Vitally Important
For labor patients, this is the frequency of temperature assessment.
What is q 4 hours if intact and q 1 hour if ruptured and q 1 hour if in the tub?
*Tub temperature must be checked and recorded every hour. Water temperature may vary within the range of 95-100 degrees F. *
A late preterm infant is born between these weeks gestation.
What is 34 0/7 and 36 6/7 weeks? Usually, anyone less than 35 weeks gestation get transferred to Baystate Medical.
When caring for a late preterm infant, it would be helpful to pull up the Care of Late Preterm Newborn policy. For example, it reminds us to start q 4 hour vital signs after the hourly vital signs are complete at 4 hours of age and to continue through the first 24 hours.
This is the preferred location for TCB testing?
What is the sternum?
These are the steps if lab calls with a critical value.
What are locate the critical value red stickers (on right side of nursery desk). Fill out. Read back to lab to verify information. Contact the the provider ASAP and document time on sticker. Place the completed critical value red sticker on a Patient Progress Note with the patient identification label and place it in the patient's chart.
The second RN who visualizes the wasting of the remaining epidural solution must complete this under their own CIS account.
What is narcotic infusion witness?
The best practice is to have primary RN tap out and have witness RN tap in immediately so the Witness RN can complete the narcotic infusion witness field. The witness RN then will tap out so the primary RN can tap back in. This should bring the Primary RN back to the screen they were on when they initially tapped out.
When looking at Forms, the document will be flagged red until completed. Good practice to look at forms at at end of your shift if possible.
We know that in PACU, vitals signs (BP,P,RR,O2 Sat) , fundus, flow, cesarean site (dressing) , bladder and sedation scale are assessed and recorded every 15 minutes for the first hour. This is how often temperature in PACU should be assessed and recorded.
What is Maternal temperature will be assessed at the start of PACU period and at the end?
The Non Stress Test is completed and these are the steps you will complete.
What are:
Complete NST task in the task list in CIS.
Export the NST.
Create a non stress test document and attach the exported NST. Save it (do not sign document).
Forward the document to OB to request signing.
Please see another coworker if you do not know how to complete this.
These are the 3 documentation steps that should be completed when checking if a patient is ruptured using Nitrazine.
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What are:
1. Ensure quality check has been completed for that day prior to using.
2. Complete the nitrazine log form.
3. In CIS, complete an ad hoc form under point of care testing under pH amniotic fluid.
These are 3 ways you can get extra hands on deck when you have a critical situation.
What are: Emergency call bell, cortex using the "!", code blue button, calling a rapid response or a code blue 4-HELP
After admitting a labor patient, the nurse should add a green, yellow or red drop to the tracking board which represents this.
What is Post Partum Hemorrhage (PPH) Risk on Tracking Board?
Utilize the PPH red folder in the labor cart to determine risk. Risk should also be reassessed with the CNM/OB at the beginning of second stage of labor.
These are the Maternal Early Warning Sign Criteria for a patient you must report to the CNM/OB:
Syst BP >/= ____ Dias BP >/= ____
HR < 50 or > _____ beats per minute
Resp Rate < 10 or >30 breaths per minute
Oxygen Saturation < ____%
Oliguria: < ____ ml/hour for 2 hours
What are?
Syst BP >/= 140 Dias BP >/= 90 (and again if in severe range)
HR < 50 or > 120 beats per minute
Resp Rate < 10 or >30 breaths per minute
Oliguria: < 30 ml/hour for 2 hours
*Remember to document that you reported it*
This is the standard solution and IV rate(s) for Postpartum Oxytocin.
What is Oxytocin 30 units in 500ml Normal Saline with a bolus rate of 334 ml/hour for 30 minutes via infusion pump (delivers 10 units) with a maintenance rate of 95 ml/hour for 3.5 hours via infusion pump (delivers the remaining 20 units).
In a postpartum hemorrhage, the provider may verbally order a higher rate to control bleeding. You will no longer be able to use the IV pump library under oxytocin to achieve a higher rate. Choose "LR" as a substitute in this critical situation.
Two Parts
1. This is the schedule for infant glucose monitoring if an infant is LGA, SGA, or is an infant of a mother with Diabetes.
2. This is the normal range for glucose for infants.
What is by 90 minutes of life, followed by 2 pre-feeds? Pre-feed glucose monitoring will need to continue until two normal values are obtained.
What is 45 or greater on day one and 50 or greater after that?
Remember SGA babies will need glucose monitoring for 24 hours.
Refer to the Glucose Monitoring Algorithm hanging on the corkboard in the nursery desk area.
These are your first 2 steps when your labor patient has a BP of 176/112 and proper steps where taken to ensure an accurate reading.
What are notify provider upon the first severe BP obtained, (Severe Hypertension: systolic BP > or = to 160 and/or diastolic BP > or = to 110) and Obtain BP's every 5 minutes for the next 15 minutes.
Don’t forget to grab the Blue Hypertension folder from the labor cart for guidance!
You can prove you assessed the effectiveness of pain medication given by completing this.
What are pain med responses?
Can complete this though the MAR or the task list.
IV pain med 30 minutes. Oral pain med 60 minutes.
If patient asleep, document when awake and comment per patient report upon awaking.
This is the schedule for assessing and documenting vital signs for the Normal Newborn according to BFMC Standard of Care.
What is:
Pulse, respirations and axillary temp taken at birth. Vitals signs at 30 minutes and 60 minutes after birth then every hour until newborn is 4 hours old then every 8 hours if stable until discharge?
Your patient is receiving the following IV medications and fluids-LR, insulin, magnesium and oxytocin. This is a correct way to arrange the IV tubing and sites.
What are two separate IV sites with the First having LR as the primary, Pitocin piggybacked into the lowest port and Magnesium piggybacked into the second lowest port. Insulin is infused per protocol into a separate site.
The heart has FOUR chambers and the Critical Congenital Heart Disease screening is abbreviated with FOUR letters-CCHD. When an infant passes the CCHD, these are the FOUR places you should document.
What are:
1.CIS task for CCHD screening.
2. Document In Plan- record pass in the CCHD line
3. Put a P for Pass in the Newborn Log on the Nursery desk.
4. Put a P for Pass on the master Bedside Report sheet.
These are two medications/infusions requiring two RN verification.
What are epidural infusion (initiation, discontinuation, shift to shift, new bag with no program change, verification after Anesthesia does a program change), blood products (except Rhogam), IV magnesium, insulin, newborn meds
This system should be assessed and documented every 4 hours for 24 hours after epidural removal.
What is Neurological?
Notify Anesthesia if any concerns such as spinal headache, change in CSM or no return of normal CSM, leakage at epidural site, increased pain at site, swelling at site or any other concern.
We tell our patients that it is vital for them not to forget about caring for themselves so they do not become depleted. As caregivers, these are 3 ways we can care for ourselves so we don't become depleted.
* Notice this is worth 500 points! *
What are:
getting good sleep, exercise, fun, eating well, support of friends and coworkers, aromatherapy, mediation, massage, acupuncture, taking vacations, deep breathing, asking others to help, using the Renewal Room, EAP ...
As nurses, upon completion of triage/assessment, we can initiate these following 4 OB Nursing Protocol Order Sets if a provider is unavailable:
OB-Labor and Delivery Admission
OB-Vaginal Delivery Postpartum
OB-Hypertension/Preeclampsia
OB-C-Section, BFMC
This protocol order set most likely will be the most helpful to care for the patient in a timely manner especially when the CNM/OB can not put the orders in themselves.
What is the
OB-Hypertension/Preeclampsia Protocol Order Set
There is a white binder at the nurses station closest to the nursery that outlines how to do this and shows these protocol orders. Please review. The HTN/Preeclampsia will be very helpful if you have a severe BP reading and a provider who is busy with another patient. It allows you to order labs.
Hearing is one of the FIVE senses. When an infant passes the hearing screen (Algo), these are the FIVE things that should be completed.
What are:
1.Fill out Newborn Hearing Pass form and review with parents, including back side.
2. Complete the CIS task for the Hearing Screening.
3. Complete the Hearing Screening field on the Worksheet for Mandatory Birth Reporting -Newborn Health form in the newborn chart.
4. Put a P for pass in the Newborn Log on the nursery desk
5. Put a P for pass on the master copy of the Bedside Report sheet.
A very active labor patient is admitted. She had a previous cesarean delivery and signed the consent to attempt a TOLAC Trial of Labor after a Cesarean. She is coping well and doesn't have an urge to push.
These are two initial actions you will complete in caring for this patient.
What are:
Initiate Continuous monitoring and
Obtain IV access.
Ensure Lab work is ordered (CBC, Type and Hold).
Contact Anesthesia to make them aware there is an active VBAC patient on the unit. Anesthesia and OB should be within a 10 minute response time.
This is how the hospital gets reimbursed for time the nurse takes preparing for a cesarean section and time in the PACU.
What are completing the pre and post op docs?
If you don't know how to do this, please ask other coworkers to show you.