APGAR
Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid,
... [Show More] limp)
Respirations (strong cry, weak cry, absent)
Woman in labor (un-reassuring FHR)
(late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!
Infant with Spina Bifida
Prone so that sac does not rupture
Prolapsed cord
Knee to chest or Trendelenburg
oxygen 8 to 10 L
Cleft Lip
position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position.
FHR patterns for OB
Think VEAL CHOP!
V-variable decels; C- cord compression caused
E-early decels; H- head compression caused
A-accels; O-okay, no problem
L- late decels; P- placental insufficiency, can't fill
what to check with pregnancy
Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope.
Position of the baby by fetal heart sounds
Posterior --heard at sides
Anterior---midline by unbilicus and side
Breech- high up in the fundus near umbilicus
Vertex- by the symphysis pubis.
Heroin withdrawal neonate
irritable, poor sucking
lead poisoning
test at 12 months of age
pt with leukemia may have
epistaxis due to low platelets
when a pt comes in and is in active labor
first action of nurse is to listen to fetal heart tones/rate
NCLEX answer tips
choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment.
1 tsp
5 mL
1 oz
30 mL
1 cup
8 oz
1 quart
2 pints
1 pint
2 cups
1 g (gram)
1000 mg
1 kg
2.2 lbs
I lb
16 oz
centigrade to Fahrenheit conversion
F= C+40 multiply 5/9 and subtract 40
C=F+40 multiply 9/5 and subtract 40
birth weight
doubles by 6 months
triples by 1 year
early sign of cystic fibrosis
meconium in ileus at birth
hemophilia is x linked
passed from mother to son
perform amniocentesis
before 20 weeks to check for cardiac and pulmonary abnormalities
Rh mothers receive Rhogam
to protect next baby
anterior fontanelle closes by...posterior by..
18 months, 6-8 weeks
caput succedaneum
diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days
pathological jaundice occurs:
physiological jaundice occurs:
before 24 hours (lasts 7 days)
after 24 hours
placenta previa s/s
placental abrution s/s
there is no pain, but there is bleeding
there is pain, but no bleeding (board like abd)
bethamethasone (celestone)
surfactant. premature babies
Developmental
2-3 months: turns head side to side
4-5 months: grasps, switch and roll
6-7 months: sit at 6 and waves bye bye
8-9 months: stands straight at 8
10-11 months: belly to butt
12-13 months: 12 and up, drink from a cup
Apgar measures
HR RR Muscle tone, reflexes, skin color.
Each 0-2 points. 8-10 ok, 0-3 resuscitate
Guthrie test
Tests for PKU. Baby should have eaten protein first
Transesophageal fistula
esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis)
Stranger anxiety is greatest at what age?
7-9 months..separation anxiety peaks in toddlerhood
infants IM site
Vastus lateralis
Toddler 18 months+ IM site
Ventrogluteal
IM site for children
deltoid and gluteus maximus
ECG
no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before. may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for seizures after the procedure.
Myelogram
NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site
Liver biopsy
administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to expect to be asked to hold breath for 5-10 sec. supide position, lateral with upper arms elevated. Post--position on RIGHT side. frequent VS. report severe ab pain STAT. no heavy lifting 1 wk
Paracentesis
semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia
laparoscopy
CO2 used to enhance visual. general anesthesia. foley. post--ambulate to decrease CO2 buildup
PTB
low grade afternoon fever
pneumonia
rusty sputum
asthma
wheezing on expiration
emphysema
barrel chest
kawasaki syndrome
strawberry tongue
pernicious anemia
red beefy tongue
downs syndrome
protruding tongue
cholera
rice watery stool
malaria
stepladder like fever--with chills
typhoid
rose spots on the abdomen
diptheria
pseudo membrane formation
measles
koplick's spots
sle (systemic lupus)
butterfly rash
pyloric stenosis
olive like mass
Addison's
bronze like skin pigmentation
Cushing's
moon face, buffalo hump
hyperthyroidism/ grave's disease
exophthalmos
myasthenia gravis
descending musle weakness
gullian-barre syndrome
ascending muscle weakness
angina
crushing, stabbing chest pain relieved by nitro
MI
crushing stabbing chest pain unrelieved by nitro
cystic fibrosis
salty skin
DM
polyuria, polydipsia,polyphagia
DKA
kussmal's breathing (deep rapid)
Bladder CA
painless hematuria
BPH
reduced size and force of urine
retinal detachment
floaters and flashes of light. curtain vision
glaucoma
painful vision loss. tunnel vision. halo
retino blastoma
cat's eye reflex
increased ICP
hypertension, bradypnea,, bradycarday (cushing's triad)
shock
Hypotension, tachypnea, tachycardia
Lymes disease
bullseye rash
intraosseous infusion
often used in peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids, blood products and meds are administered into the marrow. one med that CANNOT be administered IO is isoproterenol, a beta agonist.
sickle cell crisis
two interventions to prioritize: fluids and pain relief.
glomuloneprhitis
the most important assessment is blood pressure
children 5 and up
should have an explanation of what will happen a week before surgery
Kawasaki disease
(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms.
ventriculoperitoneal shunt
watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30 degrees
3-4 cups of milk a day for a child?
NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA
MMR and varicella immunizaions
after 15 months!
cryptorchidism
undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence
CSF meningitis
HIGH protein LOW glucose
Head injury or skull fx
no nasotracheal suctioning
otitis media
feed upright to avoid otitis media!
positioning for pneumonia
lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!) [Show Less]