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Wednesday, August 13, 2008

Nclex Tips 5: Nursing Strategies

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Kegel exercises are extremely important to strengthen the muscle tone of the perineal area. Postpartum exercises can begin soon after birth. The initial exercises should be simple, with progression to increasingly strenuous exercises. Postpartum exercises will not result in stress urinary incontinence.

The most accurate method for determining the amount of lochial flow is to weigh the perineal pads before and after use. Once these two weights are noted, the amount of lochial flow can be accurately determined. Each gram increase in the weight is roughly equivalent to 1 mL of blood loss. To obtain an accurate estimate of lochial flow, the time factor must be incorporated into the analysis.

One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. It uses five criteria to measure the infant’s adaptation. Heart rate: absent, 0; less than 100, 1; greater than 100, 2. Respiratory effort: absent, 0; slow or irregular weak cry, 1; good, crying lustily, 2. Muscle tone: limp or hypotonic, 0; some extremity flexion, 1; active, moving, and well flexed, 2. Irritability or reflexes (measured by bulb suctioning): no response, 0; grimace, 1; cough, sneeze, or vigorous cry, 2. Color: cyanotic or pale, 0; acrocyanotic, cyanosis of extremities, 1; pink, 2.

The normal respiratory rate for a newborn infant is 30 to 60 breaths/minute.

The anterior fontanel is diamond shaped and located on the top of the head. It should be flat and soft and may range in size from almost nonexistent to 4 to 5 cm across. It normally closes by age 18 to 24 months.

A caput succedaneum indicates swelling of the soft tissues of the head and scalp that may extend across suture lines. It is most pronounced after a long labor, is evident within 24 hours after birth, and resolves within a few days.

cephalhematoma is an edema resulting from bleeding below the periosteum of the cranium.

Gastroschisis is an abdominal wall defect. Embryonal weakness in the abdominal wall causes herniation of the gut on one side of the umbilical cord during early development. The viscera are located outside the abdominal cavity and are not covered with a sac.

Omphalocele is a defect in which the vicera is outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane

Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum.

Esophageal atresia and tracheoesophageal fistula (TEF) are congenital malformations in which the esophagus terminates before it reaches the stomach and/or a fistula is present that forms an unnatural connection with the trachea.

Congenital diaphragmatic hernia is an herniation of abdominal contents through an opening of the diaphram.

Clinical manifestations associated with CDH include diminished or absent breath sounds on the affected side; bowel sounds heard over the chest; cardiac sounds heard on the right side of the chest; respiratory distress developing soon after birth including dyspnea, cyanosis, nasal flaring, tachypnea, retractions; and a scaphoid abdomen.

clinical manifestation of esophageal atresia and tracheoesophageal fistula is excessive oral secretions.

clinical manifestation of gastroesophageal reflux is hiccupping and splitting up after a meal.

characteristic of a hiatal hernia includes coughing, wheezing and short periods of apnea.

Morning sickness is common during the first trimester of pregnancy and is associated with increased levels of human chorionic gonadotropin (hCG) and changes in carbohydrate metabolism. It most often occurs on arising, although a few women experience it throughout the day. Self-care measures include eating a dry cracker or toast before getting out of bed, eating small frequent meals, avoiding fatty or spicy foods, and rising slowly from a lying or sitting position to avoid orthostatic hypotension.

Urinary frequency is present in the first trimester and late in the third trimester because of the pressure placed on the bladder by the enlarged uterus. Self-care measures for urinary frequency include emptying the bladder frequently (every 2 hours) and continuing to drink at least 2000 mL of fluid a day.

Ankle edema is a common occurrence and is caused by decreased venous return from the feet because of gravity. It is a minor discomfort as long as hypertension and proteinuria are not present. Self-care measures for ankle edema include elevating the feet at hip level during the day, taking frequent rest periods, wearing supportive stockings or hose, and avoiding standing in one position or place for long periods.

Heartburn is associated with regurgitation of gastric acid contents into the esophagus. Self-care for heartburn includes eating small frequent meals, avoiding fatty or spicy foods, remaining upright for 30 minutes after eating, and drinking approximately 2000 mL of fluid per day.

To assess and evaluate the presence of pitting edema, the nurse uncovers the woman’s lower leg, presses the fingertips of the index and middle finger against the shin, and holds the pressure for 2 to 3 seconds.

When evaluating the presence of pitting edema, the nurse presses the fingertips of the index and middle fingers against the shin and holds pressure for 2 to 3 seconds. An indentation of approximately 1 inch deep would be indicative of 4+ edema. A slight indentation would indicate 1+ edema. An indentation of approximately ¼ inch deep indicates 2+ edema. An indentation of approximately 1/2 inch deep indicates 3+ edema.

When evaluating the deep tendon reflex, the normal response should be an extension and thrusting of the foot upward. A 1+ response indicates a diminished response; 2+ indicates normal; 3+ indicates increased, brisker than average; and 4+ indicates a very brisk hyperactive response.

To detect the presence of clonus, the nurse places one hand under the women’s knee and bends the knee slightly. The nurse then places the other hand on the ball of the foot, encourages the women to relax her leg and foot, and sharply dorsiflexes the foot. Clonus is present if the foot jerks or taps against the nurse’s hand.

Discomfort and pain associated with true labor contractions typically begins in the lower abdomen and back and then radiates over the entire abdomen.

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.

The FHR can first be heard with a fetoscope at 18 to 20 weeks of gestation. If a Doppler ultrasound device is used, the FHR can be detected as early as 10 weeks of gestation.

The FHR should be approximately 110 to 160 beats/minute throughout pregnancy. Because the FHR is elevated from the normal range, the nurse would contact with the physician.

An infant born to an HIV-positive mother is at risk for developing the disease. Characteristically, the newborn is asymptomatic at birth, but signs and symptoms usually become obvious during the first year of life.

Low or oddly placed ears are associated with a variety of congenital defects and should be reported immediately. Although the findings would be documented, the most appropriate action would be to notify the physician.

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.

Rho(D) immune globulin IGIM (RhoGAM) is administered at 28 weeks of gestation to a woman as described, 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, because immunity is passive.

Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant woman should have at least four servings of folic acid–rich foods per day.

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/minute, lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, and during a 20-minute period. A nonreactive nonstress test (abnormal) is described as no accelerations or accelerations of less than 15 beats/minute or lasting less than 15 seconds 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 three 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.

Slowing or stopping of fetal movement may be an indication that the fetus needs some attention and evaluation. Women are advised to count fetal movements for 30 to 60 minutes, 3 times a day (usually after meals when the fetus is more active). The client lies down on the left side during the procedure because it provides optimal circulation to the uterus-placenta-fetus unit. Most women count four movements in 1 hour. The midwife or health care provider is notified if 10 movements are not felt in a 12-hour period.

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 in 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 maternity client. Hands should be washed throughout the day when items that could be contaminated are handled.

An intervention to prevent sickle cell crisis during labor includes administering oxygen. 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.

To further to assess and plan for the newborn’s care, the newborn’s blood type and direct Coombs' must be known. Umbilical cord blood is taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs' test) of the newborn. If the newborn’s blood type is Rh negative, or if the newborn’s blood type is Rh positive with a negative direct Coombs' test, then no concern is needed for Rh incompatibility. If the newborn’s blood type is Rh positive and the direct Coombs' is positive, then Rh incompatibility exists.

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

An empty bladder contributes to a woman’s comfort during the examination. Drinking water to fill the bladder and warming sonogram gel may be performed before a sonogram but are not applicable to performing Leopold maneuvers. Often the Leopold maneuvers are performed to aid the examiner in locating the fetal heart tones.

The goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions with no evidence of fetal distress. Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia from excessive uterine activity. The nurse should also assure that the uterus maintains an adequate resting tone between contractions.

Accelerations are transient increases in the fetal heart rate (FHR). Accelerations are normally caused by fetal movement or often accompany contractions. Accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve.

Variable decelerations, present on a fetal heart monitor, suggest cord compression. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because they suggest uteroplacental insufficiency during a contraction. Short-term variability refers to the difference between successive heartbeats, identifying that the natural pacemaker activity of the fetal heart is working properly.

Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen transfer to the fetus during uterine contractions. This causes hypoxemia; therefore oxygen is necessary,

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

Relaxation techniques include specific relaxation exercises and conditioned responses, such as distraction from the discomfort of labor. The woman is an active participant in the use of these techniques, which focus in relaxing uninvolved muscles while the uterus contracts.

When the membranes rupture in the birth setting, the nurse immediately assesses the FHR to detect changes associated with prolapse or compression of the umbilical cord.

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