid inaccurate results, do not leave clothes, including diaper, on the newborn while weighing.
 Hold one hand just above the newborn’s body. Avoid touching the newborn. Never turn your back away from the newborn while they are on the scale.
 Note the weight in pounds and ounces and in grams.

Question 23

25. Objective vs subjective data:

Answer 23

Objective data:
 Information you observe directly.
 Includes height, weight, temperature, pulse, respiration, blood pressure, examination of body systems.
 Usually does not proceed in head-to-toe manner as an adult.

Subjective data:
 Information spoken by child or family is subjective.
 Private, quiet setting; allow for questions from family and child
 Include child in process.

Question 24

26. Glomerulonephritis acute manifestations:

Answer 24

Appear 1 to 3 weeks after the onset of a streptococcal infection.
 Hematuria (which may be described as smoky or bloody)
 Periorbital edema may accompany or precede hematuria.
 Hypertension: priority!
 Headache

Question 25

27. Client education for med.

Answer 25

Topical antifungal agents, such as terbinafine, clotrimazole, tolnaftate and griseofulvin, are used to treat this condition.

 Use appropriate hand hygiene.
 Avoid sharing clothes, hats, combs, brushes, towels.
 Keep the child from scratching the affected are by using distraction.
 Do not squeeze vesicle.
 Apply topical medication as prescribed.
 Administer oral medication as prescribed.
 Apply wet compresses or take site bath.

Question 26

28. Hypoglycemia manifestations (early & late)

Answer 26

Early Signs
 Jitteriness
 high-pitched cry
 poor feeding
 listlessness
 irritability
 Low temperature,
 weak
 hypotonia

Late Sign
 Respiratory distress
 Apnea
 Seizures
 coma

Question 27

29. What are pulmonary functions tests used to diagnose?

Answer 27

 Pulmonary function tests are valuable diagnostic tools and indicate the amount of obstruction in the bronchial airways, especially in the smallest airways of the lungs.
 A definitive diagnosis of asthma is made when the obstruction in the airways is reversed with bronchodilators.

Question 28

30. Priority when assessing a child in a mist tent for bacterial pneumonia?

Answer 28

Oxygen tent (also known as mist tent)
 The infant often receives oxygen while in an isolette or incubator.
 High concentrations of oxygen can be dangerous to children, so close monitoring is needed.
 Oxygen safety measures are taught to family caregivers and followed by healthcare personnel.

Nursing concerns:
 Difficult to see child in tent.
 Difficult for child to see out.
 Child feels isolated.
 Change clothing and linen often.
 Keep side rails up.