Nursing Exams 2024

Stages of Unconsciousness

•Confusional state
•Deliriu
•Obtundation
•Stupor
•Coma

1. Confusional State-Confusion is a state in which the patient cannot take into account all elements of his/her immediate environment, implying an element of sensorial clouding.

•Disoriented.
•Shortened attention span.
•Memory deficits.
•Difficulty in following commands.
•Alteration in perception of stimuli.

2. Delirium-It is characterized by a fluctuating disturbance in consciousness and change in cognition that usually develops over a short period of time.

•Disoriented to place and person.
•Increased motor activities
•Illusion, Hallucinations

3.Obtundation-Decreased alertness and hypersomnia.

•Obtundation is characterized by reduced alertness and hypersomnia.
•Hypersomnia is technically defined as a state of sleep in excess i.e, 25% more of the expected normal sleep.
•Obtundation is often seen with substance abuse in the form of narcotic or alcohol over dosage.

4. Stupor-Stupor is unresponsiveness from which the patient can only be aroused by vigorous repeated painful stimuli.

•Deep sleep or unresponsiveness
•Can be aroused only with painful stimuli.
•Responds by withdrawing or Grabbing at the source of pain.

5.Coma- State in which a patient is totally unaware of both self and external surrounding, and unable to respond meaningfully to external stimuli.

Characteristics of coma
•No eye-opening
•Inability to follow instructions
•No speech or other forms of communication
•No purposeful movement

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Naegele’s rule

• To the first day of the LMP, add 9 months and 7 days.

• Or subtract 3 months and add 7 days (not forgetting to add a year!).

• To be more accurate, as discussed above, add 9 days instead of 7.

• If available, use an obstetric calendar, but add an additional 2 days.

• Naegele's rule assumes a 28-day menstrual cycle.

• Ovulation occurs 14 days before menstruation; in a 28-day cycle that is day 14.

• If the woman's normal menstrual cycle is shorter or longer than this, you will need to add or subtract days accordingly. Calculate according to Naegele's rule above, then add or subtract the required days.

Examples

• For a regular 25-day cycle, subtract 3 days from the calculated expected birth date.

• For a regular 35-day cycle, add 7 days to the calculated expected birth date.

• For an irregular cycle that has no definite pattern, it is advisable to send a woman for an early dating scan, before 12 weeks of pregnancy, if this service is available; or do your best to calculate and use other clinical signs and symptoms of early pregnancy to help you.

• Remember that a woman may be quite clear that she knows exactly when she was conceived. Use this information as part of your judgment.

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Face presentation

When the attitude of the fetal head is one of complete extension, the occiput of the fetus will be in contact with its spine and the face will present. The incidence of a face presentation in labour is approximately 0.14%;2 most cases develop in labour from occipito- posterior positions (secondary face presentation). Rarely, face presentation is apparent before labour and may be associated with congenital abnormality (primary face presentation).

Causes

•The uterus is tilted sideways (anterior obliquity).
•Contracted pelvis.
•Tight or entangled cord.
•Polyhydramnios.
•Congenital abnormality (e.g. anencephaly).
•Multiple pregnancy.

Diagnosis

•Antenatal diagnosis is unlikely as the presentation usually develops in labour.
•On palpation: if the mentum is anterior, the presentation may not be detected. If the mentum is posterior, a deep groove may be felt between the occiput and the fetal back.

•On vaginal examination:

•The presenting part is high and irregular
•The orbital ridges, eyes, nose, and mouth of the fetus are palpable
•There may be confusion between the mouth and anus; differential signs are: open, hard gums, ridged palate, and the fetus may suck the examining finger
•To determine the position, the mentum is located
•Vaginal examinations should be undertaken with care so as not to injure or infect the eyes.

Course and outcomes of labour

•Prolonged labour.

•With a mentoanterior position: spontaneous birth is possible.

•With a mentoposterior position: following rotation of the mentum to the anterior, a spontaneous birth is possible.

•Persistent mentoposterior: the mentum is in the hollow of the sacrum, so no further mechanism takes place. Instrumental assisted birth or

•LSCS is the outcome.

Management of labour and birth

•Labour is often prolonged; the presenting part is ill-fitting, so there is slow progress.
•Maternal comfort and support are important.
•Communication and empathy are vital as the mother may become discouraged and anxious about her abilities.
•Prior to birth, explain the risk of possible facial bruising to the face of the newborn to the parents.
•Recognize delay or complications at an early stage.
•The use of a scalp electrode should be avoided.
•The use of IV oxytocin should be avoided.
•Birth may be facilitated by supporting the extended fetal position and applying gentle pressure on the sinciput until thementum escapes.
•An episiotomy may be indicated, before the occiput sweeps the perineum.

Complications:-

Mother

•Obstructed labour, as the face is resistant to moulding.
•Early rupture of the membranes.
•Cord prolapse.
•Perineal lacerations and perineal trauma.

Neonatal

•Facial bruising and oedema.
•Cerebral haemorrhage.

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