HESI MILESTONE 2 VERSION A BLUEPRINT for 2024/2025 COMPLETE SOLUTION 100% VERIFIED
ANSWERS A+ GRADED Free
Schizophrenia care-
Establish trust and rapport, encourage the client to talk with you, be consistent in setting expectations,
explain the procedures and be certain the client understands, give positive feedback for the client
successes, show empathy, do not be judgemental, never convey to the client that you accept their
delusions as reality.
When the woman arrives at the facility, place her on strict bed rest and in a left lateral position to
prevent pressure on the vena cava. This position provides uninterrupted perfusion to the fetus.
Nursing Assessment
A. Bleeding: concealed or overt (if overt, is dark red)
B. Uterine tenderness
C. Persistent abdominal pain
D. Rigid, boardlike abdomen
E. FHR abnormalities
First action: massage the uterus.
Expect to administer oxygen therapy via nasal cannula to ensure adequate tissue perfusion. Monitor
oxygen saturation levels via pulse oximetry to evaluate the effectiveness of interventions.
,Fetal heart rates tachycardia-
Fetal tachycardia is defined as a heart rate of more than 160–180 bpm. It can be intermittent or
sustained. It can indicate infection or hypoxemia.
1. Baseline FHR is above 160 bpm (assessed between contractions) for 10 minutes
2. Causes
a. Early sign of fetal hypoxia
b. Fetal anemia
c. Dehydration
d. Maternal infection, maternal fever
e. Maternal hyperthyroid disease
f. Medication-induced (atropine, terbutaline, hydroxyzine)
Nursing actions
1. Immediately turn client onto left side (change position of mom)
2. Discontinue oxytocin (Pitocin) if infusing.
3. Administer O2 at 10 L by tight facemask.
,4. Maintain intravenous (IV) line
5. Notify health care provider.
6. Document pattern and response to each nursing action.
Prolapsed Cord Care-Obstetrical emergencies-
Umbilical cord prolapse is a rare obstetric emergency occurring when the cord precedes the fetus.
Risk factors include multiparity, non-cephalic presentations, long length of cord, preterm labor, low birth
weight, multifetal pregnancy, and placement of a cervical ripening balloon.
HESI Hint
If cord prolapse is detected, the examiner should position the mother to relieve pressure on the cord
(i.e., knee-chest position) OR push the presenting part off the cord until immediate cesarean delivery can
be accomplished.
Shoulder dystocia-
Shoulder dystocia is defined as the obstruction of fetal descent and birth by the axis of the fetal
shoulders after the fetal head has been delivered. Shoulder dystocia is a fundamentally mechanical
problem. Maneuvers to relieve shoulder dystocia.
A.) McRoberts maneuver. The mother's thighs are flexed and abducted as much as possible to straighten
the pelvic curve.
, B.) Suprapubic pressure. Light pressure is applied just above the pubic bone, pushing the fetal anterior
shoulder downward to displace it from above the mother's symphysis pubis. The newborn's head is
depressed toward the mother's anus while light suprapubic pressure is applied.
Nursing management of a woman with dystocia requires patience, regardless of the etiology. The nurse
should provide physical and emotional support to the client and her family.
Fetal heart rate patterns - deceleration-
A deceleration is a transient fall in FHR caused by stimulation of the parasympathetic nervous system.
Decelerations are described by their shape and association to a uterine contraction. They are classified
as early, late, and variable only.
Nursing actions for variable decelerations
1. Change maternal position.
2. Stimulate fetus if indicated.
3. Discontinue oxytocin (Pitocin) if infusing.
4. Administer oxygen (O2) at 10 L by tight facemask.
5. Perform a vaginal examination to check for cord prolapse.
6. Report findings to physician and document.
Post-partum hemorrhage-
This is a potentially life-threatening complication that can occur after both vaginal and cesarean births. It
is the leading cause of maternal death in both developed and developing countries. PPH is defined as a
cumulative blood loss greater than 1,000 mL with signs and symptoms of hypovolemia within 24 hours of
the birth process, regardless of the route of delivery.
Excessive bleeding can occur at any time between the separation of the placenta and its expulsion or
removal.
The most common cause of PPH is uterine atony, failure of the uterus to contract and retract after birth.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Bestnursesteve. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $17.99. You're not tied to anything after your purchase.
