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Thursday, July 10, 2008

Nclex-Rn: Saunders Nursing Review 2 (Level Of Cognitive Ability)

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Lochial flow should be distinguished from bleeding originating from a laceration or episiotomy, which is usually brighter red than lochia, and presents as a continuous trickle of bleeding even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported.

Involution is a progressive descent of the uterus into the pelvic cavity. After birth, descent occurs approximately 1 fingerbreadth or approximately 1 cm per day.

The placenta provides an exchange of nutrients and waste products between the mother and fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.

Vancomycin hydrochloride (Vancocin) is an antibiotic. Adverse and toxic effects include nephrotoxicity characterized by a change in the amount or frequency of urination, anorexia, nausea, vomiting, and increased thirst; ototoxicity characterized by hearing loss due to damage to the auditory branch of the eight cranial nerve; and red-neck syndrome from too rapid injection of the medication characterized by chills, fever, fast heartbeat, nausea, vomiting, itching, rash and redness on the face, neck, arms, and back. When this medication is administered to a client, nursing responsibilities include monitoring renal function laboratory results, intake and output, and hearing acuity.

Accurate use of Nägele’s rule requires that the woman have a regular 28 day menstrual cycle. To calculate the delivery date using this Rule, add seven days to the first day of the last menstrual period (LMP), subtract 3 months, and then add one year to that date. First day of the LMP: August 19, 2006; add seven days: August 26, 2006; subtract 3 months: May 26, 2006; add 1 year: May 26, 2007.

For women with active lesions (recurrent or primary) at the time of labor, delivery should be by cesarean section; therefore, option 4 is correct. Acyclovir is used with caution during pregnancy. Clients should be advised to abstain from sexual intercourse while the lesions are present. If it is an initial infection, the client should continue to abstain from sexual intercourse until she becomes culture negative because prolonged viral shedding may occur in such cases.

HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and transmission from an infected woman to her fetus. Women who fall into the high-risk category for HIV infection include those with persistent and recurrent sexually transmitted diseases or a history of multiple sexual partners and those who have used IV drugs.

Infected house cats transmit toxoplasmosis through feces. Handling litter boxes can transmit the disease to the pregnant client. Meats that are undercooked can harbor microorganisms that can cause infection. Hands should be washed throughout the day (not just before meals) when items that could be contaminated are handled. Over-the-counter medications should be avoided by any client who is pregnant and this measure is unrelated to contracting toxoplasmosis.

During the labor process the client is at high risk for being unable to meet the oxygen demands of labor and is at high risk for sickle cell crisis. An intervention to prevent sickle cell crisis during labor includes administering oxygen

An increase in calories is needed with pregnancy, but additional glucose should be avoided because it may cause hyperglycemia. The fat intake should remain at 30% of the total calories. The diabetic client needs about 40 to 50% of the diet from carbohydrates and about 20 to 25% of the diet from protein. High fiber foods will cause blood glucose levels to rise more slowly by delaying gastrointestinal absorption.

The acceptable criterion for urine output is greater than 30 mL per hour. The amount of urine output identified in option 1 is adequate (20 mL of urine in 30 minutes). Deep tendon reflexes of 2+ are normal. Magnesium sulfate depresses the respiratory rate. If the rate is less than 12 breaths per minute, the continuation of the medication needs to be reassessed. The fetal heart rate is within normal limits for a resting fetus.

The initial nursing action when a client progresses to an eclampsia state (has a seizure) is to maintain an open airway.

It is still important to keep physician appointments to assess for any other physical changes in the mother or fetus. Blood pressures need to be taken in the same arm, in a sitting position, every day in order to obtain a consistent and accurate reading. The weight needs to be checked at the same time each day, wearing the same clothes, after voiding, and before breakfast in order to obtain reliable weights. The urine needs to be checked every day for protein and the physician is notified if it is 2+ or more.

Wound evisceration is the total separation of the layers of the wound and extrusion of internal organs or viscera (usually abdominal) through the open wound. This alteration in wound healing may be preceded by excessive coughing, not splinting the surgical site, vomiting, or straining. The client may state, “Something gave way” or “I feel as if I just split open.” Wound dehiscence is a partial or complete separation of the outer layers of the wound. Redness, swelling, and drainage at the wound site would be indicative of an infection.

Dead fetus syndrome is considered a risk factor for DIC. Hemorrhage is a risk factor with DIC; however, a loss of 475 mL is not considered hemorrhage. Severe preeclampsia is considered a risk factor for DIC, a mild case is not. Delivering a large baby is not considered a risk factor for DIC.

Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities, therefore decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however a wedge placed under the right hip provides displacement of the uterus. The Trendelenburg position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler’s or prone position is not practical for this type of abdominal surgery.

An adverse effect of an anticoagulant is bleeding. Long term use can cause bleeding in the joints. Long term use of corticosteroids can precipitate necrosis of the head of the femur. Long term use of anticonvulsants may cause osteomalacia. Phenothiazine may produce gait disturbances.

During the stages of death and dying, clients experience the stages of denial and isolation, anger, bargaining, depression, and acceptance. The anger stage is characterized by statements such as “Why me?”

Although HBV is transmitted in breast milk, once hepatitis B immune globulin and hepatitis B vaccine has been administered to the newborn infant, the woman may breastfeed without risk to the newborn infant. This vaccine is repeated at 1 month and 6 months of age.

An infant born to an HIV positive mother has a risk for developing the disease.

Hemorrhoids are varicosities and are most likely to be precipitated during pregnancy by the pressure of the growing fetus inside the abdominal cavity. Standing aggravates the problem. Dietary factors such as fluids and roughage (bulk) and manual reduction are measures to treat the hemorrhoids. Hormonal changes are not a factor in the development of hemorrhoids and hemorrhoids will not disappear after the baby is born.

Pelvic tilt exercises decrease strain to muscles of the abdomen and lower back caused by the added weight of the abdomen and the shift in the center of gravity. An abdominal support should only be worn if recommended by the physician. Relaxing abdominal muscles will add to the problem. Wearing high-heeled shoes will add to the strain on the muscles and will exaggerate the shift in the center of gravity.

For the client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and for the fetus, such as an interruption of blood flow to the respiratory system and placenta. Deficient fluid volume would be the priority nursing diagnosis followed by imbalanced nutrition. Activity intolerance and ineffective coping may compete regarding the third and fourth priority depending on the specific client symptoms at the time of care.

It is accepted practice to administer Rho(D) immune globulin IGIM (RhoGAM) at 28 weeks of gestation to a woman as described in the question, with a second injection within 72 hours of delivery. This prevents sensitization, which could jeopardize a future pregnancy. For subsequent pregnancies or abortions, the injections must be repeated since immunity is passive.

Folic acid is needed during pregnancy for healthy cell growth of the fetus. A pregnant woman should have at least four servings of folic acid rich foods per day. Peanuts, sunflower seeds, and raisins are high in folic acid.

A reactive nonstress test (normal/negative) indicates a healthy fetus. It is described as two or more fetal heart rate (FHR) accelerations of at least 15 beats per minute, lasting at least 15 seconds from the beginning of the acceleration to the end in association with fetal movement, during a 20 minute period. A nonreactive nonstress test (abnormal) is described as no accelerations or accelerations of less than 15 beats per minute or lasting less than 15 seconds in duration for a 40 minute observation. An unsatisfactory test cannot be interpreted because of the poor quality of the FHR.

A contraction stress test assesses placental oxygenation and function, determines fetal ability to tolerate labor, determines fetal well-being and is performed if the nonstress test is abnormal. The fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother and a 20 to 30 minute baseline strip is recorded. The uterus is stimulated to contract either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation until 3 palpable contractions with a duration of 40 seconds or more in a 10 minute period have been achieved. Frequent maternal blood pressure readings are done and the client is monitored closely while increasing doses of oxytocin are given.

Tamoxifen citrate is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentration of receptors such as the breasts, uterus, and vagina. Frequent side effects include hot flashes, nausea, vomiting, vaginal bleeding or discharge, pruritus, and skin rash. Adverse or toxic effects include retinopathy, corneal opacity, and decreased visual acuity.

Diphenoxylate with atropine (Lomotil) is an antidiarrheal. The client should not exceed the recommended dose of this medication because it may be habit-forming. Since this medication is an antidiarrheal, it should not be taken with a laxative. Side effects of the medication include dry mouth and drowsiness.

Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used prior to transition to promote relaxation and relieve mild to moderate pain.

Erythema marginatum is characterized by red skin lesions that start as flat or slightly raised macules, usually over the trunk and spread peripherally.

When the membranes rupture in the birth setting, the nurse immediately checks the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord.

As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Abruptio placentae is characterized by abdominal pain and vaginal bleeding. Placenta previa is the sudden onset of painless uterine bleeding in the latter half of pregnancy. Uterine atony relates to a uterus that is not firmly contracted.

The fourth stage of labor is the stage of physical recovery for the mother and newborn infant. It lasts from the delivery of the placenta through the first 1 to 4 hours after birth. A potential complication following delivery is hemorrhage. The most significant source of bleeding is the site where the placenta is implanted. It is critical that the uterus remain contracted and that vaginal blood flow is monitored every 15 minutes for the first 1 to 2 hours

Vaginal bleeding in a pregnant client most often is caused by placenta previa or a placental abruption. Uterine tenderness accompanies placental abruption especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like upon palpation as the blood penetrates the myometrium and causes uterine irritability. A sustained tetanic contraction can occur if the client is in labor and the uterine muscle cannot relax. Abruptio placenta is characterized by the presence of uterine pain and tenderness.

Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to globular shape. The client may experience vaginal fullness, but not sudden and sharp abdominal pain.

Human immune globulin is obtained from the pooled blood of many people. This type of vaccine provides antibodies to a variety of diseases such as measles, rubella, and infectious hepatitis. Its disadvantage is that it only offers temporary passive immunity. Some immune globulin can be disease specific and is derived from individuals with a specific disease

LTB usually has a gradual onset and usually occurs at night. It is usually viral but may be bacterial in nature. The child usually has a harsh cough and inspiratory stridor and it causes swelling and inflammation of the vocal cords.

The therapeutic management for viral pneumonia is supportive. Antibiotics are not given unless the pneumonia is bacterial. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and intravenous fluids.

A patent ductus arteriosus is a left to right shunt. Blood is shunted to the right side of the heart because the left side is normally functioning at a higher pressure than the right side. This shunting allows oxygenated and unoxygenated blood to mix. It results in increased pulmonary blood flow because the abnormal communication or opening sends more blood to the right side of the heart than normal.

The MMR vaccine contains minute amounts of neomycin. The MMR immunization may be contraindicated for children who have had an anaphylactic reaction to eggs or neomycin. Immunosuppression in a sibling from the use of corticosteroids, a low grade fever, and TB skin testing are not contraindications for the MMR vaccine.

The incubation period for roseola infantum is estimated to be approximately 5 to 15 days. The infectious period is unknown but is thought to extend from the febrile stage to the time the rash first appears.

Tolterodine tartrate is an antispasmodic used to treat overactive bladder and symptoms of urinary frequency, urgency, or urge incontinence. It is contraindicated in urinary retention and uncontrolled narrow-angle glaucoma. It is used with caution in renal function impairment, bladder outflow obstruction, and gastrointestinal obstructive disease such as pyloric stenosis.

Metamucil is a bulk-forming laxative. It should be taken with a full glass of water or juice, and followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. The other options are incorrect.

Assessing color, sensation, and pulses distal to the restraint determines the presence of neurovascular compromise that is associated with the use of restraints.

Denial is a defense mechanism that allows the client to minimize a threat and may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina pectoris, or myocardial infarction. Anger is often manifested by "acting out" behaviors. Depression may be manifested by passive behaviors. Anxiety is usually manifested by symptoms of sympathetic nervous system arousal.

The RN must not depend exclusively upon the judgment of an LPN, because the RN is responsible for supervising those to whom client care has been delegated. The client has recently had surgery, and there is the potential for complications, which may be signaled by alterations in vital signs and respiratory status. An analgesic may or may not be needed, but in order to make that determination, the RN must have more information. A call to the surgeon may be warranted, but the RN has insufficient data at this time. In order to provide the client with the degree of care required, the nurse must assess the client, gather additional information, and analyze that information before notifying the surgeon.

Fatigue, dry skin, polyuria, and polydipsia are classic symptoms of hyperglycemia. Fatigue occurs because of lack of energy from the inability of the body to utilize glucose. Dry skin occurs secondary to dehydration related to polyuria. Polydipsia occurs secondary to fluid loss. Diaphoresis is associated with hypoglycemia. A client should not take extra hypoglycemic agents to reduce an elevated blood glucose level. A client with hyperglycemia becomes dehydrated secondary to the osmotic effect of the elevated glucose. Therefore, the client must increase fluid intake.

Cyclosporine is an immunosuppressant medication used to prevent transplant rejection. The client should be especially alert for signs and symptoms of infection while taking this medication, and report them to the physician if experienced. The client is also taught about other side effects of the medication, including hypertension, increased facial hair, tremors, gingival hyperplasia, and gastrointestinal complaints.

After ocular surgery, the client should wear an eye patch or eyeglasses for protection of the eye. Healing takes place in about 6 weeks. Once the postoperative inflammation subsides, the client’s vision should return to the preoperative level of acuity. Sutures are usually absorbable.

The client should report a noticeable or sudden decrease in vision to the physician. The client is taught to take acetaminophen, which is usually effective in relieving discomfort. The eye may be slightly reddened postoperatively, but this should gradually resolve. Small amounts of dried material may be present on the lashes after sleep. This is expected, and should be removed with a warm facecloth.

If the client has ascites, sodium and possibly fluids would be restricted in the diet. Fat restriction is not necessary and the client should maintain a normal amount of fat intake (not increased fat intake). The total daily calories should range between 2000 and 3000. The diet should supply sufficient carbohydrates to maintain weight and spare protein. The diet should provide ample protein to rebuild tissue, but not an amount that will precipitate hepatic encephalopathy

Clients with multiple myeloma need to be taught to monitor for signs of hypercalcemia and to report them immediately to the physician. Anorexia, nausea, vomiting, polyuria, weakness and fatigue, constipation, and signs of dehydration are signs of moderate hypercalcemia. A fluid intake of about 3000 mL daily is required to dilute the calcium overload and prevent protein from precipitating in the renal tubules. Activity is encouraged. Although a high-calorie diet is encouraged, a diet low in fiber will lead to constipation.

The client needs to be advised to avoid strenuous activity for 4 to 6 weeks and to avoid lifting items weighing greater than 20 pounds. The client needs to consume an intake of at least 6 to 8 glasses daily of non-alcoholic fluids to minimize clot formation. Straining during defecation for at least 6 weeks after surgery is avoided to prevent bleeding. Prune juice is a satisfactory bowel stimulant.

Following axillary node dissection, the affected arm may swell and is at risk for infection. The client needs to be instructed in the several measures required to prevent complications. The client should use insect repellent to avoid bites and stings and should wear sunscreen to prevent a sun burn. Picking at or cutting cuticles should not be done. Moisturizing cream should be applied a few times daily. Protective gloves should be worn while doing the dishes and cleaning.



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1 comments:

Anonymous said...

sobrang daming info heheh sakit na mata ko.. thanks for posting!!!!


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