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HELLP syndrome is a life-threatening pregnancy complication usually considered to be a variant ofpreeclampsia. Both conditions usually occur during the later stages of pregnancy, or sometimes after childbirth.
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Nurses need to be aware of the normal physiologic and psychological changes that take place in women’s bodies and minds in order to provide comprehensive care during this period. Thepostpartum period covers the time period from birth until approximately six weeks after delivery. So it is important to remember the mnemonic BUBBLE-HE to denote the components of thepostpartum maternal nursing assessment.
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A nonstress test is a common prenatal test used to check on a baby’s health. Results of anonstress test are considered reactive or nonreactive. Results are considered normal (reactive) if the baby’s heartbeat accelerates to a certain level twice or more. If the baby’s heartbeat doesn’t meet the criteria described, the results are considered nonreactive.
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Chorionic villus sampling (CVS) is a first-trimester (10 to 12 weeks) alternative to amniocentesisfor prenatal diagnosis of genetic abnormalities. This procedure is accomplished by needle aspiration of a sample of chorionic villi, either by the transcervical or transabdominal route.
Alpha-fetoprotein is a fetal protein produced in the yolk sac during the first 6 weeks of gestation and later by the fetal liver. AFP is found in the amniotic fluid and maternal serum. If the fetus has neural tube defect, AFP levels are elevated.
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Intermittent abdominal discomfort or pain is a common pregnancy complaint. While itself may present to be harmless, it can also be a sign of a serious problem. There can be many causes for abdominal pain especially during pregnancy, remember the nursing mnemonic “LARA CROFT” to remind you
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Preeclampsia is a complication characterized by high blood pressure and signs of damage to another organ system (usually the kidneys). The condition usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal. Even a slight rise in blood pressure may be a sign of preeclampsia.
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Some women experience side effects with “the pill” such as irregular periods, nausea, headaches, or weight change. If she experiences the side effects with the acronym SEA CASH, calling the help of a medical provider or visiting an emergency room immediately is recommended as they may signify a serious condition.
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questions involving consent to treat?
In most states, young adults (18 years and older) can legally give consent; a client cannot give informed consent if s/he has been drinking or is premedicated.
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Erythema infectiosum (fifth disease)?
Erythema infectiosum (fifth disease) is a virus caused by human parvovirus B19; symptoms include erythema on face, lacy red rash on trunk and limbs. May have cold-like symptoms prior to onset of rash; treatment includes antipyretics, analgesics, and anti-inflammatory drugs.
fifth disease is a virus that is found in respiratory secretions; not contagious after the rash develops (
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Which of the following responses by the nurse is BEST?
Always assess unless it's not
(2) assessment; determines what client knows before responding; allows client to verbalize
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Child Safety-Car seat?
The American Academy of Pediatrics in June 2011 recommended using a backward-facing seat for children under 2 years of age; use a forward-facing seat with a harness for children over 2 years
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Neostigmine (Prostigmin)
Cholinergic (parasympathomimetic) used to treat myasthenia gravis and is an antidote for nondepolarizing neuromuscular blocking agents; side effects include nausea, vomiting, abdominal cramps, respiratory depression, bronchoconstriction, hypotension, and bradycardia. Nursing considerations include monitoring vital signs frequently, having atropine injection available, taking with milk, potentiates the action of morphine.
*cholinergics can cause bronchoconstriction in asthmatic clients; may precipitate an acute asthmatic attack
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Therapeutic communication?
directly responds to client's statement by paraphrasing; implies encouragement of expression of client's concern
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The nurse cares for the woman at 37 weeks gestation. The nurse is MOST concerned by which finding?1. The patient reports right quadrant pain.2. The patient's BP is 150/95.3. The patient has 1+ proteinuria.4. The patient has 3+ pitting edema of the ankles.
(1) indicates impaired liver function, sign of impending eclampsia
Preeclampsia causes hypertension, proteinuria, and edema
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5 year old asks a question "about sex" and babies?
Important to determine what the child knows and thinks and to offer honest explanations
help child understand his concerns, allows for answering exact question that is being asked
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38 weeks gestation to determine fetal heart rate. If the fetal heartbeat is located in the right lower quadrant, which of the following is MOST likely the presenting part?
right lower quadrant heartbeat indicates occiput of fetal head is on the right side of the mother's body and facing the front (anterior) of the mother's body
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During the transitional phase of labor, the umbilical cord becomes prolapsed. The nurse places the patient in which of the following positions?
Trendelenburg
Supine on incline with head lower than hips and legs; or put finger against presenting part and shift weight off cord
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The pregnant woman is given an epidural anesthetic in preparation for cesarean section. Following administration of the epidural, the patient's blood pressure falls from 120/84 to 94/50. The nurse recognizes that it is ESSENTIAL to assist the patient into which of the following positions?
Side-lying.
Optimizes blood return from lower extremities; displaces heavy uterus from inferior vena cava
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The nurse assesses the 8 lb 4 oz newborn infant. Which of the following observations, if made by the nurse, requires an intervention?
The infant's axillary temperature is 96.2°F (35.6°C).
subnormal indicates prematurity, infection, low environment temperature, inadequate clothing, dehydration
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The nurse cares for the 1-year-old patient who is admitted to the hospital with a fractured femur and is placed in Bryant's traction. The nurse recognizes that the child should be maintained in which of the following positions?
Bryant's traction: type of running traction used to reduce a fractured femur in a child; adhesive strips are applied to both legs and secured with elastic bandages wrapped from foot to groin; both legs are suspended by weights and pulleys.
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The nurse cares for clients in the outpatient clinic. Which of the following is the MOST important immediate nursing goal for the client just diagnosed with glaucoma?
Glaucoma is an abnormal increase in intraocular pressure, leading to visual disability and blindness; signs and symptoms include cloudy, blurry vision or loss of vision; artificial lights appear to have rainbows or halos around them; decreased peripheral vision; pain, headache, nausea, and vomiting; treatment is miotics
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The patient is admitted to the hospital for a myelogram using a water-soluble dye. What information is MOST important for the nurse to obtain about the patient's medication history?
Meds that lower the seizure threshold such as phenothiazines (chlorpromazine), MAO inhibitors (isocarboxazid, phenelzine), tricyclic antidepressants (imipramine, amitriptyline), CNS stimulants, psychoactive drugs (methylphenidate) should be held for 48 hours before and 24 hours after test. The reason to stop such meds is that their presence could increase the risk of seizures.
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The parent of the adolescent being admitted to the psychiatric unit reports that the adolescent has become increasingly withdrawn at home. During the admission interview with the nurse, the patient says, "When I look in the mirror, I cannot see myself." The nurse recognizes that the patient is experiencing which of the following?
Adolescence provides a time for development of a healthy self-concept and discovering one's role in life. If the road to these discoveries is blocked, the person experiences depersonalization
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1. Displacement.2. Dissociation.3. Denial.4. Depersonalization.
4) feelings of unreality concerning self or environment (1) unconscious placing of emotions onto others (boss yelling at employee, person yelling at spouse) (2) splitting off anxiety producing experiences (multiple personalities) (3) refusal to acknowledge reality (will not accept bad news).
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The nurse observes the behavior of the patient seen in the emergency room. Which of the following indicates to the nurse that the patient is experiencing a panic level of anxiety?
Anxiety is feeling of dread or fear in the absence of external threat, or disproportionate to the nature of the threat. In panic level anxiety, the patient is unable to see, hear, or function. Assess level of anxiety, decrease environmental stimuli, use unhurried approach, and stay with the patient.
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1. Ambivalence.2. Scapegoating.3. Double-bind communication.4. Loose associations.
(3) emotions communicated verbally are opposite of emotions communicated physically (1) mixed feelings; confusing emotional experience (2) others blamed for problems (4) disordered thought processes.
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1. Chlorpromazine.2. Carbamazepine.3. Flurazepam.4. Imipramine.
(4) imipramine (Tofranil): tricyclic antidepressant used to treat panic attacks (1) chlorpromazine (Thorazine): antipsychotic medication; not used to treat panic attacks (2) carbamazepine (Tegretol): anticonvulsant used to treat seizures and nightmares (3) flurazepam (Dalmane) : sedative-hypnotic, used to produce sleep.
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Breast exam?
"Stand with your arms at your sides. Clasp your hands behind your head and press your hands forward. Place your hands on your hips and bow slightly toward the mirror."
Perform breast self-examination monthly beginning at age 20; after inspecting breasts in the mirror, client should palpate the breasts when standing and lying down.
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The nurse cares for the client who will be taking phenelzine sulfate following discharge. Which of the following is important information for the nurse to include in the teaching plan regarding this medication?
phenelzine sulfate (Nardil) is an MAO inhibitor; interacts with foods containing tyramine or drugs containing sympathomimetic substances to cause a hypertensive crisis.
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The nurse cares for the patient on the telemetry unit. The patient's orders include nifedipine 10 mg PO TID. The patient asks the nurse how the medication works. Which is the BEST response by the nurse?
- "It decreases myocardial oxygen demand."
- nifedipine (Procardia): antianginal medication that is a calcium channel blocker (inhibits calcium ion flow across cardiac and smooth muscle). Side effects: light-headedness, HA, hypotension, hypokalemia. Nursing responsibilities: monitor BP and potassium levels.
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The nurse cares for the patient 1 hour after a percutaneous liver biopsy. The nurse is MOST concerned if which of the following is observed?
Sampling of tissue by needle aspiration; preparation for procedure includes administer IM vitamin K, NPO morning of exam, instruct patient to hold breath; post-procedure nursing care includes position on right side for 1 - 2 hours, maintain bed rest for 24 hours, obtain frequent vital signs to monitor for hemorrhage.
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The home care nurse cares for the child diagnosed with hemophilia A recovering from the acute phase of spontaneous bleeding into the joints. It is MOST important for the nurse to give the parents which of the following instructions?
Encourage active range-of-motion exercises.
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CKD
Chronic renal failure is progressive, irreversible kidney injury caused by hypertension, diabetes mellitus, lupus erythematosus, and chronic glomerulonephritis; symptoms include anemia, acidosis, azotemia, fluid retention, and urinary output alterations; nursing care includes monitoring potassium levels, daily weight, intake and output, and diet teaching about regulating protein intake, fluid intake to balance fluid losses, and some restrictions of sodium and potassium. Furosemide (Lasix) is a potassium-wasting diuretic, which increases renal potassium excretion. Monitor blood pressure, serum electrolytes, weight, I + O. Do not give at bedtime.
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The nurse cares for the patient receiving neomycin sulfate. The nurse recalls that this medication is given for which of the following reasons?
- To decrease postoperative wound infection by suppressing intestinal bacteria.
- Neomycin sulfate (Neo-fradin) is an aminoglycoside used to treat infections caused by Pseudomonas and E. coli, used to suppress intestinal bacteria, and as adjunct treatment for hepatic coma; side effects include ototoxicity and nephrotoxicity; nursing considerations include check hearing and renal function, encourage fluids, and offer small frequent meals.
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The nurse cares for the patient who is being treated for heart failure (HF) and atrial fibrillation. The physician orders digoxin 0.25 mg PO daily. Prior to administering the medication, the nurse assesses that the patient's heart rate is 98 and irregular. Which of the following actions should the nurse take FIRST?
Administer the digoxin and chart the rhythm.
Atrial fibrillation: rapid, irregular depolarization of atria. Results in irregular and rapid pulse. Treatment: digoxin (Lanoxin; strengthens the myocardial contraction and slows the rate of conduction), calcium channel blockers nifedipine (Procardia), quinidine, procainamide (Pronestyl), anticoagulants (heparin), cardioversion.
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The nurse plans postoperative care for the patient scheduled for a stapedectomy. When the patient is returned to the room after surgery, the nurse expects to observe which of the following?
Patient experiences vertigo, nausea, and vomiting.
Excision of stapes with or without prosthesis to correct hearing loss; during first 24 hours post-op position patient flat in bed with minimal head movement; instruct patient to not blow nose or sneeze; assess for facial nerve damage or muscle weakness or changes in taste.
Correct Answer: (3) close to inner ear; meclizine (Antivert) (anti-vertigo) and prochlorperazine (Compazine) (antiemetic) used; assist with ambulation, side rails up, change positions slowly
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The nurse cares for the client who is to receive warfarin sodium. The nurse recalls that which of the following is the mechanism of action of this medication
It inhibits prothrombin synthesis.
warfarin sodium (Coumadin): long acting anticoagulant that inhibits Vitamin K-dependent clotting factors. Side effects: excessive dosage may cause hemorrhage, rash, fever. Prothrombin time (PT) used to control dosage. Therapeutic range is 1.5 - 2 times normal level. Antidote vitamin K (phytonadione: Mephyton). May eat consistent amounts of green leafy vegetables containing vitamin K.
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The nurse plans care for the patient admitted reporting fever, vomiting, and diarrhea. The nurse writes the following nursing diagnosis on the patient's care plan: "Fluid volume deficit." The nurse recognizes that which of the following changes in laboratory values BEST demonstrates improvement in the patient's condition?
Decreased specific gravity of urine, decreased hematocrit.
Urine specific gravity depends on hydration; normal: 1.010 - 1.030; will increase if patient is dehydrated. Hematocrit measures % volume of RBCs in whole blood; normal: men 42 - 50%, women 40 - 48%; increases in severe dehydration (volume).
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RA and OA difference
Rheumatoid arthritis is a chronic systemic disease that causes inflammatory changes in joints; osteoarthritis is nonsystemic and degenerative; symptoms include joint pain, swelling, and limitation of movement; nursing care includes pain management, rest, activity, and exercise.
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The nurse has completed discharge instructions for the primigravida at 29 weeks gestation who is hospitalized for treatment of deep vein thrombosis (DVT). Which of the following statements, if made by the patient to the nurse, indicates that teaching has been successful?
- I will give myself heparin everyday.
- Pregnancy, immobility, obesity, and surgery are risk factors for deep vein thrombosis. Heparin is anticoagulant that blocks conversion of prothrombin to thrombin; side effects include hematuria and bleeding gums; monitor partial thromboplastin time (PTT).
(1) heparin does not cross the placenta; considered safe during pregnancy
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The community health nurse conducts a prevention program at the high school and discusses high-risk groups for suicide. The nurse recognizes that further teaching is necessary if a student states which of the following?
Those who are grieving in response to a loss for 9 months are at high risk."
(4) grieving is a normal human response that occurs in response to a loss and the entire process may take more than 1 year.
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The nurse prepares to change the central line dressing on the child. Arrange the following steps of the procedure in the correct order from first to last. All options must be used.
1. Open sterile towel to create a field.
2. Apply nonsterile gloves.
3. Apply an occlusive dressing.
4. Remove old dressing and wash hands.
5. Cleanse the area with acetone and alcohol swabs in a circular motion.
6. Cleanse the area with 1% povidone-iodine swabs.
- 2, 4, 1, 5, 6, 3
- (1) The third step is to open sterile towel to create a field.
(2) The first step is to apply nonsterile gloves.
(3) The sixth step is to apply an occlusive dressing.
(4) The second step is to remove old dressing and wash hands.
(5) The fifth step is to cleanse the area with acetone and alcohol swabs in a circular motion.
(6) The fourth step is to cleanse the area with 1% povidone-iodine swabs.
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The nurse cares for the patient with Parkinson's disease who is receiving levodopa. The nurse recalls that levodopa works by which of the following actions?
- It restores dopamine levels in extrapyramidal centers.
- Parkinson's disease: caused by impairment of dopamine-producing cells in the brain. Levodopa is converted to dopamine in the body to supply the extrapyramidal centers in the brain. Side effects: hemolytic anemia, aggressive behavior, dystonic movements, depression, hallucinations, dizziness, orthostatic hypotension.
- (2) don't take with vit B6 or fortified cereals: will block effects (1) action of benztropine mesylate (Cogentin) used with levodopa; side effects: urinary retention, dry mouth, constipation; takes 2 - 3 days before effects are seen (3) action of amantadine (Symmetrel) used with levodopa; side effects: irritability, insomnia, dizziness; take after meals (4) action of bromocriptine (Parlodel) used with levodopa; side effects: dizziness, HA, orthostatic hypotension, abdominal cramps, pleural effusion; take with meals.
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The nurse cares for the client experiencing an episode of acute pain. Which of the following physiologic changes does the nurse expect to see in this client during this episode?
Decreased skin temperature.
Pain causes increased blood pressure and heart rate, which leads to increased blood flow to the brain and muscles; rapid irregular respirations lead to increased oxygen supply to brain and muscles; increased perspiration removes excessive body heat; increased pupillary diameter leads to increased eye accommodation to light.
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The nurse cares for the patient after a traditional cholecystectomy. The patient has a nasogastric tube connected to suction, an IV of D5W infusing into the right arm, and a T-tube and Penrose drain in place. The nurse is MOST concerned by which of the following findings?
- T-tube ensures drainage of bile from common bile duct until edema in area decreases; protect skin around incision from bile drainage irritation; observe for jaundice.
- (2) would expect drainage of 400 mL/day with gradual decrease in amount; will be bloody initially and change to greenish-brown; T-tube getting dislodged is most frequent cause of ineffective drainage
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The nurse cares for the postoperative client receiving cephalexin monohydrate 500 mg PO QID. The nurse schedules the administration of this medication at which of the following times
Cephalexin (Keflex) is a first-generation cephalosporin antibiotic; side effects include diarrhea, nausea, dizziness, abdominal pain, superinfection, allergic reactions; take with food, avoid alcohol while taking medication; assess for penicillin allergy (up to 20% have cross-allergy).
Correct Answer: (2) blood level must be achieved and maintained for an antibiotic to be effective; medication should be given around-the-clock, every 6 hours (1) take with food or milk to avoid GI upset (3) schedule medication around-the-clock, every 6 hours (4) antacids will reduce the effectiveness of the medication.
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The nurse cares for the postoperative patient who is to receive psyllium. When administering psyllium, the nurse uses which of the following techniques?
Mix with 8 ounces of water; administer it immediately followed by another 8 ounces of water.
psyllium (Metamucil): bulk-forming laxative used to treat constipation; on contact with water it forms a bland, gelatinous bulk that promotes peristalsis; can be mixed with water, milk, or fruit juice.
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The nurse cares for the multipara who comes to the hospital at 29 weeks gestation with reports of backache and pelvic pressure "on and off all day." Which of the following assessments, if made by the nurse, is MOST important in determining if the patient is in premature labor?
Regular contractions are noted on a monitor tracing.
Effacement: shortening and thinning of the cervix. Dilation: enlargement of opening of cervix from a few mm to an opening large enough to allow for passage of infant. Station: indicates progress of labor; relationship of presenting fetal part to imaginary line between ischial spines of pelvis in the mother. S/S premature labor: abdominal pain resembling menstrual cramps, dull backache, pelvic pressure.
most important; if contractions are regular (occur at least every 10 min for 1 hour), would indicate premature labor
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The patient arrives at the health clinic with reports of dark urine, fever, and flank pain. The initial nursing assessment of the patient reveals which of the following EARLY symptoms of glomerulonephritis?
Acute glomerulonephritis: group of kidney diseases resulting in inflammatory changes from immunological responses. S/S: edema, abdominal pain, hypertension, fever. Nursing responsibilities: restrict sodium and water, daily weight, I + O, bed rest, high-calorie, low-protein diet.
(2) reduced urinary output (100 - 400/day); also hematuria (blood in urine), proteinuria (protein in urine) (1) excessive output seen with diabetes mellitus, acute renal failure; normal output 1,200 - 1,500 mL/day (3) excessive thirst seen with diabetes mellitus due to osmotic diuresis; normal intake 1,500 - 2,000 mL/day (4) bedwetting after age 5; not seen with glomerulonephritis.
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