Exam 2 Flashcards
(226 cards)
1
Q
Why are C3-C5 injuries the most severe?
A
damage to phrenic nerve which is associated with the diaphragm
2
Q
What injuries are most common?
A
cervical and lumbar
3
Q
What area of the body is affected during a C4 injury?
A
below neck
4
Q
What area of the body is affected during a C6 injury?
A
below shoulders
5
Q
What area of the body is affected during a T6 injury?
A
below chest
6
Q
What area of the body is affected during a L1 injury?
A
below waist
7
Q
What are the primary mechanism of injury? (6)
A
Hyperflexion
Hyperextension
Flexion & extension
Axial loading/vertical compression
Excessive rotation
Penetrating trauma
8
Q
Hyperflexion direction?
A
forward
9
Q
Hyperextension direction?
A
backward
10
Q
Flexion & Extension injury?
A
whiplash
11
Q
What are secondary mechanisms of injury?
A
worsens the primary injury; may be reversible within the 1st 4-6hrs w/ early intervention
12
Q
What are the causes of secondary injury? (5)
A
Hemorrhage
Ischemia
Hypovolemia
Impaired tissue perfusion
Local edema
13
Q
What is the emergency management of someone who has a suspected c-spine injury?
A
immobilize head and neck in neutral position w/ C-collar and hard backboard
14
Q
What are our priorities when caring for a trauma pt?
A
- Stop uncontrolled bleeding
- Immobilize C-spine
- ABCs
- resp function/perfusion/cardiac assessments
- GCS score
- sensory/mobility/neuro assessments
- pain assessment
- GI/GU assessment
15
Q
What GCS score means intubation is indicated?
A
<8
16
Q
ABCDEFGHI?
A
Airway
Breathing
Circulation and Control bleeding
Disability
Expose & Environmental control
Full set VS, Facilitate adjuncts, Family
Get monitoring devices, Give comfort
History and Head-to-Toe assessment
Inspect posterior surface
17
Q
What diagnostic studies can you anticipate for a client with a suspected SCI?
A
CT scan: complete or incomplete injury
Cervical XR: hard to see C7 & T1
MRI: soft tissue
Comprehensive neurologic exam: q1hr
CT angiogram: vertebral artery damage
18
Q
What is spinal shock?
A
Complete but temporary loss of motor, sensory, reflex, and autonomic function
19
Q
What manifestations are associated with spinal shock?
A
Bradycardia
Hypotension
Low CO
No sweating below level of injury
Flaccid paralysis
Loss of sensation
Bowl and bladder dysfunction
Warm, dry extremities
20
Q
How long does spinal shock last?
A
48hrs but can last for weeks
21
Q
What is the onset of spinal shock?
A
occurs w/in 30-60min of injury
22
Q
How do we treat spinal shock?
A
Keep MAP >85 using vasoconstrictors (levophed, sudophed)
Steriods: antiinflammatory
Keep normothermia
23
Q
What is autonomic dysreflexia?
A
Exaggerated autonomic response to stimuli
24
Q
What manifestations are associated with AD?
A
HTN (can cause stroke)
Bradycardia
Severe headache
Profuse sweating above level of injury
Flushing of skin/goosebumps
Blurred vision/spots in visual field
Apprehension
25
How is AD caused?
Distended bladder (most common)
Distended bowel
Skin stimulation
26
How do we treat and prioritize interventions for a client with AD?
1. raise HOB
2. find cause
3. treat cause
4. notify provider
5. monitor and treat BP (vasodilators)
27
What is neurogenic shock?
hemodynamic changes resulting from sudden loss of autonomic tone
28
How is neurogenic different from spinal shock?
neurogenic is circulatory in nature
29
When does neurogenic shock occur?
24hrs following injury
30
What are manifestations of neurogenic shock?
Hypotension
Bradycardia
Low CO
Wide pulse pressure
Warm, flushed skin
Labored breathing
Dizziness
31
What kind of injury is Anterior Cord Syndrome?
flexion and compression injury
32
What damage is done during Anterior Cord Syndrome?
damage to anterior spinal artery
33
Manifestations of Anterior Cord Syndrome?
motor paralysis and loss of pain and temp sensation below level of injury
34
What kind of injury is Brown-Sequard Syndrome?
penetrating injury
35
What damage is done in Brown-Sequard Syndrome?
damage to 1/2 of cord
36
Manifestations of Brown-Sequard Syndrome?
Ipsilateral loss of motor function
Contralateral loss of pain and temp sensation
37
What kind of injury is Central Cord Syndrome?
Hyperextension
38
Manifestations of Central Cord Syndrome?
burning pain in upper extremities
39
How do TED hose and abdominal binders help orthostatic hypotension?
maintain blood volume
40
What meds prevent stress ulcers?
H2 receptor blockers (Famotidine, Cimetidine)
PPIs (Omeprazole, Pantoprazole)
41
What happens to the vagina during pregnancy?
becomes more acidic, therefore, more prone to yeast infections
42
What blood components increase during pregnancy?
WBC and fibrinogens
43
What happens to the respiratory status during pregnancy?
hyperventilation
respiratory alkalosis
44
What happens to insulin levels during pregnancy?
increases
45
What meds can pregnant ladies take to help with common discomforts?
tylenol & tums
46
What is the intervention for supine hypotension?
lay pregnant lady on left lateral side
47
Recommended wt gain during pregnancy for normal BMI?
28-35lbs
48
Recommended wt gain during pregnancy for underweight?
28-40lbs
49
Recommended wt gain during pregnancy for overweight?
15-25lbs
50
Recommended wt gain during pregnancy for obese?
11-20lbs
51
1st trimester length
1-13 weeks
52
How often are prenatal visits during the 1st trimester?
monthly
53
How much wt are you supposed to gain during 1st trimester?
1-4.5lb
54
What happens in the first prenatal visit?
1. EDB (estimate due date)
2. Health assessment
3. pelvic exam/pap smear
4. med reconciliation
5. safety topics
6. labs
55
What kind of labs do they order during the initial prenatal visit?
Blood typing
Rubella viral antigen screen
Hepatitis panel
STDs
56
What ed is provided during 1st trimester?
basics of what to expect during pregnancy
required nutrition
possible complications
fetal growth/development
57
2nd trimester length
14-26 weeks
58
In what trimester do you measure fundal height?
2nd trimester
59
How do you evaluate fundal height measurements?
weeks gestation should = measurement of fundal height
60
What measured difference in fundal height identifies a problem?
>2cm< difference
61
What is leopold's maneuvers?
palpating position of baby
62
What are the 1st signs of supine hypotension syndrome?
sweaty, dizzy
63
Which labs are assessed during the 2nd trimester?
Gestational DM screening
Rh(D) factor screening
64
When is gestational DM screening performed?
24-28weeks
65
1hr glucose tolerance test details?
don't need to fast
50g oral glucose load
130-140 could indicate DM
66
3hr glucose tolerance test details?
need to fast
100g oral glucose load
1,2,3hr checks
2 of 4 elevated BS samples = diagnosis
67
What fasting glucose level indicates gestational diabetes?
>95
68
After 1hr what BS level indicates gestational diabetes?
>180
69
After 2hr what BS level indicates gestational diabetes?
>155
70
After 3hr what BS level indicates gestational diabetes?
>140
71
When is Rh(D) factor screening performed?
28 weeks
72
What Rh(D) factor screening result indicates a need for Rhogam prophylactically?
negative blood type
73
Why is Rhogam important to administer?
worried about viability of 2nd pregnancy
74
What ed is included during the 2nd trimester?
benefits of breastfeeding
seat belt safety
travel
fetal movement
complications
childbirth classes
develop birth plan
75
How many cal should pregnant lady consume during 2nd trimester?
350 calories?
76
How much wt should pregnant lady gain during 2nd & 3rd trimester?
1-2lbs per week
77
3rd trimester length?
27-40 weeks
78
How often are prenatal visits after 28 weeks?
every 2 weeks
79
How often are prenatal visits after 36 weeks?
weekly
80
How many fetal movements (kicks) should mom feel in an hour?
3 kicks
81
What labs are performed during 3rd trimester?
Hct & Hgb (H&H)
Group B strep screening
82
When is Group B strep screening performed?
35-37 weeks
83
If a pregnant lady is + for Group B strep what are the interventions?
antibiotics during labor 2-3 does
84
What ed is included during the 3rd trimester?
childbirth classes
coping methods
pain management
signs of labor
infant care
postpartum care
kick counts
85
How many calories is pregnant lady supposed to consume during 3rd trimester?
450 calories
86
When is the NST performed?
3rd trimester
87
Nursing considerations for NST?
Instruct pt to press the button on the event marker each time they feel a fetal movement
88
What NST finding is good?
reactive
89
Normal FHR?
accelerates at least 15bpmx15sec
occurs 2 or more times during 20min period
90
What assess fetal well-being measuring 5 variables with score of 0 or 2 (in 30min)?
BPP
91
What BPP result is normal?
8-10
92
What BPP result is critical?
less than 4
93
What are the 5 variables involved in a BPP?
FHR
Muscle tone
Body movements
Breathing movements
Amniotic fluid volume
94
What values can an amniocentesis provide?
fetal lung maturity
Alpha-fetoprotein (AFP)
95
What does high AFP indicate?
neural tube defects
96
What does low AFP indicate?
chromosomal disorders
97
Nursing considerations for amniocentesis?
1. wedge under R hip to displace uterus off vena cava
2. administer Rhogam if indicated
98
HELLP Syndrome?
Hemolysis
Elevated Liver Enzymes
Low Platelets
99
When does gestational HTN present itself?
20 weeks gestation
100
What are the 2 ways to diagnose preeclampsia?
>140/90 (on 2 occasions at least 4hr apart) & Proteinuria
OR
>140/90 (on 2 occasions at least 4hr apart) & S/S of organ damage
101
What is the patho of preeclampsia?
abnormal placentation = poor perfusion
102
What is the term for severe preeclampsia?
eclampsia (tonic-clonic seizure)
103
Sign of renal damage?
creatine >1.1
104
Sign of liver damage?
R upper quadrant pain
elevated liver enzymes (AST/ALT)
105
Sign of pulmonary damage?
edema occurs fast 1-2 days
106
Sign of CNS damage?
seeing stars
hyperreflexia
107
Low platelet value?
<100,000
108
What meds are administered to combat preeclampsia?
magnesium sulfate
labetalol
hydralazine
nifedipine
109
How long is magnesium sulfate administered?
throughout labor and postpartum 24hrs
110
What are the early signs of magnesium sulfate toxicity?
warmth, flushing
111
What is the antidote for magnesium sulfate toxicity?
calcium gluconate
112
What are S/S of magnesium sulfate toxicity?
decreased BP
decreased urine output
respirations <12
patella reflex absent
112
Indication for magnesium sulfate?
used to prevent seizures & provide neurological protection
113
Interventions for A1 GDM?
diet controlled & no meds
114
Interventions for A2 GDM?
meds (metformin/insulin)
115
Complications of gestational diabetes?
large babies
hypoglycemia after delivery
116
After birth, when do pts follow-up with their provider when they had gestational diabetes?
6-12 weeks
117
Description of placenta previa?
placenta is covering cervical os in different severities
118
Which pregnancy complication indicates that vaginal delivery is not possible?
placenta previa
119
S/S of placenta previa?
may or may not have vaginal bleeding
painless
120
What is the treatment for placenta previa?
no vaginal exams or intercourse
121
What are risk factors for placental abruption?
cigarette smoking
HTN disorders
cocaine use
122
What are S/S of placental abruption?
abdomen appears board-like
vaginal bleeding
123
Treatment for placental abruption?
emergency C-section
124
What is the Kleihauer-Betke test?
associates' fetal blood in maternal circulation
125
S/S of ectopic pregnancy?
sharp, stabbing pain in lower abdomen
scant, dark red, or brown vaginal discharge
referred shoulder pain
126
Treatment for ectopic pregnancy?
methotrexate
surgery
127
S/S of impending labor? (3)
contractions are regular
presence of bloody show or lose mucus plug
wt loss of 1-3lbs
128
5P's: crucial factors affecting L&D?
Powers (contractions)
Passageway
Passenger
Psyche
Postion
129
primary contractions
involuntary
130
Frequency definition?
beginning of one contraction to the beginning of another
131
Duration definition?
beginning to end of one contraction
132
How is intensity of contractions evaluated?
palpation of abdomen
133
How much should mom be dilated before pushing?
10cm
134
How much should mom be effaced before pushing?
2cm
135
Effacement definition?
thinning & shortening of cervix
136
Ballotable definition?
fetus is up high
137
3 factors involved in fetal station assessment?
engagement
presentation
position
138
Zero station?
fetal head is by ischial spine in pelvis
139
Negative station?
baby is high (not engaged)
140
Positive station?
baby is low (engaged)
141
Presentation?
lie & attitude
142
Appropriate lie for delivery?
longitudinal
143
Attitude?
flexion
144
Attitude:extension position?
face first
145
What fetal body part should come out first?
occiput
146
Ideal fetal position for delivery?
right occipitoanterior or left occipitoanterior
147
Cervical Ripening Agents (3)?
dinoprostone (cervidil)
misoprostol (cytotec)
foley bulb
148
What is a bishop score used for?
to determine need for induction
149
What factors are involved with bishop scoring?
position
consistency
effacement
dilation
baby's station
150
The higher the bishop score?
better candidate for induction
151
Bishop score indicating need for induction for primipara?
6 or greater
152
Bishop score indicating need for induction for multipara?
8 or greater
153
What does external fetal monitoring measure?
frequency and duration of contractions
154
What does internal fetal monitoring measure?
frequency, duration, intensity of contractions
155
How long do you count to obtain FHR?
2min
156
Normal FHR?
BPM
110-160
157
What is the indication for tocolytics?
slow labor
158
Examples of tocolytics?
nifidipine
magnesium sulfate
terbutaline
indomethacin
159
When to use tocolytics?
btw 24-34 weeks gestation
160
What corticosteroids are used to develop fetal lung maturity?
betamethasone
dexamethasone
161
S/S of true labor?
cervical change (dilation, effacement)
162
What is the 4-1-1 rule?
new contraction every 4min that lasts at least 1min and contractions occurring for 1hr
163
When should a mom go to the hospital? (5)
decrease in fetal activity
break their water
vaginal bleeding
consistent abdominal pain
pt is concerned about anything
164
What is involved in the 1st stage of labor?
regular contraction to complete dilation
165
What is latent dilation?
0-3cm
166
What is active dilation?
4-7cm
167
What is transitional dilation?
8-10cm
168
What is involved in the 2nd stage of labor?
cervical dilation to delivery of fetus
169
What is involved in the 3rd stage of labor?
birth of fetus to when placenta is delivered
170
How long does it take to deliver the placenta?
5-30min
171
What are S/S of placental separation? (3)
cord lengthens
uterus has globular shape (rises in abdomen)
sudden gush of blood
172
What med is used to treat placental separation?
Pitocin (oxytocin)
173
What is involved in the 4th stage of labor?
maternal hemostatic stabilization
continues for 1-4hrs after delivery of placenta
174
What is the gate control theory of pain?
focused concentration or distraction blocks painful stimuli
175
Positives of nitrous oxide?
helps reduce anxiety
quick onset
small duration
176
S/E of nitrous oxide?
giddiness or dizziness
177
Common IV opioids used during L&D?
Fentanyl
Stadol
Nubain
178
S/E of IV opioids?
lower BP
itching
nausea
179
S/E of epidural?
lower BP
slower labor
fever
180
Nursing responsibilities during epidural administration?
IV fluid bolus before
consent
assess for bladder distension
lateral in fetal position
external fetal monitor
181
Best time to get an epidural?
whenever they want
try to wait longer until the active phase
182
Benefits of not administering epidural?
reduce risk of infection
reduce risk of spinal headache
have control of body
less tearing
183
How is the pudendal block administered?
transvaginally
184
Variability definition?
difference btw lowest point of FHRr and highest point (amplitude)
185
How long is variability assessed?
over 1min
186
What is minimal variability?
<5bpm
187
What is moderate variability?
6-25bpm
188
What is the normal variability?
10-15bpm
189
What is marked variability?
>25bpm
190
What is the primary indicator of fetal well-being?
variability
191
What is normal accelerations?
rise in FHR of at least 15bpm that lasts for 15sec
192
Accelerations are a positive or negative indicator?
positive
193
VEAL CHOP MINE
(VCM)?
Variable deceleration
Cord compression
Maternal repositioning
194
VEAL CHOP MINE
(EHI)?
Early deceleration
Head compression
Identify labor progress
195
VEAL CHOP MINE
(AON)?
Acceleration
Okay
No interventions
196
VEAL CHOP MINE
(LPE)?
Late deceleration
Placental insufficiency
Excute interventions
197
What fetal heart tone pattern "mirrors" contractions?
early decelerations
198
When do variable decelerations become concerning?
when they occur with contractions
199
What fetal heart tone pattern is concerning when it occurs at the peak of a contraction?
late decelerations
200
Interventions for late decelerations?
reposition mom to L lateral side
increase IV fluids
stop pitocin
apply O2
notify provider
201
How often should vitals be taken during pitcoin administration?
30-60min
202
How often should pitcoin be titrated?
30-60min
203
What are nursing responsibilities with pitocin?
vitals
titration
continuous fetal monitoring
monitor for signs of labor
urine output
204
How often should the nurse monitor for signs of labor when administering pitocin?
5-15min
205
How long are too long contractions?
greater than 90sec
>2min apart
206
What do long contractions indicate?
hypertonic uterus
fetus hypoxia
207
If membranes are rupture for more than 24hrs what is the nurse's concern?
infection
208
What would the nurse need to notice when membranes rupture?
time, amount, color, odor
209
What is the pH of amniotic fluid?
alkaline
210
With what complications do you not want to induce labor?
cord prolapse
placenta previa
211
Risk factors for cord prolapse?
polyhydramnios
multiple fetuses
prematurity
ROM
negative station
212
What is amniotomy?
artificially rupture membranes
213
What are nursing interventions for cord prolapse?
keep hand inserted in vagina
position pt in knee-chest position
elevate fetal head off umbilical cord with gloved finger
emergency C/S
214
What is shoulder dystocia?
fetal shoulder is stuck
215
What is a sign of shoulder dystocia?
turtle sign
216
What are nursing interventions for shoulder dystocia?
suprapubic pressure
mcrobert's maneuver
217
What is mcrobert's maneuver?
frog legs
218
What is chorioamnionitis?
intraamniotic infection
219
S/S of chorioamnionitis?
maternal hyperthermia, tachycardia
fetal tachycardia
220
Nursing interventions for chorioamnionitis?
IV antibiotics for mom and infant
221
What are risk factors for preterm birth?
lower education and income level
extreme ages
african american ethnicity
222
Diagnostics for preterm birth?
fetal fibronectin (fFN)
ultrasound of cervical length
223
What does a positive fFN level indicate?
>50
active labor within 10 days
224
What cervical length indicates possibility of preterm birth?
<25mm
225
What is the treatment for preterm birth?
bedrest
reduce stress
no intercourse
L lateral position
hydration
