A decrease in Luteinizing hormone (LH) results in the loss of secondary sex characteristics. A decrease in Adrenocorticotropic hormone (ACTH) is seen in Addison’s disease. Prolactin (PRL) stimulates breast milk production by the mammary glands, and Growth hormone (GH) affects bone and soft tissue by promoting growth through protein anabolism and lipolysis.
Amenorrhea or a decreased menstrual flow is common in the client with Graves’ disease. Dysmenorrhea, metrorrhagia, and menorrhagia are also disorders related to the female reproductive system; however, they do not manifest in the presence of Graves’ disease.
The adult with normal cerebrospinal fluid has no red blood cells in the CSF. The client may have small levels of white blood cells (0 to 5 cells). Protein (15 to 45 mg/dL) and glucose (45 to 80 mg/dL) are normally present in CSF.
The client who has had a Billroth II procedure is at risk for dumping syndrome. The client should avoid drinking liquids with meals to prevent this syndrome. The client should be placed on a dry diet that is high in protein, moderate in fat, and low in carbohydrates. Frequent small meals are encouraged, and the client should avoid concentrated sweets.
Intravenous diazepam is given by IV push directly into a large vein (reduces the risk of thrombophlebitis), at a rate no greater that 1 mg per minute. It should not be mixed with other medications or solutions and can be diluted only with normal saline.
The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The posterior fontanel closes by 2 to 3 months of age. A bulging or tense fontanel may result from crying or increased ICP. Noting a bulging fontanel when the infant cries is a normal finding that should be documented and monitored. It is not necessary to notify the physician.
The normal respiratory rate for a 3-year-old is approximately 20 to 30 breaths per minute.
Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is caused by growth of the dominant follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts 1 to 3 days, and slight vaginal bleeding may accompany the discomfort.
Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in both structure and function. The response of this tissue to the stimulation of estrogen and progesterone during the menstrual cycle is identical to that of the endometrium. Primary dysmenorrhea refers to menstrual pain without identified pathology. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods, and amenorrhea is the cessation of menstruation for a period of at least three cycles or 6 months in a woman who has established a pattern of menstruation and can result from a variety of causes.
In early pregnancy, hCG is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for positive pregnancy tests.
A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the neonate needs to receive the hepatitis vaccine and hepatitis B immune globulin within 12 hours after birth.
If a woman complains of calf pain during walking, it could be an indication of venous thrombosis of the lower extremities. The appropriate nursing action would be to assess for Homans’ sign, which would assist in determining the presence of venous thrombosis. It is not appropriate to tell the mother that this is normal during pregnancy. Ambulation is an important exercise, and the woman should be encouraged to ambulate during pregnancy. Although it is important to elevate the legs during pregnancy, elevating the legs consistently is not an appropriate nursing action.
Before accessing an implanted vascular port, the nurse must palpate the port to locate the center of the septum. The port should then be anchored with the nondominant hand. Cool compresses over the site can help alleviate pain upon entry. The site should be cleansed with alcohol, working from the inside out to prevent introducing germs into the access site.
When measuring fundal height, the client lies in a supine position and the nurse should instruct the client to turn onto her left side, or the nurse can elevate the left buttock by placing a pillow under the area.
Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome (vena cava syndrome) late in pregnancy. Having the client turn onto her left side or elevating the left buttock during fundal height measurement will correct or prevent the problem.
Maternal anemia often occurs in twin pregnancies because of a greater demand for iron by the fetuses.
Pregnancy taxes the circulating system of every woman because both the blood volume and cardiac output increase.
Following a liver biopsy, the client is assisted to assume a right side-lying position with a small pillow or folded towel under the puncture site for 2 hours. This position compresses the liver against the chest wall at the biopsy site.
The Cantor tube is a single-lumen, mercury-weighted tube. The weight of the mercury tube carries the tube by gravity. Following insertion, to facilitate movement of the tube, the client is positioned on the right side.
Following supratentorial surgery (surgery above the brain’s tentorium), the client’s head is usually elevated 30 degrees to promote venous outflow through the jugular veins.
The term puerperal infection refers to a bacterial infection following childbirth.
The cord needs to be cleansed with alcohol thoroughly, and the cord and base should be cleaned two to three times per day with alcohol (or per agency protocol). The steps are (1) lift the cord, (2) wipe around the cord starting at the top, (3) clean the base of the cord, and (4) fold the diaper below the umbilical cord to allow the cord to air dry and to prevent contamination from urine. Continuation of cord care is necessary until the cord falls off within 7 to 14 days. The infant does not feel pain in this area.
The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is the bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is not uncommon in the first few hours of life.
Potassium chloride is very irritating to the vein and needs to be diluted to prevent phlebitis. Potassium chloride is never administered as a bolus injection
Ophthalmic erythromycin 0.5% ointment is a broad-spectrum antibiotic and is used prophylactically to prevent ophthalmia neonatorum, an eye infection acquired from the newborn infant’s passage through the birth canal. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against Neisseria gonorrhoeae and Chlamydia trachomatis. Vitamin K is administered to the newborn infant to prevent abnormal bleeding, and it promotes liver formation of the clotting factors II, VII, IX, and X.
Meticulous skin care helps protect the HIV-infected newborn infant from secondary infections.
Stage II of Lyme disease develops within 1 to 6 months in most untreated individuals. The most serious problems in this stage include cardiac conduction defects and neurological disorders such as Bell’s palsy and paralysis. These problems are not usually permanent. Flulike symptoms (headache and lethargy) and a rash appear in stage I.
A hallmark sign of pemphigus is Nikolsky’s sign, which is when the epidermis can be rubbed off by slight friction or injury. Other characteristics include flaccid bullae that rupture easily and emit a foul-smelling drainage leaving crusted, denuded skin. The lesions are common on the face, back, chest, and umbilicus. Even slight pressure on an intact blister may cause spread to adjacent skin. Trousseau’s sign is a sign for tetany, in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Chvostek’s sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Homans’ sign, a sign of thrombosis in the leg, is discomfort in the calf on forced dorsiflexion of the foot.
Following tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided because they may irritate the throat. Red liquids need to be avoided because they give the appearance of blood if the child vomits. Milk and milk products (pudding) are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding.
The pharyngeal (gag) reflex is tested by touching the back of the throat with an object, such as a tongue depressor. A positive response to this reflex is considered normal. The corneal light reflex is tested by shining a penlight toward the bridge of the nose at a distance of 12 to 15 inches (light reflection should be symmetrical in both corneas). Asking the client to swallow assesses the swallow reflex. To assess the palpebral conjunctiva, the nurse would pull down and evert the lower eyelid.
The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. A red swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it does not occur frequently. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication.
The nursing care of a child with RMSF will include the administration of tetracycline. An alternative medication is chloramphenicol, a fluoroquinolone. Amphotericin B (Ketoconazole) is used for fungal infections. Ganciclovir (Foscarnet) is used to treat cytomegalovirus. Amantadine (Rimantadine) is used to treat influenza A virus.
The hallmark symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total surgical removal of the tumor without residual neurological damage. Before surgery, the child’s head will be shaved, although every effort is made to shave only as much hair as is necessary. Although chemotherapy may be needed, it is not the treatment of choice.
An MRI is a noninvasive diagnostic test that visualizes the body’s tissues, structure, and blood flow. The client is positioned on a padded table and moved into a cylinder-shaped scanner. Relaxation techniques or a sedative are used before the procedure to reduce claustrophobic effects. There is no useful purpose for administering an antihistamine, corticosteroid, or antibiotic.
Tretinoin (Retin-A) is prescribed for a client with acne. Decreases cohesiveness of the epithelial cells, increasing cell mitosis and turnover. It is potentially irritating, particularly when used correctly. Within 48 hours of use, the skin generally becomes red and begins to peel.
Dimercaprol (BAL) is a chelating agent that is used to treat lead poisoning. Sodium bicarbonate may be used in salicylate poisoning. Ipecac syrup may be prescribed by the physician to induce vomiting in certain poisoning situations. Activated charcoal is used to decrease absorption in certain poisoning situations.
A small amount of serous drainage may be expected after cleaning and removing crusting around the pin sites. Redness and swelling around the pin sites and purulent drainage may be indicative of an infection. Pins should not be loose, and if this is noted, the physician should be notified.
A complete neurological assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity.
A Sengstaken-Blakemore tube is inserted in clients with cirrhosis who have ruptured esophageal varices. It has esophageal and gastric balloons. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to the esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices.
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