The endotracheal tube is moved from one corner of the mouth to the other at least every day to minimize the risk of necrosis of the mouth and pharynx due to pressure from the tube. Doing this every 6 hours is excessive. The nurse suctions the oropharynx above the endotracheal tube frequently to prevent accumulation of secretions above the endotracheal tube cuff. Products with lemon or alcohol are not used because they dry the oral mucosa. For the same reason, the lips are lubricated as needed.
Unresolved sexual trauma occurs when the following conditions are present: development of a persistent phobia such as that of being alone or going out; retreat from sexual themes and possessing low self-esteem and guilt feelings; reoccurrence of the symptoms of rape trauma triggered by seemingly minor events; reoccurrence of the symptoms of rape trauma triggered by the anniversary date of the rape trauma; avoidance of contact with members of the opposite sex; and negatively altered relationships with family and friends, such as withdrawal, unusual anger, or silence.
A power rapist wants to place a woman in a helpless controlled situation where she cannot resist or refuse him. In this situation, the power rapist is provided with a reassuring sense of strength, mastery, security, and control. He uses these feelings to compensate for his feelings of inadequacy. Although the power rapist usually does not consciously intend to hurt his victim, he does aim to have complete control over her. As the power rapist’s behavior becomes repetitive and compulsive, his need to achieve feelings of power, control, and adequacy may lead him to increase the aggression over time.
The establishment of a therapeutic relationship with the suicidal client increases feelings of acceptance. Although the suicidal behavior and thinking of the client is unacceptable, the use of unconditional positive regard acknowledges the client in a human-to-human context and increases the client's sense of self-worth. Isolating the client in a private room would intensify the client's feelings of worthlessness. Placing the client in charge of the morning chess game is a premature intervention that can overwhelm and cause the client to fail. This can reinforce the client's feelings of worthlessness. Distances of 18 inches or less between two individuals constitutes intimate space. Invasion of this space may be misinterpreted by the client and increase the client's tension and feelings of helplessness.
Caring for a child in traction includes ensuring that the child’s body is in proper alignment. Crutchfield tongs are a type of cervical skeletal traction that requires pin-site assessment and pin care to prevent infection.
An adolescent with juvenile rheumatoid arthritis may be dealing with issues related to disturbed body image. To plan care appropriately, the nurse would initially assess the adolescent’s perception of the chronic illness.
In assessment of the perineum, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (the first 1 to 4 hours after birth) is a dark red color.
Lochial flow should be distinguished from bleeding originating from a laceration or episiotomy, which is usually brighter red than lochia, and appears as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and must 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/day.
Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down; wearing a supportive well-fitting bra at all times; taking a warm shower just before feeding or applying warm compresses; and alternating the breasts during feeding.
Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the fundus is above the umbilicus, this may indicate that blood clots in the uterus should be expelled by fundal massage. A fundus that is not located in the midline may indicate a full bladder.
During the first 24 hours after delivery, the mother’s temperature may increase to 100° F (38° C) as a result of the dehydrating effects of labor. Therefore the initial nursing action is to encourage fluid intake. The nurse would document the temperature, but this is not the initial action.
The fetus is at risk in this situation. The greatest danger of a prolapsed cord is fetal cord compression, which will be indicated by changes in the fetal monitor pattern. Fetal heart rate and variability are the primary measures to determine fetal well-being and are thus the most vital indicators of the effectiveness of interventions. If interventions are ineffective, the fetal heart monitor will show a pattern of increasing early decelerations and a decreasing baseline as the situation deteriorates
Signs of hypothermia include a decrease in skin temperature; increased activity; pallor or mottling; cool skin, hands, and feet; and a flexed position. The newborn attempts to maintain temperature by vasoconstriction, increased muscle activity, metabolizing brown fat, and increased metabolism. A flexed position decreases body surface through which heat can be lost.
Jaundice is a complication of the term SGA infant and occurs as a result of an increased hematocrit. Jaundice in the 4-day-old infant should be reported to the physician, because determination of the bilirubin level and treatment for the jaundice may be appropriate. Four-day-old SGA infants should be fed at least every 3 hours because they require more calories per kilogram because of increased metabolic activity and oxygen consumption. The newborn should be fed small feedings of high-calorie formula because of decreased stomach capacity. Feedings should be done even through the night. Newborns usually wet at least six to eight diapers per day. Urine output less than normal indicates dehydration.
The preferred injection site for vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle in the newborn’s thigh. This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication.
The mother needs to be taught to feed the newborn soon after delivery, and often, as a prophylactic measure to decrease the possibility of hypoglycemia. Newborns of diabetic mothers may become hypoglycemic within 15 minutes of delivery, as exhibited by lethargy and poor feeding in the first hour after delivery. Hypoglycemia is a result of hyperinsulinism and loss of maternal glucose. Cold stress increases the metabolism of glucose. Jitteriness is one of the classic symptoms of hypoglycemia. A risk of a newborn of a diabetic mother is immature lungs.
Use of condoms is a primary method to prevent sexually transmitted diseases (STDs).
An increase in calories is needed with pregnancy, but concentrated sugars should be avoided because they may cause hyperglycemia. The fat intake should remain at 30% of the total calories. The fetus of a diabetic mother is prone to macrosomia. 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 increase more slowly by delaying gastrointestinal absorption.
When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord.
Signs of a fetal or maternal compromise include a persistent nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but does not indicate a fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.
Management of hypertonic uterine dysfunction depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. The client with hypertonic uterine dysfunction would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.
Dystocia (antonym eutocia) is an abnormal or difficult childbirth or labour.
It is recommended that the woman refrain from sexual intercourse until the episiotomy has healed and the lochia has stopped.
Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman also is unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and experience sleep disturbances.
The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs, followed by flexion and adduction of the limbs. This reflex disappears at age 6 months. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand by firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure.
More than one medication may be used to prevent growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for a pregnant woman is daily isoniazid plus rifampin for a total of 9 months. Ethambutol also is added initially if drug resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing should be repeated at 3 months on the infant, and isoniazid may be stopped if the skin test result remains negative. If the skin test result converts to positive, a full course of isoniazid would be given.
The use of alcohol and cigarettes during the pregnancy of an HIV-infected client, as well as not getting appropriate rest, can compromise the maternal immune system. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy.
The effects of maternal iron-deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores.
Station is the relation of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line.
The normal temperature during pregnancy is 98µ to 99.6° F (36.2µ to 37.6° C). A temperature above this level may suggest infection that might require medical management.
Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. Blood pressure should be obtained with the client in the sitting position with the arm supported in a horizontal position at heart level.
From 22 weeks until term, the fundal height measured in centimeters is roughly plus or minus 2 cm of the gestational age of the fetus in weeks. If the fundal height exceeds weeks of gestation, additional assessment is necessary to investigate the cause for the unexpected uterine size. If an unexpected increase in uterine size is present, it may be that the estimated date of delivery is incorrect and the pregnancy is further advanced than previously thought. If the estimated date of delivery is correct, more than one fetus may be present.
Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy,
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