lOMoARcPSD|22900539 Bundle exam 1 Nursing Practice III (State College of Florida, Manatee-Sarasota) Studocu is not sponsored or endorsed by any college or university Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Common Maternal Terminology A-Z A Abortion 3 spontaneous or intentional termination of pregnancy Accelerations 3 a temporary increase of the fetal heart rate above baseline Acme 3 peak of uterine contraction Acrocyanosis 3 bluish discoloration of the extremities due to reduced peripheral circulation Amenorrhea 3 absence of menstrual period Amniocentesis 3 procedure that removes amniotic fluid from the amniotic sac for testing (chromosome abnormalities, neural tube defects, genetic disorders, etc.) or treatment Amnioinfusion 3 infusion of saline into the amniotic cavity to relieve umbilical cord compression Amnion 3 inner membrane (fluid-filled sac) surrounding the fetus AROM 3 artificial rupture of membranes ³ intentional rupture of the amniotic sac Atony 3 lack of muscle strength or tone Attitude 3 head posture of the fetus B Bloody show 3 presence of tinged pink/brown mucous that indicates labor is approaching Breech 3 bottom fetal presentation C Cephalic 3 head-first position of the baby for birth (crown of the head) Cephalopelvic disproportion 3 the fetus is too large and cannot pass through the maternal pelvis Cervical dilation 3 opening of the cervix from 0-10cm Chorioamnionitis 3 inflammation of the chorion and amnion due to bacterial infection Chorion 3 outer membrane surrounding the fetus Colostrum 3 first form of milk produced by the breasts immediately following delivery c/s 3 cesarean section Crowning 3 baby9s head becomes visible in the birth canal cx 3 contractions D Decelerations 3 periodic decrease in fetal heart rate (early, late, or variable) Decrement 3 DEcreasing of contraction Diastasis recti 3 partial or complete separation of the abdominal muscles D&C 3 dilation and curettage ³ dilation of the cervix and removal of part of the lining of the uterus by scraping or scooping the tissue d/c 3 discontinue Dystocia 3 difficult labor due to abnormal fetal size or position E Eclampsia 3 complication of preeclampsia; pregnancy induced hypertension resulting in seizures EDD 3 estimated date of delivery Effacement 3 thinning of the cervix from 0-100% Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Effleurage 3 soothing, stroking, circular movement along the abdomen with the fingertips Engagement 3 the longest diameter of the fetal presenting part passing through the pelvic inlet F Fetal bradycardia 3 when the fetal heart rate drops below 110bpm for 10 minutes or longer Fetal tachycardia 3 when the fetal heart rate rises above 160bpm for 10 minutes or longer Fontanelle 3 anatomical landmark on the infant skull comprised of soft membranous gaps between the cranial bones (anterior and posterior fontanelles) FHR 3 fetal heart rate Fundus 3 top of the uterus G GBS 3 Group B Streptococcus GDM - gestational diabetes mellitus GTPAL 3 gravidity, term births, preterm births, abortion, living children Gravidity 3 number of times a woman has been pregnant I Increment 3 INcreasing contraction intensity Involution 3 shrinking of the uterus to its original size Ischial spine 3 the point of reference to tell when the baby is engaged with the mother9s pelvis IUGR 3 intrauterine growth restriction L Lamaze breathing 3 a form of deep breathing during contractions as a form of pain management. Goal: mother responds to contractions with relaxation rather than tension Lanugo 3 thin, soft hair that sometimes covers the body of newborns Leopold9s Maneuver 3 abdominal palpation used to determine fetal position within the uterus LGA 3 large for gestational age Lie 3 position of the baby9s spine in relation to the mother9s spine LMP 3 last menstrual period LOA 3 left occiput anterior (optimal) LOP 3 left occiput posterior Lochia 3 vaginal discharge (mixture of blood, mucous and uterine tissue) after giving birth M Macrosomia 3 newborn that is large for gestational age (>8lb 13oz) Mastitis 3 inflammation of breast tissue Meconium 3 infant9s first bowel movement Multi 3 multiple N Naegle9s Rule 3 calculation used for estimating the expected due date based on a woman9s last menstrual period Nitrazine test 3 pH strip testing used to determine the presence of amniotic fluid in vaginal secretions (will turn blue is >6.0pH ³ ruptured membranes) Nuchal cord 3 umbilical cord is wrapped around the baby9s neck Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Nulli 3 none O Occiput 3 back of the fetal head Oligohydramnios 3 a lack of amniotic fluid Oxytocin 3 hormone that can cause or strengthen labor contractions P Passageway 3 shape of the mother9s pelvis Passenger 3 the fetus Parity 3 number of times mom has given birth to a baby Pitocin 3 synthetic form of oxytocin Placenta 3 organ that provides oxygen and nutrients to the baby and removes waste products from the baby9s blood Placental abruption 3 premature detachment (partial or total) of the placenta before childbirth Placental previa 3 attachment of the placenta is partially or fully covering the cervical opening Polyhydramnios 3 an excess of amniotic fluid Power 3 strength of contractions PPH 3 postpartum hemorrhage ³ severe bleeding or blood loss after giving birth (vaginal: >500mL; csection: >1000mL) Preeclampsia 3 gestational hypertension with presence of proteinuria Primi 3 first PROM 3 premature rupture of membranes (before labor begins) PPROM 3 preterm premature rupture of membranes (before 37 weeks) Q Quickening 3 when the mother starts to feel or perceive fetal movements R ROA 3 right occiput anterior (optimal) ROP 3 right occiput posterior S SGA 3 small for gestational age Shoulder dystocia 3 the fetal head is born but the shoulder gets stuck above the symphysis pubis SROM 3 spontaneous rupture of membranes (during labor) Station 3 a measurement of where the fetal presenting part is located in relation to the ischial spine T Teratogen 3 an agent that causes malformation (physical or functional defects) of the embryo or fetus. Ex: medications, radiation, illicit drugs, maternal infections Tocolytics 3 medications that inhibit uterine contractions U Uteroplacental insufficiency 3 placenta is not delivering enough oxygen to the fetus Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 V Variability 3 fetal heart rate varies in duration, intensity and timing VBAC 3 vaginal birth after having a cesarean birth Vertex 3 head-first position of the baby for birth (crown of the head) Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Postpartum Physical Assessment: BUBBLEHE Breast (Breast, Cardiac, Respirations) B o Expose only one breast at a time. Begin using circular motion with the flat surface of your fingers o Palpate the consistency: soft, filling, tense, or engorged o Inspect nipples: observe if erect, inverted, fissures, cracks, or soreness o Ask the breast-feeding mother to pinch the nipples to note if there is any colostrum Abdomen (Uterus, Bladder) U B B Palpate for diastasis recti (abdominal separation) Explain to client diastasis recti and nursing interventions for this condition as indicated Observe for linea nigra and striae gravidarum Observe condition of abdomen (if c-section) state condition of the incision-approximation, apply THINK REEDA: redness, edema, ecchymosis, drainage, and approximation) o Palpate bladder and note if it is palpable/not palpable o Palpate the uterus by placing one hand above the symphysis pubis and locating the fundus with the opposite hand o Palpate, note consistency, location, size and height of the fundus in relation to the umbilicus, e.g. 2 FB ± or ³ umbilicus o Note any maladaptive finds and demonstrate appropriate interventions: boggy uterus, misplaced uterus, enlarged uterus o Explain actions to promote involution to client o o o o Bowel (Elimination) o Explain diuresis and diaphoresis to client o Discuss when to expect the 1st bowel movement and 3 measures to prevent constipation Lochia (Perineum, Episiotomy/Laceration, Lochia) L E H o Inspect lochia. State the color, amount, odor, and presence of clots, e.g. scant, rubra, no clots o Explain regression of lochia and when the client may resume coitus o Teach behaviors indicating infection/hemorrhage that the client should immediately report to her doctor o Inspect episiotomy/laceration for REEDA = Redness, Ecchymosis, Erythema, Dehiscence, and approximation o Teach comfort measures for an episiotomy and/or hemorrhoid Lower Extremities (legs, pulses) o Inspect and palpate legs for edema, redness, tenderness, and increased skin temperature Emotions E o Discuss what to expect with emotional status. Explain bab blues and postpartum depression o Observe for bonding KEY CONSIDERATIONS: o The BUBBLEHE does not have to be executed sequentially. o If the mother is breastfeeding, do not interrupt breastfeeding instead let her know you will return after she has finished. o If you need to provide peri care, then begin your BUBBLEHE with this area. Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 ANSWER SHEET NAEGLE9S RULE: 1. 2. 3. 4. 5. July 11th, 2021 March 23rd, 2021 January 27th, 2021 October 20th, 2020 August 8th, 2021 GRAVIDITY/PARITY/GTPAL: 1. Nulligravida HINT: Nulli 3 none; Gravidity 3 being pregnant 2. Nullipara HINT: Nulli 3 none; Parity 3 never given birth >20 weeks 3. Multigravida 3 a woman who has been pregnant more than once HINT: Multi 3 multiple; Gravida 3 being pregnant 4. Gravida 1, Para 1; or G1P1 Rationale: The number of babies does not matter; we are only counting pregnancies! So, twins count as one pregnancy. This is her first pregnancy, which would make her a <gravida 1.= She gave birth at 39 weeks so her parity would be 1 as well (>20 weeks). 5. Gravida 7, Para 3; or G7P3 Rationale: The client states that she has been pregnant 6 times and is currently pregnant. Gravidity only cares about how many times a woman is pregnant, regardless of status of the baby. So, the client9s gravidity is 7. Parity includes all births >20 weeks, regardless of the status of the baby. She gave birth to 3 children >20 weeks, so her parity would be 3. 6. G2P0; G2 T0 P0 A1 L0 Rationale: Gravidity: The client is pregnant for the 2nd time Term Births: The client has not given birth >37 weeks Preterm Births: The client has not given birth between 20-37 weeks Abortion: The client has a history of 1 terminated birth at 9 weeks Living: The client does not have any living children 7. G3P2; G3 T2 P0 A0 L2 Rationale: Gravidity: The client is pregnant for the 3rd time currently 6 weeks pregnant and has a history of 2 previous pregnancies Term Births: The client gave birth on two separate occasions at 41 weeks Preterm Births: The client has not given birth between 20-37 weeks Abortion: The client does not have a history of abortion of miscarriage Living: The client has two living children from her <term= births 8. G4P2; G4 T1 P1 A1 L3 Rationale: Gravidity: The client is pregnant for the 4th time Term Births: The client states she has had one <term= birth Downloaded by Amy Desh (amydphotodesign@gmail.com) lOMoARcPSD|22900539 Preterm Births: The client states she has given birth to two twins at preterm. NOTE: Twins count as ONE pregnancy. Abortion: The client has a history of 1 miscarriage at 16 weeks. HINT: This counts as an <abortion/miscarriage= because it happened before 20 weeks. Living: The client has 3 living children one full-term baby and two twins 9. G3P2; G3 T2 P0 A0 L3 Rationale: Gravidity: The client is pregnant for the 3rd time currently 16 weeks pregnant and has a history of 2 previous pregnancies Term Births: All of the client9s previous deliveries have been >37 weeks Preterm Births: The client has not given birth between 20-37 weeks Abortion: The client has no history of miscarriage or abortion Living: The client has 3 living children one 5-year-old and two 2-year-olds 10. G4P2; G4 T1 P1 A1 L3 Rationale: Gravidity: The client is pregnant for the 4th time Term Births: The client9s second pregnancy ended in a cesarean section of twin boys at 38 weeks. NOTE: Twins count as ONE pregnancy. Preterm Births: The client gave birth to her daughter at 34 weeks Abortion: The client has a history of spontaneous abortion at 8 weeks. Living: The client has 3 living children one daughter and two twin boys Downloaded by Amy Desh (amydphotodesign@gmail.com)
