Student Copy REP Exam 2 Blueprint Fall 2023.docx

SAFE AND EFFECTIVE CLIENT CARE ENVIRONMENT (approx. 11 questions total) MANAGEMENT OF CARE: Establishing Priorities Postpartum assessment : birth to a year Involution: by 2 weeks should be below the symphysis and should not be able to palpate Care starts 2hrs post birth. Vitals, fundal assessmen...

SAFE AND EFFECTIVE CLIENT CARE ENVIRONMENT (approx. 11 questions total) MANAGEMENT OF CARE: Establishing Priorities Postpartum assessment : birth to a year Involution: by 2 weeks should be below the symphysis and should not be able to palpate Care starts 2hrs post birth. Vitals, fundal assessment, APGAR UAP cannot perform assessments. The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis. Postpartum infections Endometritis Cesarean section incision infection Mastitis Newborn assessment Apgar score, which is a rapid assessment of respiratory and heart rate, muscle tone, reflexes, and color.  Later measurements will include height and weight and lab tests Hyperbilirubinemia: Normal levels should be 2-6 High levels of bilirubin in the blood. Baby will receive phototherapy. Cover newborns eyes while under phototherapy Initial steps neonatal resuscitation Provide warmth, position, clear airway, ventilation, chest compressions SAFETY/INFECTION CONTROL Accident/Error/Injury Prevention Oxytocin administration Helps start or continue labor Control bleeding after delivery. It is also sometimes used to help milk secretion in breast-feeding Newborn care- ex: Sudden infant death syndrome (SIDS) Education on sleep etiquette Baby sleeps on their back Cover the mattress with a fitted sheet and no other bedding. Keep soft objects and loose bedding out of the sleep area. Substernal chest retractions respiratory distress HEALTH PROMOTION AND MAINTENANCE (5 questions total) Ante/Intra/Postpartum and Newborn Care Stages/Phases of Labor Stage 1: Early Latent: Cervix dilates from 1 to 4 cm* and thins, Contractions occur every 5 to 30 minutes and 30-45 seconds in length Active Labor: Cervix dilates to *4 to 7 cm and thins. Contractions will be noticeably stronger and longer (45 to 60 seconds) every 3 to 5 minutes. Important to monitor for meconium -stained fluid which is greenish brown/yellowish ammonitic fluid…baby can aspirate this into lungs causing infection or blocking airway and this usually indicates fetal distress) Perform Nitrazine paper test to confirm the water has broken (turns blue if positive) Transition Labor: Cervix dilates to 8 to 10 cm and thins. Stage 2: Starts when cervix has fully dilated and ends when baby is fully delivered. Stage 3: Begins with delivery of baby ends with placenta and key interventions. Key intervention: Start Pitocin, document placenta delivery, assess fundus and Bleeding If C-section: manual removal of placenta will be performed by the doctor Administer oxytocin “Pitocin” as ordered by the physician AFTER delivery of the placenta…helps uterus contract after delivery of placenta and prevents hemorrhage, assess placenta to make sure it is enact (cord should have two arteries and one vein) Stage 4: Begins with placenta delivery approximately 4 hours after birth. Placental delivery appears when cord appears to get longer as it detaches with increase of blood flow. The uterus should contract and clamps down to stop the bleeding. Fundus should be massaged until firm if it appears firm. Medication will be given if the fundal massage is ineffective in firming uterus Maternal assessments q15min for 1st hour, then 30min for 2nd hour Peri care, pain meds, comfort measures, assist to bathroom, education If no epidural, up to bathroom right away If epidural: may have urinary retention. VS and fundal checks q8-12 Motrin and Tylenol C-section: Bedrest for 12hrs, foley Cath, IV fluids infusing, VS and fundal checks q4, Motrin/Toradol and/or narcotic. @12hr mark client can have fluids and catheter d/c If they can ambulate Diabetes mellitus in pregnancy (Pre-existing/Gestational) Preexisting pregnancy: Stable blood glucose, fetal anomalies Gestational: Hypoglycemia, LGA, Macrosomia Hypertensive conditions of Pregnancy (gestational HTN, chronic HTN etc;) Gestatational diabetes: Diet, exercise, maintain blood glucose within 65-95 FBG. Diet and insulin need change during pregnancy, mom will be checking blood glucose daily. More calories will be added when they enter second trimester Increased insulin release during first 20weeks which may cause hypoglycemia episodes Placental hormones arise within the first 20 weeks Deep vein thrombosis (DVT) prevention Exercise, drink plenty of fluids, compression devices, take medication as prescribed Newborn discharge teaching (NB care) Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow. Brest feeding (how to tell baby is hungry) Chorioamnionitis Health Screening True vs. false labor PSYCHOSOCIAL INTEGRITY (2 questions total) Mental Health Concepts Postpartum mood disorders The 5P’s of labor PHYSIOLOGICAL INTEGRITY (4 questions total) BASIC CARE AND COMFORT: ​​Elimination Common postpartum complaints/assessments Nutrition and Oral Hydration Newborn heat loss BF basic teaching/care Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase Non-Pharmacological Comfort Interventions The 5P’s of labor Passenger: Babys position, size, and presentation Sacral counterpressure for back pain relief to fetal posterior position Passageway: Perform pelvic exams and monitor baby descent Position: Mothers position during labor Psychological response: Emotional state of mother during labor and delivery Power: Strength and effectiveness of contractions Painful contraction Breathing exercises, massage, music, pain meds PHARMACOLOGIC THERAPIES (4 questions) Adverse Effects/Contraindications/Side Effects/Interactions Magnesium sulfate Used to stop contractions in preterm labor. No more than 125mL per hour urine output Postpartum hemorrhage medications Medication Administration & Expected Actions/Outcomes Oxytocin (Pitocin) Induces labor, stimulates contractions, stops excessive vaginal bleeding, used for flaccid uterus Administer 6-12hrs after dinoprostone (cervical rippening drug) Monitor contractions (less than 60 sec, 2-3min apart) Piggyback oxytocin in main fluids 3 consecutives late decels turn off oxytocin, if 1 turn client to side Monitor for cardiac dysrhythmias and tetanic uterine contractions Betamethasone Steroid given for lung development through surfactant in lungs Sones help increase surfactant for full lung development Doses are given 12 hours apart Terbutaline Used for preterm labor, wait in terbuataLINE for the baby An adverse effect of terbutaline is hypokalemia. Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. Assess for tachypnea and frothy sputum pulmonary edema Elevate head of bed and apply oxygen Labetalol – Antihypertensive medication Mom can still breastfeed while taking this medication, no precautions necessary REDUCTION OF RISK POTENTIAL (approx. 9 questions) Changes/Abnormalities in Vital Signs Newborn assessment NST: Tests contractions and babys heart rate. Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted. Accelerations occur, FHR increases at least 15 beats per min over baseline “reactive NST”. Baby is good No accelerations occur, “nonreactive NST”, causes concern, baby is sleeping possibly BBP: Monitors babys movement, breathing efforts 8-10 score means baby is good 0-4 means baby needs to be delivered Laboratory Values HELLP syndrome: hemolysis, elevated liver enzymes, and low platelets Red cells in the blood to break down. It also causes problems with the liver, bleeding, and blood pressure. Screening for GDM: Performed at 24-28 weeks of gestation Potential for Alterations in Body Systems Preeclampsia signs and symptoms Clonus positive means BAD Vision (seeing spots), headache, nausea/vomiting, epigastric pain, edema Assess skin, vital signs (serial semi-fowler BP), dip urine for protein, check clonus (pull foot back, count how many beats), deep tendon reflex (+2 is WNL anything greater indicates for hyperreflexia), weight gain Postpartum non-pharmacological comfort measures Potential for Complications of Diagnostic Tests/Treatments/Procedures Abnormal postpartum assessment Infection Excessive bleeding: PPH A client who has ITP has an autoimmune response that results in a decreased platelet count. SROM assessment: Spontaneous preterm rupture of the membranes System Specific Assessments Preeclampsia assessment Preterm labor risk factors Trace contractions, assess bleeding and leaking. Transvaginal ultrasound to measure how long the cervix is. If cervix is shortened (less than 4cm), administer terbutaline to stop contractions. If the contractions don’t stop, move to magnesium sulfate. Betamethasone will be administered to mom 12hrs apart, two doses to speed up maturity of baby’s lungs. Do not assess by sticking finger in cervix as it stimulates the cervix. If mom feels she needs to push then you would stick use your fingers to assess the cervix to check for baby’s position/head. Tests for preterm are a swab (didn’t get name). High-risk pregnancy risk factors Obesity, maternal age (>35), high blood pressure, prior miscarriage Nursing interventions based on fundal assessment Massage the fundus, have client ambulate, have client urinate Newborn hypoglycemia risk factors Newborns less than 24hrs old BGL should be 40-45 Preterm labor Irritability, poor tone, feeding difficulties perform heel stick glucose. Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Apgar-scoring nursing interventions Score is out of 10 Completed 1 min and 5 min after birth If score is less than 7, reassess in 5 min Appearance, pulse, grimace, activity, respiratory effort 0-3 Score: severe distress – resuscitate fully, get crash cart 4-6 Score: Oxygen, suction, stimulation (rub back, feet) 7-10: Warm baby, encourage breast feeding Newborn physical assessment APGAR score Babinski reflex (positive means good) Stroke newborns sole, toes should hyperextend PHYSIOLOGICAL ADAPTATION (approx. 15 questions) Alterations in Body Systems Epidural nursing interventions: Check clients baseline BP, check BP q5 min after epi. Eclampsia nursing interventions Hyperemesis gravidarum Hemorrhagic conditions - bleeding during pregnancy. Massage fundus to release clots First and Second stage nursing interventions (2 questions) Labor dystocia nursing interventions PPH- 4T’s recognition and nursing interventions Phototherapy nursing interventions Cold stress signs & symptoms Amniotomy: Assess clients temperature as they are at risk for infection. Procedure that speeds up labor and encourages dilation of the cervix AROM: artificial rupture of membranes Illness Management Newborn respiratory distress s/sx Medical Emergencies OB emergencies signs and symptoms and nursing interventions NGN questions each week plus dynamic quizzing practice questions (Learning System RN 2.0) Magnesium Sulfate – Complete med card – Antiseizure medication. Calcium gluconate antidote. TOLAC: Trial of labor after cesarean (TOLAC) is a planned or attempted vaginal birth after cesarean (VBAC) Fetal distress, placenta previa, post-term pregnancy, failed induction, malpresentation, malposition VBAC: A VBAC is a “successful” trial of labor resulting in a vaginal birth Bishop score: predict the likelihood of a woman entering labor naturally in the near future Misoprostol/cytotec Helps cervix thin out, balloon dilates cervix REEDA: redness, edema, ecchymosis (bruising), drainage (serous, sanguineous, serosanguineous, purulent), approximation Lacerations: especially 3rd and 4th degree. Ensure no constipation and bowel movements are soft due to rectum tear FHT: At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis. Glucose test: The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus. BUBBLE: Breast intact, soft, colostrum. Clogged ducts/Engorgement redness leads to mastitis/infection Uterus: midline, firm, at/below umbilicus. Displaced/boggy leads to uterine atony or retained placenta Bowel: Bowel care, ask usual BM. Gas/abdominal pain leads to constipation Bladder: UTI or pyelonephritis leads to sepsis Lochia: Scant, moderate, rubra, serosa, alba. Extra bleeding leads to PPH, anemia, hysterectomy Episiotomy: Inflammation/pain leads to infection incontinence, sepsis Legs: clots, thrombophlebitis leads to DVT, PE Emotions: connecting and bonding. Baby blues leads to postpartum mood disorder 4 methods of heat loss: conduction evaporation One intervention: Heat lamp, skin to skin, dry baby