Nursing 1125 Final Exam Comprehensive Study Guide

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Antepartum Pregnancy Signs and Indicators

Presumptive Signs (Subjective findings reported by the mother): - Amenorrhea (absence of menstruation). - Nausea and Vomiting (N/V). - Quickening: The mother's report of perceived fetal movement. - Breast soreness and enlargement.
Probable Signs (Objective findings perceived by the examiner): - Positive pregnancy test. - Goodell’s sign: Softening of the cervix. - Chadwick’s sign: Bluish discoloration of the cervix. - Hegar’s sign: Softening of the lower uterine segment.
Positive Signs (Definitive evidence of a fetus): - Baby is visualized on an ultrasound. - Fetal heartbeat is heard with a Doppler. - Fetal movement is felt by a healthcare provider.
Naegele's Rule for Estimated Date of Birth (EDB): - Calculation method 1: $LMP + 9\,\text{months} + 1\,\text{week}$ - Calculation method 2: $LMP - 3\,\text{months} + 1\,\text{week} + 1\,\text{year}$
Psychosocial Response: Ambivalence is considered normal at the beginning of pregnancy.

GTPAL Clinical Data Tracking

Gravidity ( $G$ ): The total number of pregnancies, including miscarriages, abortions, and the current pregnancy. Twins or triplets are counted as a single pregnancy event.
Term ( $T$ ): The number of babies born at > 37\,\text{weeks}.
Preterm ( $P$ ): The number of babies born between $20\,\text{weeks}$ and $36\,6/7\,\text{weeks}$ .
Abortions/Miscarriages ( $A$ ): The number of babies born at < 20\,\text{weeks}.
Living ( $L$ ): The number of current living children. Note: For this category, twins and triplets are counted separately.

Intrapartum Nutrition and Physiology

Weight Gain Recommendations: - For a BMI of $18.5 - 24.9$ , the normal weight gain is $25 - 35\,\text{lbs}$ . - Gaining $2 - 4\,\text{lbs}$ during the 1st trimester. - Gaining $1\,\text{lb/week}$ during the 2nd and 3rd trimesters.
Nutritional Requirements: - Folic acid: $600 - 800\,\text{mcg/day}$ to prevent neural tube defects.
Foods to Avoid: - Alcohol. - Raw fish or meat. - Unpasteurized milk. - Fish high in mercury, such as shark and swordfish.
Morning Sickness: - Expected N/V in the 1st trimester.
Hyperemesis Gravidarum: - Persistent N/V leading to weight loss, dehydration, and electrolyte imbalances. - Caused by elevated $\text{hCG}$ levels. - Treatment ( $Tx$ ): Small, frequent meals; electrolyte replacement; bland foods (BRAT diet); IVF or oral fluids; dry carbohydrates upon waking; medications like Ondansetron (Zofran) and Metoclopramide (Reglan).
Constipation Management: - Increase movement/physical activity. - Increase fluid intake. - Increase fiber intake.

Fetal Assessment Tests

Non-Stress Test (NST): - Determines fetal well-being. - Reactive: Two accelerations (increase in FHR) of $15\,\text{bpm}$ for at least $15\,\text{seconds}$ within a $20\,\text{minute}$ period. - Non-reactive: No accelerations. The test may be extended if the baby is believed to be sleeping. If no accelerations occur after $40\,\text{minutes}$ , a Biophysical Profile (BPP) is required.
Biophysical Profile (BPP): - Combines an NST and ultrasound across five categories (scored 2 points each if criteria met): - Movements: 3 or more limb/body movements in $30\,\text{minutes}$ . - Fetal Breathing Movements: At least 1 episode of breathing movements lasting > 30\,\text{seconds}. - Muscle Tone: At least 1 extension or flexion event. - Amniotic Fluid Volume: Value must be $\ge 5\,\text{cm}$ . - Reactive NST.
Contraction Stress Test (CST): - Determines fetal tolerance to maternal contractions. - Contractions are elicited via breast stimulation or IV Oxytocin. - Positive Test: Indicates late decelerations in response to at least $50\%$ of contractions (concerning). - Negative Test: Indicates 3 contractions in $10\,\text{minutes}$ with no late decelerations (reassuring).

Genetic and Diagnostic Testing

Chorionic Villus Sampling (CVS): - Performed at $10 - 13\,\text{weeks}$ . - Needle inserted under ultrasound to obtain chorionic villus from the placenta. - Tests for chromosomal abnormalities (Down syndrome, Edward’s syndrome, Cystic Fibrosis).
Amniocentesis: - Performed at $15 - 20\,\text{weeks}$ . - Needle inserted under ultrasound to collect amniotic fluid. - Detects chromosomal abnormalities, neural tube defects, and assesses fetal lung maturity. - Administer RhoGAM for Rh-negative mothers.

Pregnancy Complications

Placenta Previa: - Placenta is implanted over the cervix. - S/S: Bright red, painless bleeding; no fetal distress.
Placental Abruption: - Placenta detaches from the uterine wall. - S/S: Dark red, painful bleeding; board-like abdomen; fetal distress (e.g., late decelerations).
Rh Incompatibility: - Occurs when the mother is Rh-negative and the baby is Rh-positive. - If blood mixes, the mother's body creates antibodies against the baby's RBCs, leading to RBC breakdown (buildup of bilirubin and jaundice). - Indirect Coombs Test: Screens for Rh incompatibility. A positive result means antibodies are present. - RhoGAM: Prevents antibody formation. Administered at $28\,\text{weeks}$ , after an amniocentesis, and within $72\,\text{hours}$ after birth.

Preeclampsia and Eclampsia Management

Preeclampsia: - Hypertension ( $140/90$ ) occurring at $20\,\text{weeks}$ gestation. - Symptoms: Proteinuria, headache, edema, visual disturbances (blurred vision), increased Deep Tendon Reflexes (DTRs), and increased BUN/Creatinine (indicating kidney dysfunction).
HELLP Syndrome: - H: Hemolysis. - EL: Elevated Liver Enzymes (AST, ALT: indicating liver damage). - LP: Low Platelets (< 100,000): High risk of hemorrhage.
Eclamptic Seizures: - Administer Magnesium Sulfate (causes CNS depression). Assess Respiratory Rate (RR), Level of Consciousness (LOC), and DTRs. - Have the antidote, Calcium Gluconate, at the bedside.
Seizure Precautions: - Dark, quiet room; side-lying position. - Loosen clothing; remove objects around the patient; pad side rails. - Nothing in the patient's mouth. - $O_2$ and suction at the bedside. - Provide privacy, stay with the patient, and document duration.

Fetal Heart Rate Tracings and Interventions

Normal FHR: $110 - 160\,\text{bpm}$ .
Variable Decelerations: Indicate Cord Compression.
Early Decelerations: Indicate Head Compression.
Accelerations: OK (indicate fetal oxygenation).
Late Decelerations: Indicate Placental Insufficiency.
LIONS Interventions (for Late and Variable Decels): - L: Left side-lying position. - I: Increase IVF. - O: Oxygen ( $O_2$ ). - N: Notify provider. - S: Stop Oxytocin.

Fetal Presentation and Positions

Most Common Position: LOA (Left Occiput Anterior).
Presenting Parts: - Occiput: Top of the head. - Mentum: Chin. - Sacrum: Bottom/buttocks.
Directional Terms: - Right: Baby’s spine faces mother's right. - Left: Baby’s spine faces mother's left. - Anterior: Back of baby’s head faces the front of the pelvis. - Posterior: Back of baby’s head faces the back of the pelvis. - Transverse: Back of baby’s head faces between the front and back.

Stages of Labor

Stage 1 (Dilation): - Latent Phase: $0 - 3\,\text{cm}$ ; mild contractions. - Active Phase: $4 - 7\,\text{cm}$ ; moderate contractions every $3 - 5\,\text{minutes}$ (lasting $30 - 60\,\text{seconds}$ ). - Transition Phase: $8 - 10\,\text{cm}$ ; strong contractions every $2 - 3\,\text{minutes}$ ( $60 - 80\,\text{seconds}$ ). - Note: Contractions lasting > 90\,\text{seconds} are defined as tachysystole.
Stage 2: Delivery of the baby.
Stage 3: Delivery of the placenta. If delayed > 30\,\text{minutes}, it is a "retained placenta," increasing risk for infection and hemorrhage.
Stage 4: Recovery.

True vs. False Labor Differentiation

True Labor: - Regular contractions increasing in intensity, duration, and frequency. - Contractions persist despite comfort measures. - Pain is felt in the lower back. - Rupture of membranes, changes in dilation and effacement, and "bloody show" (watery bloody discharge) occur. - Lightening: Baby drops into the pelvis, making breathing easier via less diaphragm pressure.
False Labor: - Irregular contractions, far apart, that stop with movement, water intake, or elevating feet. - Patient can talk through contractions. - Pain is felt in the abdomen; no significant changes in dilation/effacement.

Postpartum BUBBLE-LE Assessment

B (Breasts): Expected to be soft/non-tender early on. Engorgement may occur; pump/breastfeed to prevent. Observe for Mastitis (fever, chills, pain) or trauma (redness, blisters).
U (Uterus/Fundus): Should be firm and midline. At $12\,\text{hours}$ , it should be between the umbilicus and pubic symphysis. If boggy, massage it. If displaced, have the mother empty her bladder. Subinvolution (failure to drop) suggests retention or infection.
B (Bowel): Monitor for return of movements especially after C-section. Hemorrhoids are normal.
B (Bladder): Monitor for distention which displaces the fundus from midline.
L (Lochia): - Rubra: Dark red, days 1-3. - Serosa: Pinkish-brown, days 3-10. - Alba: Yellowish-white, creamy. - Alert: Monitor for 1 pad saturated in $15\,\text{minutes}$ .
E (Episiotomy/Incision): Monitor REEDA (Redness, Edema, Ecchymosis, Drainage, Approximation).
L (Legs): Signs of DVT (unilateral swelling, heat, tenderness).
E (Emotional): Assess for postpartum blues vs. depression and maternal bonding.

Postpartum Complications

Hemorrhage Monitoring: - Signs: Boggy fundus, poor uterine involution, 1 pad saturated in $15\,\text{minutes}$ , drop in BP, tachycardia, cool/pale skin, confusion, oliguria. - Interventions: Massage the fundus; weigh pads; administer uterine stimulants (Oxytocin, Methylergonovine, Misoprostol); encourage breastfeeding; give IVF and blood products.
Infections: - Mastitis: Tender, painful breast with flu-like symptoms (Temp > 100.4^{\circ}\text{F}, fatigue, chills). Tx: Antibiotics, breastfeed with unaffected side, pump and dump with affected side, cold compress, supportive bra. - Endometritis: Infection of inner uterine wall. S/S: Purulent discharge, Temp > 100.4^{\circ}\text{F}, chills, tachycardia, uterine tenderness. Tx: Antibiotics, rest, antipyretics (Tylenol), fluids.

Newborn APGAR Scoring

Scores: - $7 - 10$ : Adjusting well. - $4 - 6$ : Moderately depressed, some resuscitation needed. - $1 - 3$ : Severely depressed, extensive resuscitation needed ( $O_2$ , PPV, epinephrine).
General Initial Care: Dry, warm, stimulate, place on mom's chest; suction mouth then nose.

Newborn Vitals and Physical Characteristics

Vital Signs: - Heart Rate (HR): $110 - 160\,\text{bpm}$ (up to 180 if crying). - Temperature: $97.7 - 99.5^{\circ}\text{F}$ . - Blood Pressure: $MAP = \text{gestational age}$ . - Respiratory Rate (RR): $30 - 60\,\text{breaths/min}$ . Irregular patterns and short apnea are expected.
Respiratory Distress Signs: Apnea > 20\,\text{seconds}, grunting, nasal flaring, retractions, head bobbing.
Fontanelles: Should be flat. Bulging indicates increased ICP; sunken indicates dehydration. Anterior (diamond) closes at $12 - 18\,\text{months}$ ; Posterior (triangle) closes at $8 - 12\,\text{weeks}$ .
Scalp Findings: - Caput Succedaneum: Fluid/edema that crosses suture lines. - Cephalohematoma: Blood collection that does not cross suture lines.
Newborn Medications: - Vitamin K: IM in vastus lateralis to prevent bleeding. - Erythromycin Ophthalmic Ointment: Prevents conjunctivitis. - Hepatitis B: IM in vastus lateralis.

Newborn Jaundice (Hyperbilirubinemia)

Pathophysiology: Breakdown of RBCs leads to bilirubin levels > 12\,\text{mg/dL}.
Risk Factors: Prematurity, Rh incompatibility, birth trauma (cephalohematoma).
Types: - Pathological: Occurs in the first $24\,\text{hours}$ . - Physiological: Occurs in $2 - 4\,\text{days}$ ; no treatment usually needed; ensure feeding and weight gain.
Treatment (Phototherapy): - Fluorescent lights turn bilirubin into a water-soluble form for excretion through stool. - Nursing: Baby in diaper only, eye shield, no lotions, turn q2h, weigh diapers. - Note: Increased wet diapers indicate decreasing bilirubin levels. - Untreated jaundice can result in Kernicterus (brain damage).

Dosage Calculations and Formulas

Flow Rate (mL/hr): - $\frac{\text{Total mL Solution}}{\text{Total hrs}}$
IV Drop Factor (gtt/min): - $\frac{\text{Total mL}}{\text{Total mins}} \times \text{Drop Factor (gtt/mL)}$
Typical Formula: - $\frac{\text{Desired}}{\text{On Hand}}$
Conversions: - $1\,\text{mg} = 1000\,\text{mcg}$ ; $1\,\text{g} = 1000\,\text{mg}$ . - $1\,\text{lb} = 16\,\text{oz}$ ; $1\,\text{kg} = 2.2\,\text{lbs}$ . - $1\,\text{tsp} = 5\,\text{mL}$ ; $1\,\text{tbsp} = 15\,\text{mL}$ ( $3\,\text{tsp} = 1\,\text{tbsp}$ ). - $1\,\text{oz} = 30\,\text{mL}$ ; $1\,\text{cup} = 8\,\text{oz}$ ( $240\,\text{mL}$ ).
Pediatric Dosing: Always based on weight in kg. Determine if a dose is safe by checking if it falls within the manufacturer's min/max parameters.

Pediatric Assessment Triangle (PAT)

Appearance (TICLS): - T: Tone (floppy?). - I: Interactiveness (follows, smiles?). - C: Consolability. - L: Look/Gaze. - S: Speech/Cry (vigorous?).
Work of Breathing: Check for tripoding, nasal flaring, tracheal tug, retractions, abdominal breathing, grunting, wheezing, stridor.
Circulation to Skin: Capillary refill, pallor, mottling, cyanosis, grey/ashen color.
Interpretation-Based Treatment: - Respiratory Distress: Position, $O_2$ . - Respiratory Failure: Airway/ventilation. - Shock: Fluids, $O_2$ . - CNS/Metabolic: Check glucose. - Cardio-pulm Failure: CPR.

Pediatric Respiratory Conditions

Croup: Upper airway inflammation. S/S: Stridor, hoarseness, barking (seal-like) cough. Tx: Keep calm, cool humidified air, corticosteroids. Avoid OTC cough meds and Aspirin (Reye's Syndrome risk).
Pneumonia (PNA): Infection causing alveoli to fill with fluid/pus. Predisposing factors: smoking exposure, URIs, lung disease, immobility.
RSV: Virus; incubation $2 - 8\,\text{days}$ . S/S: Congestion, dry cough, low-grade fever, difficulty breathing. Tx: $O_2$ , IV fluids, antivirals, Tylenol/NSAIDs.

Antihypertensive Medications

ACE Inhibitors (-pril): Blocks Angiotensin I to II conversion. SE: Orthostatic hypotension, persistent cough, angioedema, hyperkalemia. Avoid high K+ and salt substitutes.
ARBs (-sartan): Blocks Angiotensin II receptors. Used if ACE inhibitors aren't tolerated. SE: Orthostatic hypotension, angioedema, hyperkalemia.
Calcium Channel Blockers (-dipine): Decreases SVR. Avoid grapefruit juice (hypotension risk). SE: Constipation, edema.
Beta Blockers (-lol): Decreases SV and HR. SE: Bradycardia, bronchospasm (do not give to Asthma/COPD pts), masks hypoglycemia. Hold if HR < 60.
Alpha Blockers (-sin, -opa, -ine): Decreases SVR. Give 1st dose at bedtime. Report impotence.
Vasodilators (Hydralazine, Nitroglycerin): Decreases PVR. Do not give with ED meds. Normal SE: Headache, palpitations.
Diuretics: - Loop (-ide, Furosemide): K+ wasting. Administer slowly to avoid ototoxicity. - Thiazide (-ide, Hydrochlorothiazide): K+ wasting. Contraindicated with Sulfa allergy. - K+ Sparing (Spironolactone): Avoid high K+ foods and salt substitutes.

Cardiovascular Emergencies and Shock

Hypertensive Crisis: BP > 180 / > 120. S/S: Headache, papilledema, blurred vision, cerebral edema. Tx: $O_2$ , IV antihypertensives, neuro checks.
Hypovolemic Shock: Occurs due to significant fluid/blood loss. Tx: Fluids (LR, NS), $O_2$ , Blood transfusion, Trendelenburg position, Vasopressors (Norepinephrine, Epinephrine, Dopamine), Albumin $5\%$ .
Blood Transfusion Protocols: - Type & screen good for $72\,\text{hours}$ . 2nd RN verification required. - Start within $30\,\text{minutes}$ of leaving blood bank; complete within $4\,\text{hours}$ . - Monitor vitals at start and $15\,\text{minutes}$ in. Stay with patient for the first $15\,\text{minutes}$ . - Reaction Intervention: Stop transfusion, assess, notify provider, give Benadryl/Epi, return bag to bank.

Peripheral Vascular and Arterial Disease

PVD (Peripheral Venous Disease): Blood pools due to CVI. S/S: Venous stasis ulcers (pink/irregular on ankles), aching, brown skin, warm, edema. Tx: Elevate legs, compression stockings, avoid crossing legs.
PAD (Peripheral Artery Disease): Insufficient perfusion (Atherosclerosis). S/S: Intermittent claudication (pain with activity), rest pain, cool extremities, shiny hairless skin, pale ulcers on toes/heels. Tx: Keep legs dependent, exercise $30\,\text{min/day}$ , keep warm (socks).

Deep Vein Thrombosis (DVT)

Virchow Triad: Circulatory stasis, vascular damage, hypercoagulability.
Pulmonary Embolism (PE) Signs: Dyspnea, hypoxemia, chest pain, feeling of impending doom.
Interventions: Anticoagulants, elevation, ambulation. DO NOT massage or apply SCDs to an active DVT.
Anticoagulant Pharmacology: - Warfarin: Monitor INR ( $2.0 - 3.0$ ). Antidote: Vitamin K. Avoid NSAIDs and "G" herbs. - Heparin: Monitor aPTT and platelets (HIT risk). Antidote: Protamine Sulfate. - Factor Xa Inhibitors: Apixaban, Rivaroxaban. Implement bleeding precautions.

Anaphylaxis and Hypersensitivity

S/S: Angioedema, SOB, laryngeal edema, hives, chest tightness.
Interventions: Airway management; Epinephrine (stab middle outer thigh, hold $10\,\text{seconds}$ , rub). Hospitalize even if symptoms resolve due to bi-phasic reaction risk.
Coombs Hypersensitivity Types: - Type 1: Immediate. - Type 2: Cytotoxic (Incompatible blood). - Type 3: Immune Complex (Lupus, RA). - Type 4: Delayed (Poison ivy, occurs $24 - 48\,\text{hours}$ later).