Mark Klimek NCLEX Review: Fetal Complications, Stages of Labor, Assessments, Variations for NB, Maternity Medications
Mark Klimek NCLEX Review: Fetal Complications, Stages of Labor, Assessments, Variations for NB, Maternity Medications, Medication Hints, Psych Tips, Operational Stages.
Fetal Monitoring Patterns
There are 7 fetal monitoring patterns to learn … The ones that start with the letter “L” are bad heart tracings. Use the mnemonic “LION” as the nursing intervention.
Normal fetal heart rate = 120 to 160 beats per minutes
1. Low Fetal HR (heart rate)—HR <110
- This is BAD
- You do “LION”
- Left side (place mother on the left side)
- IV
- Oxygen
- Notify HCP
• Stop Pitocin (pit) if it was running
- Implement before “LION”
2. High Fetal HR—HR >160
- Document acceleration of fetal HR
- Take the mother’s temp
- Not a high priority … Baby is WNL
3. Low Baseline Variability
- This is BAD
- Fetal HR stays the same—it doesn’t change
- You do “LION”
- Left side
- IV
- Oxygen
- Notify HCP
- Stop pit if it is running (first)
4. High Baseline Variability
- Fetal heart rate is always changing—This is GOOD
- Document finding
Note
In utero, low variability of V/S is a bad sign, but highly variable V/S is a good sign.
5. Early Deceleration
- This is normal … No big deal
- Document finding
6. Variable (VERY) Decelerations
- This is very BAD
- This indicates prolapsed cord
- What is the nursing intervention?
- PUSH and POSITION
7. Late Decelerations
- This is BAD
- You do “LION”
- Left side
- IV
- Oxygen
- Notify HCP
- Stop pit if it is running
Recap
- Look at the first letter of a fetal heart rate tracing, it is a bad heart tracing if it starts with an “L”
- Therefore, do “LION” which also starts with the letter “L”
- Variable deceleration is very bad
- PUSH and POSITION
- Ace of spades means that this answer works every time
- Check the FHR
Second stage of L&D (labor and delivery)
Delivery of the fetus … This is about order.
1. Deliver head … The mother needs to stop pushing
2. Suction the mouth then the nose … ABC order
3. Check for nuchal (around the neck) cord
4. Deliver the shoulders, next, the body
5. Make sure baby has ID band on before it leaves the delivery area
Third stage of L&D
- Delivery of the placenta
- What do you check for with the delivery of the placenta?
- Make sure the placenta is complete and intact
- Check for 3-vessel cord—2 arteries and 1 vein, AVA
Fourth Stage of L&D
- Recovery
- There are 4 things you do in the 4th stage, 4 times an hour (every 15 minutes)
1. Vital signs: Assessing for shock … Blood pressure goes down, HR goes up … Pt looks pale, cold, and clammy
2. Fundus: If it is boggy, massage it … If displaced, catheterize it
3. Check perineal pads … If there is excessive bleeding, the pad will saturate in 15 minutes or less
4. Roll patient over and check for bleeding underneath her
Recap
4 things to do every 15 minutes in the 4th stage of labor
- V/S à Fundus à Peri pads à Roll
Post-partum Assessment
- Assess every 4 to 8 hours
- Assess for “BUBBLE HEAD”
- Make sure you focus on the 3 designated steps stated as important from BUBBLE HEAD
“BUBBLE HEAD” stands for
• Breasts
• Uterine fundus should be firm … Important
- Massage if fundus is boggy and midline
- Catheterize patient if fundus is boggy and not midline
Question
What should the postpartum uterine tone, height, and location normally be?
- The tone of the fundus should be firm, not boggy
- The height of the fundus after delivery should be at the umbilicus (or navel)
- Fundus involutes about 2 cm everyday PP (postpartum)
- The location of the uterus should be midline
- If not midline, the bladder is distended
- Bladder
- Bowel
- Lochia is vaginal drainage postpartum (Know the order)
- Rubra—red
- Serosa (if your cheeks are rosy)—pink
- Alba (albino)—white
- Moderate amount: 4 to 6 inches on pad in an hour
- Excessive: saturate a pad in 15 minutes
- Episiotomy
- Hemoglobin/hematocrit
- Extremities—Looking for thrombophlebitis … Important
- What is the best way to determine if a patient has thrombophlebitis?
The best way is to measure Bilateral calf circumference (Best answer)
Homan sign is not the best answer
- Affect - emotional
- Discomforts
Recap
The 3 big things about postpartum on the exam are
- Fundus
- Lochia
- Thrombophlebitis
Variations in the newborn
All of the following skin conditions are Normal
- Milia - White, pinhead-size, distended sebaceous glands on the nose, cheek, chin, and occasionally on the trunk. Usually disappear after a few weeks of bathing
- Epstein pearls - Palatal cysts of the newborn,
which are small white or yellow cystic vesicles
- Mongolian spot - Bluish discoloration in the sacral region of newborn
usually seen in African Americans … Carefully document its presence
as such action may prevent child abuse charges against parents or
caregiver
- Erythema toxicum neonatorum - Described as flee-bitten lesion … pink
rash with firm, yellow-white papules or pustule on the face, chest,
abdomen, back and buttocks of some newborns. Usually appears 24 to
48 hours after birth and disappear in a few days
- Hemangioma - An abnormal accumulation of blood vessels in the skin of the newborn. It is one of the most common birthmarks associated with childhood and affect 10% of all children
Cephalohematoma vs. Caput succedaneum … Make sure you know these 2
• Cephalohematoma - A collection of blood between the periosteum of a skull bone and the bone itself
- Occurs in one or both sides of the head
- Occasionally forms over the occipital bone
- Develops within the first 24 to 48 hours after birth
• Caput succedaneum - An edema of the scalp of the neonate during birth from mechanical trauma of the initial portion of scalp pushing through a narrowed cervix
- The edema crosses the suture lines
- May involve wide areas of the head or it may just be a size of a large egg
- Caput Succedaneum (CS)—Crosses Suture line, and Caput Symmetrical
Hyperbilirubinemia in the Newborn
- Physiologic jaundice is normal and appears after 24 hours after birth … Disappears in about one week
- Pathologic jaundice is seen in the 1st 24 hours after birth
Vernix caseosa - Fatty, whitish secretion of the fetal sebaceous
gland to protect the skin from amniotic fluid exposure
Acrocyanosis - Blue discoloration of the hands and feet in the newborns during the first few days after birth
- Normal finding and not indicative of poor oxygenation, respiratory distress, or cold stress
Nevi (Telangiectatic nevi)
Nevi or telangiectatic nevi, a.k.a. “stork bites,” are pink and easily blanched skin lesion that appear on upper eyelid, nose, upper lip, lower occipital area, and nape of the neck.
- No clinical significance
- Disappears by 2 years of age
Port wine stain
Port-wine stain or nevus flammeus is seen at birth and is composed of a plexus of newly formed capillaries in the papillary layer of the corium
- Commonly found on the face and neck
- Red to purple, varies in size, shape and location
- Does not blanch on pressure
OB Medications - 6
- Terbutaline (Brethine)
- Mag sulfate
- Pitocin
- Methergine
- Dexamethasone
- Surfactant
1. Tocolytics (Stop contractions, stop labor)
- Tocolytics are given to women in premature labor that must be stopped
- Terbutaline (Brethine)
- S/E: maternal tachycardia (don’t give with cardiac disease)
- Mag sulfate
- Treatment with Mag sulfate will induce hypermagnesemia, which will cause
everything to go down
- HR will go down, BP go down, Reflexes go down, RR go down, LOC go down
Question
So, what is the nursing intervention for hypermagnesemia due to mag sulfate treatment?
- Monitor respiration
- If RR <12, decrease dose of Mag sulfate
- Assess for reflexes
- Normal reflex is 2+
- If reflexes are 0 or 1+ … Decrease dose of mag sulfate
- If reflexes are 3+ or 4+ … Increase dose of mag sulfate
2. Oxytocics (Stimulate and strengthen labor)
- Pitocin (Oxytocin)
- S/Es: Uterine hyperstimulation (defined as longer than 90 seconds, closer than 2 minutes) The nursing intervention is to lower the dose of Pitocin in case of uterine hyperstimulation
- Methergine
- Causes HTN—if it contracts blood vessels it makes sense that this increases BP
3. Fetal/Neonatal Lung Meds
- Dexamethasone (steroid)
- Given to mother IM
- Can repeat as long baby is in utero
- S/E: increase glucose (steroid)
- Surfactant (Survanta)
- Given to baby via transtracheal route
- Given After birth
Medication Helps and Hints
1. What is Humulin 70/30?
- Mix of insulin N and R … 70% = N … 30% = R
- So, if 100 units of 70/30 is given to a patient …
the patient gets 70 units of N and 30 units of R
- Or, for 50 units—35 units of N and 15 units of R
- To remember the bigger number, think of a fraction … The numerator N is on top; therefore, Insulin N is the bigger number
Question
Can you mix insulin in same syringe and how?
- Yes, insulin can be mixed in the same syringe
- How do you mix insulin?
(1) Pressurize vial and (2) Draw up insulin
(1) To pressurize the vial … Inject air into N, the into R, Draw up R
(2) To draw up insulin … Think of RN
Needle for Insulin Injections
Know what needle to use for insulin injection?
Giving an IM injection
- Pick answer in which both answers have a “1” in them
- “I” in IM looks like the “#1”
- Use a 21-gauge, 1-inch long needle
Giving a SubQ injection
- 5 looks like an “S” in “SubQ”
- Pick the answer that has “5s” in it
- Use a 25-gauge, 0.5 inch needle
2. Heparin
- Given IV or SubQ
- Works immediately
- Cannot be given for more than 3 weeks (21 days)
Except for Lovenox (enoxaparin)
- Antidote: Protamine sulfate
- Labs: PTT
- Can be used during pregnancy—Class C medication
3. Coumadin
- Given only PO
- Takes few days to a week to work (likely 4 to 5 days)
- Patients can be on Coumadin for their entire life
- Antidote: Vitamin K
- Labs: PT/INR
- Can’t be used during pregnancy—Class X medication
Note: The only antipsychotic that can be given
to pregnant women is Haldol
4. Diuretics
- K-wasting and K-sparing diuretics
- Any diuretic ending in “X,” “Xes” out K
- So, it wastes “K” like Lasix
- PLUS Diuril
- If it does not end in “X,” it is a sparer
- Examples:
Spironolactone
Amiloride - Hydrochlorothiazide
Furosemide
Bumetanide
Clotrimazole
Hydrochlorothiazide
Torsemide
Chlorothiazide
5. Baclofen and Cyclobenzaprine
- 2 muscle relaxants to know for the NCLEX
- Baclofen - Lioresal
- Cyclobenzaprine - Flexeril
- The 2 things being tested on the board are
a) Fatigue/Drowsiness
b) Muscle weakness (paresis)
- The 3 things to teach
a) Don’t drink
b) Don’t drive
c) Don’t operate heavy machinery
*Note: The following phrase help you remember baclofen as a muscle relaxant …
“When you are on baclofen, you are on your back loafing”
Pediatric Teaching
Piaget’s Theory of Cognitive Development—4 Stages
- There is some overlap with Piaget’s Theory of Cognitive Development and toy appropriateness based on age on page 50
- Make sure not to confused between the two
1. Sensorimotor—0 to 2 years
- They only think about what they are sensing right now
- You can teach only in the present (while you are doing it)
- Think Present Tense
- Just tell them
- Children at this age don’t understand play
- Tell them as it is happening
Question
A 19-month-old infant is about to have a lumbar puncture (LP) for csf analysis and culture. How would the nurse teach the child?
- Tell the child how the LP is done while it is being done.
- There is no such thing as preop teaching for this age group
- Preop teaching are only for the parents—mom and dad—or guardian
2. Preoperational (Preschooler)—3 to 6 years
- They are fantasy-oriented, imaginative, and illogical, there thinking obeys no rules
- However, they understand the future and they understand the past
Question
A 3-year-old child is schedule for a lumbar puncture (LP) for csf analysis and culture. What is the nurse’s best action to teach the child about the procedure?
- Teach 2 hours before …, the morning of …, or the day of the procedure how it will be performed
- They are in the “imaginative” stage … Don’t give them a whole lot of time to imagine the worst
- Teach them what will be done … Future Tense
- They can learn by playing
3. Concrete Operations—7 to 11 years
- “7/11 Grocery Stores are surrounded by concrete”—no trees, no flowers
- Children in this age group are rule-oriented
- Live and Die by the Rules and Cannot Abstract
- There is one way to do things … Everything else is wrong
- Teach them a day or two ahead of time
- Teach them what you’re going to do and how to do skills
- Use age-appropriate reading and demonstration (skill)
Question
An 8-year-old child is schedule for a lumbar puncture (LP) for csf analysis and culture. What is the nurse’s best action to teach the child about the procedure?
- Use age-appropriate demonstration 1 or 2 days before the procedure
4. Formal Operations—12 to 15 years
- They can abstract and think Cause and Effect
- As soon as children become twelve, teach them like an adult
- This is now a regular Med-Surge question
- When is the first age a child can manage his care?
- 12 years old
- Manage means making decisions which require the person to abstract
Question
Which of the following 4 children will be able to manage his own care?
a. A 7-year-old with Cystic Fibrosis
b. An 8-year-old with Diabetes Mellitus
c. A 10-year-old with a scraped knee
d. A 13-year-old with Chronic Renal Failure
- A 10-year-old with a scraped knee as one of the answer choices is a diversion to fool the exam taker. Answer to these questions is not about the severity of the condition but about the age-appropriateness to make decision
The 10-year-old will Wash, Dry, apply Neosporin and Bandaid the wound as thought … He will continue to do the same thing if the wound becomes is exudating pus and swollen the 4th day … A 12-year-old will likely stop and seek help
- A 13-year-old with chronic renal failure will get help if they are thought to auscultate for a bruit over a shunt and heard nothing on day 3
- This is managing
- This means that knowing what you can do when you can, and seek help when you cannot
Note: Manage = 13-year-lod … Skill = 8-year-old
Seven Principles to Obey When Taking Psychiatric Tests
1. Make sure you know what phase of the nurse-patient
relationship you are in
2. Don’t give/accept gifts in psych
- If a schizophrenic patient gives you flowers, to you the HCP it may be flowers; to him, it may be a marriage proposal
3. Don’t give advice!
- If the patient says, “What do you think I should do?”
- Reply by asking them the same question” “What do you think you should do?”
- The pt won’t be able to blame you in the future even if things work in his favor
- Avoid giving advice in psych
4. Never give guarantees
- For instance, “If you cry, you will feel better.”
- There are chances that crying may not help the patient
5. Immediacy
- If you are between 2 answer choices and you don’t know which one to pick, pick the one that keep him talking
- Don’t refer to someone
6. Concreteness
- Psych pts take you literally. Therefore …
- Never use slang
- If a patient says “I feel rotten.” Don’t reply by saying, “You feel rotten?”
- Don’t ever say to an upset patient to “Chill out!”
- Don’t use figurative speech such as: “What goes around, comes around”
7. Empathy
- Empathy is about the nurse accepting the patient’s feelings
- Don’t ever pick an answer that says, “Don’t you worry …” … “You shouldn’t feel …” … “Anybody would feel …” … “I know how you feel …” …
4 steps to answering empathy questions
- Empathy questions will always have a quote
- Role play the feelings (Put yourself in their place) and say the words as you really meant them
- Ask yourself if I said these words, how would I be feeling right now?
- Choose the answer that reflects the patient’s feeling, and ignore what the pt said