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NursingSpring Exam 1

Nursing Spring Exam 1

QuestionAnswer
Three theories of labor onset 1) Hormonal 2) Mechanical 3) Fetus
What is the fetus theory of labor onset? The pressure of the head and cervix helps stimulate production of oxytocin
What is the mechanical theory of labor onset? 1) Uterine: Distension; stretched to the limit; increased pressure; aging placenta reached a certain point 2) Cervical: True signs when it gets thinner and it softens up
Estrogen Stimulates myometrial contractions and production of prostaglandins; stimulates muscles; progesterone has to decrease
Progesterone Relaxation of the myometrium
Prostaglandin Cause the connective tissue in the cervix to soften and thin out; ripens the cervix; increases during pregnancy
Fetal Cortisol Produced by the fetus hypothalamus and helps with labor progess
Oxytocin Hormone produced by the pituitary and plays a major role in the contractions during labor; this increases and milk lactic is produced by this
What is lightening? The baby has dropped because the presenting part of the fetus descended into pelvis -For first time: 1-2 weeks before delivery -For second time: when labor starts
What is show? Increase of vaginal discharge; the cervix has a plug of mucous which comes out when the cervix begins dilating
What is ROM (Rupture of Membrane)? Can be SROM (spontaneous) or AROM (when it is ruptured by someone artificially)
"Nesting" Pregnant person has the urge to do little chores before delivery
Length of Labor For first time: 12-35 hours For after one: 7-20 hours
The Components of labor- 5 "P's" 1) Passageway: Is mom pelvis large enough for fetus 2) Passenger: The fetus 3) Powers: Forces of labor and muscles contractions 4) Partnership: Fetus and pelvis have to work together 5) Psychologic responses
The 4 kinds of pelvis 1) Gynecoid (the typical one) 2) Anthropoid (the longest) 3) Android (perfect heart) 4) Platypeltoid (the widest)
Fetal Attitude Posture of the fetus in the uterus; Flexion would be arm to chest and leg to abdomen
Fetal Lie Indicates the relationship of the long axis of the fetus to the long axis of the mother (spinal column to spinal column)
Longitudinal Lie Long axis of baby is parallel to long axis of the mother
Transverse Lie Long axis of baby is at a 90 degree angle of the long axis of the mother
Fetal Presentation (presenting part) Designates the part of the fetus which lies closest to or has entered the true pelvis
Cephalic Presentation Head is the presenting part and it could be vertex (head is in flexion) or face (head is in extension)
Breech Presentation The buttocks or lower extremities are the presenting part and it can be complete or full (both leg is down), frank (both leg is up), incomplete (one leg up and the other down)
Transverse Presentation Shoulder is the presenting part
The second letter in fetal position 1) O-Occipital 2) F-Fronto (brow) 3) M-Mentum (chin) 4) S-Breech 5) SC-Shoulder
EDFIEEE E-Engagement D-Descent F-Flexion I-Internal Rotation E-Extension E-External Rotation E-Expulsion
Engagement occurs when the fetal head has enter the pelvic inlet to the level where it is large enough to accommodate the head
Descent Head descend until it rest on the pelvic floor
Flexion Bending of the neck so head is flexed to the chest
Station Refers to the degree of descent of the presenting part into the pelvis 1) At the ischial spine=0 2) Above spines=-3,-2,-1 3) Below spines=+3,+2,+1
What are the methods in determining feto-pelvic relationship 1) CT Pelvimetry 2) Internal Exam 3) Leopold's Maneuver 4) Feel of the baby's heart rate 5) Ultrasound and MRI
First stage of labor Early phase; Active phase; Transition phase
Second stage of labor Full effacement and dilation and end with the birth of the baby
Third stage of labor Begins at the birth and ends with the placenta being delivered
Fourth stage of labor Begin with the placenta being delivered and ends 1 hour post-partum
What are the four purpose of vaginal exam? 1) Check cervical dilation and effacement 2) Check for the presenting part 3) Identify the station 4) Labor progress
Intact membrane 1) Protect the baby from bacteria 2) It cushions the baby 3) Prevents pressure sore or point 4) Act as a wedge to help dilation
Early phase of labor (6-8 hours) Cervix is effacing and dilated 0-3 cm, contractions are 5-10 mins apart, last for 30 seconds, and they are mild to moderate, have slight bloody show (check vital signs and FHR every hour)
Meconium Stain The baby is in distressed when its green-brown and when the nitrocene paper shows blue that is good
Active phase of labor (3-6 hours) Effacement is either complete or near complete and the cervix is 4-8 cm, contractions are every 3-5 mins apart lasting 35-45 sec(could be a minute) and they are moderate ending strong
Transition phase (15 mins-multi and 2 hours-first time) cervix is 8-10 cm with 1-3 mins apart lasting 90 seconds and they are strong and overwhelming
Nursing Interventions during transition phase 1) Keep room quiet 2) Fetal heart rate monitoring is continuous and every 15 minutes each time do the mom's vital signs
Nursing Interventions during the active phase 1) Keep hydrated 2) Do the vitals on mom and FHR every half hour 3) Give pain medication when necessary 4) Have mom change positions
Nursing Intervention during early phase 1) Every hour 2) Encouragement 3) Hydration 4) Comfort
What is the preparation of labor client? 1) Child birth classes 2) Birth plan 3) Explain what is going on (teach) 4) Accurate assessment 5) Make sure consent is signed 6) Prepare the room for delivery (warmer is on) 7) Resuscitation is prepared
Birthing Rooms Home centered; Family oriented; good atmosphere for both labor and delivery
LDR This is switching between both labor and delivery room
Birth Plans Patient share to the provider the kind of care the want during delivery
Normal Range of FHR 120-160
What are 2 types of periodic change? 1) Acceleration 2) Deceleration
Acceleration heart rate 1) Could be fetal movement 2) Could be uterine contraction 3) Don't let it go beyond 160
Deceleration heart rate 1) Last a few seconds to minutes 2) Variable deceleration 3) Late deceleration 4) Early deceleration
Early deceleration Compression of the fetal head and no action really should be taken but keep monitoring
Late deceleration (WATCH) Acute uteroplacental insufficiency and you should turn the mother to the left side, give oxygen, stop uterine stimulant and need an IV
Variable deceleration Compression of the umbilical cord and you should turn mom to the lateral position and give her oxygen (notify the doctor)
L.O.C.K. L-Left lateral position O-Giver her oxygen C-Correct attributing factor K-Keep constant FHR
What are fetal distress management? 1) Call for help 2) Turn mom to the left 3) Oxygen 4) Discontinue oxydocin 5) Start IV if not started (no glucose) 6) Notify the provider 7) Prepare for rapid delivery
Internal Fetal Heart Monitoring Scalp electrode which gives you an accurate fetal heart rate
External Fetal Heart Monitoring Doppler on the abdomen and it gives you the estimate of the fetal heart rate
What would be the reason for fetal distress? 1) Prolonged labor 2) Induced labor 3) Medication 4) Infection 5) Cord compression 6) Hypoxia (no oxygen) 7) Uteroplacental insuffiency
What would be the signs of fetal distress? 1) Meconium stain (amniotic fluid) 2) Bradycardia or tachycardia 3) Late deceleration 4) Loss of variability 5) Prolonged variable deceleration or continuous
What would be the diagnosis of fetal distress? 1) Internal fetal monitor 2) Fetal scalp stimulation (rub presenting part) 3) Fetal scalp sampling (check blood for PH)
PH blood for fetus If it is greater the 7.25 then it is normal, if its less than 7.21 then there is no oxygen and if its in between then check every 15 minutes
After the membrane are ruptured Count FHR immediately because the cord may prolapsed causign fetal distress
Early period of first stage of labor Count FHR every hour because contractions may cause stress to the fetus
First stage of labor has been established Count FHR every half hour because stronger contractions can cause more stress
Second stage of labor Count FHR every 5 minutes because frequent and strong contraction increase stress
With oxytocin infusion Continuous assessments
What is the optimal time to give anesthesia? 4-7 cm dilation
General anesthesia during labor Depresses CNS, relieve pain and all sensation by loss of consciousness (this is only for emergency)
Regional anesthesia during labor Blocks nerves that carry sensation from uterus and pelvis to spinal cord
Analgesia Relieves pain
What do you do before giving analgesic? 1) Provide optimum environment 2) Check V/S every 15-30 mins 3) Encourage patient to empty bladder 4) Safety (side rails up) 5) Encourage patient to relax after each contractions 6) Observe closely the progress of labor (assessments)
What are the nursing preparation for delivery? 1) Contact the provider 2) Have the IV ready 3) Warm blankets 4) Isolette (type of incubator bed for infant) 5) Methergin (oxytocic)- stimulate uterine and smooth muscles (must check BP because this can cause a rise)
What are maternal safety consideration for second stage of labor? 1) Never leave the patient 2) Maintain asepsis 3) Move her in a safe manner 4) Do not take your eyes of the perineum until the provider is there and ready
What are the maternal response for the second stage of labor? 1) Worried 2) Fatigued 3) Overwhelmed 4) Burning sensation 5) Concerned
What is the physiology for the second stage of labor? 1) Must stay with client 2) Contractions are overwhelming 3) May not be frequent contractions 4) If mom is not fully dilated she cannot push (encourage her not to)
What is the physiology for the third stage of labor? Placenta separates from the wall of uterus
What are the two mechanism with the placenta separating from the uterus? 1) Sudden collapse of uterus creates an uneven surface of uterine wall 2) Blood clots develop between uterus and placenta forcing the separation
Nursing intervention of the third stage of labor 1) DOCUMENT 2) Maternal V/S every 15 mins 3) Clean 4) After the placenta, massage the fundus to stimulate contractions 5) Ice pack to the perineum 6) Give Methergine
Boggy Fundus This is when the fundus is hard and they can bleed more
What is the difference between labor induction and labor augmentation? Labor induction is to start labor and augmentation is after it has started and it starts progressing slowly
What are the nursing intervention following amniotomy? 1) Check FHR immediately after 2) Observe fluid amount and color 3) Keep client dry and clean 4) Document carefully
What are the potential labor complications? 1) Precipitate labor 2) Uterine rupture 3) Cord prolapse 4) Posterior presentation 5) Breech presentation 6) Shoulder presentation 7) Macrosomia 8) Shoulder dystocia
Precipitate Labor This is fast and the labor can take less than 3 hours
Uterine Rupture This is rare and would have to happen if mom had previous C-section and it would increase the risk with oxytocin. The S/S would be FHR crashes, mom will have sudden burning abdominal pain due to the internal bleeding
Cord Prolapse Umbilical cord protrudes into or from vaginal canal
Posterior Presentation Fetal head (sunny side up) and counter-pressure can be used here
Breech Presentation Buttocks is first (C-section is done for safety), if it is frank then a vaginal delivery can be possible
Shoulder Presentation AKA transverse and a C-section is a must
Macrosomia "large infant" over 9 pounds and it can be more found in diabetes mother
Shoulder Dystocia Baby head was delivered but then the shoulder got stuck and forceps would have to be used and this can cause clavicle fracture
External Version Manual manipulation is to attempt to rotate fetus from a breech or transverse position to a vertex position. This is not successful most of the time and it would have to depend on the expertise of the doctor (very painful)
Forceps/Vacuum Extraction 1) Needed due to fetal distress, maternal exhaustion, shoulder dystocia 2) Mom can be given anesthesia for relaxing
What are indications of C-section? 1) Prolonged labor 2) Previous C-section 3) Breech or transverse position 4) Failure to progress 5) Multiple birth 6) Prolapse cord 7) Medical condition of mom 8) Cephalopelvic disproportion (head no match with pelvis) 9) Placenta previa and abru
What are the pre-op procedures for C-section? 1) Obtain consent 2) Make sure ultrasound is on chart 3) Start IV, draw labs 4) Maternal V/S and FHR (document) 5) Need to do shave prep of abdomen 6) Insert foley catheter 7) Explain everything to mom and support (reassure truthfully)
What are the major maternal risk with C-section? 1) Hemorrhage 2) Wound infection 3) Injury to bladder/bowel 4) Pulmonary emboli or deep vein thrombosis 5) Complication of anesthesia (could aspirate) 6) UTI (due to foley) 7) Rare injury to uterus where future labor can be impossible
Two Types of Cesarean 1) Lower transverse (AKA bikini cut) horizontal. Less likely to rupture with future labors 2) Classical (vertical)used in pre term emergency and this can cause rupture in future labors
Educational need in cesarean 1) OOB as soon as possible 2) Post-partum teaching 3) Teach deep breathing, cough, splinting every 1-2 hrs 4) Pain control 5) Breast-feeding instruction
Significant other role in cesarean 1) Allowed in the OR 2) The can hold the newborn in the OR 3) They can encourage and support mom 4) RN need to keep an eye on them
VBAC 1) Mom need to have a transverse incision with previous C-section 2) Will need continuous fetal and contraction monitoring 3) RN needs to be prepared for C-section 4) "Trial of Labor" they are similar to primip labor and mom will have increase anxiety
Uterine Inversion 1) Uterus turns inside out 2) Can be complete(top of uterus is coming out vagina) or incomplete(top of uterus is at bottom) 3) The placenta may still be attached 4) Hemorrhage 5) Must be kept sterile 6) Surgical procedure is done and future babies is
Placenta/Cord Anomalies 1) Should be intact 2) If provider doesn't, you check the placenta 3) Cord have to be inspected for 3 vessels (2 arteries and vein)
Fourth Stage (puerperium stage)physiology 1) Oxytocin is released from the posterior pituitary gland and induce strong contraction. The uterus returns to approximately 20 weeks of pregnancy and in 6 weeks it should be pre-pregnancy (involution)
Blood Status for Hct/Hgb If it is decreased will need nutritional education. Usually placed on FeSO4 which will be ordered TID (3x a day) and BID (2x a day) and encourage Vitamin C
Blood Status for Rubella Titer If equivocal or not immune will be offered vaccine prior to discharge (controversial if breast feeding)
Blood Status for HIV If mom is positive then breast feeding is contraindicated
What is the signs of post-partum depression? 1) Overwhelming status 2) Extreme fatigue 3) Libial (crying, laughing, crying) 4) Anxiety is high 5) Do not bond with baby
Clinical Problems 1) Postpartal psychosis 2) Pregnancy induced hypertension 3) Engorgement; Mastitis (infection of the mammary gland) 4) Hemorrhage 5) Distension 6) Thrombophlebitis 7) Delayed healing of episiotomy
Molding Misshapen head because of the pressure of labor "cone head"
What is the difference between cephalhematoma and caput succedaneum? Cephalhematoma does not crosses the suture line while caput does
Placement of the ears It has to be level with the outer canthus of the eye, if it is not and its located downward that could be indication of downs-syndrome
Jaundice Looking at the sclera of the eye gives you a good hint of jaundice which is yellow coloring with liver problems
Subconjunctival Hemorrhage Small amount of bleeding in the conjuctive part of the eye
Epstein's Pearl On the palate or the gums in the mouth and it is shiny round spots, accumulation of keratin (it resolves in one week or so)
Vernix Caseosa White greasy covering, protect the skin from amniotic fluid (a lubricant)-this is one way to tell if the baby is premature or full term
Desquamation Peeling of the skin the palms and soles
What are the the two types of jaundice? Psysiologic(happens 24 hours after birth) and Pathological(present at birth)
Lanugo Fine hair on the newborn and it should be gone by 40 weeks (this is another factor that determines if the baby is premature or full term)
Milia Yellow or white papules usually found on the brow, cheek or nose. It is secretion of the sebaceous gland and it should go away in a couple of weeks
Mongolian Spots Bruises looking things that appear on the buttocks, flank or shoulder and it should be gone in 2 years (DOCUMENT)
What is the cardiac of a newborn? They should be regular with a slight murmur. Regular apical pulse should be 110-160. (Mottling and acrocyanosis are related to this)
What are the respiration in newborns? They are irregular because they are abdominal breather so look at their chest and abdomen
What are the assessment for bladder/bowel for newborns? Newborns should have their first bowel movement in 24 hour of birth. They should be urinating 2-3 times in the first 24 hour (if breast feeding then it will be less)
What are the assessment for genitalia for newborns? Male (40 weeks): Both testes should descend and rugae should be present Female (40 weeks): Labia majora should be covering the clitoris and labia minora (this is another factor that determines if the baby is premature or full term)
The cord on the baby It should have 3 vessels and it should dry and be maintained dry and it will fall out 7-10 days
What is the suck reflex? It is a protection mechanism (for food)
What is the rooting reflex? Touching the newborn in the corner of the mouth or cheek will cause them to turn their head in that direction
What is the babinski reflex? At the soles of the foot you would begin at the heel and stroke toward the toes and their toes should go outward
What is the moro reflex? It is a startle reflex where the hand and feet "jerk"
What is the plantar and palmar grasp reflex? Place a finger in the newborn palm or sole of the feet and they will curl the fingers or toes
What is the step reflex? Half a step looks like its taken when you lift newborn up
Weight and Length of Newborn They can lose 10% of body weight initially but should be back to birth weight by two weeks of age Average Weight: 7.5 lb Average Height: 18-21 inches
What is the temperature regulation for newborn? Have them be dry and put a hat on them because they lose heat from there because it is a major surface on newborn (evaporation happens because they come out wet)
What are the resuscitation technique for newborns? 1) Bulb syringue 2) Deep suction 3) Suction the mouth first because of the mucus then the nose -Nurse should not see nasal flaring or retraction (seeing the ribs clearly)
Banding the newborns Mom identification should match the baby identification and an alarm is put on the baby that matches the mother
What are the newborn sight? They can see 8-12 inches (1 foot) and they enjoy faces, circles, color and geometric shape
What are the newborn hearing? They hear well especially knows mother voice. Screening is done before discharge
What are the newborn smell? They can tell the difference between mother's milk and something else by day 3
What are the newborn tactile? Highly developed and sensitive to air and touch. Touch and motion soothes like patting, stroking and rocking while wetness, abrupt pats and jiggling disrupts
What are the newborn taste? Fairly well developed but they may prefer sweet mom milk over bottle plus the tip of the tongue is very sensitive
What are infection prevention methods for newborns? 1) Nursing scrubs (5 minutes) 2) Wash hands between patients 3) Wash hand between changing and diaper change 4) Wear gloves 5) Isolate (if they have infection) 6) Clean infants scale between uses
What are the signs of neonatal infection? 1) Temperature will go down 2) Respiration will go up or down 3) Heart rate will decrease 4) Cyanosis becomes present in the whole body 5) If sepsis, baby can have seizures
When can newborns be bathe? It has to be a consistent temperature of 99 rectally
Aquamephyton Vitamin K IM shot given in the thigh
Eye Prophylaxis Emycin (ointment) placed in both eyes, to prevent GC and chlamydia infection transmission
Immunization Hep B can be given if mom has Hep B
When do you know the baby is dehydrated? When there is less than 6-8 wet diapers
What is the process of lactation? Mom produces the milk by having the pituitary stimulate the hormones then prolactin produces the milk while oxytocin makes it able for the milk to be let down
La Leche League A support system for breast feeding
What are the advantages of breast feeding? The involution of the uterus happens faster ad there is close bonding and for the baby there is colustrum which helps with antibodies and the baby is less likely to be obese and milk breaks down easier so it is tolerable
What are the advantages of bottle feeding? Mom can sleep through the night and plus a career opportunity is possible. The baby can sleep longer and they may find it easier than breast
What is the correct positioning for breast feeding? 1) Hold the baby close and bring baby to her 2) Head, shoulder and butt in the correct alignment 3) Infant with mouth wide open (get the areola and nipple)
Temperature Regulation and Cold Stress Baby system is immature because of little subcutaneous fat and large body surface so it is important to maintain temperature; If the baby is too cold then RR will go up, Oxygen is needed, need for energy increase
HIV in newborns if antibodies are detected, the mother is infected and baby has been exposed the first test can be a false (+) will be tested at 6,12,18 months and at 18 they should be either (+) or (-)
PKU A component of food protein (phenylalanine)cannot be broken down by the body due to a lack of enzyme (baby will need special diet low in phenylalanine or brain damage occurs) AVOID: dairy,meat,fish,nuts,bean,egg,and chicken
Created by: nonelily