NUR 283 - All Comp Review
Maternity
Stage 1: active labor. Ends @ 10 cm.
F/U: FHR consistently 132.
Stage 2: baby out.
Fetal Distress Stage 3: placenta out.
Stage 4: Recovery.
1. FHR <110 or >160
2. Decreased or Absent Variability
3. Hyperactivity or No Activity
Considered Late Decels = Placental Insufficiency
Spontaneous Rupture of Membrane = Labor Initiated
Interventions/Monitor:
o Check Amniotic Fluids
o Watery & Clear/Yellow = Good around 700-1000mL
o Blood, yellow/green, meconium, odor = BAD Notify/Report!!
o Report to doctor = bloody ruptured membrane/bloody show(dark red)
Uterine Tachystole
o 5 or more contractions in 10 min
o Contractions 2 min or longer
o No relaxation between contractions
o Babies heart should fluctuate with contractions... If not = BAD
STOP OXYTOCIN
Monitor for Magnesium Toxicity
Magnesium Sulfate B – BP
Depress CNS & Prevent Seizures U – UOP
Eclampsia/Severe Preeclampsia R – RR
P – Patella reflex (DTR)
Education on Initial Feelings:
H.V.A.C.L = Headache, Visual
Flushing/Diaphoresis
Disturbances, Abnormal Labs,
Sedation
Cardiac Dysrhythmias, LOC
Burning at IV Site
decreased
Toxicity Suspected
Discontinue
Postpartum Infusion Give
Calcium Gluconate
Monitor Vital Signs every 15-
1
30 minutes
Report to Doc – BP
160/110 or higher,
Respirations less than 12,
UA output less than 25-
,Risk for = Hemorrhage – Shock – Infection
Calf Swelling Postpartum – DVT concern – Assess 1st
Hemorrhage = Massage the Fundus + Watch for Hypovolemic Shock/Anemia
>500mL Vaginal >1000mL C-Section
Hemorrhage Interventions:
Massage uterus
Insert IV
Call for help
Call Provider
No meds-don’t admin
Assessment/Interventions:
Fundus/Lochia q15min for first hour
Massage the fundus
Monitor for shock/hemorrhage
Hypotension, Tachycardia, Pallor
Encourage Voiding – to prevent bladder distention
Rubella Vaccine:
Pregnant? Contraindicated
Avoid Crowds/Young Children
Administer Vaccine=Postpartum (Avoid Pregnancy for 28 days)
Rhogam vaccine: mom has - blood type. Given @ 28 weeks pregnant & 72 hrs post-partum (if baby +
antigen blood)
Pediatrics
Newborn 110 – 170 60-85/40-55 97.6 – 99.3 30 – 60
Infant 90 – 160 65-100/55-65 97.6 – 99.5 30 – 53
Toddler 80 – 140 90-105/55-70 97.6 – 99.5 22 – 37
Preschooler 75 – 120 95-110/60-75 97.6 – 99.5 20 – 28
School-Age 70 – 100 100-120/60-75 97.6 – 99.5 18 – 25
Adolescents 60 – 100 110-125/65-85 97.6 – 99.5 12 – 20
Weight:
2x = 6 months
3x = 12 months
Car Seat – rear – middle – anchored – 2 yo – nurse does not put in –
Fontanels Closed: buckle @ nipple/armpit.
2-3 mts. social smile
Posterior: 8 weeks 6-12 mts. 1st tooth
Newborn Care/Assessment/Interventions:
Anterior: 12-18 months 1 yo. 6-8 teeth. Babinski
Cleft Lip Baby = No pacifier, breaks during feeds, Soothe
reflex Baby(rocking)
gone.
9-12 mts. Grasps/Pulls
2 objects; Stands with support
Hold sippy cup
by 12 mts. After 12 mts.
Intervene.
3 yo. 1000 words
, Umbilical Cord = falls of 7-14days (Intervention needed for 5 or less)
Measure Newborn Chest – Nipple Line
Newborn Medications = Vitamin K – Erythromycin Ointment – Hep B vaccine
Circumcision = no wipes - clean with water - petroleum jelly
Hyperbilirubinemia - Phototherapy
Interventions:
● Undressed with private area and eyes covered
● Reposition every 2 hours
● Monitor temp and signs of dehydration
● Turn lamp off to draw labs
Goal = Induce stools to decrease bili levels (expected = loose green stools)
Adverse Rxn = bronze baby syndrome - gray/brown discoloration
Pediatric Illnesses
Spina Bifida = Latex allergy
Intussusception = Jelly like stools – knee to chest position
Botulism = no honey first year
Pyloric Stenosis = projectile vomiting – olive shaped mass on abdomen – NPO
Hip dysplasia = click is bad
Pediatric Assessment
Sclerosis Screening = 10 -14 years old, yearly
Delegation
LPN UAP
Monitor STABLE findings ADLs
Reinforce Teaching Transferring/Positioning
Trach Care/Suctioning Ambulating
Admin Routine Meds I&O’s
Wound Care/Cultures Vital Signs
Enteral Feeds Collect Specimens
Collecting Data (then given to RN) Empty Foley/Ostomy
Routine assessment
RN
1st time ambulating, New admission V/S, Post-Op V/S
Aspiration risk/swallow precautions
IV Meds
Initial Teaching
Admin Blood & monitor first 15 mins.
Plan of Care
Irrigate JP drains
Initial Assessment
Documentation
Fundamentals (Legal Terms)
Battery = physical contact without a person’s consent
patient tries to leave and RN grabs arm
3
Maternity
Stage 1: active labor. Ends @ 10 cm.
F/U: FHR consistently 132.
Stage 2: baby out.
Fetal Distress Stage 3: placenta out.
Stage 4: Recovery.
1. FHR <110 or >160
2. Decreased or Absent Variability
3. Hyperactivity or No Activity
Considered Late Decels = Placental Insufficiency
Spontaneous Rupture of Membrane = Labor Initiated
Interventions/Monitor:
o Check Amniotic Fluids
o Watery & Clear/Yellow = Good around 700-1000mL
o Blood, yellow/green, meconium, odor = BAD Notify/Report!!
o Report to doctor = bloody ruptured membrane/bloody show(dark red)
Uterine Tachystole
o 5 or more contractions in 10 min
o Contractions 2 min or longer
o No relaxation between contractions
o Babies heart should fluctuate with contractions... If not = BAD
STOP OXYTOCIN
Monitor for Magnesium Toxicity
Magnesium Sulfate B – BP
Depress CNS & Prevent Seizures U – UOP
Eclampsia/Severe Preeclampsia R – RR
P – Patella reflex (DTR)
Education on Initial Feelings:
H.V.A.C.L = Headache, Visual
Flushing/Diaphoresis
Disturbances, Abnormal Labs,
Sedation
Cardiac Dysrhythmias, LOC
Burning at IV Site
decreased
Toxicity Suspected
Discontinue
Postpartum Infusion Give
Calcium Gluconate
Monitor Vital Signs every 15-
1
30 minutes
Report to Doc – BP
160/110 or higher,
Respirations less than 12,
UA output less than 25-
,Risk for = Hemorrhage – Shock – Infection
Calf Swelling Postpartum – DVT concern – Assess 1st
Hemorrhage = Massage the Fundus + Watch for Hypovolemic Shock/Anemia
>500mL Vaginal >1000mL C-Section
Hemorrhage Interventions:
Massage uterus
Insert IV
Call for help
Call Provider
No meds-don’t admin
Assessment/Interventions:
Fundus/Lochia q15min for first hour
Massage the fundus
Monitor for shock/hemorrhage
Hypotension, Tachycardia, Pallor
Encourage Voiding – to prevent bladder distention
Rubella Vaccine:
Pregnant? Contraindicated
Avoid Crowds/Young Children
Administer Vaccine=Postpartum (Avoid Pregnancy for 28 days)
Rhogam vaccine: mom has - blood type. Given @ 28 weeks pregnant & 72 hrs post-partum (if baby +
antigen blood)
Pediatrics
Newborn 110 – 170 60-85/40-55 97.6 – 99.3 30 – 60
Infant 90 – 160 65-100/55-65 97.6 – 99.5 30 – 53
Toddler 80 – 140 90-105/55-70 97.6 – 99.5 22 – 37
Preschooler 75 – 120 95-110/60-75 97.6 – 99.5 20 – 28
School-Age 70 – 100 100-120/60-75 97.6 – 99.5 18 – 25
Adolescents 60 – 100 110-125/65-85 97.6 – 99.5 12 – 20
Weight:
2x = 6 months
3x = 12 months
Car Seat – rear – middle – anchored – 2 yo – nurse does not put in –
Fontanels Closed: buckle @ nipple/armpit.
2-3 mts. social smile
Posterior: 8 weeks 6-12 mts. 1st tooth
Newborn Care/Assessment/Interventions:
Anterior: 12-18 months 1 yo. 6-8 teeth. Babinski
Cleft Lip Baby = No pacifier, breaks during feeds, Soothe
reflex Baby(rocking)
gone.
9-12 mts. Grasps/Pulls
2 objects; Stands with support
Hold sippy cup
by 12 mts. After 12 mts.
Intervene.
3 yo. 1000 words
, Umbilical Cord = falls of 7-14days (Intervention needed for 5 or less)
Measure Newborn Chest – Nipple Line
Newborn Medications = Vitamin K – Erythromycin Ointment – Hep B vaccine
Circumcision = no wipes - clean with water - petroleum jelly
Hyperbilirubinemia - Phototherapy
Interventions:
● Undressed with private area and eyes covered
● Reposition every 2 hours
● Monitor temp and signs of dehydration
● Turn lamp off to draw labs
Goal = Induce stools to decrease bili levels (expected = loose green stools)
Adverse Rxn = bronze baby syndrome - gray/brown discoloration
Pediatric Illnesses
Spina Bifida = Latex allergy
Intussusception = Jelly like stools – knee to chest position
Botulism = no honey first year
Pyloric Stenosis = projectile vomiting – olive shaped mass on abdomen – NPO
Hip dysplasia = click is bad
Pediatric Assessment
Sclerosis Screening = 10 -14 years old, yearly
Delegation
LPN UAP
Monitor STABLE findings ADLs
Reinforce Teaching Transferring/Positioning
Trach Care/Suctioning Ambulating
Admin Routine Meds I&O’s
Wound Care/Cultures Vital Signs
Enteral Feeds Collect Specimens
Collecting Data (then given to RN) Empty Foley/Ostomy
Routine assessment
RN
1st time ambulating, New admission V/S, Post-Op V/S
Aspiration risk/swallow precautions
IV Meds
Initial Teaching
Admin Blood & monitor first 15 mins.
Plan of Care
Irrigate JP drains
Initial Assessment
Documentation
Fundamentals (Legal Terms)
Battery = physical contact without a person’s consent
patient tries to leave and RN grabs arm
3
