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401 Flashcards

1
Q

What is hellp

A

Hemolysis
Elevated
Liver enzymes
Low
Platelet count

Severe life-threatening complication related to Pre eclampsia in the third trimester

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2
Q

Where does systematic lupus erythematosus (SLE) originate in the body

A

Connective tissue.

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3
Q

A 2hr post partum client with a soaked perineal pad in less than 15 minutes, ashen color, and report of weakness and lightheadedness is at risk for hypovolemic shock. What is the next action the nurse should take.

A

Applying oxygen and then massage the clients fungus to expel blood clots and promote uterine contraction to stop bleeding.

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4
Q

What is a physical change that if a pregnant client experiences it would be concerning to the nurse as a warning sign of a hypertensive condition or preeclampsia?

A

Facial edema. Report to the provider immediately

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5
Q

If someone is diagnosed with a STI it’s important for the nurse to obtain information about the clients recent sexual experiences.
T/f

A

True

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6
Q

Immunity is influenced by what 3 body systems

A

Nervous
Endocrine
GI

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7
Q

What is autoimmunity

A

The immune system fails to recognize certain body cells or tissues as “self”

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8
Q

Are there cures for autoimmune diseases?

A

No

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9
Q

Can organ rejection responses be hyperacute, acute or chronic?

A

All of them

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10
Q

How is endometriosis treated

A

Oral contraceptives
Hormone therapy
Pain medicine
Surgery

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11
Q

Risk for a patient taking oral contraceptive and smoking

A

Thrombotic stroke

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12
Q

The first step in effective communication is

A

To establish a relationship

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13
Q

Symptoms of gonorrhea in men

A

Foul smelling drainage from penis and painful urination.

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14
Q

Males are more likely to manifest symptoms of gonorrhea than females.
T/f

A

True.

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15
Q

Which STDs must be reported to the public health department

A

Syphilis
Chlamydia
Gonorrhea

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16
Q

What problem has occurred recently with treating gonorrhea

A

The bacteria that cause gonorrhea have become resistant to certain antibiotics

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17
Q

What class of antibiotics is recommended by cdc to treat gonorrhea

A

Cephalosporins

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18
Q

Women with gonorrhea can develop what complications

A

Pid
Etopic pregnancy
Infertility

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19
Q

A women is considered to be in menopause after she has missed how many periods

A

12

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20
Q

Hormone replacement therapy is associated with what increased risk for the first year after initiation

A

Ischemic stroke and subarachnoid hemorrhage

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21
Q

Why assess lung sounds in a client diagnosed with cardiac disease

A

To detect fluid overload and early heart failure

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22
Q

What color should the lochia be in the 4th stage of labor (1-4 hr post birth)

A

Dark red

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23
Q

What is the major symptom of eclampsia that the nurse needs to be aware of

A

Seizures So the nurse needs to be prepared to maintain an open airway

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24
Q

What changes in the perineum indicate the baby is imminent in stage 2 of labor

A

Bulging perineum and rectum

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25
At days 10-14 postpartum the lochia should be what color
White or alba
26
Risk factors for RA
Family history Genetic Environmental Lifestyle Physiological factors. More prevalent in women
27
What happens to the immune system of a person who has lupus
The immune system makes autoantibodies which attack the healthy cells and cause inflammation that harms organs and tissues.
28
Lack of conception despite unprotected intercourse for at least 12 months is considered
Infertility
29
3 types of menstrual dysfunction
Dysmenorrhea - pain with menses Abnormal uterine bleeding- heavy uterine bleeding irregular and painless Dysfunctional uterine bleeding- irregular bleeding commonly caused by lack of egg production
30
5 Ps of collecting accurate sexual history
Partners Protection from sti Practices Past history Prevention of pregnancy
31
Antepartum is before childbirth. Priority role of nurse during this period is what?
To provide woman with anticipatory guidance and education on what is normal and abnormal.
32
A hemoglobin less than 11g/dL during pregnancy is indicative of what and what is the nurses responsibility
Anemia Monitor for symptoms of anemia (fatigue, pallor, sob, altered loc) Provide education on nutrition And iron supplements as needed
33
Hyperglycemia during the first trimester is the main cause of what
Diabetes associated birth defect. It is when organs and systems are forming.
34
Recommended weight gain for pregnancy based on bmi
Underweight: gain 28-40lbs (bmi <18.5) Normal weight: gain 25-35lbs (bmi 18.5-24.9) Overweight: gain 15-25lbs (bmi 25-29.9) Obese: gain 11-20 lbs (bmi >30)
35
5 Ps of factor important to labor and birth
Passageway (shape of pelvis and birth canal) Passenger (how fetus is sitting) Position (the maternal postures physical positions) Powers (strength of uterine contractions) Psychological response (response of the mother)
36
The onset of of uterine contractions that cause the cervix to dilate is considered what stage of labor
Stage 1
37
What are the 3 phases of the first stage of labor
Latent: efface 0-3cm Active: 1cm per 1-2 hrs (4-7cm) Transition: (7-10cm)
38
The stage of labor when the cervix is fully dilated to 10cm which is also known as pushing stage is what stage
Stage 2
39
The delivery of baby and placenta is what stage of labor? What risk increases as the length of this stage increases?
Stage 3 Risk for hemorrhage
40
What stage of labor is also known as the recovery stage and how long does it last
Stage 4 from 1-4 hrs returning mom to homeostasis
41
During stage 4 of labor how often are vital assessed
Every 5 min until patient is stable then every 15 minutes for an hour and then every 30 minutes until discharged to postpartum unit.
42
How long does postpartum period last
Until the woman’s body is restored to its near prepregnant state. About 6weeks
43
What is involution of the uterus. How long is the process
The rapid reduction in size of the uterus and return to non pregnant state. About 3weeks although it takes about 6 weeks for the placenta site to heal
44
A fungus above the umilibus and boggy indicates what
Excessive uterine bleeding
45
If the fund is is higher than expected or not midline what should the RN do
Have patient empty bladder
46
The fund us descends approximately how much during postpartum
It is at the umbilicus for about half a day after birth. On day 1 postpartum it descends about 1cm and continues daily 1cm descention until into pelvis on day 10
47
Any slowing of fundal descent is called what?
Subinvolution
48
Severe discomfort after birth for 2-3 days indicates what
This is normal after pains. Warm water bottle against lower abdomen or mild analgesic can help
49
If lochia serosa or lochia alba continue 3-4 weeks after birth can indicate what
Endometriosis
50
A 35 week patient complains of a headache that is unrelieved with analgesics. What does this indicate
Can indicate preeclampsia and should be reported to provider
51
“Crowning” is what and indicates what
The head no longer recedes between contractions and means birth is imminent
52
The delivery of the placenta should occur within what time frame after birth of baby
30 min
53
Blood pressure readings taken during labor contractions are going to be…
High. And not accurate
54
An increase of wbc during labor is normal due to stress. This can make it difficult for what?
To identify infection
55
Maternal blood glucose levels during labor do what?
Decrease.
56
Fetal heart rate assessment during stage 1 normal range Should be assessed how often
110-160 bpm Every 60 min low risk/ 30 min high risk
57
Nitrazine test tape indicates what at what color
Yellow, olive, olive green = membranes are possibly intact Blue green, blue grey, deep blue= membranes probably ruptured
58
What are the steps for Leopoldo maneuvers and what do they tell
1. Palpate the fundus to identify lie and presentation 2. Palms on sides of abdomen (one stationary, the other palpates) to locate the fetal back and identify presentation 3. Facing clients head, Use dominant hand to palpate over the true pelvis. If the head is presenting- determine fetal attitude (whether head is flexed or extended) 4. Face clients feet and using both hands outline the fetal head to determine the ceohalic prominence.
59
Fundal height measurement in cm correlates with weeks of gestation from which weeks of pregnancy
Second trimester. Weeks 18-30
60
Apgar assesses
Appearance Pulse Grimace Activity Respirations
61
Apgar normal range
7-10
62
A high eosinophil count is an indication of what
Allergies
63
Which vaccines should be anticipated during an adolescent well child visit
Meningococcal and HPV
64
What are signs of a systemic reaction after vaccine administration to a child
Irritability
65
A client with HIV and T-cell deficiency required a blood transfusion. Which type of blood should the nurse anticipate administrating
Blood products that are CMV negative and irradiated due to the risk of infection.
66
What are the risks of developing a disorder if the immune system
Genetic, physical stress, psychological stress, African American, women
67
Acute stage HIV assessment findings
Normal lymphocyte count Malaise, flu like symptoms , presence of arthralgia and myalgia.
68
Manifestations in stage 3 of HIV indicates AIDS. These are
CD4 count of less than 200, >10% weight loss, chronic diarrhea >1mo, persistent fever >1mo, persistent gingivitis, oral candidiasis, oral hairy leukoplakia, severe opportunistic infections.
69
Clinical manifestations of HIV that are herpes zoster and less than 10% weight loss are in stage what?
2
70
Involved antibody IGE, happens after immediate exposure to antigen, 15-30 min. Histamine is involved. Vasodilation occurs. Throat constriction can occurs. What type of hypersensitivity is this and name an example
Type 1. Example allergic rhinitis.
71
Cytotoxic hypersensitivity that involves IGG or IGM antibodies and destroys healthy cells. What type is this and an example.
Type 2 Example : blood transfusion reaction
72
RH- mother that has a pregnant baby needs a Rhogan shot to protect her baby from being rejected by her immune system T/f
T
73
Immune complex reaction hypersensitivities. The immune system attacks its own healthy cells.
Type 3 Example SLE
74
Delayed hypersensitivity does not involve antibodies. Type what and example
Type 4 Contact allergic reaction.

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