Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet: Continue to monitor (normal).
20 weeks gestation, gained 20 lbs, fundal hei... [Show More] ght 20, clear liquid from breasts. What warrants further evaluation? Too much weight gain, gestational weight gain should only be approx 10.3 lbs.
. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is "vigorous"? Active movement and lusty cry.
24 hour old baby, mom is scared she is not breastfeeding right, the nurse should say... If your baby's urine is straw colored , then she is feeding well.
. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with moderate Inspect perineal and rectal area.
Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery. Nursing Dx? Fluid volume excess.
RATIONALE: 3rd spacing.
Cesarean - hemorrhage risk assessment? Check for fundal firmness Q15 min.
RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after delivery. Q15 min checks stimulate fundus to contract and prevents bleeding.
Water broke, umbilical cord is on perineum, what does nurse do? Place pt in trendelenburg.
RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and holding up the presenting part as much as possible.
Primipara 20 week, schedule u/s, what's the reason for the u/s? To evaluate fetal growth and to determine gestational age.
Assessing a 3 day old with cephalohematoma. What intervention is highest priority? Examine Q8 hrs for jaundice (look for hyperbilirubinemia).
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled anesthesia. What would be a therapeutic response to the injection? Increased HR and decrease in oral secretions.
Newborn assessment that indicates a cardiac problem? RR 78/min.
RATIONALE: Normal respiratory rate for a newborn is 40 - 60.
Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give? Give 1.5 tabs.
Sore nipples on day 2 of breastfeeding. Assess infants position while feeding.
RATIONALE: To make sure baby is latching properly.
Rh negative refuses Rhogam after delivery. Rhogam prevents maternal antibody formation for future Rh positive babies.
24 hours after birth, cephalohematoma, what intervention? Examine jaundice Q8 hours.
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
. Patient had twins born to multigravida, 12 hours ago. Nursing Dx? Assess fundal tone and lochia flow.
. Primigravida, 36 week, admitted, water broke, 2cm dilated, 50% effaced, -2 station, vertex presentation, greenish colored amniotic fluid, contractions Q3-5 min with deceased in FHR after the last 4 contraction peaks. What to do FIRST? 02 via facemask.
Terbutaline (Brethine) injections for preterm labor. When do you hold and call the MD? Bilateral crackles in lungs on auscultation (critical complication).
RATIONALE: Could indicate pulmonary edema.
APGAR 3. Intervention? Continue resuscitation efforts.
In PACU, the most important assessment for first 8 hours after cesarean: Uterine atony.
RATIONALE: Uterine atony can lead to hemorrhage.
Cytotec (Misoprostol) for peptic ulcer (Synthetic Prostaglandin E Drug). Nurse response? Increased risk for spontaneous miscarriage.
RATIONALE: Cytotec (Misoprostol) can induce uterine contractions resulting in miscarriage.
Multigravida at term with back labor, cervix is 3 cm dilated, 50% effaced, -1 station. Apply counter pressure to sacral area.
RATIONALE: Caused by malposition of the fetus.
Not Rubella immune (negative titer) and 6 weeks pregnant. When should the vaccine be given? Give early postpartum within 72 hours.
HESI HINT: "Rubella is teratogenic to the fetus during the first trimester, causing congenital heart disease, congenital cataracts, or both. All women should have their titers checked during pregnancy. If a woman's titers are low, she should receive the vaccine after delivery and be instructed not to get pregnant within 3 months. Breast-feeding mothers may take the vaccine" (p. 288).
Gravida 1, para 0, cervix dilated 8 cm, contractions Q2 min, bloody show, and nausea. Nurse Dx? Pain r/t transitional phase of labor.
Baby weighs 7.5 lbs today, tomorrow 7 lbs (5 lb weight loss). What does the nurse do? Tell mother it is normal.
RATIONALE: Newborns can lose 10% of their wt and regain it later.
Receiving report on laboring pt from ER. Water broke and didn't know it. First thing the nurse does? Take temperature.
RATIONALE: Length of time membranes ruptured is important to monitor for infection.
Postpartum temporary bed-rest should be placed if? Positive Homan's sign.
. Fundus hand placement: 1 massages the fundus the other is for... The other hand anchors the lower uterine section.
DM I, HbgA1c level 7.8 at 10 weeks pregnant. What should the nurse do? Contact MD for BPP (BioPhysical Profile).
Symptoms of hemorrhage/bleeding out: LR 200 mL/hr using 18 gauge needle.
Most accurate way to determine fetal position at 29 weeks gestation. Ultrasound.
RATIONALE: Provides direct view of the fetus.
To measure contractions... From beginning of a contraction, to the beginning of the next contractions.
. Newborn assessment for respiratory distress. Flaring of the nares.
RATIONALE: Forced inspiration, grunting, tachy (respirations >60), cyanosis, and retractions over chest wall).
40 weeks pregnant, laboring, patient states supine is position of comfort, the nurse should? Place pillow wedge under right hip.
RATIONALE: Hypotension from pressure on vena cava is risk, the wedge relieves the pressure on the vena cava.
MVA, 36 weeks, BP 80/50, HR 130, what does the nurse do? Tilt the backboard to displace uterus.
. Patient concerned about yellow nipple discharge. Tell the patient it is normal.
Nutrition teaching for pregnant teens. Iron-deficient anemia.
38 weeks, laboring, which finding (condition) warrants a cesarean? Active herpes lesions on perineum.
. Second stage of labor, what does nurse do first? Let pt know that birth is imminent.
RATIONALE: Second stage pt is fully dilated and fetus is crowning.
Baby born breech, in the NICU they assess? Ortolani's test.
RATIONALE: (from Saunders, couldn't find it in HESI). It is a test of hip laxity, used to diagnose hip dysplasia.
IV LR 1000 mL with oxytocin (Pitocin) 40 units to deliver 15mL/hr. How many milli-units/minute is the client receiving? 10 mu/min.
38 week (IDM) infant of diabetic mother admitted to NICU @ 8.2 lbs. What is the priority Nursing Dx? Hypoglycemia.
FHR decreases after each contraction. What should the nurse do? Give 10 lpm 02 via mask.
. Post partum teaching to prevent pregnancy. Use condom and spermicidal gel.
1st trimester, Hgb 8.6, Hct 25.1, what food should the nurse encourage? Chicken.
Oxytocin (Pitocin) 20 units in 1000 LR after delivery is for? To stimulate uterine contractions to prevent hemorrhage.
RATIONALE: Admin after placenta delivery. Prior to placental delivery would cause uterus to contract and retain placenta.
. Full term infant, vaginal birth, placed in radiant warmer, is apneic. What to do FIRST? Flick soles of feet.
RATIONALE: Infant needs additional stimulation to initiate breathing.
One hand above pubic symphysis while massaging fundus of a patient who has a boggy uterine tone 15 min after delivery (7 lb baby). What does the nurse tell the patient? Tell the patient that clots can form in a boggy uterus.
Patient with preeclampsia is receiving IV Mag 6 grams administered over 20 min. The nurse attaches a volume control device between the infusion pump and the bag of solution labeled "Magnesium Sulfate 20 grams/500 mL of D5W". How many mL should nurse place in volume controlled device? 150 mL
Eye ointment QS is for? Prevent eye infection.
Heelstick blood specimen on neonate for T4 and TSH prior to D/C home on 2 day old. Parents ask why, the nurse states? Required by law to screen for metabolic def.
Patient is 5 weeks pregnant, educate on nutrition... Eat a well balanced diet, adjust PRN for proper weight gain.
Assessing a 39 week pregnant patient admitted to L&D, which do you call MD for? Temperature of 101.2
Patient asks if she can use the same diaphragm for birth control after her pregnancy, the nurse answers ... Use alternative form of birth control until new diaphragm can be obtained. [Show Less]