Health Promotion And Maintenance Flashcards
(123 cards)
1
Q
Growth and development characteristics: 1 month
A
Head sags (neck muscles not strong enough)
2
Q
Growth and development characteristics: 2 months
A
- closure of posterior fontanelle
- infant can turn from side to back
- infant develops social smile
- infant’s eye will begin to follow a moving object
3
Q
Growth and development characteristics: 3 months
A
- infant brings objects to mouth
- infant can hold head erect, smile at mother, and laugh
4
Q
Growth and development characteristics: 4 months
A
- thumb apposition, drools
- absent tonic neck reflex/moro reflex
- pleasure in social contact
5
Q
Growth and development characteristics: 5 months
A
- birth weight doubled
- infant takes objects presented to him/her
6
Q
Growth and development characteristics: 6 months
A
- weight gain 4 oz/week in second 6 months
- begins teething
- infant can turn from back to stomach
7
Q
Growth and development characteristics: 7 months
A
- sits for short periods
- grasps toys with one hand
- fear of stranger begins to appear
- abrupt mood shifts
8
Q
Growth and development characteristics: 8 months
A
- anxiety with strangers
- separation anxiety
9
Q
Growth and development characteristics: 9 months
A
- elevates self to sitting position
- says “Dada”
- responds to parental anger
10
Q
Growth and development characteristics: 10 months
A
- crawls well
- pulls self to standing position
- vocalize one or two words
11
Q
Growth and development characteristics: 11 months
A
Infant can stand erect with support
12
Q
Growth and development characteristics: 12 months
A
- birth weight tripled
- needs help while walking
- sits from standing position
- eat with fingers
- may say words other than “mama” and “dada”
13
Q
Age-appropriate toys for infants from birth to 2 months
A
Mobiles
14
Q
Age-appropriate toys for infants 2-4 months
A
Rattles, cradle gyms
15
Q
Age-appropriate toys for infants 4-6 months
A
Brightly colored toys to grasp
16
Q
Age-appropriate toys for infants 6-9 months
A
Large toys with bright colors, movable parts, noise makers
17
Q
Age-appropriate toys for infants 9-12 months
A
Books with large pictures, push pull toys, teddy bears
18
Q
At what age is solid food typically introduced to infants?
A
4-6 months
19
Q
Solid food introduction considerations
A
- introduce one food at a time each 2-week period
- introduce least allergenic foods first half of first year, and more allergenic foods last half of first year
20
Q
Usual order to introduction of solid foods
A
Cereal, vegetables & fruits (non-citrus), potatoes, meats, eggs, orange juice*
NOTE: * indicates allergenic foods
21
Q
Growth and development characteristics: 15 months
A
- walks alone
- throws objects
- holds spoon
- names commonplace objects
22
Q
Growth and development characteristics: 18 months
A
- anterior fontanelle closure
- walks backward
- climbs stairs
- hold crayon and scribble
- 10 word vocabulary
- thumb sucking
23
Q
Growth and development characteristics: 24 months
A
- 300-word vocabulary
- obeys easy commands
- jumping
24
Q
Growth and development characteristics: 30 months
A
- walks on tiptoe
- stands on one foot
- sphincter control fully developed for toilet training
25
Age-appropriate toys for toddlers (12-36 months)
- push-pull toys
- stuffed animals
- dolls
- low rocking horse
NOTE: avoid toys with small pieces to prevent airway obstruction; PARALLEL play develops at this age and these children often play through imitation
26
Growth and development characteristics: 3 years
- copies a circle
- decrease in tantrums
- rides a tricycle
- walks downstairs without assistance
- undresses without help
- 300-word vocabulary
- may invent imaginary friend
27
Growth and development characteristics: 4 years
- climbs and jumps wells
- laces shoes
- brushes teeth
- 1,500-word vocabulary
- skips and hops on one foot
- can throw ball or object overhead
28
Growth and development characteristics: 5 years
- runs well
- jumps rope
- dresses without help
- 2,100-word vocabulary
- tolerates increasing periods of separation from parents
- beginning of COOPERATIVE play
- learns how to tie shoes
29
Age-appropriate toys for preschool children (ages 36 months-6 years)
- playground materials
- housekeeping toys
- coloring books
- tricycle with helmet
30
Growth and development characteristics: 6 years
- self centered, show off
- Sensitive to criticism
- begins losing temporary teeth
31
Growth and development characteristics: 7 years
- participates in team games/sports
- develops concept of time
- plays with other children of same sex
32
Growth and development characteristics: 10-12 years
- remainder of teeth (except wisdom) erupt
- begins to develop interest in opposite sex
33
Play characteristics age 0-1 year
Holding toys
34
Play characteristics ages 1-7 years
Imitation
35
Play characteristics ages 8-12 years
Games and hobbies
36
Type of play exhibited throughout infancy
Solitary play
37
Type of play exhibited by toddlers
Parallel play
38
Type of play exhibited by preschoolers
Associative play
39
Type of play exhibited by school-age children
Cooperative play
40
Erikson’s trust v.mistrust stage of development
- Age: birth-1 year
- positive outcome: trusts self and others
- negative outcome: withdrawn, isolated
41
Erikson’s autonomy v. Shame and doubt stage of development
- Age: 1-3 years
- positive outcome: exercises self control
- negative outcome: defiant and negative
42
Erikson’s initiative v. Guilt stage of development
- Age: 3-6 years
- positive outcome: learns limits
- negative outcome: fearful, pessimistic
43
Erikson’s industry v. Inferiority stage of development
- Age: 6-12 years
- positive outcome: sense of confidence
- negative outcome: self doubt and feelings of inadequacy
44
Erikson’s identity v. Role diffusion stage of development
- age: 12-20 years
- positive outcome: coherent sense of self and plans for education, work, and future
- negative outcome: lack of personal or vocational identity
45
Erikson’s intimacy v. Isolation stage of development
- age: 20-35 years
- positive outcome: intimate relationship
- negative outcome: avoidance of intimacy
46
Erikson’s generatively v. Stagnation stage of development
- age: 35-65 years
- positive outcome: creative and productive
- negative outcome: self-centered
47
Erikson’s integrity v. Despair stage of development
- age: 65+
- positive outcome: sees life as meaningful
- negative outcome: fear of death and life lacking meaning
48
Mild intellectual delay
- IQ 55-70
- slow to walk, feed self, and talk
- may be able to learn reading and math for 3rd-6th grade level
49
Moderate intellectual delay
- IQ 40-55
- delay in motor movement
- able to perform some self-help activities
- will respond to training
- will NOT progress with reading or math skills
- communication skills will be poor
50
Severe intellectual delay
- IQ 24-40
- marked delay in development
- may not be able to perform self-care activities
- will profit from habit training
- will have some understanding of speech
51
Profound intellectual delay
- IQ <25
- significant delay
- minimal capacity to function
- may respond to skill training
- show basic emotions
52
Fundal height is above the symphysis at ___-___ weeks gestation
12-24
53
Fundal height is at the umbilicus or 20 cm at ___ weeks gestation
20
54
Fundal height rises ___ cm/week until 36 weeks
1
55
Total number of pregnancies regardless of duration (including present)
Gravida
56
Number of pregnancies beyond period of viability (20 weeks or 500 g)
Para
57
Quickening is maternal perception of fetal movement occurring between ___ and ___ weeks gestation
16; 20
58
Total recommended weight gain throughout pregnancy
24-28 lbs
59
Recommended weight gain during first trimester
2-4 lbs
60
Recommended weight gain during second trimester
12-14 lbs
61
Recommended weight gain during third trimester
8-12 lbs
62
Presumptive signs of pregnancy
- amenorrhea
- morning sickness
- breast sensitivity
- fatigue
- quickening
- urinary frequency
63
Probable signs of pregnancy
- uterine enlargement
- positive urine test
- hegar’s sign: softening of isthmus of uterus
- Chadwick’s sign: bluish discoloration of cervix
64
Positive (definitive) signs of pregnancy
- fetal heartbeat: 12 weeks by ultrasound, and 18-20 weeks by auscultation
- palpation of fetal movement
- visualization of fetus by ultrasound
65
Normal FHR
120-160 bpm
66
Normal fetal movement
Regular pattern of 10 movements in 20 minutes to 2 hours twice/day
NOTE: report less than 3 movements/hour
67
Maternal alpha-fetoprotein test (AFT)
- predicts neural tube defects (spinal bifida)
- decreased levels may predict Down syndrome
- done at 16-18 weeks gestation
68
Ultrasound nursing consideration
Full bladder assists in clarity of image
69
Favorable non-stress test (NST) result
2+ FHR accelerations of 15 bpm lasting 15 sec over a 20 min period
70
Positive contraction stress test
Late decelerations with at least 50% of contractions; potential risk to fetus; C-section may be indicated
71
Negative contraction stress test
No late decelerations with minimum of 3 contractions lasting 40-60 sec in 10 min period
72
Danger signs of pregnancy
- gush of fluid or bleeding from vagina
- regular uterine contractions
- severe headaches, visual disturbances, abdominal pain, persistent vomiting
- fever or chills
- swelling in face and fingers
- decrease in fetal movement
73
Latent phase of labor
- 0-3 cm dilated
- contractions 10-30 sec long, 5-30 min apart
- mild to moderate intensity
74
Active phase of labor
- 4-7 cm dilated
- contractions 30-40 sec long, 3-5 min apart
- moderate to strong intensity
75
Transition phase of labor
- 8-10 cm dilated
- contractions 45-90 sec long, 2-3 min apart
- strong intensity
76
Postpartum fundal height
- at level of umbilicus for first 12 hours
- descends by 1 fingerbreadth each day
77
Postpartum lochia
Day 1-3: rubra (bloody)
Day 4-9: serosa (pink-brown)
Day 10+: alba (yellow-white)
78
Abruptio placentae assessment
- Painful vaginal bleeding
- tender, painful abdomen
79
It is important to test all women with average risk for diabetes at ___-___ weeks gestations
24-28
80
Ectopic pregnancy assessment
- unilateral lower quadrant pain
- rigid, tender abdomen
- referred shoulder pain
- low Hct and hCG levels in blood and urine
- bleeding
81
Hydatidiform mole assessment
- elevated hCG
- uterine size larger than expected for dates
- no fetal heart tones
- minimal dark red/brown vaginal bleeding with grape-like clusters**
- N/V
82
Hydatidiform mole client education
Monitor hCG levels for 1 year, pregnancy discouraged for 1 year
83
Mild preeclampsia
- begins past 20th week
- BP > 140/90 mm Hg
- 2+ to 3+ proteinuria
- slight generalized edema
84
Severe preeclampsia
- BP > 160/110 mm Hg
- 4+ proteinuria
- headache
- epigastric pain
- may develop pulmonary edema
- hyperreflexia
85
Eclampsia assessment
- hypertension
- proteinuria
- tonic-clonic seizures
- coma
86
Placenta previa assessment
- first and second trimester spotting
- third trimester — painless, profuse bleeding
87
Postpartum hemorrhage is defined as blood loss greater than _____ mL after a vaginal birth or _____ mL after a cesarean birth
500; 1000
88
Postpartum blood loss is measured by weight perineal pads and is considered large if it exceeds ___ inches to saturated in _____
6; 1 hr
89
Moderate postpartum blood loss
Greater than 4 inches but less than 6 inches in 1 hr
90
Apgar score criteria
- color
- HR
- reflexes
- muscle tone
- respirations
NOTE: each category scored from 0-2
91
Apgar scoring
< 3: critical
4-6: fair
7-10: normal
92
Normal newborn respirations
30-60 breaths/min with short periods of apnea (<15 sec)
93
Normal newborn blood pressure
65/40 in arm and calf
94
Umbilical cord care
Keep it dry and exposed to air (will fall off after 1-2 weeks)
95
Prevention of cold stress in newborns
- delivery room set at 22 degrees Celsius (71 degrees Fahrenheit)
- infant dried with pre-warmed towels and given a cap
- skin to skin contact with mom
96
Hypoglycemia in the infant is when the blood sugar is less than ___ mg/dL
35
NOTE: normal blood sugar is 40-80 mg/dL
97
Breast self-examination
- perform 1 week after onset of menstrual period OR on a designated day (first of month)
- inspect breasts in mirror
- examine with arms at sides, with arms above head, and with hands on hips
- use pads of 3 middle fingers
- assess for dimpling, discharge, changes
98
Testicular self-examination
- support testes in palm of hand
- palpate between thumb and forefinger
- perform during warm shower
- perform monthly
99
Diaphragm contraception patient education
- fitted by HCP
- do NOT insert > 6 hrs prior to sex
- remove at least every 24 hours
- higher risk of UTI and TSS
100
Cranial nerve I
- Olfactory
- test this by having client smell an nonirritating substance with eyes closed; test each nostril separately
101
Cranial nerve II
- optic
- test with snellen chart and ophthalmoscopic exam
102
Cranial nerve III
- oculomotor: controls pupil constriction and raising of eyelids
- test by having client look up, down, and open eyes; shine penlight and assess PERRLA
103
Cranial nerve IV
- trochlear: controls downward and inward movement of eyes
- test by having client look down and watch finger as moved towards client’s face
104
Cranial nerve V
- trigeminal: controls jaw movement, sensation on face and neck
- test by touching both sides of face with pin and cotton; have client open jaw and bite down
105
Cranial nerve VI
- abducens: controls lateral movement of eyes
- test by having client look up, down, and inward; have client watch finger go towards their face
106
Cranial nerve VII
- facial: controls facial movement and taste on anterior 2/3 of tongue
- to test, have client frown, smile, and raise eyebrows; place sweet, sour, bitter, salty substances on tongue to assess taste
107
Cranial nerve VIII
- acoustic: controls sense of hearing and balance
- to test, have client listen to ticking watch; have client stand with eyes closed to assess balance
108
Cranial nerve IX
- glossopharyngeal: controls swallowing and taste on posterior of tongue
- assess by placing sweet, sour, bitter, salty substance on tongue; elicit gag reflex
109
Cranial nerve X
- vagus: controls swallowing and speech
- instruct client to say “ahh” to assess soft palate and uvula; have client speak to assess quality of voice
110
Cranial nerve XI
- spinal accessory: controls flexion and rotation of head, shrugging of shoulders
- assess by having client shrug shoulders against resistance, and move head side to side against resistance
111
Cranial nerve XII
- hypoglossal: controls tongue movement
- assess by asking client to stick out tongue and move it quickly side to side
112
The nurse performs a caloric test as part of the neurological assessment. Which information does the client need to know before the caloric test?
Vertigo and dizziness may occur during the examination
NOTE: this assesses cranial nerve 8
113
Hep B vaccination schedule
1) birth - 3 mo.
2) 1-4 mo.
3) 6-18 mo.
114
DTaP vaccination schedule
1) 2 months
2) 4 months
3) 6 months
4) 15-18 months
5) 4-6 years
6) Td (booster) 11-16 years
115
Hib vaccination schedule
1) 2 months
2) 4 months
3) 6 months
4) 12-15 months
116
Inactivated polio (IPV) vaccination schedule
1) 2 months
2) 4 months
3) 6-18 months
4) 4-6 years
117
MMR vaccination schedule
1) 12-15 months
2) 4-6 years
118
Varicella vaccination schedule
12-15 months
119
Pneumococcal (PCV) vaccination schedule
1) 2 months
2) 4 months
3) 6 months
4) 12-15 months
120
Sequence for assessment of abdomen
Inspection, auscultation, percussion, palpation
121
Sequence for physical assessment
Inspection, palpation, percussion, auscultation
122
The _________ of the stethoscope should be used to auscultate high-pitched sounds such as lung, bowel, and heart
Diaphragm
123
The _________ of the stethoscope should be used to auscultate low-pitched sounds such as murmurs
Bell
