NLE TIPS

Pls Read

Breath sounds are the best way to assess the onset of heart failure. The presence of
crackles or rales or an increase in crackles is an indicator of fluid in the lungs caused by
heart. failure.

A positive reaction to a tuberculin skin test indicates exposure to tuberculosis infection.

Because the response to tuberculin skin testing may be decreased in the
immunosuppressed client, induration reactions more than 5 mm are considered positive.
A reading of 6-mm induration is a positive result in a client who is HIV positive. A positive
result indicates exposure to tuberculosis and possibly the development of tuberculin
infection. Further diagnostic tests should be performed to confirm infection with
tuberculosis.

The TNM classification system for staging tumors is widely used. T refers to the tumor
size, with T0 indicating no primary tumor found and T1 to T4 referring to progressively
larger tumors. TIS is used to indicate a carcinoma in situ. N refers to regional lymph
node involvement. N0 indicates regional nodes were normal, and N1 to N4 indicates
increasingly abnormal regional lymph nodes. M1 indicates that distant metastasis is
present.
The complications associated with thoracic surgery include pulmonary edema, cardiac
dysrhythmias, hemorrhage, hemothorax, hypovolemic shock, and thrombophlebitis.
Signs of pulmonary edema include dyspnea, crackles, persistent cough, frothy sputum,
and cyanosis. A urinary output of 45 mL/hour is an appropriate output. The nurse would
become concerned if the output were below 30 mL/hour. Between 100 and 300 mL of
drainage may accumulate during the first 2 hours after thoracic surgery. Normal arterial
blood pH is 7.35 to 7.45. An arterial blood pH of 7.35 is not indicative of a complication.

The client with Raynauds disease suffers from body-image disturbance when physical
changes begin to occur. Therapeutic nursing interventions are implemented to
encourage verbalization about the body changes and to develop appropriate problemsolving techniques for coping with the changes.

Specific gravity is a measure of the concentration of particles in the urine. A normal

range of urine specific gravity is approximately 1.005 to 1.030. Early in polycystic kidney
disease, the ability of the kidneys to concentrate urine decreases. A urine specific gravity
of 1.000 is lower than normal, indicating dilute urine.

Giving the client with chronic emphysema a high liter flow of oxygen could stop the
hypoxic drive and cause apnea.

Assays of catecholamines are performed on single-voided urine specimens, 2- to 4-hour

specimens, and 24-hour urine specimens. The normal range of urinary catecholamines
is up to 14 mcg/100 mL of urine, with higher levels occurring in pheochromocytoma.

After a cerebrovascular accident, clients are often emotionally labile, confused, forgetful,
and frustrated. Clients may use profanity, which is often termed automatic language.

The complications associated with severe scoliosis interfere with respiration. The lungs
may not fully expand as a result of the severe curvature of the spine. Atelectasis and
dyspnea are complications that can occur as a result of a decrease in lung expansion.

The purpose of a venogram is to assess the severity of venous obstruction. The test will
locate obstructions and/or thrombi by x-ray films after a radiopaque dye is injected into a
vein that has been previously emptied by gravity. This test is a diagnostic procedure and
will not eliminate leg problems or determine whether the support stockings can be
discontinued. Injections can cause discomfort.

The complications associated with pheochromocytoma include hypertensive retinopathy

and nephropathy, myocarditis, congestive heart failure (CHF), increased platelet
aggregation, and cerebrovascular accident (CVA). Death can occur from shock, CVA,
renal failure, dysrhythmias, and dissecting aortic aneurysm. Rales heard on auscultation
are indicative of CHF.

In myxedema, the TSH level is elevated, and the T3 and T4 levels are decreased.
Secretion of T3 and T4 is regulated by a hypothalamic-pituitary-thyroid gland feedback
mechanism. TSH regulates the secretion of thyroid hormone from the thyroid gland. The
circulating levels of thyroid hormone are the major factor regulating the release of TSH.
If the thyroid levels are low, TSH release is increased, and if the thyroid levels are high,
TSH is inhibited. In hyperthyroidism, T3 and T4 secretions are elevated because the
normal regulatory controls of thyroid hormone are lost.
Hypoparathyroidism is
associated with a decrease in serum calcium and an increase in serum phosphate.

Cutting the blood glucose monitoring strips in half may affect the accuracy in reading the
results.

Hydrocortisone is the topical treatment of choice for cutaneous inflammation and pruritus
associated with contact dermatitis. If a rash does not respond to this over-the-counter
medication, it should be evaluated by a health care provider.

The client should be taught to take the pulse in the wrist or neck every day at the same
time, preferably in the morning, and to rest a full 5 minutes before taking the pulse. The
pulse is counted for 1 full minute by using a watch or clock that has an accurate second

hand. The pulse is recorded every day in a log that indicates a description of the rate,
rhythm, and date and time of day. If a change in rate or rhythm is noted, the physician
should be notified.

Crutch tips should remain dry. Water could cause slipping by decreasing the surface
friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with
a cloth or paper towel. The client should use only crutches measured for the client. The
tips should be inspected for wear, and spare crutches and tips should be available if
needed.

The normal random blood glucose level is 70 to 115 mg/dL but may vary depending on
the time of the last meal.

On removal of a chest tube, an occlusive dressing consisting of petrolatum gauze

covered by a dry sterile dressing is usually placed over the chest tube site dressing. This
is maintained in place until the physician states it may be removed. Monitoring and
reporting respiratory difficulty and increased temperature are appropriate client activities
on discharge. The client should avoid heavy lifting for the first 4 to 6 weeks after
discharge to facilitate continued wound healing.

Postoperative care after a parathyroidectomy includes instructing the client that the
weight of the clients head must be supported when the client flexes the neck or moves
the head. This decreases the stress on the suture line, which prevents bleeding.

Boiling the vegetables and discarding the water can decrease the potassium content of
vegetables. Bananas and oranges are high in potassium and should be avoided. Meats
contain some potassium and are high in protein and should be limited to 6 oz/day. Salt
substitutes are often high in potassium and are to be avoided.

Plasmapheresis is a process that separates the plasma from the blood elements, so that
plasma proteins that contain antibodies can be removed. It is used as an adjunct therapy
in myasthenia gravis and may give temporary relief to clients with actual or impending
respiratory failure. Usually three to five treatments are required. Improvement in vital
(respiratory) capacity is an intended effect of this treatment.

The client with CAL should use energy-conservation techniques to conserve oxygen.
These include sitting to perform many household chores or activities, and alternating
activity with rest periods. The client should avoid raising the arms above the head,
because use of the arms could increase dyspnea. The client should never hold the
breath during an activity.

When a client is placed in pelvic traction, the foot end of the bed is raised to prevent the
client from being pulled down in bed by the traction. The head of the bed is usually kept
flat, and the client is maintained in good body alignment. The girdle or belt should be
applied snugly so it does not slip off of the client, and therefore the skin should be
checked for pressure sores.

Traditional treatment of a UTI involves 7 to 10 days administration of oral antimicrobial

therapy. It is important to take antibiotics, even if the client is feeling better. While taking
these medications, the client should drink at least eight glasses of fluid per day to keep
urine dilute. Voiding regularly will flush bacteria out of the bladder and urethra. Teaching
the client to cleanse the perineal area from front to back helps to prevent urinary tract
infection.

The cane is held on the stronger side to minimize stress on the affected extremity and
provide a wide base of support. The cane is held 6 inches lateral to the fifth toe. The
cane is moved forward with the affected leg. The client leans on the cane for added
support while the stronger side swings through.

Older and immunocompromised clients may not have a positive reaction to the initial
tuberculin skin test, even if they had prior exposure to the tubercle bacillus. If the test is
negative (no reaction), the client may have a delayed reaction and should have a
repeated tuberculin skin test in 1 to 2 weeks. The second test should reveal positive
results if the client had prior exposure. The tuberculin skin test is read in 48 to 72 hours.
Erythema or redness alone is not considered significant. The size of induration, if any, is
what determines the significance of the test. A positive test does not indicate active
disease. Persons with a positive reaction are followed up with a chest radiograph.

After restoring circulation to the affected limb, the nurse reinforces teaching that was
done after the original surgery. This includes exercise and dietary recommendations, as
well as instructions on foot care and prevention of injury to the limb. The client should
check the condition of the leg and foot every day. Taking a baby aspirin every day does
not ensure that further complications will not occur. Walking will be a component of the
treatment plan.

Instructions to a client after a aorto-iliac bypass grafting about measures to improve

circulation while in the hospital includes clot formation in the graft can result from any
form of pressure that impairs blood flow through the graft, including bending at the hip or
knee, crossing the knees or ankles, or use of the knee gatch or pillows. All of these
actions are avoided in the postoperative period.

The presence of multiple organisms in a urine culture usually indicates that

contamination has occurred. The urinary tract is normally sterile, and infection, if it
occurs, is usually with one organism. A repeat of the urine culture is indicated.

Spinal shock that occurs after spinal cord injury lasts 3 to 6 weeks after the injury and is
characterized by a flaccid neurogenic bladder with urinary retention. Intermittent
catheterization used to empty the bladder should be carried out in a manner that
prevents urinary tract infection (UTI). Cloudy or blood-tinged urine may indicate the
onset of infection. Because fluid is lost through the skin, lungs, and bowel, intake does
not normally equal output. Sensations of the need to void require an intact cord, which
would not be present in this client. Cholinergic action stimulates bladder emptying, so
anticholinergics would produce the undesirable effect of relaxation of the bladder in this
client.

First-degree heart block indicates a delayed conduction somewhere between the

junctional tissue and the Purkinje network, causing a prolonged PR interval. Lying still
will not relieve the problem. A pacemaker is not necessary for first-degree heart block.
Medication may be prescribed to treat this condition.

The client should use the walker by placing the hands on the handgrips for stability. The
client lifts the walker to advance it, and leans forward slightly while moving it. The client
walks into the walker, supporting the body weight on the hands while moving the weaker
leg. A disadvantage of the walker is that it does not allow reciprocal walking motion. If
the client were to try to use reciprocal motion with a walker, the walker would advance
forward one side at a time as the client walks; thus the client would not be supporting the
weaker leg with the walker during ambulation.

Within 2 or 3 days of surgery, a lung is generally fully re-expanded. The nurse notes an
absence of fluctuation or bubbling in the water seal chamber or drainage from the chest
tube. At this time, the clients status is confirmed by chest x-ray. If the lung is fully reexpanded, the physician may remove the chest tube.

The irreversible stage of cardiogenic shock represents the point along the shock
continuum when organ damage is so severe that the client does not respond to
treatment and is unable to survive. Multiple organ failure has occurred, and death is
imminent. As it becomes obvious that the client is unlikely to survive, the clients family
needs to be informed about the prognosis and outcome. Support to the grieving family
members becomes an integral part of the nursing care plan.

The purpose of ECG monitoring is to record cardiac electrical activity during the
depolarization and repolarization phases. The two types of single-lead monitoring are
hardwire and telemetry. With a wireless battery-operated telemetry system, the client is
afforded more freedom and mobility than with the hardwire system. The most common
problems with ECG monitoring are related to client movement, electrical interference
from equipment in the room, poor choice of monitoring leads, and poor contact between
the skin and electrode.

Tracheostomy dressings should be changed whenever they get wet or damp. A soiled
dressing promotes microorganism growth and enhances tissue irritation and skin
breakdown. The oxygen collar may be cleaned if it becomes soiled between collar and
tubing changes, which are done every 24 hours. Tracheostomy care should be done at
least every 8 hours or per agency policy. It would not be beneficial to the client to limit
fluids, because thicker secretions pose added problems with airway management.

Before discharging a ventilator-dependent client to home, the nurse determines that the
family is able to perform CPR, including mouth-to-tracheostomy ventilation. The CPR
course designed for lay people in the community does not include this element of care.
The electrical service to the home must be sufficient for the equipment that will be used.
The ventilator should have a built-in converter to battery power if the electrical power
should fail. Otherwise, a generator must be installed. The home itself should be free of
drafts and provide adequate air circulation.

Back pain after AAA repair may indicate a problem with the repair. It should be reported
to the physician immediately.

Disease processes, such as cirrhosis, damage the blood flow through the liver, resulting
in hypertension in the portal venous system. The increased portal pressure causes
esophageal varices, which are swollen and distended veins. Factors such as increased
intrathoracic pressure or irritations can cause these varices to rupture with subsequent
hemorrhage.

Cryosurgery entails freezing cervical tissue with nitrous oxide. It is performed in an

outpatient setting. Cryosurgery may result in cramping and a vasovagal response that
may cause faintness. A watery discharge is normal for a few weeks after the procedure.

The client who experiences epididymitis from a urinary tract infection should increase the
intake of fluids to flush the urinary system. Because organisms can be forced into the
vas deferens and epididymis from strain or pressure during voiding, the client should
limit the force of the urinary stream. Condom use can help to prevent epididymitis that
can occur as a result of STDs. Antibiotics is always taken until the full course of therapy
is completed.

Treatment of prostatitis includes medication with antibiotics, analgesics, and stool

softeners. The client also is taught to rest, increase fluid intake, and use sitz baths for
comfort. Antimicrobial therapy is always continued until the prescription is completely
finished.

The client with respiratory disease may have Ineffective Coping related to the inability to
tolerate activity and social isolation. The client demonstrates adaptive responses by
increasing the activity to the highest level possible before symptoms are triggered, using

relaxation or other learned coping skills, or enrolling in a pulmonary rehabilitation

program.

The primary symptom in placenta previa is painless vaginal bleeding in the second or
third trimester of pregnancy. Passage of the mucus plug appears pink or as blood-tinged
mucus. A ruptured amniotic sac would include findings such as a watery vaginal
drainage. Findings of abruptio placenta include dark red vaginal bleeding and abdominal
pain.

Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12
breaths per minute, the continuation of the medication should be reassessed.

The symptoms of jitteriness and tachypnea (respiratory rate of 62 breaths per minute) in
a 42-week-gestation newborn infant are indicative of hypoglycemia. Hypoglycemia may
develop in a 42-week-gestation newborn infant because of the insufficient stores of
glycogen, which may have been depleted during the post-term period. Insufficient
amounts of glucose in the infants brain could possibly cause central nervous system
damage.

A normal blood glucose level for newborn infants is 40 mg/dL and higher.

Rho(D) immune globulin is not administered if a client has experienced a severe reaction
to its component, human globulin. Rho(D) immune globulin is indicated when Rhnegative clients are exposure to Rh-positive fetal blood cells in any way, including
amniocentesis and abortion.

A person who lacks hope feels that life is too much to handle. By seeing no way out of
the situation except death, the client meets the criteria for hopelessness.

Abdominal exercises should not be started after abdominal surgery until 3 to 4

postoperative weeks to allow healing of the incision.

Coagulation failure, particularly disseminated intravascular coagulopathy (DIC), is a

common result of an amniotic fluid embolus. Manifestations are internal and external
hemorrhage clinically determined by bleeding at the site of any trauma (pressure, needle
prick, or incision), and petechiae resulting from slight to moderate touch. A postpartum
woman who saturates a Peripad in 15 minutes or less is considered to be hemorrhaging,
which in this case is caused by lack of coagulation at the placental site.

A pulsating rope-like object seen in the vagina indicates the presence of the umbilical
cord. Each contraction will press the presenting part downward against the bony pelvis,
applying pressure to the prolapsed cord, compressing it between the presenting part and
the bony pelvis. The compression will shut off the fetal circulation at the point of
compression, leading to impaired fetal tissue perfusion and hypoxia of the fetus.

Situational Low Self-Esteem represents temporary negative feelings about self in

response to an event. This is a normal response to cesarean section.

Pregnancy taxes the circulating system of every woman because both the blood volume
and cardiac output increase approximately 30%. This is especially important to monitor
in the client whose heart may not tolerate this normal increase.

HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV
for T lymphocytes leads to significant cell destruction. Angiotensin is produced in the
kidney and plays a role in blood pressure control.

HIV infection in a pregnant woman may cause both maternal and fetal complications.
Fetal compromise can occur because of premature rupture of the membranes, preterm
birth, or low birth weight. Potential maternal effects include an increased risk of
opportunistic infections. Individuals in the later stages of HIV are further susceptible to
other invasive conditions, such as tuberculosis and a wide variety of bacterial infections.

The anterior fontanel is normally 2.5 to 5 cm in width and diamond-like in shape. It can
be described as soft, which is normal, or full and bulging, which could be indicative of
increased intracranial pressure. Conversely, a depressed fontanel could mean that the
neonate is dehydrated.

Clients with Cushings syndrome experience weight gain with truncal obesity. The
extremities appear thin with the presence of muscle wasting and weakness. The skin is
often described as being thin and translucent. A butterfly rash across the cheeks of the
face is seen in systemic lupus erythematosus. Polydipsia and polyphagia are seen in
diabetes mellitus. Weight loss and peripheral edema may be seen in a number of
conditions.
Situations that precipitate sickle cell crisis include hypoxia, vascular stasis, low
environmental and/or body temperature, acidosis, strenuous exercise, anesthesia,
dehydration, and infections.
The client undergoing radiation therapy should avoid washing the site until instructed to
do so. The client should then wash with mild soap and warm or cool water, and pat the
area dry. No lotions, creams, alcohol, or deodorants should be placed on the skin over
the treatment site. Lines or ink marks that are placed on the skin to guide the radiation
therapy should be left in place. The affected skin should be protected from temperature
extremes, direct sunlight, and chlorinated water (as from swimming pools).
Prevention of recurrence of urinary stones is accomplished by drinking at least 3 L of
fluid per day; voiding every 2 hours; following an acid ash diet if the stones are calcium
oxalate stones; and notifying the physician promptly if symptoms of UTI occur.
The client with polycystic kidney disease should report any signs and symptoms of
urinary tract infection so that treatment may begin promptly. The client should also report
increases in blood pressure, because control of hypertension is essential. The client may
experience heart failure as a result of hypertension, and thus any symptoms of heart
failure, such as shortness of breath, also are reported.

The goal of therapy in nephrotic syndrome is to heal the leaking glomerular membrane.
This would then control edema by stopping loss of protein in the urine. Fluid balance and
albumin levels are monitored to determine effectiveness of therapy.

Stair climbing may be restricted or limited for several weeks after spinal fusion with
instrumentation. The nurse assures that resources are in place before discharge so that
the client may sleep and perform all activities of daily living on a single living level.

The skin under a casted area may be discolored and crusted with dead skin layers. The
client should gently soak and wash the skin for the first few days. The skin should be
patted dry, and a lubricating lotion should be applied. Clients often want to scrub the
dead skin away, which irritates the skin. The client should avoid overexposing the skin to
the sunlight.

Expected outcomes for Impaired Physical Mobility for the client in traction include
absence of thrombophlebitis (measurable by negative Homans' sign), active baseline
ROM to uninvolved joints, clear lung sounds, intact skin, and bowel movement every
other day.

After three unsuccessful defibrillation attempts, CPR should be done for 1 minute,
followed by three more shocks, each delivered at 360 joules.

Typical discharge activity instructions for the first 6 weeks include lifting nothing heavier
than 5 pounds, not driving, and avoiding any activities that cause straining. The client is
taught to use the arms for balance, but not weight support, to avoid the effects of
straining. These limitations are to allow sternal healing, which takes approximately 6
weeks.

Clients can resume sexual activity on the advice of a physician, which generally occurs
when the client can walk one block and climb two flights of stairs without discomfort.
Suggestions to minimize potential problems include waiting for 2 hours after meals or
alcohol consumption, making sure one feels well rested, using a comfortable position,
and keeping the room at a mild (not chilly) temperature.

Expected outcomes for the client with pulmonary edema include improved cardiac output
as evidenced by stable vital signs, and urine output of at least 30 mL/hour.

The clients blood gas results indicate respiratory acidosis. Symptoms of respiratory
acidosis include headache, irritability, muscle twitching, behavioral changes, confusion,
lethargy, and coma.

When the carboxyhemoglobin levels are greater than 25% (acute toxicity), the
respiratory center becomes depressed because of inadequate oxygenation, and hypoxia
occurs.

A long-range approach to the prevention of pulmonary edema is to minimize any

pulmonary congestion. During recumbent sleep, fluid (which has seeped into the
interstitium by day with the assistance of the effects of gravity) is rapidly reabsorbed into

the systemic circulation. Sleeping with the head of the bed elevated helps prevent
circulatory overload.

Complications after pleural biopsy include hemothorax, pneumothorax, and temporary

pain from intercostal nerve injury. The nurse notes indications of these complications,
such as dyspnea, excessive pain, pallor, or diaphoresis. Mild pain is expected, because
the procedure itself is painful.

The nurse teaches the client that the pain of fractured ribs generally lasts for about 5 to 7
days. Full healing takes about 6 weeks, after which full activity may be resumed.

Coughing and deep breathing will effectively promote lung expansion and clearance of
mucus. Using an incentive spirometer is helpful, but it is most effective if the client uses
it independently without coaching. The nurse may not need to suction the client if the
client is not intubated

Prinzmetals angina results from spasm of the coronary vessels. The risk factors are
unknown, and it is relatively unresponsive to nitrates. Beta blockers may worsen the
spasm.

Exercise is most effective when done at least 3 times a week for a client with angina
pectoris. Other positive habits include limiting salt and fat in the diet, using stressmanagement techniques, and knowing when and how to use medications.

Nosebleeds may occur during the winter because of decreased humidity in the home.
The use of a humidifier helps to alleviate this problem.

If pulse oximeter values fall below a preset norm, which is usually 90% to 91%, the client
should be instructed to take several deep breaths. This is especially true of a client
without a respiratory history who is still under the effects of sedation. If the client did
have a respiratory disease history, it might be an indication that supplemental oxygen
should be put in place or increased if already in place.

A Gram stain classifies the organism as gram-negative or gram-positive, and may be

done immediately by the laboratory. This gives initial information about the type of
organism when initiation of antibiotic therapy is a high priority. The specimen is then
incubated on a culture medium for at least 24 hours more to identify the specific
organism(s). The sensitivity test gives the physician precise information about which
antibiotics the organism is sensitive to.

In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic
vasoconstriction, which causes Goodells sign. Cervical softening will be noted during
pelvic examination by the examiner. A soft blowing sound that corresponds to the
maternal pulse may be auscultated over the uterus and is due to blood circulation
through the placenta. hCG is noted in maternal urine in a urine pregnancy test. Goodells
sign does not indicate the presence of fetal movement.

Quickening is fetal movement and is not perceived until the second trimester. Between
16 and 20 weeks of gestation, the expectant mother first notices subtle fetal movements
that gradually increase in intensity. A soft blowing sound that corresponds to the
maternal pulse may be auscultated over the uterus and this in known as uterine souffle.
This sound is due to the blood circulation to the placenta and corresponds to the
maternal pulse. Braxton Hicks contractions are irregular, painless contractions that occur
throughout pregnancy, although many expectant mothers do not notice them until the
third trimester. A thinning of the lower uterine segment occurs about the sixth week of
pregnancy and is called Hegars sign

Fetal heart sounds can be heard with a fetoscope by 18 to 20 weeks of gestation.

To check for the presence of ballottement, near midpregnancy, a sudden tap on the
cervix during a vaginal exam may cause the fetus to rise in the amniotic fluid and then
rebound to its original position. When the cervix is tapped, the fetus floats upward in the
amniotic fluid. The examiner feels a rebound when the fetus falls down.

Fetal movement, called quickening, is not perceived until the second trimester. Between
16 and 20 weeks' gestation, the expectant mother first notices subtle fetal movements
that gradually increase in intensity.

A rubella titer is performed to determine immunity to rubella. If the mothers titer is less
than 1:8, the mother is not immune. A retest during pregnancy is prescribed, and the
mother is immunized postpartum if not immune.

A maternal glucose assay is prescribed to screen for gestational diabetes. If it is

elevated, a 3-hour glucose tolerance test is recommended to determine the presence of
gestational diabetes.

A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If

antigens are present, the infant should receive a hepatitis immune globulin and a
vaccine soon after birth.

During a menstrual period, a woman loses about 40 mL of blood. Because of the

recurrent loss of blood, many women are mildly anemic during their reproductive years,
especially if their diets are low in iron.

Montgomerys tubercles are sebaceous glands in the areola. They are inactive and not
obvious except during pregnancy and lactation, when they enlarge and secrete a
substance that keeps the nipples soft. Within each breast are lobes of glandular tissue
that secrete milk. Alveoli are small sacs that contain acinar cells to secrete milk. The
alveoli drain into lactiferous ducts that connect to drain milk from all areas of the breast.

Before conception, the uterus is a small pear-shaped organ entirely contained in the
pelvic cavity. Before pregnancy, the uterus weighs approximately 60 grams (2 oz) and
has a capacity of about 10 mL (one third of an ounce). At the end of pregnancy, the
uterus weighs approximately 1000 grams (2.2 pounds) and has a sufficient capacity for
the fetus, placenta, and amniotic fluid, a total of about 5000 mL.

At 12 weeks' gestation, the uterus extends out of the maternal pelvis and can be
palpated above the symphysis pubis. At 16 weeks, the fundus reaches midway between
the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located at the
umbilicus. By 36 weeks, the fundus reaches its highest level at the xiphoid process.

The muscular action of the fallopian tube and movement of the cilia within the tube
transport the mature ovum through the fallopian tube. Fertilization normally occurs in the
distal third of the fallopian tube near the ovaries. The ovum, fertilized or not, enters the
uterus about 3 days after its release from the ovary.

The uterus has three divisions, the corpus, isthmus, and the cervix. The upper division is
the corpus or the body of the uterus. The uppermost part of the uterine corpus, above
the area where the fallopian tubes enter the uterus, is the fundus of the uterus.

By week 13, the fetal sex can be determined by the appearance of the external genitalia
on ultrasound.

Mineral oil should not be used as a stool softener because it inhibits the absorption of
fat-soluble vitamins in the body. Constipation should be treated with increased fluids (six
to eight glasses per day) and a diet high in fiber. Increasing exercise is also an excellent
way to improve gastric motility.

The genitalia of a newborn female are frequently red and swollen. This edema
disappears in a few days. A vaginal discharge of thick white mucus is seen in the first
week of life. The mucus is occasionally blood tinged by about the third or fourth day, and
stains the diaper. The cause of the pseudomenstruation, like that of breast engorgement,
is the withdrawal of maternal hormones.

A myelomeningocele is a neural tube defect caused by failure of the posterior neural

tube to close. The meninges are exposed through the surface of the skin in a herniated
sac that may be either healed or leaking. Skin integrity is impaired because a thin
membrane covers the protruding sac.

Prolactin stimulates the secretion of milk, called lactogenesis. Testosterone is produced

by the adrenal glands in the female and induces the growth of pubic and axillary hair at
puberty. Oxytocin stimulates contractions during birth and stimulates postpartum
contractions to compress uterine vessels and control bleeding. Progesterone stimulates
the secretions of the endometrial glands, causing endometrial vessels to become highly
dilated and tortuous in preparation for possible embryo implantation.

The normal duration of the menstrual cycle is about 28 days, although it may range from
20 to 45 days. Significant deviations for the 28-day cycle are associated with reduced
fertility. The first day of the menstrual period is counted as day 1 of the adolescents
cycle.

The ovaries are the endocrine glands that produce estrogen and progesterone. FSH and
LH are produced by the anterior pituitary gland. Oxytocin is produced by the posterior
pituitary gland and stimulates the uterus to produce contractions during labor and birth.

Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual
periods or at the time of ovulation. The pain is due to growth of the dominant follicle
within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and
blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side
of the pelvis. It generally lasts a few hours to 2 days, and slight vaginal bleeding may
accompany the discomfort.

Endometriosis is defined as the presence of tissue outside the uterus that resembles the
endometrium in both structure and function. The response of this tissue to the
stimulation of estrogen and progesterone during the menstrual cycle is identical to that of
the endometrium. Primary dysmenorrhea refers to menstrual pain without identified
pathology. Mittelschmerz refers to pelvic pain that occurs midway between menstrual
periods, and amenorrhea is the cessation of menstruation for a period of at least three
cycles or 6 months in a woman who has established a pattern of menstruation, and can
be due to a variety of causes.

In early pregnancy, hCG is produced by trophoblastic cells that surround the developing
embryo. This hormone is responsible for positive pregnancy tests.

Progesterone maintains uterine lining for implantation and relaxes all smooth muscle,
including the uterus. Relaxin is the hormone that softens the muscles and joints of the
pelvis. Thyroxine increases during pregnancy to stimulate basal metabolic rates, and
prolactin is the primary hormone of milk production.

Estrogen stimulates uterine development to provide an environment for the fetus and
stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining
for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the
metabolism of glucose and converts the glucose to fat. Human chorionic gonadotropin
(hCG) prevents involution of the corpus luteum and maintains the production of
progesterone until the placenta is formed.

During pregnancy, the breasts change in both size and appearance. The increase in size
is due to the effects of estrogen and progesterone. Estrogen stimulates the growth of
mammary ductal tissue, and progesterone promotes the growth of lobes, lobules, and
alveoli. A delicate network of veins is often visible just beneath the surface of the skin.

The cervix undergoes significant changes after conception. The most obvious changes
occur in color and consistency. In response to the increasing levels of estrogen, the
cervix becomes congested with blood, resulting in the characteristic bluish color that
extends to include the vagina and labia. This discoloration, referred to as Chadwicks
sign, is one of the earliest signs of pregnancy.

Ovulation ceases during pregnancy because the circulating levels of estrogen and
progesterone are high, inhibiting the release of the follicle stimulating hormone (FSH)
and the luteinizing hormone (LH), which are necessary for ovulation.

The ovarian cycle consists of three phases, the follicular, ovulatory, and luteal phases.
The proliferative phase is a phase of the endometrial cycle.

A nutritional supplement commonly needed during pregnancy is iron. Anemia of

pregnancy is primarily caused by iron deficiency. Iron supplements usually cause
constipation. Meats are an excellent source of iron. Iron for the fetus comes from the
maternal serum.

Signs of congenital neonatal syphilis may be nonspecific at first, including poor feedings,
slight hyperthermia, and snuffles. Snuffles refers to copious, clear serosanguineous
mucus discharge from the nose. By the end of the first week, a copper-colored
maculopapular dermal rash is characteristically observed on the palms of the hands,
soles of the feet, diaper area, and around the mouth and anus.

Effective pain management during labor does not interrupt the labor process but does
provide relaxation and moderate pain relief to the mother. The increased bloody show
and intensity of the contractions are not measures of effective pain management.

Accelerations are an indication of fetal well-being and an oxygenated fetal central

nervous system. Bradycardia, late decelerations, and decreased variability are
representative of decreased oxygenation of the fetus.

Signs of impaired fetal oxygenation include late decelerations, decreased baseline

variability, and tachycardia or bradycardia. A normal fetal heart range is 120 to 160 beats
per minute. Accelerations occur in a fetus with a mature central nervous system and who
is well oxygenated.

Breastfeeding is contraindicated if the mother is positive for HIV because the virus may
be spread to the infant in the breast milk. HIV is not spread through casual contact, so
holding, hugging, and sleeping with other family members is not prohibited. A newborn
may test positive for HIV for up to 2 years after birth because of placental transfer of
maternal antibodies. It is vital that the nurse ascertain that the client has correct
knowledge regarding the transmission of the disease and precautions necessary to
prevent the spread of HIV.

AIDS decreases the bodys immune response, making the infected person susceptible to
infections. AIDS affects helper T lymphocytes, which are vital to the bodys defense
system. Opportunistic infections are a primary cause of death in persons affected with
AIDS. Therefore preventing infection is a priority of nursing care.

In this client, diuresis is a positive sign that indicates that edema and vasoconstriction in
the brain and kidneys have decreased. Diuresis also reflects an increased tissue
perfusion to the kidneys. Clients who have severe preeclampsia are not considered to
be out of danger until birth and diuresis occurs. Diuresis is not an indication of impending
seizure. Although renal failure is a complication of severe preeclampsia, it is not of the
high-output type of failure. Potassium is lost through the urine; therefore hyperkalemia is
not associated with diuresis.

In a pregnant woman, the supine position adds gravity pressure onto the inferior vena
cava, which is already displaced and partially compressed by the term gravid uterus.
The increased compression decreases the cardiac output, leading to beginning tissue
hypoxia, which brings on the signs and symptoms as described in the question. The
signs and symptoms identified in the question are not indicative of progression to active
first-stage labor.

Short-term variability averages 6 to 10 beats per minute, and long-term variability

averages 2 to 6 cycles per minute. The FHR should accelerate with fetal activity. The
baseline range for the FHR is 120 to 160 beats per minute. Late decelerations are a
result of decreased uteroplacental perfusion that causes a decrease in fetal oxygenation.
Late decelerations are not a reassuring pattern.