lOMoARcPSD|44532475
Galen College Nur 283 comp 1
Transition To Registered Nursing Practice (Galen College of Nursing)
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Galen College Nur 283
Comprehensive 1 Exam
1. Priority= ABC’s; safety ; who will die first!!!!
st
a. Triage 1 client w/ multiple compound fractures and reporting chest pain
b. Report to HCP pt who has drainage that has was serosanguineous and has not become
sanguineous
c. See patient first who polycystic fibrosis is bleeding with black tarry stool
d. Pt w/ asthma suddenly stops wheezing
e. Pancreatitis with pain upon inspiration
2. Delegation= LPN vs UAP within scope
a. UAP- change linens, VS NOT NEW ADMIN, REMIND, administer tap water enema (NOT
FLEET). Document drainage, Output
i. UAP turns patient every 2 hours ; or can recheck VS 2 hours after kidney biopsy
b. LPN- Reinforce teaching, enteral feeding , PPN, Meds, PO SQ, IM, IV (isotonic) monitor, 24 hr
post op, wound care
3. Unit assignment= related to nurses skill set if from MedSurg, ortho ect,
a. OB nurse gets appendicitis patient
4. Management – use translator ...speak with eye contact patient NOT translator
5. Nurse suspect child abuse. Nurse should first
a. Assess/ Obtain detail bruising
6. Signs of labor=
a. True labor S/S= bloody show, water breaks, contractions increase freq, duration, intensity,
Cervix dilated 10 cm , effacement 0-100% (cervix thinner shorter)
i. Regular contractions= increase in freq , duration, intensity, DOES NOT decrease
with rest
b. False Labor – Braxton hicks= disappear with walking or position changes
i. Irregular contractions alleviated with rest or position change, no changes to
7. Stage 1 of labor= Active, laten post labor expected ; Normal FHR 110-140
a. Late decelerations tell Dr as priority
nd st
b. Pt is 2 stage of labor FHR decrease = turn patient to the left 1 ( least invasive)
c. Stage 1=contractions=cervix dilation
i. 1. Early/latent phase (early education 0-3 cm, dilation, monitor FHR)
ii. 2. active phase (breathing technique, pain management, cervix 4-7cm, continue,
OXYTOCIN, EPIDURAL, IV narcotics slowly over peak of contractions),
iii. 3. transition phase (8-10cm, 100% effacement, ANXIETY & VOMITY, urge for BM,
Push @ 10cm, BLOODY SHOW assess amniotic fluid, emotional support,
breathing techniques ONLY PUSH @ 10cm)
d. Stage 2 delivery of baby (cervix 100% effaced 10cm dilated, urge to bear down, Fergueson
reflex) position= high fowler's, lithotomy, side-lying (assess- FHR, freq, duration,)
e. Stage 3 delivery of placenta= high risk for infection, uterine inversion (NEVER pull cord), give
PITOCIN
f. Stage 4 postpartum recovery (check bleeding peri pads (report fully saturated in 1 hr, infection
over 100.4 report) 2-4 hours after birth= breastfeeding and skin to skin
st 3 times every 5 mins then every 15 mins
i. Interventions= check fundus 1 , void (every 2-
3hrs) or use cath, Pitocin IV or IM, breast feeding,
ii. Treatment for boggy fundus-fundal massage, void, oxytocin, methergine (increases
BP)
iii. Lochia= Rubra/ dark red 3-4 days; Serosa/ pink brown= 4-10 days; Alba/
white/yellow= 10-28 days
iv. Peri-care- Squeeze peri-bottle with warm water, front to back wipe, blot area,
v. Report bloody fluid should be clear
vi. If FHR is 180 turn mom to left side
vii. Report late deceleration
Downloaded by madiba South Africa stuvia ()
Galen College Nur 283 comp 1
Transition To Registered Nursing Practice (Galen College of Nursing)
Scan to open on Studocu
Studocu is not sponsored or endorsed by any college or university
Downloaded by madiba South Africa stuvia ()
, lOMoARcPSD|44532475
Galen College Nur 283
Comprehensive 1 Exam
1. Priority= ABC’s; safety ; who will die first!!!!
st
a. Triage 1 client w/ multiple compound fractures and reporting chest pain
b. Report to HCP pt who has drainage that has was serosanguineous and has not become
sanguineous
c. See patient first who polycystic fibrosis is bleeding with black tarry stool
d. Pt w/ asthma suddenly stops wheezing
e. Pancreatitis with pain upon inspiration
2. Delegation= LPN vs UAP within scope
a. UAP- change linens, VS NOT NEW ADMIN, REMIND, administer tap water enema (NOT
FLEET). Document drainage, Output
i. UAP turns patient every 2 hours ; or can recheck VS 2 hours after kidney biopsy
b. LPN- Reinforce teaching, enteral feeding , PPN, Meds, PO SQ, IM, IV (isotonic) monitor, 24 hr
post op, wound care
3. Unit assignment= related to nurses skill set if from MedSurg, ortho ect,
a. OB nurse gets appendicitis patient
4. Management – use translator ...speak with eye contact patient NOT translator
5. Nurse suspect child abuse. Nurse should first
a. Assess/ Obtain detail bruising
6. Signs of labor=
a. True labor S/S= bloody show, water breaks, contractions increase freq, duration, intensity,
Cervix dilated 10 cm , effacement 0-100% (cervix thinner shorter)
i. Regular contractions= increase in freq , duration, intensity, DOES NOT decrease
with rest
b. False Labor – Braxton hicks= disappear with walking or position changes
i. Irregular contractions alleviated with rest or position change, no changes to
7. Stage 1 of labor= Active, laten post labor expected ; Normal FHR 110-140
a. Late decelerations tell Dr as priority
nd st
b. Pt is 2 stage of labor FHR decrease = turn patient to the left 1 ( least invasive)
c. Stage 1=contractions=cervix dilation
i. 1. Early/latent phase (early education 0-3 cm, dilation, monitor FHR)
ii. 2. active phase (breathing technique, pain management, cervix 4-7cm, continue,
OXYTOCIN, EPIDURAL, IV narcotics slowly over peak of contractions),
iii. 3. transition phase (8-10cm, 100% effacement, ANXIETY & VOMITY, urge for BM,
Push @ 10cm, BLOODY SHOW assess amniotic fluid, emotional support,
breathing techniques ONLY PUSH @ 10cm)
d. Stage 2 delivery of baby (cervix 100% effaced 10cm dilated, urge to bear down, Fergueson
reflex) position= high fowler's, lithotomy, side-lying (assess- FHR, freq, duration,)
e. Stage 3 delivery of placenta= high risk for infection, uterine inversion (NEVER pull cord), give
PITOCIN
f. Stage 4 postpartum recovery (check bleeding peri pads (report fully saturated in 1 hr, infection
over 100.4 report) 2-4 hours after birth= breastfeeding and skin to skin
st 3 times every 5 mins then every 15 mins
i. Interventions= check fundus 1 , void (every 2-
3hrs) or use cath, Pitocin IV or IM, breast feeding,
ii. Treatment for boggy fundus-fundal massage, void, oxytocin, methergine (increases
BP)
iii. Lochia= Rubra/ dark red 3-4 days; Serosa/ pink brown= 4-10 days; Alba/
white/yellow= 10-28 days
iv. Peri-care- Squeeze peri-bottle with warm water, front to back wipe, blot area,
v. Report bloody fluid should be clear
vi. If FHR is 180 turn mom to left side
vii. Report late deceleration
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