review-signs and symptoms

1. RN review nuggets
To test visual acuity, the nurse should ask the patientto cover eacheye separately andread the eye chart with glasses
and without, as appropriate.
Before teaching any procedure to the patient, the nurse must first assess the patient’swillingnessto learn and his
current knowledge.
A blood pressure cuff that istoo narrow can cause a falsely elevatedblood pressure reading.
When preparing a single injection for a patientwho takes regular andNPHinsulin, the nurse should draw the regular
insulin into the syringe firstbecause it isclear and can be measured more accurately than the NPH insulin, whichis
turbid.
Rhonchi refersto the rumbling soundsheard on lung auscultation; they are more pronouncedduring expiration than
during inspiration.
Gavage refersto forcedfeeding, usually througha gastric tube (a tube passed into the stomach by way of the mouth).
According to Maslow’shierarchy of needs, physiologic needs(air, water, food, shelter, sex, activity, andcomfort) have
the highest priority.
Checking the identification bandon a patient’swristis the safest and surest way to verify a patient’sidentity.
A patient’s safety isthe priority concern in developing a therapeutic environment.
The nurse should place the patient witha Sengstaken-Blakemore tube in semi-Fowler’sposition.
The nurse can elicitTrousseau’ssign by occluding the brachial or radial artery; hand andfinger spasmsduring occlusion
indicate Trousseau’ssign andsuggesthypocalcemia.
For blood transfusion in an adult, the appropriate needle size is16 to 20G.
Pain that incapacitiesa patientandcan’tbe relievedby drugs is calledintractable pain.
In an emergency, consentfor treatment can be obtainedby fax, telephone, or other telegraphic transmission.
Decibel is the unitof measurement of sound.
Informedconsent isrequiredfor any invasive procedure.
A patient who can’twrite his or her name to give consentfor treatment must have hisor her X witnessed by two
persons, such as a nurse, priest, or doctor.
The Z-track I.M. injection technique sealsmedication deep into the muscle, thereby minimizing skin irritation and
staining. Itrequiresa needle that is1’’ (2.5 cm) or longer.
A registered nurse (RN) should assign a licensedvocational nurse (LVN) or licensedpractical nurse (LPN) to perform
bedside care, such assuctioning andmedication administration.
The therapeutic purposedof a mist tent is to increase hydration of secretions.
The most convenientveinsfor venipuncture in a adult patientare the basilic andmedian cubital veinsin the antecubital
space.
From 2 to 3 hours before beginning a tube feeding, the nurse should aspirate the patient’sstomach contents to verify
adequate gastric emptying.
People with type O blood are consideredto be universal donors.
People withtype AB blood are consideredto be universal recipients.
Herts (Hz) refersto the unit of measurement of sound frequency.
Hearing protection isrequiredwhen the sound intensity exceeds84 dB; double hearing protection isrequiredif it
exceeds 104 dB.
Prothrombin, a clotting factor, isproducedin the liver.
If a patient is menstruating when a urine sample iscollected, the nurse should note this on the laboratory slip.
During lumbar puncture, the nurse must note the initial intracranial pressure andthe cerebrospinal fluidcolor.
A patient who can’tcoughto provide a sputum sample for culture may require a heated aerosol treatment to facilitate
removal of a sample.
If eye ointment and eyedropsmust be instilledin the same eye, the eyedropsshould be instilledfirst.
When leaving an isolation room, the nurse should remove the glovesbefore the mask because fewer pathogens are on
the mask.
Skeletal traction isappliedto a bone using wire pinsor tons. It isthe most effective meansof traction.
The total parenteral nutrition solution shouldbe stored in a refrigerator andremoved 30 to 60 minutes before use
because delivery of a chilledsolution can cause pain, hypothermia, venousspasm, andvenousconstriction.
Medication isn’troutinely injectedI.M. into edematous tissue because it may not be absorbed.
When caring for a comatose patient, the nurse should explain eachaction to the patient in a normal voi ce.
When cleaning dentures, the sink should be linedwith a washcloth.
A patient should voidwithin 8 hoursafter surgery.
An EEG identifiesnormal andabnormal brain waves.
Stool samples for ova andparasite tests should be deliveredto the laboratory withoutdelay or refrigeration.
The autonomic nervoussystem regulates the cardiovascular andrespiratory systems.
When providing tracheostomy care, the nurse shouldinsert the catheter gently into the tracheostomy tube. When
withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 secondsanduse a slight
twisting motion.

2. A low-residue diet includessuchasfoodsas roasted chicken, rice, andpasta.
A rectal tube should not be inserted for longer than 20 minutes; it can irritate the mucosa of the rectum and cause a
loss of sphincter control.
A patient’s bed bath should proceedin this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum.
When lifting andmoving a patient, the nurse should use the upper leg musclesmost to prevent injury.
Patient preparation for cholecystography includesingestionof a contrast mediumand a low-fatevening meal.
During occupiedbed changes, the patient should be coveredwith a black blanket to promote warmth and prevent
exposure.
Anticipatory grief refersto mourning that occursfor an extended time when one realizesthat death isinevitable.
The following foodscan alter stool color: beets (red), cocoa (dark red or brown), licorice (black), spinach(green), and
meat protein (dark brown).
When preparing a patientfor a skull X-ray, have the patient remove all jewelry and dentures.
The fight-or-flight response isa sympathetic nervoussystem response.
Bronchovesicular breathsounds in peripheral lung fieldsare abnormal andsuggest pneumonia.
Wheezing refersto an abnormal, high-pitchedbreath sound that is accentuatedon expiration.
Wax or a foreign body in the ear should be gently flushedout by irrigationwithwarmsaline solution.
If a patient complainsthat his hearing aidis“not working,” the nurse should check the switchfirst to see if it’s
turned on andthen check the batteries.
The nurse should grade hyperactive bicepsandtricepsreflexes+4.
If two eye medicationsare prescribedfor twice-daily instillation, they should be administered5 minutes apart.
In a postoperative patient, forcing fluidshelpspreventconstipation.
The nurse must administer care in accordance withstandards of care established by the American Nurses
Association, state regulations, andfacility policy.
The kilocalorie (kcal) isa unitof energy measurement that represents the amount of heat needed to raise the
temperature of 1 kilogramof water 1º C.
As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and
excretion.
The body metabolizes alcohol at a fixedrate regardless of serum concentration.
In an alcoholic beverage, itsproof reflectsits percentage of alcohol multipliedby 2. For example, a 100-proof
beverage contains50% alcohol.
A living will is a witnesseddocumentthat states a patient’sdesire for certain types of care andtreatment, which
depends on the patient’swishesandviewsandquality of life.
The nurse should flusha peripheral heparin lock every 8 hours(if itwasn’tused during the previous8 hours) and as
needed with normal saline solution to maintain patency.
Quality assurance isa method of determining whether nursing actionsandpracticesmeet established standards.
The five rightsof medication administration are the right patient, right medication, rightdose, right route of
administration, andthe right time.
Outside of the hospital setting, only the sublingual andtransligual formsof nitroglycerin shouldbe used to relieve
acute anginal attacks.
The implementation phase of the nursing processinvolvesrecording the patient’sresponse to the nursing plan, putting
the nursing plan into action, delegating specificnursinginterventions, andcoordinating the patient’sactivities.
The Patient’s Bill of Rights offersguidance andprotection to patients by stating the responsibilitiesof the hospital
and its staff toward patients andtheir familiesduring hospitalization.
To minimize the omissionsanddistortion of facts, the nurse should recordinformation assoon asit is gathered.
When assessing a patient’shealth history, the nurse should record the current illnesschronologically, beginning with
the onset of the problem and continuing to the present.
Drug administration isa dependent activity. The nurse can administer or withhold a drug only with the doctor’s
permission.
The nurse shouldn’tgive false assurance to a patient.
After receiving preoperative medication, a patientisn’tcompetent to sign an informedconsentform.
When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms.
A nurse may clarify a doctor’sexplanation to a patient about an operation or a procedure but must refer questions
about informedconsentto the doctor.
The nurse shouldn’tuse her thumb to take a patient’spulse rate because the thumb has a pulse of its own andmay be
confusedwiththe patient’spulse.
An inspiration andan expiration countasone respiration.
Normal respirationsare known aseupnea.
During a bloodpressure measurement, the patientshould rest the arm againsta surface because using muscle strength
to hold up the arm may raise the blood pressure.
Major unalterable risk factorsfor coronary artery disease include heredity, sex, race, andage.
Inspection is the most frequently used assessment technique.

3. Family members of an elderly person in a long-term care facility shouldtransfer some personal items (suchas
photographs, a favorite chair, andknickknacks) to the person’sroomto provide a homey atmosphere.
The upper respiratory tract warmsand humidifiesinspiredair andplaysa role in taste, smell, and mastication.
Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, andscalene and
sternocleidosmastoidmuscle use during respiration.
When patients use axillary crutches, their palms should bear the brunt of the weight.
Activitiesof daily living include eating, bathing, dressing, grooming, toileting, andinteracting socially.
Normal gaithas two phases: the stance phase, in whichthe patient’sfoot rests on the ground, and the swing phase, in
whichthat patient’sfoot movesforward.
The phases of mitosis are prophase, metaphase, anaphase, andtelophase.
The nurse should follow standardprecautionsin the routine care of all patients.
The nurse should use the bell of the stethoscope to listen for venoushums andcardiac murmurs.
The nurse can assess a patient’sgeneral knowledge by asking questionssuchas“Who isthe president for the United
States?”
Coldpacks are appliedfor the first20 to 48 hours after an injury; then heat isapplied. During coldapplication, the
pack is appliedfor 20 minutesand then removedfor 10 to 15 minutes to preventreflex dilation (reboundphenomenon)
and frostbite injury.
The pons is located above the medulla and consistsof white matter (sensory and motor tracts) andgray matter (reflex
centers).
The autonomic nervoussystem controls the smooth muscles.
A correctly written patient goal expresses the desired patientbehavior, criteria for measurement, time frame for
achievement, andconditionsunder whichthe behavior will occur. Itis developedin collaboration withthe patient.
The optic disk isyellowishpink andcircular witha distinct border.
A primary disability resultsfrom a pathologic process; a secondary disability, frominactivity.
Before a patient’srecord can be released to a third party, the patient or patient’slegal guardian must give written
consent.
Under the Controlled SubstancesAct, every dose of a controlled drug dispensedby the pharmacy must be counted for,
whether the dose wasadministeredto a particular patientor discardedaccidentally.
A nurse can’tperformduties that violate a rule or regulation establishedby a state licensing boardeven if itis
authorizedby a health care facility or doctor.
The nurse should select a private room, preferably with a door that can be closed, to minimize interruptionsduring a
patient interview.
In categorizing nursing diagnosis, the nurse should address actual life-threatening problems first, followedby
potentially life-threatening concerns.
The major components of a nursing care plan are outcome criteria (patientgoals) andnursing interventions.
Standing orders, or protocols, establish guidelinesfor treating a particular disease or set of symptoms.
In assessing a patient’sheart, the nurse normally findsthe pointof maximal impulse atthe fifthintercostals space
near the apex.
The S1 soundheard on auscultation iscausedby closure of the mitral andtricuspidvalves.
To maintain package sterility, the nurse should open the wrapper’stop flap away fromthe body, open side flap by
touching only the outer part of the wrapper, andopen the final flap by grasping the turned-down corner andpulling it
toward the body.
The nurse shouldn’tuse a cotton-tipped applicator to dry a patient’sear canal or remove wax because it may force
cerumen againstthe tympanic membrane.
A patient’s identificationbraceletshould remain in place until the patient has been dischargedfromthe health care
facility andhas left the premises.
The Controlled SubstancesAct designatedfive categories, or schedules, that classify controlleddrugsaccordingto
their abuse liability.
Schedule I drugs, suchas heroin, have a highabuse potential and have no currently accepted medical use in the United
States.
Schedule II drugs, such as morphine, opium, andmeperidine (Demerol), have a highabuse potential but have currently
acceptedmedical uses. Their use may lead to physical or psychological dependence.
Schedule III drugs, such as paregoric andbutabarbital (Butisol), have a lower abuse potential than Schedule I or II
drugs. Abuse of Schedule III drugs may leadto moderate or low physical or psychological dependence, or both.
Schedule IV drugs, suchas chloral hydrate, have a low abuse potential comparedwith Schedule III drugs.
Schedule V drugs, suchas coughsyrupsthat contain codeine, have the lowest abuse potential of the controlled
substances.
Activitiesof daily living are actionsthat the patient must perform every day to provide self-care andinteractwith
society.
Testing of the six cardinal fieldsof gaze evaluatesthe function of all extraocular musclesandcranial nervesIII, IV,
and VI.
The six types of heart murmurs are gradedfrom 1 to 6. A grade 6 heart murmur can be heard withstethoscope

4. slightly raised fromthe chest.
The most important goal to include in a care plan isthe patient’sgoal.
Fruits are highin fiber and low in protein andshould be omitted from a low-residue diet.
The nurse should use an objective scale to assess andquantify pai n because postoperative pain variesgreatly among
individuals.
Postmortem care includescleaning andpreparing the deceasedpatient for family viewing, arranging transportation to
the morgue or funeral home, anddetermining the disposition of belongings.
The nurse should provide honestanswersto the patient’squestions.
Milk shouldn’tbe includedin a clear liquiddiet.
Consistency in nursing personnel isparamountwhen caring for a child, andinfant, or a confusedpatient.
The hypothalamus secretes vasopressin andoxytocin, whichare stored in the pituitary gland.
The three membranes that enclose that brain andspinal cordare the dura mater, pia mater, andarachnoid.
A nasogastric tube isused to remove fluidandgas fromthe small intestine preoperatively or postoperatively.
Psychologists, physical therapists, andchiropractorsaren’tauthorizedto write prescriptionsfor medication.
The area arounda stoma should be cleanedwithmild soap and water.
Vegetables have a highfiber content.
The nurse should use a tuberculin syringe to administer an S.C. injection of lessthan 1 ml.
For adults, S.C. injectionsrequire a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a
25G to 27G ½" needle.
Before administering medication, the nurse should identify the patient by checking the identification bandandasking
the patient to state hisname.
To clean the skin before an injection, the nurse should use a sterile alcohol swabandwipe fromthe center of the site
outward in a circular motion.
The nurse alwaysshouldinjectheparin deep into S.C. tissue at a 90-degree angle (perpendicular to the skin) to prevent
skin irritation.
If blood is aspiratedinto the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another
syringe, andrepeat the procedure.
For the patientabiding by Jewishcustom, milk and meat shouldn’tbe served in the same meal.
Whether the patient can performa procedure (psychomotor domain of learning) isa better indicator of the effectiveness
of patient teaching than whether the patient can simply state the steps of the procedure (cognitive domainof learning).
Developmental stages according to Erik Erikson are trust versusmistrust (bi rth to 18 months), autonomy versusshame
and doubt (18 months to 3 years), initiative versusguilt(3 to 5 years), industry versusinferiority (5 to 12 years), identi ty
versus identity diffusion (12 to 18 years), intimacy versusisolation(18 to 25 years), generativity versusstagnation (25 to
60 years), and ego integrity versus despair (older than 60 years).
Face the hearing impairedpatientwhen communicating withhim.
A proper nursing intervention for the spouse of the patient who has suffereda seriousincapacitating disease isto assist
him in mobilizing a supportsystem.
Hyperpyrexia refersto extreme elevation in temperature above 106º F (41.1º C).
Unlike false labor, true labor producesregular rhythmic contractions, abdominal discomfort, no changedin fetal
movement, progressive fetal descent, bloody show, andprogressive cervical effacementanddilation.
To help a mother break the suction of her breast-feeding infant, the nurse should teach her to insert a finger atthe
corner of the infant’smouth.
Administering highlevelsof oxygen to a premature newborn can cause blindnesssecondary to retrolental fibroplasia.
Amniotomy refers to the artificial rupture of the amniotic membranes.
During pregnancy, weightgain averages25 to 30 lb (11.3 to 13.5 kg).
Rubella has a teratogenic effecton the fetus during the first trimester andproducesabnormalitiesin up to 40% of cases
without interrupting the pregnancy.
Immunity to rubella can be measuredby a hemagglutination inhibition test (rubella titer). This test identifiesexposure to
rubella infection anddeterminessusceptibility to it in pregnantwomen (a woman has an immunity witha titer greater than
1:8).
In describing the degree of fetal descent during labor; floating occurswhen the presenting part isn’tengagedin the
pelvic inletbut isfreely movable (ballotable) above the pelvic inlet.
In describing the degree of fetal descent, engagementoccurswhen the largest diameter of the presenting part has
passed through the pelvic inlet.
To elicitMoro’s reflex, the nurse should hold the neonate in both hands and suddenly but gently drop the neonate’shead
backward. Normally, thiscausesthe neonate to abduct andextend all extremitiesbilaterally and symmetrically, forma C
shape withthumb andforefinger, andfirstadducts andthen flexesthe extremities.
Pregnancy-inducedhypertension (preeclampsia) isdefinedasan increasedin bloodpressure of 30/15 mHg over baseline
or a blood pressure of 140/95 mmHg on two occasions atleast 6 hours apart, edema, andalbuminuria that occur after 20
weeks’ gestation.
Positive signs of pregnancy include ultrasoundevidence, fetal heart tones, and fetal movement felt by the examiner (not

5. usually present until 4 months’ gestation).
Goodell’s sign is softening of the cervix.
Hegar’s sign is softening of the lower uterine segment.
Quickening, a presumptive sign of pregnancy, occursbetween 16 to 19 weeks’ gestation.
Ovulation ceasesduring pregnancy.
Vaginal bleeding isthe number one danger sign in pregnancy.
To estimate the date of confinementusing Nägele’srule, the nurse countsbackward3 months from the first day of the
last menstrual periodandthen adds 7 days to this date.
At 12 weeks’ gestation, the fundusshould be at the top of the symphysispubis.
Koplik’s spots are small, irregular red spots withminute bluishwhite centers that appear on the buccal mucosa of patients
with measles (rubeola).
Cow’s milk shouldn’tbe given to infantsunder age 1 year because of its low linoleicacidcontentand its protein, whichis
difficultfor infantsto digest.
If jaundice is suspected in a neonate, the nurse should examine the infantunder natural light froma window. If natural
light is unavailable, the nurse should examine the infantunder a white light.
The three phasesof a uterine contraction are increment, acme and decrement.
A labor contraction’sintensity can be assessed by indentability of the uterine wall at the contraction’speak. Intensity is
graded as mild(uterine muscle issomewhat tense), moderate (uterine muscle ismoderately tense,) or strong (uterine
muscle is boardlike).
Chloasma, the mask of pregnancy, refersto skin pigmentation of a circumscribedarea (usually over the bridge of the nose
and cheeks) that isseen issome pregnancies.
The gynecoidpelvisismost ideal for delivery. Other types of pelvesinclude platypelloid(flat), anthropoid(apelike), and
android(malelike).
Pregnantwomen should be advisedthat there isno safe level of alcohol intake.
A uterine contraction’sfrequency ismeasuredin minutesandrepresents the time from the beginning of one contraction to
the beginning of the next.
Vitamin K is administeredto a newborn to preventhemorrhagic fever because a newborn’sintestine isunable to synthesize
vitamin K.
Before internal fetal monitoring can be done, a pregnantpatient’scervix must be dilated at least 2 cm, her amniotic
membranes must be ruptured, and the fetus’spresenting part (scalp or buttocks) must be at station –1 or lower; so that a
small electrode can be attached to it.
Fetal alcohol syndrome presents in the first 24 hours after birth andproduceslethargy, seizures, poor sucking reflex,
abdominal distention, andrespiratory difficulty.
Variability refersto any change in the fetal heart rate (FHR) from its normal rate of 20 to 160 beats/minute. An
increasedFHR is known asacceleration; a decreasedFHR isknown asdeceleration.
Fetal station (location of the presenting part) is describedas -1, -2, -3, -4, or -5 to indicate the number of centimeters it
is above the level of the ischial spines; station -5 is at the pelvic inlet.
Fetal station also is describedas +1, +2, +3, +4, or +5 to indicate the number of centimeters it isbelow the level of the
ischial spines; station 0 isat the level of the ischial spines.
During the first stage of labor, the side-lying position usuallyprovidesthe greatest degree of comfort, although the
patient may assume any position of comfort.
During delivery, ifthe umbilical cordcan’tbe loosenedand slippedfromaroundthe neonate’sneck, it should be clamped
with two clamps. Then the cord should be cut between the two clamps.
An Apgar score of 7 to 10 indicatesno immediate distress, 4 to 6 indicatesmoderate distress, and0 to 3 indicatessevere
distress.
Heroin withdrawal symptoms in a neonate may begin several hoursto 4 daysafter birth.
Methadone withdrawal symptoms in a neonate may begin 7 days to several weeksafter birth.
The cardinal signsof neonatal narcotic withdrawal include coarse flapping tremors, sleepiness, restlessness, prolongedand
persistent high-pitchedcry, and irritability.
The nurse should alwayscounta neonate’srespirationsfor 1 full minute.
Circumcision is postponedin neonateswithhypospadias.
Chlorpromazine hydrochloride (Thorazine) isusedto treat an infantwho isaddicted to narcotics.
The nurse should provide a dark, quietenvironmentfor an infantwho isexperiencing narcotic withdrawal.
A goodtechnique for assessing jaundice in a neonate isto blanchthe tip of the nose or gum line by applying slightpressure
under natural light andwatching for yellow discoloration after removing pressure.
Signs of respiratory distress in a premature infantinclude nostril flaring, substernal retractions, andinspiratory grunting.
Premature infantsdevelop respiratory distress syndrome (hyaline membrane disease) because their pulmonary alveoli lack
surfactant.
Any time an infantisbeing putdown to sleep, the mother should position the infanton the back (remember “back to
sleep”).
The male sperm contributesan X or a Y chromosome; the female ovumcontributes an X chromosome.

6. Fertilization producesa total of 46 chromosomes, including an XY combination (male) or an XX combination (female).
The percentage of water in a newborn’sbody isabout 78% to 80%.
To performnasotracheal suctioning in an infant, the nurse should position the infantwiththe neck slightly hyperextended
in a “sniffing” position withthe chin up andthe head tilted back slightly.
Organogenesis occursduringthe first trimester of pregnancy; specifically, days14 and56 of gestation.
After birth, the neonate’sumbilical cordistied1” (2.5 cm) from the abdominal wall witha cotton cord, plastic clamp, or
rubber band.
The term gravida refersto the number of pregnanciesregardlessof their outcomes.
The term para refers to the number pregnanciesthat reached viability regardlessof whether the fetus is deliveredalive
or stillborn. (A fetus isconsideredviable at20 weeks’ gestation.)
An ectopic pregnancy isone that implantsabnormally, outside the uterus.
The first stage of labor beginswiththe onset of labor andends with full cervical dilati on at10 cm.
The second stage of labor beginswithfull cervical dilation andendswiththe neonate’sbirth.
The third stage of labor beginsafter the neonate’sbirth andends with expulsion of the placenta.
In a full-term infant, skin creasesappear over two-thirds of the newborn’sfeet. Heel creases of less than two-thirds are
seen in preterm infants.
The fourth stage of labor (postpartal stabilization) lasts for up to 4 hours after delivery if the placenta (the time required
to stabilize the mother’s physical andemotional state after the stress of childbirth).
At 20 weeks’ gestation, the fundusshould be at the height of the umbilicus.
At 36 weeks’ gestation, the fundusshould be at the lower border of the rib cage.
A premature infantisone born before the end of the 37th week of gestation.
Pregnancy-inducedhypertension isa leading cause of maternal death in the UnitedStates.
A habitual aborter isa woman who has had three or more consecutive spontaneousabortions.
Threatened abortion occurswhen bleeding ispresent without cervical dilation.
A complete abortion occurswhen all products of conception have been expelled.
Hydramnios (polyhydramnios) refersto excessive amniotic fluid(more than 2,000 ml in the third trimester).
Stress, dehydration, andfatigue may reduce a breast-feeding mother’s milk supply.
During the transition phase of the first stage of labor; the cervix isdilated8 to 10 cm andcontractionsusually occur 2 to
3 minutesapart and last for 60 seconds.
A nonstress test isconsiderednoreactive (positive) if fewer than two fetal heart rate accelerationsof atleast 15
beats/minute occur in 20 minutes.
A nonstress test isconsideredreactive (negative) if two or more fetal heart rate accelerationsof 15 beats/minute above
baseline occur in 20 minutes.
A nonstress test usually isused to assess fetal well-being in a pregnantpatientwith a prolongedpregnancy (42 weeksor
more), diabetes, a history of poor pregnancy outcomes, or pregnancy-inducedhypertension.
A pregnantwoman should drink at least eight 8-oz glasses (about 2,000 ml) of water daily.
When both breasts are used for breast-feeding, the infantusually doesn’tempty the secondbreast; therefore, the second
breast should be used first at the next feeding.
A low-birth-weight infantisone who weighs2,500 g (5 lb 8 oz) or less at birth.
A very-low-birth-weightinfantisone who weighs1,500 (3 lb 5 oz) of less at birth.
When teaching parentsto provide umbilical cordcare, the nurse should teach them to clean the umbilical area withalcohol
on a cotton ball after every diaper change to prevent infectionandpromote drying.
Teenage mothers are more likely to have low-birth-weightinfantsbecause they seek prenatal care late in the pregnancies
(as a result of denial) andare more likely to have nutritional deficiencies.
Linea nigra, a dark line that extends from the umbilicusto the mons pubis, commonly appearsduring pregnancy and
disappears after pregnancy.
Implantation in the uterus occurs6 to 10 days after ovumfertilization.
Placenta previa refersto the abnormally low implantation of the placenta so that it encroacheson or coversthe cervical os.
In complete (total) placenta previa, the placenta completely coversthe cervical os.
In partial (incomplete or marginal) placenta previa, the placenta coversonly a portion of the cervical os.
Abruptio placentae refers to the premature separation of a normally implantedplacenta. It may be partial or complete and
usually causesabdominal pain, vaginal bleeding, anda board-like abdomen.
Cutis marmorata (mottling or purple skin discoloration) refersto a transient vasomotor response that occursprimarily in
the arms and legs of infantsexposedto cold.
The classic triadof symptoms of preeclampsia are hyperextension, edema, andproteinura. Additional symptomsin severe
preeclampsia include hyperreflexia, cerebral andvisual disturbances, andepigastric pain.
Ortolani’s sign (an audible click or palpable jerk withthigh abduction) confirmscongenital hip dislocationin a neonate.
The first immunization for a newborn isthe hepatitis B vaccine, whichisgiven in the nursery shortly after birth.
If a patient misses a menstrual periodwhile taking an oral contraceptive exactly asprescribed, she should continue taking
the contraceptive.

7. If a patient misses two consecutive menstrual periodswhile taking an oral contraceptive, she should discontinue the
contraceptive andhave a pregnancy test.
If a patient taking an oral contraceptive missesa dose, she should take the pill as soon as she remembers or take two at
the next scheduled interval andcontinue withthe normal schedule.
If a patient taking an oral contraceptive missestwo consecutive doses, she should double the dose for 2 days and then
resume her normal schedule. She should also use an additional birthcontrol method for 1 week.
Eclampsia is the occurrence of seizuresnotcausedby a cerebral disorder in a patient withpregnancy-inducedhypertension.
In placenta previa, bleedingispainlessandseldom fatal on the first occasionbutbecomes heavier witheachsubsequent
episode.
Treatment for abruptio placentae usually isimmediate cesarean section.
Drugs used to treat neonatal withdrawal symptoms include phenobarbital (Luminal), camphoratedopiumtincture (paregoric),
and diazepam(Valium).
Infants with Down syndrome typically display markedhypotonia, floppiness, slantedeyes, excessskin on the back of the
neck, flattened bridge of the nose, flat facial features, spade-like hands, short and broad feet, small male genitalia,
absence of Moro’sreflex, anda simian crease on the hands.
Amniocentesis (needle aspirationof amnioticfluid) usually isperformedat15 to 17 weeks’ gestation to detect fetal
abnormalities.
The ectoderm is the outermost layer of the three primary germ layersof the embryo.
The failure rate of a contraceptive isdetermined by the experience of 100 women for 1 year andisexpressed as
pregnancies per 100 women years.
The narrowest diameter of a pelvic inletisthe anteroposterior (diagonal conjugate).
The chorion is the outermost extraembryonic membrane that givesrise to the placenta.
The corpus luteum secretes large quantitiesof progesterone.
From the 8th week of gestation through delivery, the developing cellsare termed a fetus.
In an incomplete abortion, the fetus isexpelledbut parts of the placenta andmembrane remain in the uterus.
A neonate’s headcircumference isnormally 2 to 3 cm greater than the chest circumference.
After administering magnesiumsulfate to a pregnantpatient for hypertension or preterm labor, the nurse should monitor
her respiratory rate anddeep tendon reflexes.
During her first hour after birth (the periodof reactivity), the neonate isalert andawake.
When a pregnantpatient has undiagnosedvaginal bleeding, vaginal examination shouldbe avoideduntil ultrasonography rules
out placenta previa.
After a neonate is delivered, the first nursing action isto establish the neonate’sairway.
Nursing interventionsfor a patientwith placenta previa include positioning the patienton her left side for maximumfetal
perfusion, monitoring fetal heattones, andadministering I.V. fluidsandoxygen, asordered.
The specific gravity of a neonate’surine is1.003 to 1.030. A lower specific gravity suggests overhydration; a higher one
suggests dehydration.
The neonatal periodextends from birth to day 28. It may also be calledthe first 4 weeksor first months of life.
A woman who is breast-feeding should rub a mild emollientcreamor a few drops of breast milk (or colostrum) on the nipples
after eachfeeding andlet breasts air-dry to preventthem from cracking.
Breast-feeding mothers should increase their fluidintake to 2.5 to 3 qt (2,500 to 3,000 ml) daily.
After feeding an infantwitha cleft lip or palate, the nurse should rinse the infant’smouthwith sterile water.
The nurse instillserythromycin in the neonate’seyesprimarily to preventblindnesscausedby gonorrhea or chlamydia.
Because the human immunodeficiency virus(HIV) hasbeen cultured in breast milk, it couldbe transmitted by an HIV-
positive mother who breast-feeds her infant.
A fever in the first 24 hours postpartum ismost likely causedby dehydration, rather than infection.
Preterm infants or infantswho can’tmaintain a skimtemperature of at least 97.6º F (36.4º C) shouldreceive care in an
incubator (Isolette) or a radiantwarmer. In a radiantwarmer, a heat-sensitive probe taped to the infant’sskin activatesthe
heater unitautomatically to maintain the desiredtemperature.
During labor, the resting phase between contractionsshouldbe at least 30 seconds.
Lochia rubra refersto the vaginal discharge of almostpure blood that occursduring the first few daysafter childbirth.
Lochia serosa refersto the serous vaginal discharge that occurs4 to7 days after childbirth.
Lochia alba refersto the vaginal discharge of decreasedbloodandincreased leukocytesthat isthe final stage of lochia; it
occurs 7 to 10 daysafter childbirth.
Colostrum (the precursor of milk) refers to the first secretion from a maternity patient’sbreasts.
The length of the uterus increasesfrom2.6” (6.5 cm) before pregnancy to 12.8” (32 cm) at term.
To estimate the true conjugate (the smallest inletmeasurement of the pelvis), deduct 1.5 cm fromthe diagonal conjugate
(usually 12 cm). A true conjugate of 10.5 cm will enable the fetal head (usually 10 cm) to pass.
The smallest outlet measurement of the pelvisisthe intertuberous diameter, whichisthe transverse diameter between the
ischial tuberosities.
Electronic fetal monitoring isusedto assess fetal well-being during labor. If compromisedfetal status is suspected, fetal

8. blood pH may be evaluatedby obtaining a scalp sample.
In an emergency delivery, enoughpressure shouldbe appliedto the emerging fetus’sheadto guide the descent and prevent
a rapidchange in pressure within the molded fetal skull.
After delivery, a multiparouswoman ismore prone to bleeding than a primiparouswomanbecause her uterine muscles may be
overstretched andmay not contact efficiently.
Neonatesdeliveredby cesarean section have a higher incidence of respiratory distresssyndrome.
The nurse should suggest ambulation to a postpartal patientwho complainsof gaspain andflatulence.
Massaging the uterus helps stimulate contractionsafter the placenta isdelivered.
When providing phototherapy to an infant, the nurse should cover the infant’seyesandgenital area.
The narcotic antagonistnaloxone (Narcan) may be given to a neonate to correct respiratory depression causedby narcotic
administration to the mother during labor.
Symptoms of respiratory distress syndrome in a neonate include expiratory grunting or whining, sandpaper breath sounds,
and seesaw retractions.
Cerebral palsy presents as asymmetrical movement, irritability, andexcessive feeble crying in long, thin infant.
The nurse should assess a breech-birth neonate for hydrocephalus, hematomas, fractures, and other anomaliescausedby
birth trauma.
When a patientis admitted to the unit in active labor, the nurse’sfirst action isto listen for fetal heart tones.
In a neonate, long, brittle fingernailsare a sign of postmaturity.
Desquamation (skin peeling) iscommon in postmature neonates.
A mother should allow her infantto breast-feed until he or she issatisfied. Thistime may vary from5 to 20 minutes.
Nitrazine paper isused to test the presence of amniotic fluid.
The average weightgain during a normal pregnancy is25 to 30 lb (11.3 to 13.6 kg) total. The patient normally gains2 to 5 lb
(0.9 to 2.3 kg) during the first trimester and slightly less than 1 lb (0.45 kg) per week during the last two trimesters.
Neonatal jaundice in the first 24 hours after birth is known aspathological jaundice andissign of erythroblastosis fetalis.
A classic difference between abruptio placentae andplacenta previa isthe degree of pain; abruptio placentae producespain,
whereas placenta previa causespainlessbleeding.
Because a major role of the placenta isto function asa fetal lung, any condition that interrupts normal blood flow to or from
placenta will increase fetal partial pressure of arterial carbon dioxide anddecrease fetal pH.
Precipitate labor lasts for only 3 hours andends with delivery of the neonate.
Methylergonovine maleate (Methergine) isan oxytocic agentusedto prevent andtreat postpartum hemorrhage causedby
uterine atony or subinvolution.
As emergency treatment for excessive uterine bleeding, 0.2 mg of methylergonovine maleate (Methergine) isinjectedI.V.
over 1 minute while the patient’sblood pressure anduterine contractionsare monitored.
Braxton-Hicks contractionsusually are feltin the abdomen and don’t cause cervical change, whereastrue labor contractions
are felt in the front of the abdomen and back andlead to progressive cervical dilation andeffacement.
The average birth weightof neonates born to mothers who smoke is 6 oz (170 g) less than that of neonates born to non-
smoking mothers.
Culdoscopy is visualization of the pelvic organsthroughthe posterior vaginal fornix.
The nurse should teach a pregnantvegetarian to obtain protein from alternative sources, suchas nuts, soybeans, and
legumes.
The nurse should instruct a pregnantpatient to take only prescribedprenatal vitaminsbecause over-the-counter
megavitamins may harmthe fetus.
High-sodiumfoodscan cause fluidretention, especially inpregnantpatients.
A pregnantpatient can avoidconstipation andhemorrhoidsby adding fiber to her diet.
If the fetus developslate deceleration (a sign of fetal hypoxia), the nurse should instruct the mother to lie on her left side
and then should administer 8 to 10 L of oxygen per minute by mask or cannula.The nurse should notify the doctor. (The side-
lying position removespressure on the inferior vena cava.)
Oxytocin (Pitocin) promoteslactation anduterine contractions.
Lanugo covers the fetus’sbody until about 20 weeks’ gestation. Then it beginsto disappear fromthe face, trunk, arms, and
legs, in the order.
In a neonate, hypoglycemia ismanifestedby temperature instability, hypotonia, jitteriness, andseizures. Premature,
postmature, small-for-gestational-age, andlarge-for-gestational-age neonatesare prone to this disorder.
Neonatestypically needto consume 50 to 55 cal/lbof body weightdaily.
Because oxytocin (Pitocin) stimulatespowerful uterine contractionsduring labor, itmust be administeredunder close
observation to help preventmaternal and fetal distress.
During fetal heart monitoring, variable deceleration indicatesumbilical cordcompression or prolapse.
Cytomegalovirus isthe leading cause of congenital viral infections.
Tocolytic therapy is indicatedin premature labor but contraindicatedin fetal death, fetal distress, or severe hemorrhage.
Through ultrasonography, the biophysical profile assessesfetal well-being by measuring fetal breathing movements, gross
body movements, fetal tone, reactive fetal heart rate (nonstress test), and qualitative amniotic fluidvolume.
A neonate whose mother has diabetes should be assessed for hyperinsulinism.

9. Epigastric painisa late symptom in a patient with preeclampsia andrequiresimmediate medical intervention.
After a stillbirth, the mother should be allowedto hold the neonate to help her come to terms with the death.
A pregnantpatient who has experiencedmembrane rupture or vaginal bleedingshouldn’tengage in sexual intercourse.
A patient scheduled for positron emission tomography shouldavoidalcohol, tobacco, andcaffeine for 24 hoursbefore the
test.
Milia may occur aspinpointspots over a neonate’snose.
The duration of a contraction istimed from the moment the uterine muscle beginsto tense to the moment it reaches full
relaxation andis measuredin seconds.
The union of a male anda female gamete producesa zygote, whichdividesinto the fertilizedovum.
Spermatozoa (or their fragments) remain in the vaginafor 72 hoursafter sexual intercourse.
Prolactin stimulates andsustains milk production.
Strabismus is a normal finding ina neonate.
A postpartum patient may resume sexual intercourse when perineal anduterine woundshave healed(usually within 4 weeks
after delivery).
A pregnantstaff member shouldn’tbe assignedto work with a patient who has a cytomegalovirusinfection.
The nurse should suspect elder abuse if woundsare inconsistentwith the history, multiple woundsare present, or wounds are
in differentstages of healing.
Fetal demise refersto death of the fetus after viability.
Premature infantsdevelop respiratory distress syndrome because their alveoli lack surfactant.
The most common method of inducing labor after artificial rupture of the membrane isoxytocin (Pitocin) infusion.
After the patient’samniotic membranesrupture, the initial nursing action isto assess the fetal heart rate.
The most common reasonsfor caesarean birth are malpresentation, fetal distress, cephalopelvic disproportion, pregnancy-
inducedhypertension, previouscesarean birth, andinadequate progressin labor.
Amniocentesis increasesthe risk of spontaneousabortion, trauma to the fetus or placenta, premature labor, infection, and
Rh sensitization of the fetus.
After amniocentesis, abdominal cramping or spontaneousvaginal bleeding may indicate complications.
An Rh-negatvie primagravida shouldreceive Rho(D) immune globulin (RhoGAM) after deliveringan Rh-positive infantto
prevent her fromdeveloping Rhantibodies.
If a pregnantpatient’stest results are negative for glucose but positive for acetone, the nurse should assess the patient’s
diet for inadequate caloric intake.
The preterm neonate may require gavage feedingsbecause of a weak sucking reflex, uncoordinatedsucking, or respiratory
distress.
Acrocyanosis (bluenessandcoolnessof the arms andlegs) isnormal in neonatesbecause of their immature peripheral
circulatory system.
To prevent ophthalmia neonatorum(a severe eye infectioncausedby maternal gonorrhea), the nurse may administer one of
three medications, asprescribed, in the neonate’seyes: tetracycline, silver nitrate, or erythromycin.
Neonatal testing for phenylketonuria hasbecome mandatory in most states.
The nurse should place the neonate in a 30-degree Trendelenburg position to facilitate mucusdrainage.
The nurse may suction the neonate’snose and mouth as needed with a bulb syringe or suction trap.
To prevent heat loss, the nurse first should place the neonate under a radiantwarmer during suctioning andinitial delivery-
room care andthen should wrap the neonate in a warmedblanket for transport to the nursery.
The umbilical cordnormally hastwo arteries andone vein.
When providing care, the nurse should expose only one part of an infant’sbody at a time.
Lightening is the setting of the fetal head into the brim of the pelvis.
If the neonate isstable, the mother should be allowedto breastfeed within the neonate’sfirst hour of life.
The nurse should check the neonate’stemperature every 1 to 2 hoursuntil it ismaintainedwithin normal limits.
At birth, the neonate normally weighs5 to 9 lb (2.3 to 4.1 kg), measures 18"to 22" (45.7 to 55.9 cm) in length, has a head
circumference if 13½" to 14" (34.3 to 35.6 cm), and has a chest circumference that is 1" (2.5 cm) less than the head
circumference.
In the neonate, temperature normally rangesform98º to 99º F (36.7º to 37.2º C), apical pulse rate averages120 to 160
beats/minute, andrespirationsare 40 to 60 breaths/minute.
Prostaglandin gel may be appliedto the vaginal or cervix to ripen an unfavorable cervixbefore labor inductionwithoxytocin
(Pitocin).
Supernumerary nipplesoccasionally are seen on neonatesand usually appear along a line that runsfrom eachaxilla throughthe
normal nipple area to the groin.
Meconiumis a material that collects in the fetus’sintestines andforms the neonate’sfirststools, whi chare black and tarry.
The presence of meconiumin the amniotic fluidduring labor indicatespossible fetal distress and then needto evaluate the
neonate for meconiumaspiration.
To assess the rooting reflex, the nurse touches a finger to the neonate’scheck or corner of mouth. Normally, the neonate
turns his head toward the stimulus, opensthe mouth, and searchesfor the stimulus.
Harlequin sign is presentwhen the neonate lying on the side appearsred on the dependent side andpale on the upper side.