1. Determine obstetrical data. Luisa is pregnant for the first time… 1. Determine obstetrical data.Luisa is pregnant for the first time and is carrying twins. At 37-38 weeks, Luisa delivered twins.Emma is pregnant for the second time. Her 1st pregnancy three years ago ended in an abortion. Her current pregnancy resulted to preterm.Pinky is pregnant for the first time. After 34 weeks, she delivered a 4lb baby boy with no signs of life.Determine TPALM Present: 3 monthsDaughter: 38 weeks Present: 3 monthsDaughter: 38 weeksMiscarriage: 12 weeksBoy: 32 weeksDetermine EDCLMP: Jan 2, 2017LMP: July 17, 2017LMP: July 30, 2017LMP: Mar 3, 2017LMP: June 26, 2017LMP: October 30, 2017Determine AOG using McDonald’s RuleFH is 31.5 cm in monthsFH is 36 cm in weeks 2.Formulate a care plan based on the following Nursing Diagnosis. Provide 8 Nursing Interventions. Rationalize and evaluate each interventions. Use NANDA as your guide in formulating the care plan.Risk for injury related to side effects of phototherapy treatmentReadiness for enhanced knowledge (how to recognize worsening jaundice in newborn)3. I’ve been having trouble / pain pooping, it seems that there’s a skin protruding at my anus) as verbalized by the patient.OBJECTIVE DATA:Pt. Name: Romeo GarciaAge: 18 y/oGuarding behaviorRestlessnessFacial mask of painV/S taken as follows:Temp – 37.2OCPR – 95RR – 20BP – 130/80Instructions:Formulate 2 nursing care plans BASED ON THE GIVEN ASSESSMENT.Submission will be according to the preference of your clinical instructor.4. Read the following case study. Then, work through the steps of analyzing the case study data. First identify abnormal data and strengths in subjective and objective findings, assemble cue clusters, draw interferences, make possible nursing diagnoses, identify defining characteristics, confirm or rule out the diagnoses, and document your conclusions. Formulate nursing diagnoses that are specific to the client in the case study. Identify collaborative problems, if any, for this client. Finally, identify data, if any, which point toward a medical problem requiring a referral.Evelyn Vaughn is a 47-year-old white woman, who comes to the clinic for evaluator. She is a single mother and sells cosmetics in her home. She is lethargic and walks slowly into the room. She asks if she can have some “special lotion” for her dry skin.When interviewed, Evelyn states that her skin has been dry and scaly for the past several months, unrelieved by numerous moisturizers. She expresses concern about “fly-away hair that I can’t do anything with” and about brittle, easily broken fingernails. When asked about medications, she explains that she is supposed to take Synthroid daily for “my low thyroid” but cannot afford to get the prescription filled. She has a poor appetite, and with “not enough money to go around,” she has been nibbling on crackers, lunch meat, and sodas daily. Exercise is out of the question because she lacks energy, and she is rarely able to get through a day without one or two 30-minute naps. Evelyn takes a shower and washes her hair using ivory soap and baby shampoo. She applies moisturizer to her skin and conditioner to her hair but states that neither helps for any length of time. She keeps her nails cut short because they break so easily. She states that she cut down on her cosmetic sales appointment because “I look like I never use my own products.”Your physical assessment reveals dry flaking skin that is cool to the touch and yellow tinged. Facial and preorbital edema are present. the client’s facial expression is blank. She has multiple bruises on both forearms and anterior lower legs, which are in various stages of healing and tender when touched. Her scalp hair is dry and dull and breaks easily. Her scalp is scaling. Sparse hair is noted in the axillae and the pubic area. Her fingernails are short and dry; her cuticles are dry and torn. Her toenails are thick and yellow. 5.TRUE OR FALSEStrict asepsis is applied when performing dressing of the newborn’s umbilical cordTape measure is the equipment of choice when measuring the newborn’s weightWhen measuring for the chest circumference, the tape measure is place at the nipple line and is wrapped around the newbornThe normal breathing of a newborn can be largely assessed on their chestVernix Caseosa is an abnormal characteristic of the skin of a newborn and should be removed immediately upon deliveryThe anterior fontanelle closes between 12 – 18 months of ageThe posterior fontanelle is soft, flat, 3-4 cm wide by 2-3 cm long, and diamond – shapedCephalhematoma is a swelling caused by bleeding into an area between the bone and its periosteumThe eyes of a newborn is farsighted and has a visual acuity of 20/200Newborns are obligatory nose breathersIDENTIFICATIONAn initial care of the newborn when the nurse uses an ophthalmic ointment to prevent ophthalmia neonatorum or neonatal conjunctivitisIt is the rapid assessment of the need for resuscitation based in 5 signs that indicate the physiologic needs of the neonateAn abnormal finding when assessing lung sounds characterized by the newborn’s nostrils that widens to every inhaled breathThe term for assessing the newborn’s skin where hands and/or feet appear blueIt is the common treatment for physiologic jaundice where the newborn is exposed under a blue spectrum lightThe term for assessing the newborn’s head characterized by an edematous scalp due to prolonged laborThis is passed during the first 24 hours of life of the newborn signifying anal patencyA newborn’s reflex where the nurse touches the upper or lower lip or cheek with a gloved finger or sterile nipple. The newborn will move the head toward the stimulated area and open the mouth.The reflex is manifested by the infant slightly flexing and abducting the legs, laterally extending and abducting the arms, forming a “C” with thumb and forefinger, and fanning the other fingersGiven to prevent hemorrhage related to physiologic hypoprothrombinemiaENUMERATIONThe 5 vital indicators of APGAR ScoreThe 5 anthropometric measurements in newborns Health Science Science NursingShare
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