(pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)
Woman in labor (un-reassuring FHR) - Verified Answer: (late decels,
decreased variability, fetal bradycardia, etc) Turn pt on Left side, give
O2, stop pitocin, Increase IV fluids!
Infant with Spina Bifida - Verified Answer: Prone so that sac does not
rupture
Prolapsed cord - Verified Answer: Knee to chest or Trendelenburg
,oxygen 8 to 10 L
Cleft Lip - Verified Answer: position on back or in infant seat to prevent
trauma to the suture line. while feeding hold in upright position.
FHR patterns for OB - Verified Answer: Think VEAL CHOP!
V-variable decels; C- cord compression caused
E-early decels; H- head compression caused
A-accels; O-okay, no problem
L- late decels; P- placental insufficiency, can't fill
what to check with pregnancy - Verified Answer: Never check the
monitor or machine as a first action. Always assess the patient first. Ex..
listen to fetal heart tones with stethoscope.
Position of the baby by fetal heart sounds - Verified Answer: Posterior --
heard at sides
Anterior---midline by unbilicus and side
, Breech- high up in the fundus near umbilicus
Vertex- by the symphysis pubis.
Heroin withdrawal neonate - Verified Answer: irritable, poor sucking
lead poisoning - Verified Answer: test at 12 months of age
pt with leukemia may have - Verified Answer: epistaxis due to low
platelets
when a pt comes in and is in active labor - Verified Answer: first action
of nurse is to listen to fetal heart tones/rate
NCLEX answer tips - Verified Answer: choose assessment first! (assess,
collect, auscultate, monitor, palpate) only choose intervention in an
emergency or stress situation. If the answer has an absolute, discard it.
Give priority to the answers that deal with the patient's body, not
machines, or equipment.