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Saturday, August 9, 2008

Nclex Tips 1: Nursing Strategies

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In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell’s sign. Cervical softening will be noted during pelvic examination by the examiner. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is due to blood circulation through the placenta. hCG is noted in maternal urine in a urine pregnancy test. Goodell’s sign does not indicate the presence of fetal movement.

Quickening is fetal movement and is not perceived until the second trimester. Between 16 and 20 weeks of gestation, the expectant mother first notices subtle fetal movements that gradually increase in intensity. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and this in known as uterine souffle. This sound is due to the blood circulation to the placenta and corresponds to the maternal pulse. Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. A thinning of the lower uterine segment occurs about the sixth week of pregnancy and is called Hegar’s sign

Fetal heart sounds can be heard with a fetoscope by 18 to 20 weeks of gestation.

To check for the presence of ballottement, near midpregnancy, a sudden tap on the cervix during a vaginal exam may cause the fetus to rise in the amniotic fluid and then rebound to its original position. When the cervix is tapped, the fetus floats upward in the amniotic fluid. The examiner feels a rebound when the fetus falls down.

Fetal movement, called quickening, is not perceived until the second trimester. Between 16 and 20 weeks' gestation, the expectant mother first notices subtle fetal movements that gradually increase in intensity.

A rubella titer is performed to determine immunity to rubella. If the mother’s titer is less than 1:8, the mother is not immune. A retest during pregnancy is prescribed, and the mother is immunized postpartum if not immune.

A maternal glucose assay is prescribed to screen for gestational diabetes. If it is elevated, a 3-hour glucose tolerance test is recommended to determine the presence of gestational diabetes.

A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the infant should receive a hepatitis immune globulin and a vaccine soon after birth.

During a menstrual period, a woman loses about 40 mL of blood. Because of the recurrent loss of blood, many women are mildly anemic during their reproductive years, especially if their diets are low in iron.

Montgomery’s tubercles are sebaceous glands in the areola. They are inactive and not obvious except during pregnancy and lactation, when they enlarge and secrete a substance that keeps the nipples soft. Within each breast are lobes of glandular tissue that secrete milk. Alveoli are small sacs that contain acinar cells to secrete milk. The alveoli drain into lactiferous ducts that connect to drain milk from all areas of the breast.

Before conception, the uterus is a small pear-shaped organ entirely contained in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 grams (2 oz) and has a capacity of about 10 mL (one third of an ounce). At the end of pregnancy, the uterus weighs approximately 1000 grams (2.2 pounds) and has a sufficient capacity for the fetus, placenta, and amniotic fluid, a total of about 5000 mL.

At 12 weeks' gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At 16 weeks, the fundus reaches midway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located at the umbilicus. By 36 weeks, the fundus reaches its highest level at the xiphoid process.

The muscular action of the fallopian tube and movement of the cilia within the tube transport the mature ovum through the fallopian tube. Fertilization normally occurs in the distal third of the fallopian tube near the ovaries. The ovum, fertilized or not, enters the uterus about 3 days after its release from the ovary.

The uterus has three divisions, the corpus, isthmus, and the cervix. The upper division is the corpus or the body of the uterus. The uppermost part of the uterine corpus, above the area where the fallopian tubes enter the uterus, is the fundus of the uterus.

By week 13, the fetal sex can be determined by the appearance of the external genitalia on ultrasound.

Mineral oil should not be used as a stool softener because it inhibits the absorption of fat-soluble vitamins in the body. Constipation should be treated with increased fluids (six to eight glasses per day) and a diet high in fiber. Increasing exercise is also an excellent way to improve gastric motility.

The genitalia of a newborn female are frequently red and swollen. This edema disappears in a few days. A vaginal discharge of thick white mucus is seen in the first week of life. The mucus is occasionally blood tinged by about the third or fourth day, and stains the diaper. The cause of the pseudomenstruation, like that of breast engorgement, is the withdrawal of maternal hormones.

A myelomeningocele is a neural tube defect caused by failure of the posterior neural tube to close. The meninges are exposed through the surface of the skin in a herniated sac that may be either healed or leaking. Skin integrity is impaired because a thin membrane covers the protruding sac.

Prolactin stimulates the secretion of milk, called lactogenesis. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation.

The normal duration of the menstrual cycle is about 28 days, although it may range from 20 to 45 days. Significant deviations for the 28-day cycle are associated with reduced fertility. The first day of the menstrual period is counted as day 1 of the adolescent’s cycle.

The ovaries are the endocrine glands that produce estrogen and progesterone. FSH and LH are produced by the anterior pituitary gland. Oxytocin is produced by the posterior pituitary gland and stimulates the uterus to produce contractions during labor and birth.

Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is due to 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 a few hours to 2 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 be due to 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.

Progesterone maintains uterine lining for implantation and relaxes all smooth muscle, including the uterus. Relaxin is the hormone that softens the muscles and joints of the pelvis. Thyroxine increases during pregnancy to stimulate basal metabolic rates, and prolactin is the primary hormone of milk production.

Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat. Human chorionic gonadotropin (hCG) prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

During pregnancy, the breasts change in both size and appearance. The increase in size is due to the effects of estrogen and progesterone. Estrogen stimulates the growth of mammary ductal tissue, and progesterone promotes the growth of lobes, lobules, and alveoli. A delicate network of veins is often visible just beneath the surface of the skin.

The cervix undergoes significant changes after conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish color that extends to include the vagina and labia. This discoloration, referred to as Chadwick’s sign, is one of the earliest signs of pregnancy.

Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, inhibiting the release of the follicle stimulating hormone (FSH) and the luteinizing hormone (LH), which are necessary for ovulation.

The ovarian cycle consists of three phases, the follicular, ovulatory, and luteal phases. The proliferative phase is a phase of the endometrial cycle.

A nutritional supplement commonly needed during pregnancy is iron. Anemia of pregnancy is primarily caused by iron deficiency. Iron supplements usually cause constipation. Meats are an excellent source of iron. Iron for the fetus comes from the maternal serum.

Signs of congenital neonatal syphilis may be nonspecific at first, including poor feedings, slight hyperthermia, and “snuffles.” Snuffles refers to copious, clear serosanguineous mucus discharge from the nose. By the end of the first week, a copper-colored maculopapular dermal rash is characteristically observed on the palms of the hands, soles of the feet, diaper area, and around the mouth and anus.

Effective pain management during labor does not interrupt the labor process but does provide relaxation and moderate pain relief to the mother. The increased bloody show and intensity of the contractions are not measures of effective pain management.

Accelerations are an indication of fetal well-being and an oxygenated fetal central nervous system. Bradycardia, late decelerations, and decreased variability are representative of decreased oxygenation of the fetus.

Signs of impaired fetal oxygenation include late decelerations, decreased baseline variability, and tachycardia or bradycardia. A normal fetal heart range is 120 to 160 beats per minute. Accelerations occur in a fetus with a mature central nervous system and who is well oxygenated.

Breastfeeding is contraindicated if the mother is positive for HIV because the virus may be spread to the infant in the breast milk. HIV is not spread through casual contact, so holding, hugging, and sleeping with other family members is not prohibited. A newborn may test positive for HIV for up to 2 years after birth because of placental transfer of maternal antibodies. It is vital that the nurse ascertain that the client has correct knowledge regarding the transmission of the disease and precautions necessary to prevent the spread of HIV.

AIDS decreases the body’s immune response, making the infected person susceptible to infections. AIDS affects helper T lymphocytes, which are vital to the body’s defense system. Opportunistic infections are a primary cause of death in persons affected with AIDS. Therefore preventing infection is a priority of nursing care.

In this client, diuresis is a positive sign that indicates that edema and vasoconstriction in the brain and kidneys have decreased. Diuresis also reflects an increased tissue perfusion to the kidneys. Clients who have severe preeclampsia are not considered to be out of danger until birth and diuresis occurs. Diuresis is not an indication of impending seizure. Although renal failure is a complication of severe preeclampsia, it is not of the high-output type of failure. Potassium is lost through the urine; therefore hyperkalemia is not associated with diuresis.

In a pregnant woman, the supine position adds gravity pressure onto the inferior vena cava, which is already displaced and partially compressed by the term gravid uterus. The increased compression decreases the cardiac output, leading to beginning tissue hypoxia, which brings on the signs and symptoms as described in the question. The signs and symptoms identified in the question are not indicative of progression to active first-stage labor.

Short-term variability averages 6 to 10 beats per minute, and long-term variability averages 2 to 6 cycles per minute. The FHR should accelerate with fetal activity. The baseline range for the FHR is 120 to 160 beats per minute. Late decelerations are a result of decreased uteroplacental perfusion that causes a decrease in fetal oxygenation. Late decelerations are not a reassuring pattern.

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