NUR-230 EXAM 3 WITH COMPLETE EXAM QUESTIONS AND ANSWERS (VERIFIED ANSWERS) (2026) A!!

NUR-230 EXAM 3 WITH COMPLETE EXAM QUESTIONS AND ANSWERS (VERIFIED ANSWERS) (2026) A!! 1. Cultural competence - ANSWER A continuous, lifelong process in which nurses develop the ability to provide care that is respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients. 2. Key Principle of Cultural Competence - ANSWER Cultural competence is not an end goal but an evolving process built through awareness, knowledge, skills, encounters, and desire. 3. Assessment in Cultural Competence - ANSWER Nurses gather culturally relevant data during the health assessment. 4. Culturally Congruent Practice - ANSWER Nurses provide care that aligns with the patient's cultural beliefs, values, and preferences. 5. ANA Code of Ethics - ANSWER Nurses deliver compassionate, respectful, and equitable care to all, regardless of race, ethnicity, religion, gender identity, or sexual orientation. 6. Population aging - ANSWER Older adults will outnumber children by 2030. 7. Increased diversity - ANSWER The U.S. population is becoming more racially and ethnically mixed. 8. Immigration Birthrate - ANSWER Immigration is now the main driver of population growth. 9. Increased need for bilingual staff/interpreters - ANSWER A consequence of the demographic trends in the U.S. 10. Culture - ANSWER Shared system of values, beliefs, art, laws, customs, and habits of a group. 11. Ethnicity - ANSWER Shared cultural traits such as language, origin, religion, and traditions. 12. Race - ANSWER Genetic and biological characteristics (e.g., skin color, hair, blood type). 13. Spirituality - ANSWER Search for meaning, purpose, and connection; may or may not include religion. 14. Religion - ANSWER Organized system of beliefs and practices about the sacred. 15. Sex - ANSWER Biological and genetic traits. 16. Gender Identity - ANSWER Internal sense of being male, female, both, or neither. 17. Gender Expression - ANSWER External presentation of gender (behavior, dress, speech). 18. Cultural Desire - ANSWER Motivation to engage with and learn from other cultures. 19. Cultural Awareness - ANSWER Self-examination of one's own cultural identity and biases. 20. Cultural Knowledge - ANSWER Learning about worldviews, values, and health beliefs of others. 21. Cultural Skill - ANSWER Ability to collect relevant cultural data and perform assessments. 22. Cultural Encounters - ANSWER Engaging directly with patients from diverse backgrounds. 23. Avoiding Stereotyping - ANSWER Treat each person as a unique individual and avoid assuming that all members of a group share identical beliefs. 24. Culturally Sensitive Assessment - ANSWER Key behaviors include being observant of nonverbal communication and respecting personal space preferences. 25. Key Interview Techniques - ANSWER Ask open-ended questions, use active listening, and avoid medical jargon. 26. Best Practice for Interpreter Use - ANSWER Use certified medical interpreters - never family members or untrained staff. 27. Certified medical interpreters - ANSWER Professionals trained to facilitate communication between patients and healthcare providers. 28. FICA Tool - ANSWER A framework for assessing spiritual and religious needs in patient care. 29. Faith/Belief - ANSWER The aspect of spirituality that pertains to an individual's faith tradition. 30. Importance/Influence - ANSWER The significance of faith in an individual's life. 31. Community - ANSWER The social aspect of spirituality, referring to participation in a faith community. 32. Address/Apply - ANSWER The process of integrating spiritual needs into patient care. 33. Cultural Consideration - ANSWER Factors related to a patient's cultural background that may affect care. 34. Nursing Action - ANSWER Specific interventions taken by nurses to accommodate cultural needs. 35. Mobility - ANSWER The ability to move freely, easily, and purposefully. 36. Gas Exchange & Perfusion - ANSWER The delivery of oxygen to muscles and tissues necessary for movement. 37. Intracranial Regulation - ANSWER The coordination of voluntary and reflex movement by the brain and nervous system. 38. Pain - ANSWER A sensation that can limit movement and functional independence. Nutrition - ANSWER The intake of food that provides energy and nutrients for muscle contraction and bone strength. Tissue Integrity - ANSWER The health of body tissues, which can be compromised by immobility. Elimination - ANSWER The physiological process that can be affected by decreased activity. Oxygenation - ANSWER The process of delivering oxygen to the body, which can be diminished by reduced activity. Musculoskeletal System Functions - ANSWER The roles of the musculoskeletal system including support, protection, and movement. Support - ANSWER The function of providing a framework for body shape and posture. Protection - ANSWER The function of shielding internal organs from injury. Movement - ANSWER The interaction of bones, muscles, and joints to facilitate motion. Barriers to Spiritual Assessment - ANSWER Challenges such as nurse discomfort and lack of training that hinder spiritual discussions. Cultural Humility - ANSWER Ongoing self-reflection and learning about cultural differences. Effective Communication - ANSWER The essential exchange of information that fosters patient safety and trust. Holistic Care - ANSWER An approach to patient care that considers the whole person, including cultural and spiritual needs. Mineral Storage - ANSWER Calcium and phosphorus. Hematopoiesis - ANSWER Blood cell production in bone marrow. Bones - ANSWER Provide structure, leverage, and protection. Continuously remodel. Ligaments - ANSWER Connect bone to bone; provide joint stability. Tendons - ANSWER Connect muscle to bone; transmit muscular force. Cartilage - ANSWER Smooth surface for articulation; absorbs shock; nourished by synovial fluid. Bursae - ANSWER Fluid-filled sacs reducing friction between tendons and bones. Synarthrodial Joints - ANSWER Immovable joints, e.g., skull sutures. Amphiarthrodial Joints - ANSWER Slightly movable joints, e.g., symphysis pubis. Diarthrodial Joints - ANSWER Freely movable joints, e.g., knee, shoulder. Synovial Fluid - ANSWER Fluid for lubrication in synovial joints. Hinge Joint - ANSWER Type of synovial joint, e.g., knee, elbow. Pivot Joint - ANSWER Type of synovial joint, e.g., radius-ulna. Saddle Joint - ANSWER Type of synovial joint, e.g., thumb. Condyloid Joint - ANSWER Type of synovial joint, e.g., wrist. Ball-and-socket Joint - ANSWER Type of synovial joint, e.g., hip, shoulder. Gliding Joint - ANSWER Type of synovial joint, e.g., vertebrae. Axial Skeleton - ANSWER Includes skull, vertebrae, ribs, sternum; provides protection and posture. Appendicular Skeleton - ANSWER Includes limbs, shoulders, pelvis; facilitates movement and locomotion. Osteoporosis - ANSWER Condition characterized by bone resorption formation leading to fragile bones. Osteoarthritis (OA) - ANSWER Degeneration of cartilage in joints causing unilateral pain and stiffness. Rheumatoid Arthritis (RA) - ANSWER Autoimmune inflammation of synovial tissue causing bilateral pain and stiffness. Bursitis - ANSWER Inflammation of bursae from overuse resulting in pain and limited motion. Gout - ANSWER Condition caused by uric acid crystal deposits in joints leading to sudden severe pain. Strength Testing - ANSWER Graded 0-5 scale Gait & Balance - ANSWER Timed Up-and-Go test (fall risk) Impaired Physical Mobility - ANSWER Related to pain and decreased strength Risk for Injury - ANSWER Related to decreased coordination or balance Activity Intolerance - ANSWER Related to weakness and fatigue Risk for Impaired Skin Integrity - ANSWER Related to immobility Constipation - ANSWER Related to decreased physical activity Maintain mobility - ANSWER Encourage ROM exercises; provide assistive devices; collaborate with PT/OT Prevent complications - ANSWER Turn every 2 hrs; encourage fluids; high-fiber diet Pain control - ANSWER Administer analgesics, use heat/cold, teach relaxation Prevent falls - ANSWER Assess environment, use non-slip footwear, assist with ambulation Promote bone health - ANSWER Encourage diet rich in calcium and vitamin D Intracranial Regulation (ICR) - ANSWER Refers to the mechanisms that facilitate or impair neurologic function within the brain and central nervous system (CNS) Cerebral perfusion - ANSWER Essential to maintain oxygen and glucose delivery to neurons Impaired oxygenation - ANSWER Leads to decreased brain function and altered level of consciousness (LOC) Sensory Perception - ANSWER Sensory input and interpretation rely on intact neural pathways Neurologic dysfunction - ANSWER Can affect swallowing, appetite, and bowel/bladder control Brain growth, perception, and response - ANSWER Are neurologically regulated Central Nervous System (CNS) - ANSWER Composed of the brain and spinal cord; processes and sends information Peripheral Nervous System (PNS) - ANSWER Composed of cranial and spinal nerves; transmits sensory/motor signals Autonomic Nervous System (ANS) - ANSWER Regulates involuntary body functions Cerebrospinal Fluid (CSF) - ANSWER Produced in the choroid plexus of ventricles; cushions brain, maintains ICP, delivers nutrients, removes wastes Major Brain Structures - ANSWER Cerebrum is the largest part; consists of two hemispheres and four lobes Crossover Principle - ANSWER Motor and sensory tracts cross in the medulla, meaning the right brain controls the left body side and vice versa Thalamus - ANSWER Relay station for sensory input to the cortex Hypothalamus - ANSWER Maintains homeostasis (temperature, hunger, thirst, hormones, ANS control) Basal Ganglia - ANSWER Includes putamen, caudate nucleus, globus pallidus, substantia nigra, thalamus, red nucleus; controls smooth, voluntary movement Midbrain - ANSWER Relays stimuli for muscle movement, controls reflexes (visual/auditory); CN III & IV Pons - ANSWER Relays impulses to brain/spinal cord; origin of CN V-VIII Medulla Oblongata - ANSWER Controls vital reflexes: breathing, HR, BP, coughing, swallowing, vomiting; CN IX-XII RAS (Reticular Activating System) - ANSWER Maintains consciousness and arousal Cerebellum - ANSWER Coordinates voluntary movement, balance, muscle tone, and proprioception. Cerebellum Hemispheres - ANSWER Each hemisphere controls movement on the same side (ipsilateral). Spinal Cord - ANSWER Continuation of medulla; ends at L1-L2 → cauda equina. White Matter - ANSWER Myelinated tracts (ascending = sensory; descending = motor) Gray Matter - ANSWER Nerve cell bodies (butterfly-shaped center) Corticospinal (Pyramidal) Tract - ANSWER Voluntary movement Fasciculus gracilis - ANSWER Touch, vibration, position sense Spinothalamic Tract - ANSWER Pain, temperature, light touch Cranial Nerves (I-XII) - ANSWER Overview of cranial nerves and their functions. CN I - Olfactory - ANSWER Sensory; Smell CN II - Optic - ANSWER Sensory; Vision CN III - Oculomotor - ANSWER Motor/Parasymp; Eye movement, pupil constriction CN IV - Trochlear - ANSWER Motor; Downward/inward eye movement CN V - Trigeminal - ANSWER Both; Facial sensation, chewing CN VI - Abducens - ANSWER Motor; Lateral eye movement CN VII - Facial - ANSWER Both; Facial expression, taste (anterior 2/3 tongue), tears, saliva CN VIII - Acoustic (Vestibulocochlear) - ANSWER Sensory; Hearing, balance CN IX - Glossopharyngeal - ANSWER Both; Swallowing, taste (posterior 1/3), gag reflex CN X - Vagus - ANSWER Both; Speech, parasympathetic control of heart, lungs, GI CN XI - Spinal Accessory - ANSWER Motor; Shoulder/head movement CN XII - Hypoglossal - ANSWER Motor; Tongue movement, speech articulation Spinal Nerves - ANSWER 31 pairs (8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal) Reflex Arc - ANSWER Involuntary response to stimulus. Reflex Grading Scale - ANSWER 0 = Absent, 1+ = Diminished, 2+ = Normal, 3+ = Brisk, 4+ = Hyperactive (with clonus) Sympathetic Nervous System (SNS) - ANSWER Thoracolumbar; 'Fight or flight': ↑HR, ↑BP, bronchodilation, ↓GI activity Parasympathetic Nervous System (PNS) - ANSWER Craniosacral; 'Rest and digest': ↓HR, ↑peristalsis, pupil constriction Risk Factors: Cerebrovascular Accident (Stroke) - ANSWER Includes biographic/genetic and behavioral factors. Age-Related Considerations - ANSWER Assessments vary by age group: Infants/Children, Adolescents, Older Adults. Multiple Sclerosis (MS) - ANSWER Demyelination of CNS neurons Meningitis - ANSWER Inflammation of meninges (bacterial/viral) Encephalitis - ANSWER Inflammation of brain tissue (viral) Spinal Cord Injury (SCI) - ANSWER Trauma causing disruption of cord pathways Head Injury (TBI) - ANSWER Trauma to scalp/skull/brain Parkinson Disease (PD) - ANSWER Dopamine neuron loss in substantia nigra Cerebrovascular Accident (Stroke) - ANSWER Ischemia or hemorrhage → neuronal death Myasthenia Gravis (MG) - ANSWER Autoimmune destruction of ACh receptors Guillain-Barré Syndrome (GBS) - ANSWER Acute demyelination of PNS after infection 5-6 mo - ANSWER When can an infant typically fully roll over? 8 mo - ANSWER An infant should be sitting unsupported by how many months? 10 mo - ANSWER An infant can waive bye bye when? 10-12 mo - ANSWER When can an infant walk with assistance? 10 yrs - ANSWER Growth spurts in girls typically happens at what age? 24 mo - ANSWER When can a toddler begin to kick a ball? 5 yrs - ANSWER When can a child typically tie their shoes? 4 yrs - ANSWER When can a child begin to use scissors? 24 mo - ANSWER Daytime toilet training can usually start when? 5 yrs - ANSWER When can a child begin to ride a bike without training wheels? 10 mo - ANSWER When can an infant vocalize 2 words? 9-12 mo - ANSWER What age would be appropriate for push pull-toys? 6-9 mo - ANSWER What age would be appropriate for noise maker toys? Teenagers 12 yrs and older - ANSWER When in the hospital this age group will want their peers visit the most Infants - ANSWER Appropriate foods for ________________ would be? - Breast milk or iron fortified formula - If less than a year, use iron fortified formula when weaned from breast milk - Introduce iron fortified cereal at 5-6 mo Toddlers - ANSWER Appropriate foods and eating habits for ___________ would be? - Cutting food into small pieces such as grapes, hotdogs, and carrots - They will be busy, will not eat big meals (because they are busy exploring) - Need small frequent meals and snacks - Are at risk for aspiration due to them running around. - Avoid foods like peanuts, gummies and skittles Teenagers - ANSWER This age group is typically into fast food, high fat foods such as pizza, burgers, french fries - easily influenced by peers Iron-fortified cereal - ANSWER _____________ is given to infants because it is least allergenic and the Fe2+ storages in body have been depleted. - Idiopathic type 1, rare forms of the disease that has no known cause Type 1 diabetes - ANSWER - Pancreatic beta cells that produce insulin are destroyed, starts in children or in slim young adults - 2 forms: Immune-mediated DM or Autoimmune destruction of the beta cells S/S of Type 1 diabetes - ANSWER - Polyuria - Polydipsia - Polyphagia - Weight loss - Tachycardia - Fatigue Treatment for Type 1 Diabetes - ANSWER - Insulin therapy SQ - Regular insulin may be IV - Insulin pumps for age 2 or greater - Food plan Type 2 Diabetes - ANSWER - Insulin resistance due to the body failing to use insulin properly while combined with relative insulin deficiency - Typically occurs in adults over 30 S/S of DKA - ANSWER - Glucose 250 - pH 7.2 - bicarbonate 15 mEq/L - Kussmaul respirations - Acetone (fruity breath) - Dehydration - Flushed facial skin - Hypotension - Decreased LOC DKA treatment - ANSWER - IV insulin - Increased fluids of NS - Monitor K levels IV fluids - ANSWER - No ___________ w/glucose in it - You will give NS and then the insulin to get they're glucose down Cause of Hypoglycemia - ANSWER - Too much insulin - Inadequate intake or meals - Strenuous exercise S/S of Hypoglycemia - ANSWER - Diaphoresis - Tremors - Hunger - Weakness - Pallor - Dizziness - Emotional out bursts - Coma, convulsions and death Signs of Hypoglycemia in children - ANSWER - Unusual behaviors (it may seem like they're having a tantrum or behavior that you aren't able to reason with them at all) Preventing Hypoglycemia in children - ANSWER - Give them adequate snacks - Monitor their blood glucose particularly if they're going to exercise or be out doing things - Checking glucose levels and giving them a snack before exercise Treatment for Hypoglycemia - ANSWER - Juice or regular soda - Glucose tab or gel - Glucagon subQ Cause of PKU - ANSWER - Autosomal recessive disease - Inability to produce enzyme to break down essential amino-acid phenlyalanine Newborn screening for PKU - ANSWER - After 2-3 days or at least 24 hrs on breast milk or formula Treatment for PKU in Newborns - ANSWER - Placed on formula that contains low levels of phenylalanine, or breast milk which already has low levels and isn't an issue S/S of PKU - ANSWER - Musty smell from body - Seizures - Hyperactivity - Irritability - Vomiting - Eczema type rash PKU not treated - ANSWER - Profound cognitive deficits Meats - ANSWER Food to avoid if you have PKU Hypothyroidism - ANSWER - Thyroxine (T4) is not produced S/S of Hypothyroidism - ANSWER - Large fontanelles - Protruding tongue - Watch for temp. instability...they can drop their temp very easily - Constipation, lethargy, prolonged jaundice - Profound cognitive defects & developmental delays Levothyroxine - ANSWER Treatment for hypothyroidism Parent teaching for Hypothyroidism - ANSWER - Parents need to be taught how to administer medication, it can be crushed or given a small amount of juice/liquid, and can be given through a syringe. Hyperthyroidism in babies - ANSWER Parents will state "really good baby, sleeps all the time" - Baby sleeping all time is not a good sign - Cognitive deficits and developmental delays can occur if not caught in time Hirshsprungs Disease in Newborn - ANSWER - Diagnosed first few months of life - Initial S/S of severe constipation - May fail to pass meconium within 24 hrs of birth - Reluctance to ingest fluids - FTT (failure to thrive) - May repeatedly vomit yellow or green colored bile - May have a distended (swollen, uncomfortable), abdomem...they have meconium ileus, and you'll look for ribbon like stool - Omimous sign: explosive diarrhea, fever, enterocolitis Rotovirus - ANSWER Diarrhea which is typically spread by the fecal-oral route Treatment for Rotovirus - ANSWER - Teach personal hygiene - Oral hydration to prevent dehydration - DO NOT use BRAT diet for children - Careful food preparation - Clean water supply/protect from contamination - There is a vaccine but it must be given in the first 3 mo (bc there is 3 injections).....isn't given after 1 yr bc it doesn't really cause a problem in older children Gastroesophageal Reflux (GER) - ANSWER Can occur throughout the day, but most frequently after meals and at night GER - ANSWER The lower esophageal sphincter (LES) is being affected by pressures that can vary due to gastric distention, increased abdominal pressure caused by coughing, spitting up, CNS disease, delayed gastric emptying, hiatal hernia, and gastrostomy placement. (transient relaxation)..... causes gastric contents to transfer into the esophagus. Treatment for GER - ANSWER - Small, frequent feedings - Sitting upright for 1 hr after feedings - For infants, thickening the formula (1 tsp to 1 tablespoon of rice cereal per ounce of formula) - Children older than 1 year, benefit to left-side position during sleep and the elevation of the head of the bed Parent teaching with GER - ANSWER - Administer Protonics 30 mins prior to feedings....only 1x a day - Majority of infants have improvement by age 12 to 18 mo of age and require only conservative lifestyle changes or medical interventions - Older children: avoid caffeine, chocolate, spicy foods, citrus, and peppermint - Tobacco and alcohol may aggravate Pyloric Stenosis - ANSWER - Obstructive disorder, causes constriction of pyloric sphincter with obstruction of gastric outlet - You will start to see signs and symptoms develop in these infants between 2 and 5 weeks of life...typically the 3rd wk of life and seen 30 mins after eating - You will see thickening of the circular muscle of the pylorus causing constriction of the pylorus and obstruction of the gastric outlet. S/S of Pyloric Stenosis - ANSWER Three P's - Projectile vomiting - Palpable olive-like mass - Visible Peristaltic waves ** Metabolic alkalosis (bc throwing up and don't have bile in it)** Treatment of Pyloric Stenosis - ANSWER - Infant must undergo surgical treatment to correct this obstruction - Pylormyotomy (Fredet-Ramstedt procedure) with RUQ incision - Laparoscopic surgery (reduces surgical time, feeding delay, and discharge) - Preop: important to make sure that they are not dehydrated or metabolic alkalosis occuring - Postop: feedings will begin about 4-6 hrs later. They will be small, frequent feeding w/glucose water and electrolytes (pedialyte) - Teach parents to watch for vomiting after surgery, bc it can still occur a few days after before it stops Labs to monitor with Pyloric Stenosis - ANSWER Decreased: Na, k, Cl Increased: pH, bicarbonate, BUN Intussusception - ANSWER - Occurs when one portion of the bowel slides into the next, much like the pieces of a telescope - When this occurs, it creates an obstruction in the bowel, with the walls of the intestines pressing against one another - Leads to swelling, inflammation, and decreased blood flow to the intestines involved S/S of Intussception - ANSWER - Severe colicky abdominal pain in a child with vomiting and currant jelly-like stools (stool mixed up blood and mucus), to or mucousy red like stools - Intense abdominal pain, which begins suddenly causing loud, anguished crying, causing the child to draw the kinees up to the chest...pain usually is intermittent, but recurs and becomes stronger - Abdominal swelling or distention - Lethargy (i.e drowsy, sluggishness), shallow breathing, and grunting Treatment for Intussusception - ANSWER - Radiologist guided pneumo-enema - Ultrasound guided saline enema - Watch for normal bowel movement after procedure, it reversed and they will cancel the surgery, notify the physician ASAP Tracheoesophageal Fistula (TEF) - ANSWER - Failure of esophagus to develop as a continuous passage...may occur separately or in combination - Most frequent is with the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation - Occurs in 1 in every 2000 births - Unknown cause S/S of TEF - ANSWER Three C's: - Coughing - Choking - Cyanosis Treatment for TEF - ANSWER - Elevate the bed to prevent aspiration @ least 30 degrees - Broad spectrum antibiotics will be started to prevent pneumonia...need to monitor temp bc they are newborn and may aspirate - NPO immediately - Need non-nutritive sucking (pacifier) - IVF'S - Removal of secretions from the mouth and upper pouch - Broad spectrum antibiotics - Surgical repair of anomaly S/S of Appendicitis - ANSWER - Fever, vomiting, abdominal pain and increased WBC - Can cause other issues such as: gastroenteritis, PID, UTI, intussception - Presence of fluid around appendix on ultrasound - CT will show enlarged appendicle diameter - Riding the gurney and hitting bumps or in a car will aggravate the pain - Assess severity of pain: change in behavior- refuses to play - Younger child: rigid position, side-lying, knees flexed at abdomen, decreased ROM of right hip - Older child: can point to location of pain - No laxatives, enemas or heat: stimulates bowel motility and increases risk of perforation - Post op: IV fluids, NPO, NG until intestinal activity returns, check bowel sounds, antibiotics, if ruptured hospitalized 7-10 days. Celiac disease - ANSWER - Steatorrhea - General malnutrition - Abdominal distention - Secondary vitamin deficiencies Treatment for Celiac disease - ANSWER - Gluten Free diet (actually low in gluten) - Eliminate wheat, rye, barley and oats - Substitute wheat, rye, barely, and oats w/corn and rice Iron Deficiency Anemia - ANSWER - Anemia with reduced Hgb concentration may be caused by dietary depletion of iron - Caused by inadequate supply of dietary iron - Generally preventable - Two age groups at highest risk: infants and adolescents/teens - Infants given iron fortified formulas and cereal - Special needs for preemies - Adolescents develop due to poor eating habits and rapid growth S/S of Iron Deficiency Anemia - ANSWER - pallor (paleness of mucous membranes) - tiredness - fatigue (keep them on bed rest or low activity) - tachy - cook skin Nursing interventions/treatments for Iron Deficiency Anemia - ANSWER - Decrease oxygen demands (bed rest or low activity) - prepare child and family for lab tests - prevent complications - support family - administer iron (do not get on tongue) - young children: use a dropper to administer - older children: mix it in a cup w/a straw Sickle Cell Anemia - ANSWER - Autoosmal recessive disease - partial or complete replacement of normal Hgb w/abnormal Hgb - Hgb in the RBC's takes on an elongated "sickle" shape. Sickled cells are rigid and obstruct capillary blood flow - Microscopic obstructions lead to engorgement and tissue ischemia. Hypoxia occurs and causes sickling - Often occurs w/triggers such as stress S/S: Fever Pain Tissue engorgement Treatment for Sickle Cell - ANSWER - Fluids - Oxygen - Pain medication Acute Lymphoid Leukemia (ALL) - ANSWER - ______________ is an unrestricted proliferation of immature WBC's in the blood-forming tissues of the body S/S of ALL - ANSWER - fever - pallor - overt signs of bleeding - lethargy - malaise - anorexia - large joint or bone pain - petechiae (purple spots bc bleeding under skin) - frank bleeding (rectal bleeding) - joint pain - liver and spleen enlargement - lymphadenopathy CNS: - Increased ICP - Headache - Vomiting - Papilledema & nerve palsy Other: - Anemia for decreased RBC's - Infection from neutropenia - Bleeding tendencies from decreased platelet production Testing for ALL - ANSWER - Bone marrow aspiration or biopsy - Complete CBC's - Lumbar puncture to evaluate CNS involvement Treatment for ALL - ANSWER - Induction therapy: Corticosteroids (prednisone), Vincristine, L-Asparaginase Immediate following this therapy pts are extremely vulnerable to infection & spontaneous hemorrhage - CNS prophylactic therapy (If spinal fluid is involved and has cancer s=cells present in it) Intrathecal chemotherapy IE methotrexate, cytarabine and hydrocortisone - Intensification therapy: After complete remission is attained, this therapy is administered to eradicate residual leukemic cells which consists of more chemotherapy - Maintenance therapy: Combined drug regimens over next 2-3 years Nursing care for ALL - ANSWER - Use a private room for patients - Screening and restriction of all visitors and health personal w/active infection - Strict hand washing ALL Anaphylaxis shock S/S (to chemotherapy) - ANSWER - Cyanosis - Hypotension - Wheezing - Uticartia (nurse must stop the drug immediately) S/S of drug toxicity for all ALL patients - ANSWER - N/V (give zofran or ondazetron)(COOL CLEAR LIQUIDS) - Anorexia - Mucous ulceration - Neuropathy - Hemorrhagic cystistis - Alopecia - Mood changes - Moon face Risks for pt w/ALL - ANSWER - Increased risk for infection - Imbalanced nutrition - Decreased appetite - Hair loss Eczema - ANSWER - localized or migrates, constant or intermittent, aggravating condition (sunlight) - allergic conditions: asthma, may be precursor to asthma and hay fever - atopic dermatitis, often associated w/allergies, frequently begins in infancy Eczema prevention - ANSWER - Avoid irritants - Wear cotton clothing - Do not use telecom powder or lotions Scabies - ANSWER - Lesions are created as the impregnated female burrows into the stratum corneum (outermost layer) of the epidermis to deposit her eggs and feces - Topical ointment used for tx must stay on skin for at least 8 hrs after acquiring it - The inflammatory response and intense itching occur after the host becomes sensitized to the mite, response occurs w/in 48 hours after 2nd exposure S/S of Scabies - ANSWER - Areas where the mite has traveled turn red and will begin to itch Treatment/Pt teaching with Lice - ANSWER - Easily spread - Destroy the eggs (wills) by using specialized shampoos and high temp. water when washing bedding - Dry bedding on high heat for at least 20 min Cellulitis - ANSWER - Bacterial infection in a specific area or region of the body - Rapid onset, ill, erythema - Warmth, tenderness, chills - Fever, malaise, lymphadenopathy - Septicema, edema of infected site Treatment of Cellulitis - ANSWER - Warm compress - Antibiotics - Spreads easily, refrain from itching area and touching another area Impetigo - ANSWER - Staph infection which usually occurs on face or legs - Spreads easily Treatment: - Remove honey colored crusts - Apply topical antibiotic - Antibacterial soap for 5-7 days Acne - ANSWER - Most common skin problem treated by physician's during adolescence - One half of all adolescents experience acne by the end of the teenage years - Peak incidence occurs in middle to late adolescence - May range from mild to severe - Great significance to the adolescent Treatment options: - Wash with soap & water - Adequate rest - Moderate exercise - A well-balanced diet - Wash hair more frequently - Reduction of emotional stress, and elimination Poison Ivy - ANSWER - Burshin oil causes irritation on skin Tx: - Lather irritated area in shower 2x or 3x - Scratching the irritated area will make it worse Immunizations - ANSWER - Babies can pick up Pertussis (whopping cough) as early as 6 wks of age - Remember that the babies are NOT getting their DPT's at this point, making them at an increased risk for picking up the virus - If pt is infected: most are placed on droplet and airborne precautions when admitted to the hospital what age can infants smile emotionally - ANSWER 2months what age predicts height? - ANSWER 2yrs Expected Findings for Tracheostomy Tube - ANSWER Skin intact, small amount of thin secretions. Abnormal Findings for Tracheostomy Tube - ANSWER Red, excoriated skin or thick, discolored secretions → infection or inadequate humidification. Chest Tube - ANSWER Inspect dressing (should be dry, intact). Assess pain during deep inspiration. Note amount and color of drainage. Recognize suction sounds may mimic breath sounds. Expected Findings for Chest Tube - ANSWER No leak, dressing clean/dry, serosanguineous drainage. Abnormal Findings for Chest Tube - ANSWER Increased drainage, air leak, or redness → possible complication or infection. Nasogastric (NG) Tube - ANSWER Inspect nare for redness or pressure injury. Check tape and tube security. Expected Findings for Nasogastric (NG) Tube - ANSWER Intact skin, secure tubing. Abnormal Findings for Nasogastric (NG) Tube - ANSWER Erythema or ulceration at nares → pressure injury. Gastrostomy Tube (G-Tube) - ANSWER Inspect stoma and surrounding skin for redness, drainage, or edema. Assessment Focus for G-Tube - ANSWER Inspect stoma and surrounding skin for redness, drainage, or edema; inspect oral mucosa for moisture. Expected Findings for G-Tube - ANSWER Pink, moist stoma; skin intact; mucous membranes moist. Abnormal Findings for G-Tube - ANSWER Redness, purulent drainage, or leakage → infection or skin breakdown. Ostomy (Colostomy / Ileostomy) - ANSWER A surgical opening created in the abdominal wall for waste elimination. Assessment Focus for Ostomy - ANSWER Inspect stoma for color and moisture; assess peristomal skin for irritation; describe output color and consistency. Expected Findings for Ostomy - ANSWER Stoma red and moist; surrounding skin intact. Abnormal Findings for Ostomy - ANSWER Pale, dry, or dark stoma → ischemia; excoriation or leakage → poor appliance fit. Stool Consistency by Site - ANSWER Transverse colon: mushy stool; Descending/sigmoid colon: formed stool; Ileostomy: continuous liquid stool. Cast - ANSWER A rigid dressing used to immobilize broken bones. Assessment Focus for Cast - ANSWER Check circulation, movement, and sensation (CMS) of distal extremities; assess capillary refill, color, temperature, and pain. Expected Findings for Cast - ANSWER Warm skin, cap refill ≤ 2 sec, movement and sensation intact. Abnormal Findings for Cast - ANSWER Pale, cool skin, pain, numbness, or immobility → compartment syndrome risk. External Fixator - ANSWER A device used to stabilize bone fractures externally. Assessment Focus for External Fixator - ANSWER Assess circulation, movement, sensation (CMS) of distal extremities; inspect pin insertion sites for redness, edema, or drainage. Expected Findings for External Fixator - ANSWER Pulse 2+, cap refill 2 sec, clean/dry pin sites. Abnormal Findings for External Fixator - ANSWER Redness, swelling, purulent drainage → pin-site infection. Sex vs Gender - ANSWER Sex refers to a person's genetic composition and its phenotypic expression; Gender is society's perception of a person's sex. Gender Identity vs Gender Expression - ANSWER Gender identity is a person's internal sense of self; Gender expression is a person's visible expression of social norms. Myalgia - ANSWER Viral illnesses can cause muscle aches and pain. Flexion - ANSWER Movement that brings a joint into a bent position. Extension - ANSWER Movement that brings a joint into a straight position. Rotation - ANSWER external and internal (turning a limb) Adduction - ANSWER towards the body Abduction - ANSWER away from the body Plantar Flexion - ANSWER points foot towards ground away from the body Dorsiflexion - ANSWER brings foot up towards the body Scoliosis - ANSWER a lateral curvature of the spine Kyphosis - ANSWER a posterior curvature (convexity) of the thoracic spine Hypotonia (flaccidity) - ANSWER a condition characterized by decreased muscle tone, making muscles seem limp or loose Hypertonia (spasticity) - ANSWER specific type of hypertonia characterized by a velocity-dependent increase in muscle stiffness TMJ - ANSWER temporomandibular joint Contralateral - ANSWER relating to or denoting the side of the body opposite to that on which a particular structure or condition occurs Ipsilateral - ANSWER belonging to or occurring on the same side of the body Stereognosis - ANSWER identification of a familiar object by touch Hyporeflexia - ANSWER medical condition characterized by a diminished or absent response to a reflex Hyperreflexia - ANSWER an abnormal finding that may indicate eclampsia Tinnitus - ANSWER Tinkling or ringing sound heard in one or both ears Dysphagia - ANSWER difficulty swallowing Aphasia - ANSWER the term for defective or absent language function Dysphasia - ANSWER an impairment of speech not as severe as aphasia Ataxia - ANSWER Inability to coordinate muscular movement Wound Dehiscence - ANSWER a complication where the edges of a surgical incision or wound separate, exposing underlying tissues Thoracotomy - ANSWER incision into the thoracic cavity Colostomy - ANSWER The remaining colon was brought to the abdominal wall to create an artificial anus Stoma - ANSWER General term that means opening no evidence of contractility - ANSWER 0 evidence of slight contractility - ANSWER 1 complete range of motion with gravity eliminated - ANSWER 2 complete range of motion with gravity - ANSWER 3 complete range of motion against gravity with some resistance - ANSWER 4 complete range of motion against gravity with full resistance - ANSWER 5 lordosis - ANSWER an anterior curvature (concavity) of the spine Bouchard nodes - ANSWER may cause Bouchard nodes in the PIP joints Heberden nodes - ANSWER form in the DIP joints Osteoarthritis - ANSWER includes asymmetric joint involvement, bony enlargements, crepitus, and reduced range of motion without significant redness or warmth Rheumatoid arthritis - ANSWER shows symmetric joint swelling, warmth, erythema, and tenderness, often with morning stiffness lasting longer than an hour and possible joint deformities such as ulnar deviation or swan-neck fingers REEDA: R - ANSWER redness REEDA: E - ANSWER edema REEDA: E* - ANSWER brusing REEDA: D - ANSWER discharge REEDA: A - ANSWER approximation explain this perineal care intervention: ice packs - ANSWER reduce swelling explain this perineal care intervention: topical anesthetics - ANSWER numbing explain this perineal care intervention: waffle cushion - ANSWER redirect pressure explain this perineal care intervention: surgigator - ANSWER spray warm water to cleanse and soothe explain this perineal care intervention: sitz bath - ANSWER sitting in warm water to soothe explain this hemorrhoid care intervention: rectal suppositories - ANSWER gives medicine right where issue is explain this hemorrhoid care intervention: witch hazel pads - ANSWER helps with pain explain this hemorrhoid care intervention: side lying - ANSWER takes pressure off explain this hemorrhoid care intervention: adequate fluid intake + stool softeners - ANSWER avoids constipation how are C/S incisions closed (2) - ANSWER derma bond or staples once staples are removed, what is placed on incision - ANSWER steristraps how can we minimize respiratory risks after C/S - ANSWER ambulate, deep breath, incentive spirometer how can we minimize gas pain risks after C/S - ANSWER ambulation and mylicon what is homans sign - ANSWER dorsiflex foot and if there is pain that could indicate a clot what else can we look for when assessing for clot - ANSWER warmth, redness, pain, edema unilaterally where would pain be if there was a clot - ANSWER leg, inguinal area, lower abdomen how can we prevent thrombophlebitis - ANSWER avoid prolonged sitting or standing, ambulate describe what taking in is - ANSWER passive, mom does not feel confident and needs lots of help describe what taking hold is - ANSWER mom resumes control describe this stage of BAM: anticipatory - ANSWER during pregnancy mom fantasizes about what life will be like with baby describe this stage of BAM: formal - ANSWER infant is born and mom has help (social standards) describe this stage of BAM: informal - ANSWER mom begins to develop role describe this stage of BAM: personal - ANSWER gaining and developing confidence in role what is postpartum blues - ANSWER transient depression after giving birth what are s/s of postpartum blues - ANSWER episodic crying, irritable, mood swings when does blues usually resolve - ANSWER 2 weeks after why do blues happen - ANSWER hormonal changes, fatigue, emotional letdown what are some important nursing interventions for the blues - ANSWER anticipatory guidance, rest, validate feelings, painting references, support networks, rooming in what is postpartum depression - ANSWER persistent depression after childbirth who is at risk for postpartum depression - ANSWER history of PP depression, or depression, primigravida, ambivalent, lack of social support, body image issues difference between depression and blues - ANSWER blues resolves on its own what is postpartum psychosis - ANSWER syndrome occurring after childbirth characterized by severe depression, manic episodes, hallucinations, and/or delusions what are s/s of postpartum psychosis - ANSWER hallucinations, severe confusion, insomnia, agitation, hyperactivity, delusions what are some nursing interventions for depression and psychosis - ANSWER seek help from a professional, teach signs to recognize, anticipatory guidance, dispel myths, educate, screen what is the first line of defense for postpartum depression - ANSWER zoloft what is second line of defense for postpartum depression - ANSWER Paxil which drug is NOT recommended - ANSWER prozac what are possible solutions for psychosis - ANSWER lithium, psychotherapy, antipsychotics, remove infant describe enfacement - ANSWER face to face with baby describe engrossment - ANSWER observing baby how can we promote parent-infant attachment - ANSWER rooming in, kangaroo care, provide private time, involve sibling, prepare and help adjust how can we encourage mom to get rest - ANSWER rest when baby is asleep and have help from family how should we advice mom to resume activities - ANSWER avoid heavy lifting, avoid frequent stair climbing, avoid strenuous activity what can we tell moms about sexual activity - ANSWER resume after lochia has stopped and episiotomy has healed, lube may be required list some discharge criteria - ANSWER stable vitals, appropriate involution, appropriate lochia, knowledge signs of infection, laceration are well approximated, can perform pericarp, understands teachings when is bulb suctioning used - ANSWER mouth and nose secretions when is suction catheter used - ANSWER meconium fluid in lungs, baby is pale and has respiratory issues when clamping and cutting umbilical cord, why would we squeeze it a few times first - ANSWER to get all the blood into baby what are ways to stimulate baby - ANSWER flick heel, slap sole of feet, rub back why is drying and stimulating baby important - ANSWER drying to decrease cold apnea and stimulation to get baby to breath how does identification work - ANSWER mom and baby each get 2 identification bands APGAR: A1 - ANSWER appearance/ color APGAR: P - ANSWER pulse/ HR APGAR: G - ANSWER grimace/ reflex irritability APGAR: A2 - ANSWER activity/ muscle tone APGAR: R - ANSWER respiratory effort describe 0, 1, 2 for heart rate - ANSWER 0: none 1: less than 100 2: 100 or greater describe 0, 1, 2 for respiratory effort - ANSWER 0: none 1: slow and irregular 2: vigorous cry describe 0, 1, 2 for muscle tone - ANSWER 0: flaccid 1: some flexion 2: active motion describe 0, 1, 2 for reflex irritability - ANSWER 0: none 1: grimace 2: vigorous cry describe 0, 1, 2 for color - ANSWER 0: blue all over 1: blue extremities 2: pink how long should you count newborn pulse and respiration for - ANSWER 1 minute what should pulse be - ANSWER 110-160 it can be as low as ______ when sleeping and as high as ______ when crying - ANSWER 80;180 what should temperature be - ANSWER 97.7-99.5 what should respirations be - ANSWER 30-60 what 4 changes are put into initiation of respiration - ANSWER mechanical, thermal, sensory, chemical describe mechanical changes - ANSWER pushing fluid out of lungs during birth describe chemical stimuli - ANSWER changes in CO2 and O2 describe thermal changes - ANSWER coolness makes baby breath describe sensory stimuli - ANSWER light, touch, gravity what could respirations be for the first 2 hours of life - ANSWER 60-70 define periodic breathing - ANSWER up to 20 seconds of breaks between breaths define apneic breathing - ANSWER longer than 20 seconds what are signs of respiratory distress - ANSWER nasal flaring, seesaw, grunting, tachypnea, intercostal/ xiphoid retractions what are 2 ways we could help clear a newborns airway - ANSWER chest percussion and bulb suction what is transient tachypnea - ANSWER temporary fluid in lungs (1-3 days) what are some causes of transient tachypnea - ANSWER LGA, preterm birth, C-section, maternal over sedation, prolapsed cord explain this treatment option: chest x-ray - ANSWER look for hyper-expanded lungs explain this treatment option: oxyhood or cannula - ANSWER provide oxygen explain this treatment option: IV fluids or tube feedings - ANSWER aspiration risk so avoid mouth feeds ***the younger the baby, the less alveoli, the greater risk for RDS*** - ANSWER what are 2 ways surfactant can be developed - ANSWER betamethasone, ROM explain this treatment option: oxygen therapy - ANSWER CPAP explain this treatment option: surfactant admin - ANSWER help develop lungs explain this treatment option: thermoregulation - ANSWER keeping warmer helps with breathing explain this treatment option: ECMO - ANSWER severe cases cardio changes: increased ________ vascular resistance and decreased _________ vascular resistance - ANSWER systemic, pulmonary describe the foramen ovale - ANSWER atrium connector describe the ductus arteriosus - ANSWER aorta and artery describe ductus venous - ANSWER bypass liver what 2 pulses should be assessed on newborn assessments - ANSWER brachial and femoral bilaterally describe convection - ANSWER heat loss to cooler air describe radiation - ANSWER heat loss form surface around describe evaporation - ANSWER heat loss to moisture describe conduction - ANSWER heat loss to direct contact how should we take a newborns temperature - ANSWER axillary explain this cause of heat loss: large surface area to body mass ratio - ANSWER skin loses heat easily explain this cause of heat loss: decreased subq fat - ANSWER no insulation explain this cause of heat loss: increased body water content - ANSWER more water loss explain this cause of heat loss: immature skin - ANSWER thin skin explain this cause of heat loss: poorly developed metabolic mechanism - ANSWER can not shiver explain this cause of heat loss: altered skin blood flow - ANSWER why are preterm babies even more at risk - ANSWER do not flex, VERY thin skin what are s/s of hypothermia - ANSWER pale, cyanosis, transient hyperglycemia then hypoglycemia, respiratory issues, bradycardia, tachypnea, hypoxemia, metabolic acidosis, decreased weight gain, poor feeding what are causes of hyperthermia - ANSWER overheating, moms epidural, maternal fever, CNS disorders, dehydrations, phototherapy what are s/s of hyperthermia - ANSWER warm and flushed skin, tachycardia, tachypnea, dehydration, irritable, weak cry what are consequences of hyperthermia - ANSWER seizures, hypotension, dehydration, hypernatremia, respiratory distress how can we manage hyperthermia - ANSWER adjust environment what is brown fat - ANSWER baby fat that is used to produce heat how long does brown fat stay post partum - ANSWER 3-5 weeks how much should an infant weigh at 6 months - ANSWER double their birth weight how much should an infant weigh at 12 months - ANSWER triple their birth weight should head or chest circumference be larger - ANSWER head what should each be - ANSWER 13-14; 12-14 describe weighing a baby - ANSWER scale and use lbs + ounces and grams describe measuring a baby - ANSWER measure length, head, chest measure from top of head to toe what do we want a newborns skin color to be - ANSWER pink define acrocyanosis + is this ok? - ANSWER pale blue extremities, yes define central cyanosis + is that ok? - ANSWER blue all over, no what do term babies extremities do - ANSWER flexion what do preterm babies extremities do - ANSWER extension describe preterm skin - ANSWER no creases, thin and transparent describe term skin - ANSWER creases present, vernix cases disappears describe post term skin - ANSWER peeling and dry describe a cephalohematoma - ANSWER blood collection that does NOT cross suture line what might a cephalohematoma result in - ANSWER anemia, hypotension, jaundice when does cephalohematoma disappear - ANSWER 2-3 weeks - months describe caput succedaneum - ANSWER fluid collection that DOES cross suture line when does caput succedaneum disappear - ANSWER 12 hours - a few a days describe subconjuntival hemorrhage - ANSWER blood behind sclera describe transient strabismus - ANSWER cross eyed describe dolls eyes - ANSWER eyes move in opposite direction of head describe preterm ears - ANSWER no recoil, not a lot of cartilage, flat, shapeless describe term ears - ANSWER recoil, in line with eyes, cartilage present where do we want ears to sit - ANSWER in line with eyes describe cleft lip - ANSWER separation of lip describe cleft palate - ANSWER separation of palate what is a big risk for cleft palate babies - ANSWER aspiration describe precocious teeth - ANSWER teeth that come in early... like at birth describe epsteins pearls - ANSWER harmless cysts in the mouth when assessing the umbilical cord what should we see - ANSWER 2 arteries and 1 vein what is a sacral dimple - ANSWER indentation at end of spine what should we do if it is not closed - ANSWER x-ray what is spina bifida - ANSWER spine doesnt close properly what is tethered cord syndrome - ANSWER tissue attaches to cord what should the breast bud measure if full term - ANSWER 1/2 to 1 cm when should umbilical hernia resolve - ANSWER 2 years describe preterm male genitals - ANSWER few rugae, small scrotum, testes palpable describe term male genitals - ANSWER lots of rugae, full sized scrotum describe preterm female genitals - ANSWER clitoris is visible and labia majora is separated describe term female genitals - ANSWER labia majora is covering and protecting define pseudomenstruation - ANSWER vaginal discharge with blood define hypospadias - ANSWER urethral opening on ventral side define epispadias - ANSWER urethral opening on dorsal side define phimosis - ANSWER foreskin can not be retracted define hydrocele - ANSWER fluid around scrotum define cryptorchidism - ANSWER testes fail to descend describe vernix caseosa - ANSWER cheese like substance that covers baby in womb describe milia - ANSWER little white bumps on the face what should we teach parents - ANSWER to not pop, it will resolve on own describe telangiectatic nevi - ANSWER little red spots Reflexes - ANSWER DTRs, Babinski, corneal, gag Cerebellar Function - ANSWER Balance, gait, Romberg test Speech & Language - ANSWER Clarity, comprehension, articulation Vital Signs - ANSWER Especially changes suggesting ↑ICP or brainstem dysfunction Purpose of Physical Examination - ANSWER To perform a systematic, organized, and comprehensive physical examination Preparation for Examination - ANSWER Provide privacy, perform hand hygiene, introduce yourself, explain procedure, gather equipment Mindset Tips - ANSWER Develop a consistent routine, visualize the sequence, practice frequently, treat the patient respectfully General Tools for Examination - ANSWER Writing surface, scale with height rod, thermometer, watch with second hand Specialized Equipment - ANSWER Otoscope, tuning fork, ophthalmoscope, nasal speculum, tongue blade, penlight Health History Includes - ANSWER Biographical data, reason for seeking care, history of present illness, present and past health Vital Signs and Baseline Measurements - ANSWER Measure temperature, pulse, respirations, and BP (bilaterally if needed) Systematic Head-to-Toe Examination Sequence - ANSWER Inspect color, moisture, integrity, temperature, symmetry of hands/skin/nails TMJ Assessment - ANSWER Palpate TMJ for pain or crepitus; assess ROM. Eye Inspection - ANSWER Inspect external structures (eyelids, lashes, conjunctiva, sclera, cornea, iris). Assess pupils for PERRLA. Test visual acuity and fields (CN II). Assess EOMs (CN III, IV, VI). Fundoscopic exam if indicated. Ear Examination - ANSWER Inspect and palpate for alignment, color, lesions, tenderness. Inspect canal and tympanic membrane with otoscope. Evaluate hearing (CN VIII) with whisper, Weber, Rinne tests. Nose & Sinuses Inspection - ANSWER Inspect for symmetry, patency, discharge. Test CN I (olfaction) if indicated. Palpate sinuses for tenderness; transilluminate if congested. Mouth & Throat Examination - ANSWER Inspect lips, mucosa, gums, teeth, tongue, palate, uvula, tonsils. Assess CN IX, X, XII (swallow, gag, tongue movement). Note color, odor, lesions, or discharge. Neck Assessment - ANSWER Inspect symmetry, skin, trachea alignment. Palpate lymph nodes and thyroid. Assess CN XI (shoulder shrug/neck rotation). Palpate carotids; auscultate for bruits; check JVD. Upper Extremities Examination - ANSWER Inspect symmetry, color, hair, lesions. Palpate pulses (brachial, radial), temperature, turgor. Test ROM, strength, tone, and reflexes (biceps, triceps, brachioradialis). Posterior & Lateral Thorax Inspection - ANSWER Inspect shape, symmetry, muscular development. Observe breathing patterns. Palpate expansion, fremitus, tenderness. Auscultate for breath sounds bilaterally. Anterior Thorax / Heart Examination - ANSWER Inspect chest contour, symmetry, movement. Palpate PMI. Auscultate heart sounds at Aortic, Pulmonic, Erb's, Tricuspid, Mitral areas. Note S1, S2, any murmurs or extra sounds. Breasts & Axillae Examination - ANSWER Female: Inspect size, shape, symmetry, skin, nipples. Palpate tissue and axillary lymph nodes. Male: Inspect and palpate for lumps, tenderness, or discharge. Abdomen Examination - ANSWER Position supine, knees slightly flexed. Sequence: Inspect → Auscultate → Palpate (→ Percuss if indicated). Inspect contour, color, scars, pulsations. Auscultate bowel and vascular sounds. Palpate lightly, then deeply for tenderness, masses, organ size. Lower Extremities Examination - ANSWER Inspect color, hair, symmetry, edema, varicosities. Palpate pulses (femoral, popliteal, posterior tibial, dorsalis pedis). Assess cap refill, temperature, edema. Test ROM, strength, tone, DTRs (patellar, Achilles). Observe gait and balance. Genitalia & Rectum Examination - ANSWER Male: Inspect and palpate penis, scrotum, inguinal region, anus, and rectum. Assess for hernias, tenderness, discharge, or nodules. Female: Lithotomy position. Inspect external genitalia, urethra, perineum, anus. Palpate for tenderness, discharge, tone, or masses. Musculoskeletal & Neurologic Overview - ANSWER Inspect alignment and posture (spine, shoulders, hips). Test ROM and muscle strength. Observe gait, balance, and coordination. Assess cranial nerves, sensation, and reflexes. Documentation Example - ANSWER "Alert, oriented ×4. Speech is clear. Skin warm, dry, intact. PERRLA. TMs pearly gray. Lungs clear bilaterally. Heart RRR, S1/S2 normal, no murmurs. Abdomen soft, non-tender, BS active ×4. Pulses 2+ throughout. No edema. Intravenous (IV) Infusion Site - ANSWER Inspect for redness, edema, or drainage. Palpate for pain or tenderness. Ensure dressing is clean, dry, intact, and IV line is secure. Expected Findings for IV Infusion Site - ANSWER No redness, edema, drainage, or tenderness; skin intact. Abnormal Findings for IV Infusion Site - ANSWER Erythema, warmth, pain, swelling → may indicate phlebitis or infiltration. Surgical Incision - ANSWER Inspect for redness, edema, drainage, and intact staples or sutures. Measure length and approximation of wound edges. Assess pain level and impact on mobility. Expected Findings for Surgical Incision - ANSWER Edges well-approximated, minimal swelling, no drainage. Abnormal Findings for Surgical Incision - ANSWER Dehiscence, purulent drainage, gaping edges → possible infection or poor healing. Open Wound - ANSWER Inspect color, size, width/depth, and drainage type. Note granulation tissue (pink/red = healing). Document with measurements and photographs. Expected Findings for Open Wound - ANSWER Red/pink granulation tissue, serous drainage. Abnormal Findings for Open Wound - ANSWER Necrotic tissue, foul odor, purulent discharge → infection or necrosis. Infected Incision / Dehisced Wound - ANSWER Measure length, width, depth using a sterile applicator. Describe tissue type (granulation, necrotic, exudate). Identify odor, color, and drainage amount. Expected Findings for Infected Incision / Dehisced Wound - ANSWER Red granulation tissue with minimal serous drainage. Abnormal Findings for Infected Incision / Dehisced Wound - ANSWER Yellow/green exudate, necrotic tissue, foul odor → infection. Nasal Cannula - ANSWER Check respiratory effort, oxygen saturation, and cough. Inspect nares and ears for redness or breakdown. Assess interference with self-care and sleep. Expected Findings for Nasal Cannula - ANSWER No redness, O₂ sat within target range, skin intact. Abnormal Findings for Nasal Cannula - ANSWER Erythema or skin breakdown behind ears → pressure injury. Oxygen Mask (Venturi or Simple) - ANSWER Inspect facial skin and ears for pressure marks. Observe for use of accessory muscles or tripod position. Expected Findings for Oxygen Mask - ANSWER Even breathing pattern, no facial redness. Abnormal Findings for Oxygen Mask - ANSWER Indentations, redness, or mask pressure injuries → poor fit or prolonged wear. Tracheostomy Tube - ANSWER Inspect stoma and neck for redness, drainage, or skin breakdown. Assess respiratory effort and suctioned secretion characteristics. Evaluate ability to communicate (mouthing/writing). what might a postpartum moms temp be elevated to - ANSWER 100.4 when should the postpartum mom be afebrile - ANSWER 24 hours after when else might the moms temp increase - ANSWER when milk comes in describe what happens to BP for postpartum moms - ANSWER increase describe what happens to HR for postpartum moms - ANSWER bradycardia when should HR go back to normal - ANSWER 6-10 days what might a high BP indicate - ANSWER gestational or chronic HTN, renal disease, anxiety, pre-eclampsia how can we treat high BP - ANSWER labetalol, procadria what might low BP indicate - ANSWER hematoma, hemorrhage why might tachycardia be happening - ANSWER infection, difficult birth, anxiety what could marked tachypnea indicate - ANSWER respiratory distress, pulmonary edema what can a temp of 100.4 or above indicate - ANSWER infection cardiac output declines by _____% in the first 2 weeks - ANSWER 30 when is normal level reached - ANSWER 6th week why does diuresis occur - ANSWER shift of extracellular fluid what might we hear if mom fails to eliminate fluid - ANSWER crackles in lungs how should lungs sound postpartum - ANSWER clear how should breathing patterns be postpartum - ANSWER unlabored what might tachypnea indicate - ANSWER infection, pain what might bradypnea indicate - ANSWER respiratory compromise, meds what 3 things could cause fluid overload - ANSWER mag, Pitocin, fluid bolus what is most common neuro symptom - ANSWER headache what are some causes of headaches - ANSWER fluid shift, leakage of fluid, HTN, stress what could we give if patient is having visual changes (spots, blurring, bright lights) - ANSWER caffeine, acetaminophen encourage women to eat foods high in ______ - ANSWER iron what might they need to continue taking - ANSWER prenatal vitamins how should nutrition change for breastfeeding moms - ANSWER 300 kcal increase how should nutrition change for non-breastfeeding moms - ANSWER 200 kcal decrease explain WBC changes postpartum - ANSWER leukocytosis (25-30) when do plasma levels reach pre pregnant state - ANSWER 6 weeks when should platelet and blood values levels return - ANSWER 6 weeks for when nonbreastfeeding women when does menstruation usually occur - ANSWER 7-12 weeks what about ovulation - ANSWER 70-75 days for when breastfeeding women when does menstruation usually occur - ANSWER 3 + months is breastfeeding a form of birth control? - ANSWER no what is the initial weight loss post partum - ANSWER 10-12 lbs on average, when do women return to pre pregnant weights - ANSWER 6-8 weeks, differs per patient postpartum assessment: B - ANSWER breast postpartum assessment: U - ANSWER uterus/ abdomen postpartum assessment: B* - ANSWER postpartum assessment: B! - ANSWER postpartum assessment: L - ANSWER postpartum assessment: E - ANSWER postpartum assessment: H - ANSWER postpartum assessment: E* - ANSWER what should you look for in your breast assessment - ANSWER size, shape, fullness, swelling, reddened areas, nipples what should moms do if they do not want to lactate - ANSWER cabbage leaves, cold compress, avoid warm water, anti-inflammatory meds, supportive bra how often should moms feed - ANSWER every 1.5-3 hours how much time should be spent on a breast - ANSWER 10-20 minutes breast should feel ________ but not ________ - ANSWER heavy; hard or sore can breastfeeding moms drink alcohol - ANSWER yes but not 2 hours before feeding describe the cradle position - ANSWER holding a baby describe the modified cradle position - ANSWER holding a baby + hand supporting breast describe the football hold - ANSWER holding baby to side describe the side lying hold - ANSWER lying down and feeding baby how should the baby latch - ANSWER not just on nipple, on areolar part too when are nipple shields helpful - ANSWER flat or inverted nipples why is it important to let nipples dry - ANSWER to avoid cracks or fissures what are 4 ways we can note the infants are getting enough milk - ANSWER 6-8 wet diapers, swallowing sound, soft breasts, milk at edges of mouth what can we do for insufficient milk production - ANSWER increase moms fluid intake what can we do for sore nipples - ANSWER lanolin cream what can we do for flat nipples - ANSWER nipple shield or roll nipples what can we do for plugged ducts - ANSWER warm compress, express milk, use baby or pump to unclog, frequent nursing, avoid pressure what is mastitis - ANSWER infection for plugged ducts (unilateral) what are S/S of mastitis - ANSWER fever, chills, malaise, reddened area, swollen breasts, possible discharge how can we treat mastitis - ANSWER antibiotics, warm compress, express what is engorgement - ANSWER hard and painful breasts when filled with lots of milk (bilateral) what is the key difference between this and mastitis - ANSWER infection vs no infection what can we do for engorgement - ANSWER don't miss feedings, express, cold applications in-between to slow filling why is weaning important when you want to stop breastfeeding - ANSWER to prevent engorgment what will the abdomen be like post partum - ANSWER flabby and loose will it respond to exercise - ANSWER yes describe distaseis recti abdominis - ANSWER separating of abdominal muscles describe red vs silver striae marks - ANSWER red = newer, silver = older what are after pains - ANSWER contraction as involution happens how can we help with after pains - ANSWER prone lying and motrin when would we not want to give motrin - ANSWER pre clammy patients and a platelet count of 70,000 or less what happens to the spongy layer - ANSWER sheds what happens to the basal layer - ANSWER splits to 2, outer layer shed, inner layer helps form endometrium how does the placental site heal - ANSWER sheds/ exfoliation what is endometritis - ANSWER infection of endometrial lining what are S/S of endometritis - ANSWER spiked fever, uterine tenderness, foul smelling loch what are risks for this infection - ANSWER C/S, prolonged labor, PPROM, instrument assisted birth, multiple vaginal exams, chorio a fundal assessment relates the position of the fundus to the ____ - ANSWER umbilicus where should the fundus be 6-12 hours post partum - ANSWER