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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 tuberculosis infection. Beca Becaus use e the the resp respon onse se to tube tuberc rcul ulin in skin skin test testin ing g may may be decr decrea ease sed d in the the immunosuppressed immunosuppressed client, induration reactions more than 5 mm are considered positive. A reading reading of 6mm 6mm induration is a positive result result in a client client who is !"# positive. positive. A positive result indicates exposure to tuberculosis and possibly the development of tuberculin infec infectio tion. n. $urth $urther er diagn diagnost ostic ic tests tests shou should ld be perfo performe rmed d to confir confirm m infec infectio tion n with with tuberculosis.
The T%& classification system for staging tumors is widely used. T refers to the tumor si'e, with T( indicating no primary tumor found and T) to T* referring to progressively larger tumors. T"+ is used to indicate a carcinoma in situ. % refers to regional lymph node involvement. %( indicates regional nodes were normal, and %) to %* indicates increasingly abnormal regional lymph nodes. &) indicates that distant metastasis is present. The complications associated with thoracic surgery include pulmonary edema, cardiac dysrhyth dysrhythmias mias,, hemorrha hemorrhage, ge, hemotho hemothorax, rax, hypovole hypovolemic mic shock, shock, and thrombop thrombophleb hlebitis. itis. +igns of pulmonary edema include dyspnea, crackles, persistent cough, frothy sputum, and cyanosis. A urinary urinary output of *5 m-hour is an appropriate output. The nurse would become concerned if the output were below ( m-hour. Between )(( and (( m of drainage may accumulate during the first / hours after thoracic surgery. %ormal arterial blood p! is 0.5 to 0.*5. An arterial blood p! of 0.5 is not indicative of a complication.
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The client with 1aynaud2s disease suffers from bodyimage disturbance when physical chang changes es begin begin to occur occur.. Thera Therape peuti utic c nursi nursing ng inter interven ventio tions ns are are implem implemen ented ted to encourage verbali'ation about the body changes and to develop appropriate problem solving techni3ues for coping with the changes.
+pecific gravity is a measure of the concentration of particles in the urine. A normal range of urine specific gravity is approximately approximately ).((5 to ).((. 4arly in polycystic kidney disease, the ability of the kidneys to concentrate urine decreases. A urine specific gravity of ).((( is lower than normal, indicating dilute urine.
iving the client with chronic emphysema a high liter flow of oxygen could stop the hypoxic drive and cause apnea.
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Assays of catecholamines are performed on singlevoided urine specimens, / to *hour specimens, and /*hour urine specimens. The normal range of urinary catecholamines is up to )* mcg-)(( m of urine, with higher levels occurring in pheochromocytoma.
After a cerebrovascular accident, clients are often emotionally labile, confused, forgetful, and frustrated. lients may use profanity, which is often termed 7automatic language.8
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 xray films after a radiopa3ue dye is in9ected 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. "n9ections can cause discomfort.
The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, congestive heart failure :!$;, increased platelet aggregation, and cerebrovascular accident :#A;.
"n myxedema, the T+! level is elevated, and the T and T* levels are decreased. +ecretion of T and T* is regulated by a hypothalamicpituitarythyroid gland feedback mechanism. T+! regulates the secretion of thyroid hormone from the thyroid gland. The circulating levels of thyroid hormone are the ma9or factor regulating the release of T+!. "f the thyroid levels are low, T+! release is increased, and if the thyroid levels are high, T+! is inhibited. "n hyperthyroidism, T and T* secretions are elevated because the normal regulatory controls of thyroid hormone are lost. !ypoparathyroidism is associated with a decrease in serum calcium and an increase in serum phosphate.
utting the blood glucose monitoring strips in half may affect the accuracy in reading the results.
!ydrocortisone is the topical treatment of choice for cutaneous inflammation and pruritus associated with contact dermatitis. "f a rash does not respond to this overthecounter 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 ) 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. "f a change in rate or rhythm is noted, the physician should be notified.
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rutch tips should remain dry. =ater could cause slipping by decreasing the surface friction of the rubber tip on the floor. "f 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 0( to ))5 mg-d but may vary depending on the time of the last meal.
>n removal of a chest tube, an occlusive dressing consisting of petrolatum gau'e 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. &onitoring and reporting respiratory difficulty and increased temperature are appropriate client activities on discharge. The client should avoid heavy lifting for the first * to 6 weeks after discharge to facilitate continued wound healing.
?ostoperative care after a parathyroidectomy includes instructing the client that the weight of the client2s 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. &eats contain some potassium and are high in protein and should be limited to 6 o'-day. +alt substitutes are often high in potassium and are to be avoided.
?lasmapheresis is a process that separates the plasma from the blood elements, so that plasma proteins that contain antibodies can be removed. "t is used as an ad9unct therapy in myasthenia gravis and may give temporary relief to clients with actual or impending respiratory failure. @sually three to five treatments are re3uired. "mprovement in vital :respiratory; capacity is an intended effect of this treatment.
The client with A should use energyconservation techni3ues 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.
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=hen 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 @T" involves 0 to )( days administration of oral antimicrobial therapy. "t is important to take antibiotics, even if the client is feeling better. =hile taking these medications, the client should drink at least eight glasses of fluid per day to keep urine dilute. #oiding 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 minimi'e 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.
>lder 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. "f the test is negative :no reaction;, the client may have a delayed reaction and should have a repeated tuberculin skin test in ) to / weeks. The second test should reveal positive results if the client had prior exposure. The tuberculin skin test is read in * to 0/ hours. 4rythema or redness alone is not considered significant. The si'e of induration, if any, is what determines the significance of the test. A positive test does not indicate active disease. ?ersons 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 in9ury 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. =alking will be a component of the treatment plan.
"nstructions to a client after a aortoiliac 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.
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+pinal shock that occurs after spinal cord in9ury lasts to 6 weeks after the in9ury and is characteri'ed by a flaccid neurogenic bladder with urinary retention. "ntermittent catheteri'ation used to empty the bladder should be carried out in a manner that prevents urinary tract infection :@T";. loudy or bloodtinged urine may indicate the onset of infection. Because fluid is lost through the skin, lungs, and bowel, intake does not normally e3ual output. +ensations of the need to void re3uire an intact cord, which would not be present in this client. holinergic action stimulates bladder emptying, so anticholinergics would produce the undesirable effect of relaxation of the bladder in this client.
$irstdegree heart block indicates a delayed conduction somewhere between the 9unctional tissue and the ?urkin9e network, causing a prolonged ?1 interval. ying still will not relieve the problem. A pacemaker is not necessary for firstdegree heart block. &edication 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. "f 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.
=ithin / or days of surgery, a lung is generally fully reexpanded. The nurse notes an absence of fluctuation or bubbling in the water seal chamber or drainage from the chest tube. At this time, the client2s status is confirmed by chest xray. "f the lung is fully re expanded, 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. &ultiple organ failure has occurred, and death is imminent. As it becomes obvious that the client is unlikely to survive, the client2s family needs to be informed about the prognosis and outcome. +upport to the grieving family members becomes an integral part of the nursing care plan.
The purpose of 4 monitoring is to record cardiac electrical activity during the depolari'ation and repolari'ation phases. The two types of singlelead monitoring are hardwire and telemetry. =ith a wireless batteryoperated telemetry system, the client is afforded more freedom and mobility than with the hardwire system. The most common problems with 4 monitoring are related to client movement, electrical interference from e3uipment in the room, poor choice of monitoring leads, and poor contact between the skin and electrode.
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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 /* hours. Tracheostomy care should be done at least every hours or per agency policy. "t would not be beneficial to the client to limit fluids, because thicker secretions pose added problems with airway management.
Before discharging a ventilatordependent client to home, the nurse determines that the family is able to perform ?1, including mouthtotracheostomy ventilation. The ?1 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 e3uipment that will be used. The ventilator should have a builtin converter to battery power if the electrical power should fail. >therwise, a generator must be installed. The home itself should be free of drafts and provide ade3uate air circulation.
Back pain after AAA repair may indicate a problem with the repair. "t should be reported to the physician immediately.
ryosurgery entails free'ing cervical tissue with nitrous oxide. "t is performed in an outpatient setting. ryosurgery 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. ondom use can help to prevent epididymitis that can occur as a result of +T
Treatment of prostatitis includes medication with antibiotics, analgesics, and stool softeners. The client also is taught to rest, increase fluid intake, and use sit' baths for comfort. Antimicrobial therapy is always continued until the prescription is completely finished.
The client with respiratory disease may have "neffective oping 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.
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The primary symptom in placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. ?assage of the mucus plug appears pink or as bloodtinged mucus. A ruptured amniotic sac would include findings such as a watery vaginal drainage. $indings of abruptio placenta include dark red vaginal bleeding and abdominal pain. &agnesium sulfate depresses the respiratory rate. "f the respiratory rate is less than )/ breaths per minute, the continuation of the medication should be reassessed. The symptoms of 9itteriness and tachypnea :respiratory rate of 6/ breaths per minute; in a */weekgestation newborn infant are indicative of hypoglycemia. !ypoglycemia may develop in a */weekgestation newborn infant because of the insufficient stores of glycogen, which may have been depleted during the postterm period. "nsufficient amounts of glucose in the infant2s brain could possibly cause central nervous system damage. A normal blood glucose level for newborn infants is *( mg-d and higher. 1ho:<; immune globulin is not administered if a client has experienced a severe reaction to its component, human globulin. 1ho:<; immune globulin is indicated when 1h negative clients are exposure to 1hpositive 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 to * postoperative weeks to allow healing of the incision. oagulation failure, particularly disseminated intravascular coagulopathy :<";, is a common result of an amniotic fluid embolus. &anifestations 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 ?eripad in )5 minutes or less is considered to be hemorrhaging, which in this case is caused by lack of coagulation at the placental site. A pulsating ropelike ob9ect seen in the vagina indicates the presence of the umbilical cord. 4ach 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. +ituational ow +elf4steem represents temporary negative feelings about self in response to an event. This is a normal response to cesarean section.
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?regnancy taxes the circulating system of every woman because both the blood volume and cardiac output increase approximately (C. This is especially important to monitor in the client whose heart may not tolerate this normal increase. !"# has a strong affinity for surface marker proteins on lymphocytes. This affinity of !"# for T lymphocytes leads to significant cell destruction. Angiotensin is produced in the kidney and plays a role in blood pressure control. !"# infection in a pregnant woman may cause both maternal and fetal complications. $etal compromise can occur because of premature rupture of the membranes, preterm birth, or low birth weight. ?otential maternal effects include an increased risk of opportunistic infections. "ndividuals in the later stages of !"# are further susceptible to other invasive conditions, such as tuberculosis and a wide variety of bacterial infections. The anterior fontanel is normally /.5 to 5 cm in width and diamondlike in shape. "t can be described as soft, which is normal, or full and bulging, which could be indicative of increased intracranial pressure. onversely, a depressed fontanel could mean that the neonate is dehydrated.
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lients with ushing2s 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. ?olydipsia and polyphagia are seen in diabetes mellitus. =eight loss and peripheral edema may be seen in a number of conditions. +ituations that precipitate sickle cell crisis include hypoxia, vascular stasis, low environmental and-or body temperature, acidosis, strenuous exercise, anesthesia, dehydration, and infections.
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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. %o lotions, creams, alcohol, or deodorants should be placed on the skin over the treatment site. ines 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;. ?revention of recurrence of urinary stones is accomplished by drinking at least of fluid per day voiding every / hours following an acid ash diet if the stones are calcium oxalate stones and notifying the physician promptly if symptoms of @T" occur.
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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.
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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. $luid balance and albumin levels are monitored to determine effectiveness of therapy. +tair 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. lients often want to scrub the dead skin away, which irritates the skin. The client should avoid overexposing the skin to the sunlight. 4xpected outcomes for "mpaired ?hysical &obility for the client in traction include absence of thrombophlebitis :measurable by negative !omansD sign;, active baseline 1>& to uninvolved 9oints, clear lung sounds, intact skin, and bowel movement every other day. After three unsuccessful defibrillation attempts, ?1 should be done for ) minute, followed by three more shocks, each delivered at 6( 9oules. 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. lients 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. +uggestions to minimi'e potential problems include waiting for / 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. 4xpected outcomes for the client with pulmonary edema include improved cardiac output as evidenced by stable vital signs, and urine output of at least ( m-hour. The client2s blood gas results indicate respiratory acidosis. +ymptoms of respiratory acidosis include headache, irritability, muscle twitching, behavioral changes, confusion, lethargy, and coma. =hen the carboxyhemoglobin levels are greater than /5C :acute toxicity;, the respiratory center becomes depressed because of inade3uate oxygenation, and hypoxia occurs. A longrange approach to the prevention of pulmonary edema is to minimi'e any pulmonary congestion.
the systemic circulation. +leeping with the head of the bed elevated helps prevent circulatory overload. •
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omplications after pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve in9ury. The nurse notes indications of these complications, such as dyspnea, excessive pain, pallor, or diaphoresis. &ild 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 0 days. $ull healing takes about 6 weeks, after which full activity may be resumed. oughing and deep breathing will effectively promote lung expansion and clearance of mucus. @sing 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 ?rin'metal2s 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. 4xercise is most effective when done at least times a week for a client with angina pectoris. >ther positive habits include limiting salt and fat in the diet, using stress management techni3ues, and knowing when and how to use medications. %osebleeds may occur during the winter because of decreased humidity in the home. The use of a humidifier helps to alleviate this problem. "f pulse oximeter values fall below a preset norm, which is usually E(C to E)C, 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. "f 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 ram stain classifies the organism as gramnegative or grampositive, 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 /* hours more to identify the specific organism:s;. The sensitivity test gives the physician precise information about which antibiotics the organism is sensitive to.
"n the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes oodell2s sign. ervical 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. h is noted in maternal urine in a urine pregnancy test. oodell2s sign does not indicate the presence of fetal movement.
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Fuickening is fetal movement and is not perceived until the second trimester. Between )6 and /( 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 !icks 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 !egar2s sign $etal heart sounds can be heard with a fetoscope by ) to /( 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. =hen the cervix is tapped, the fetus floats upward in the amniotic fluid. The examiner feels a rebound when the fetus falls down. $etal movement, called 3uickening, is not perceived until the second trimester. Between )6 and /( weeksD gestation, the expectant mother first notices subtle fetal movements that gradually increase in intensity. A rubella titer is performed to determine immunity to rubella. "f the mother2s titer is less than )G, the mother is not immune. A retest during pregnancy is prescribed, and the mother is immuni'ed postpartum if not immune. A maternal glucose assay is prescribed to screen for gestational diabetes. "f it is elevated, a 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. "f antigens are present, the infant should receive a hepatitis immune globulin and a vaccine soon after birth.
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At )/ weeksD gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At )6 weeks, the fundus reaches midway between the symphysis pubis and the umbilicus. At /( weeks, the fundus is located at the umbilicus. By 6 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. $ertili'ation normally occurs in the distal third of the fallopian tube near the ovaries. The ovum, fertili'ed or not, enters the uterus about 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 ), the fetal sex can be determined by the appearance of the external genitalia on ultrasound. &ineral oil should not be used as a stool softener because it inhibits the absorption of fatsoluble vitamins in the body. onstipation should be treated with increased fluids :six to eight glasses per day; and a diet high in fiber. "ncreasing exercise is also an excellent way to improve gastric motility. The genitalia of a newborn female are fre3uently 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. +kin integrity is impaired because a thin membrane covers the protruding sac. ?rolactin 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. >xytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. ?rogesterone 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 / days, although it may range from /( to *5 days. +ignificant deviations for the /day cycle are associated with reduced fertility. The first day of the menstrual period is counted as day ) of the adolescent2s cycle. The ovaries are the endocrine glands that produce estrogen and progesterone. $+! and ! are produced by the anterior pituitary gland. >xytocin is produced by the posterior pituitary gland and stimulates the uterus to produce contractions during labor and birth.
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&ittelschmer' :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 subse3uent 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. "t generally lasts a few hours to / days, and slight vaginal bleeding may accompany the discomfort. 4ndometriosis 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. ?rimary dysmenorrhea refers to menstrual pain without identified pathology. &ittelschmer' 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. "n early pregnancy, h is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for positive pregnancy tests.
?rogesterone maintains uterine lining for implantation and relaxes all smooth muscle, including the uterus. 1elaxin is the hormone that softens the muscles and 9oints of the pelvis. Thyroxine increases during pregnancy to stimulate basal metabolic rates, and prolactin is the primary hormone of milk production. 4strogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. ?rogesterone maintains the uterine lining for implantation and relaxes all smooth muscle. !uman placental lactogen stimulates the metabolism of glucose and converts the glucose to fat. !uman chorionic gonadotropin :h; prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. vulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, inhibiting the release of the follicle stimulating hormone :$+!; and the luteini'ing hormone :!;, which are necessary for ovulation.
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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. "ron supplements usually cause constipation. &eats are an excellent source of iron. "ron for the fetus comes from the maternal serum. +igns of congenital neonatal syphilis may be nonspecific at first, including poor feedings, slight hyperthermia, and 7snuffles.8 +nuffles refers to copious, clear serosanguineous mucus discharge from the nose. By the end of the first week, a coppercolored maculopapular dermal rash is characteristically observed on the palms of the hands, soles of the feet, diaper area, and around the mouth and anus. 4ffective 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 wellbeing and an oxygenated fetal central nervous system. Bradycardia, late decelerations, and decreased variability are representative of decreased oxygenation of the fetus. +igns of impaired fetal oxygenation include late decelerations, decreased baseline variability, and tachycardia or bradycardia. A normal fetal heart range is )/( to )6( 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 !"# because the virus may be spread to the infant in the breast milk. !"# is not spread through casual contact, so holding, hugging, and sleeping with other family members is not prohibited. A newborn may test positive for !"# for up to / years after birth because of placental transfer of maternal antibodies. "t 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 !"#. A"<+ decreases the body2s immune response, making the infected person susceptible to infections. A"<+ affects helper T lymphocytes, which are vital to the body2s defense system. >pportunistic infections are a primary cause of death in persons affected with A"<+. Therefore preventing infection is a priority of nursing care.
"n this client, diuresis is a positive sign that indicates that edema and vasoconstriction in the brain and kidneys have decreased.
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"n 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 3uestion. The signs and symptoms identified in the 3uestion are not indicative of progression to active firststage labor.
+hortterm variability averages 6 to )( beats per minute, and longterm variability averages / to 6 cycles per minute. The $!1 should accelerate with fetal activity. The baseline range for the $!1 is )/( to )6( beats per minute. ate decelerations are a result of decreased uteroplacental perfusion that causes a decrease in fetal oxygenation. ate decelerations are not a reassuring pattern.
