predictor test 1
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Oxytocin is used to stimulate an active labor pattern; nursing care includes
administering with infusion pump, closely monitoring mother and fetus; if
contractions occur less than 2 min apart, last longer than 60 to 90s, or if there is
significant change in fetal heart rate, stop infusion and turn client to left side.
Osteomyelitis-infection of the bone caused by staph aureus, carried by blood fromprimary site of infection ( upper respiratory, otitis media and tonsillitis
acyclovir- to treat genital herpes, herpes zoster and varicella)
Cholecytectomy-surgical removal of the gallbladder,; monitor T-tube if present
inserted to ensure drainage from bile from common bile duct until edema in area
diminishes; check amount of drainage-usually 500-1,000 mL/day, protect area from
the incision, position pt in semi fowlers
Pancreatic cx-6 months to live after diagnosis
Infectious mononucleosis- acute, self limiting infections dz caused by the herpes likeEpstein barre virus: sxs- malaise, fever, enlarged lymph nodes, sore throat, flulike
aches; tansmission is thru direct contact with secretion- avoid contact with saliva
( cups & silverware) avoid aspirn, avoid strenuous exercise due to rupture of spleen
Hypercalcemia: muscle weakness, lack of coordination, constipation, abdominal
pain and distentsion, confusion, depressed or absent tendon reflexes,,
dysrhythmias.
Sleep apnea: avoid alcohol and medications that depress the upper airway, wight
reduction diet and activity, use of cpap and bipap
Sputum specimen: obtained to determine pathogenic organisms and to identify
malignant cells; early morning specimen best; encourage client to clear nose and
throat and rinse mouth, instruct patient to deep breathe , cough, and expectorate
specimen into sterile container, deliver specimen to the lab within 2 hrs
Lactulose- laxative administered for tx of hepatic encephalopathy, decreased blood
ammonia by excreting it in stool; side effects: belching, cramping, distention,
flatulence. Nursing L mixng with fruit juice, water, milk, or carbonated citrus
beverage, admin with full glass of liquid, giving on empty stomach for more rapid
results. Assess pts mental status throughout treatment.
Ineffective endocarditis: infection of heart lining and valves; indications include
fever, malaise, back and joint pain, splinter hemorrhages under fingernails and
toenails, petechiae in conjunctive and mucous membranes, heart murmur, nursing
care includes IV antibiotics for 4-6 weeks
BuSpar- anti-anxiety med
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Normal newborn: RR: 30-50; HR 120-140; bp 80/40
Hydrocephalus- position on the unoperative side, keep flat to prevent complication
of due to rapid reduction of intracranial fluid, assess for increased ICP & infection
Postural drainage- a component to chest physiotherapy
Placenta previa- abnormally implanted near or over the cervical opening; indication
include painless bright red vaginal bleeding accompanied by soft uterus usually in
third trimester bewee 29 & 30 weeks, caused by scarring of uterus from pregnancy,
tumor, or treatments includes bedrest, ultrasound to locate placenta, no
vaginal/rectal exams before fetal vviability, amniocentesis for lung maturity, daily
hgb and hct
Total hip replacement- complication includes: dislocation of hip prosthesis,
excessive wound drainage, thromboembolism, and infection; nursing responsibilities
: positioned leg in aduction, abduction splints, wedge, or 2-3 pillows used between
the legs, hip should not b e flexed more than 45 to 60 degrees, and the head of thebed should not be elevated more than 45 degrees, to use a fracture bedpan, the pt
should flex unoperaed hip and use a trapeze while lifting the pelvis; semi reclining
toilet seats and wheelchairs are used to prevent hip joint flexion
Postpartum: check lochia ( color, volume) day 1-3 rubra ( bloody with fleshy odor,
may have clots; day 4-9 serosa ( pink/rown with fleshy odor); day 10+ alba ( yellow-
white)Fundus should be at or 1 cm/finger breadth above the umbilicus for the first
12 hr, then descent by one finger breadth each succeeding day;
The first stage of labor is divided into three phases:
- Phase one ( latent): cervix is dilated 0-3 cm, contractions 10-30 sec long. 5-
30 min aport, mild to moderate
- Phase two ( active); cervix is dilated t 4-7 cm, contractions 30-40 sec long, 3-
5 min apart, moderate to strong
- Phase three ( transition): cervix is dilated 8-10 cm, contractions are 45-90 sec
long, 2-3 min apart, strong, impending delievery marked by increase in dark
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red bloody show, increased urgency to bear down; Second stage: from full
dilation of cervix to delivery of baby
Third stage: birth of baby to expulsion of placenta
Fourth stage: first 2 hr after the birth of the baby
Parkinsons disease: characterized by fine, slowly spreading tremor, muscular
rigidity, and altered gate; nursing care include encouraging finger exercises, e.g
typing, piano-playing, rom,
Ambulation: goose stepping walk, walk with wider base, concentrate on swinging
arms while walking, turn around slowly using small steps. Intellect not impaired,
sight and hearing are intact. Meds: cogentitn, L-dopa, sinemet, symmetrel
Ultrasound- done as early as 5 weeks to determine pregnancy-client must drink fluid
prior to test to have full bladder to assist in clarity
Defense mechanisms: denial-failure to acknowledge intolerable thoughts, feelings,
experience , or reality
Displacement- redirection of emotions or feelings to a subject that is more
acceptable
Or less threatening.
Projections: attributing to others ones feelings, impulses, thoughts, or wishes
Undoing : : an attempt to earse an act, thought , or desire
Compensation: attempt to overcome a real or imagined shortcoming
Repression: unacceptable thoughts kept from awaremness
Suppression : consciously putting a disturbing thought or incident out of
Awareness
iM- vastus lateralis is preferred for infants;
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Rice- rest ice compression and elevation