Pitocin: Indication? Adverse Effects/Monitoring?
Given to strengthen contractions and labor.
Can cause uterine hyperstimulation. Contractions should be NO LONGER than 90 seconds and no closer than 2 minutes apart.
If they are any more than that; slow pitocin
How to Mix insulins (step 1-5)
- Draw up the total amount of (AIR)
- Air into N
- Air into R
- Draw up R
- Draw up N
IM injection – Needle size + length? Sub-Q Size + length?
IM: 21g 1 inch needle
Memory clue: I looks like 1
Sub-Q: 25g 0.5 inch
Memory clue: S looks like 5
Cephalohematoma vs Caput Succedaneum
Cephalohematoma: bleeding in brain of newborn. Does not cross suture line and is asymmetrical
Caput Succedaneum: Crosses suture line and is symmetrical.
Memory clue: think CS = crosses suture, CS = Caput symmetrical
Terbutaline: Indications? Nursing considerations? Contraindication?
Used to slow down birth and contractions
Contraindicated: in mothers with heart disease due to its common side effect of tachycardia
Fundal Height – Postpartum: Height right after birth? Everyday after that?
Fundal height right after birth is at the umbilicus
- Every day after birth it will go down by 1, height correlates with the day postpartum
Put the following tracheostomy care steps in order:
- Remove old dressing
- clean around stoma w/ sterile water or saline then replace gauze
- Don sterile gloves, remove old disposable inner cannula and replace with new one
- Collect supplies and position patient
- Don PPE
- Collect supplies and position patient
- Don PPE
- Remove old dressing
- DON sterile gloves and remove old disposable inner cannula then replace with new one
- Clean around stoma with sterile water or saline then replace gauz
Second stage of labor (delivery): Place steps in order for delivering BB.
- Make sure baby has an ID before leaving delivery area
- Suction babies mouth then nose
- Deliver shoulder then body
- Check for nuchal cord
- Deliver babies head then tell mom to stop pushing
- Deliver babies head and tell mom to stop pushing
- Suctions babies mouth then nose
- Check for nuchal (cord around neck) around neck
- Deliver shoulders then body
- Make sure BB has ID before leaving delivery area
After the delivery of the placental: What are the nursing interventions and assessments?
Ensure placenta is intact and check for vessels in the cord should be AVA
Fourth stage of labor: what is it? what are we assessing? What are nursing Interventions?
Fourth stage is recovery.
NOTE: assess 4 things during the 4th stage of labor four times an hour (every 15 minutes)
- Assess V/S q15 to monitor for shock plus S/S cool, pale, clammy skin, tachycardia, hypotension
- Monitor fundus: If boggy massage it, if displaced catheterize
- Monitor Lochia: Pt is bleeding too much if she is saturating a pad every 15 minutes. report ASAP.
- Monitor for Thrombophlebitis: measure bilat calf circumference!!
Medical Battery – What is it?
The intentional touching of a patient without consent
ex: doing a procedure that the patient denied, lying about the medication you’re giving
Hirschsprung’s Dz S/S? Critical findings that must be reported ASAP?
S/S: failure to pass meconium, abdominal distention, bilious vomit
Critical finding that should be reported: fever and diarrhea
Normal weight gain for pregnancy?
28 + or – 3lb
How to calculate what weight gain should be in pregnancy? What to do if Shes overweight or underweigt
can range -/+ 1-2 lbs = normal
If +/- 3 = assess the patient
If +/- 4 = trouble perform biophysical profile on the baby
When is the fundus palpable?
- Not until 12 weeks
NOT palpable in first trimester!
When is the fundus at umbilicus?
20-22 weeks gestation
When can you first detect FHR and quickening?
FHR: 8wks
Quickening: 16 weeks
When would you most likely detect FHR and quickening?
FHR: 10 weeks
Quickening: 18 weeks
When should you be able to detect FHR and quickening?
FHR: 12 wks
Quickening: 20wks