APGAR - ✔✔ Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed,
... [Show More] flaccid, 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 [Show Less]