NCLEX REVIEW- LATEST UPDATE WITH 100% SOLUTIONS

Pitocin: Indication? Adverse Effects/Monitoring? - Answer- Given to strengthen contractions and labor. Can cause uterine hyperstimulation. Contractions should be NO LONGER than 90 seconds and no closer than 2 minutes apart. If they are any more than that; slow pitocin How to Mix insulins (step 1-5) - Answer- 1. Draw up the total amount of (AIR) 2. Air into N 3. Air into R 4. Draw up R 5. Draw up N IM injection - Needle size + length? Sub-Q Size + length? - Answer- IM: 21g 1 inch needle *Memory clue: I looks like 1* Sub-Q: 25g 0.5 inch *Memory clue: S looks like 5* Cephalohematoma vs Caput Succedaneum - Answer- Cephalohematoma: bleeding in brain of newborn. Does not cross suture line and is asymmetrical Caput Succedaneum: Crosses suture line and is symmetrical. *Memory clue: think CS = crosses suture, CS = Caput symmetrical* Terbutaline: Indications? Nursing considerations? Contraindication? - Answer- Used to slow down birth and contractions Contraindicated: in mothers with heart disease due to its common side effect of tachycardia Fundal Height - Postpartum: Height right after birth? Everyday after that? - Answer- Fundal height right after birth is at the umbilicus - Every day after birth it will go down by 1, height correlates with the day postpartum Put the following tracheostomy care steps in order: - Remove old dressing - clean around stoma w/ sterile water or saline then replace gauze - Don sterile gloves, remove old disposable inner cannula and replace with new one - Collect supplies and position patient - Don PPE - Answer- 1. Collect supplies and position patient 2. Don PPE 3. Remove old dressing 4. DON sterile gloves and remove old disposable inner cannula then replace with new one 5. Clean around stoma with sterile water or saline then replace gauz Second stage of labor (delivery): Place steps in order for delivering BB. - Make sure baby has an ID before leaving delivery area - Suction babies mouth then nose - Deliver shoulder then body - Check for nuchal cord - Deliver babies head then tell mom to stop pushing - Answer- 1. Deliver babies head and tell mom to stop pushing 2. Suctions babies mouth then nose 3. Check for nuchal (cord around neck) around neck 4. Deliver shoulders then body 5. Make sure BB has ID before leaving delivery area After the delivery of the placental: What are the nursing interventions and assessments? - Answer- Ensure placenta is intact and check for vessels in the cord should be AVA Fourth stage of labor: what is it? what are we assessing? What are nursing Interventions? - Answer- Fourth stage is recovery. NOTE: assess 4 things during the 4th stage of labor four times an hour (every 15 minutes) 1. Assess V/S q15 to monitor for shock plus S/S cool, pale, clammy skin, tachycardia, hypotension 2. Monitor fundus: If boggy massage it, if displaced catheterize 3. Monitor Lochia: Pt is bleeding too much if she is saturating a pad every 15 minutes. report ASAP. 4. Monitor for Thrombophlebitis: measure bilat calf circumference!!