III.

Laboratory and Diagnostic Tests (BURGOS & CACATIAN)

TEST SIGNIFICANT PROCEDURE AND NURSING CONSIDERATION RESULTS

CAPILLARY TO MONITOR THE BLOOD BEFORE THE TEST: Normal:

BLOOD GLUCOSE OF THE  IDENTIFY THE PATIENT BY ASKING THE PATIENT  Fasting: At or above 95 mg/dL
GLUCOSE MOTHER WHERE TO STATE HIS/HER NAME OR CHECK THE  1 Hour: At or above 180 mg/dL
HYPOGLYCEMIA CAN BE CLIENT’S IDENTIFICATION BRACELET.  2 Hour: At or above 155 mg/dL
CAUSE OF HYPOTONIC  EXPLAIN TO THE PATIENT THAT NPO IS REQUIRED  3 Hour: at or above 140 mg/dL
FOR 4 HOURS FOR GETTING THE FASTING BLOOD
GLUCOSE LEVEL.
 EXPLAIN THE PROCEDURE TO THE PATIENT TO
GAIN COOPERATION.
DURING THE TEST:
 IDENTIFY THE PATIENT BY ASKING THE PATIENT
TO STATE HIS/HER NAME OR CHECK THE
CLIENT’S IDENTIFICATION BRACELET.
 EXPLAIN AGAIN THE PROCEDURE TO THE
PATIENT
 CHOOSE THE PUNCTURE SITE.
 WASH HANDS OR USE CLEAN GLOVES
 IF GLUCOMETER IS USED, LOAD THE STRIP INTO
THE DEVICE BEFOREHAND.
 SWAB A DRY COTTON OR A WARM WARM TO THE
SIDE OF THE FINGER.
 TO COLLECT A BLOOD SAMPLE, POSITION THE
LANCET AT THE SIDE OF THE FINGERTIPS
 DO NOT SQUEEZE THE PUNCTURE SITE OR THE
FINGER TIPS TO PREVENT DILUTING THE SAMPLE
WITH FLUIDS FROM TISSUES.
 COVER THE ENTIRE PATCH OF STRIP WITH
BLOOD.
 PLACE GAUZE OVER THE PUNCTURED FINGERTIP
OF THE PATIENT AND BRIEFLY APPLY PRESSURE
UNTIL THE BLEEDING STOPS
 APPLY AN ADHESIVE BANDAGE ONCE THE
BLEEDING ON THE FINGERTIP HAS STOPPED.
 REMOVE GLOVES AND RECORD THE RESULT.
URINALYSIS TO DETERMINE  EXPLAIN TO THE PATIENT THE PROCEDURE
(DIPSTICK DEHYDRATION THROUGH  USE A CLEAN COTTON BALL MOISTENED WITH
METHOD) THE HELP OF THE URINES LUKEWARM WATER OR AN ANTISEPTIC SOLUTION
PH LEVELS AND TO CLEANSE THE EXTERNAL GENITALIA ARE
PRESENCE OF KETONES BEFORE COLLECTING THE SPECIMEN
IN THE URINE WHICH MAY  PREPARE THE WHITE PLASTIC STRIP AND USE
HELP TO INDICATE CLEAN GLOVES
DEHYDRATION.  AND GET THE SPECIMEN TO DIP THE WHITE
PLASTIC STRIP IN THE URINE
 WAIT FOR 1-2 MINS AND COMPARE THE COLOR
TO A STANDARD CHART
Unit Count
COMPLETE TO EVALUATE BLOOD  EXPLAIN THE PROCEDURE TO THE PATIENT HB g/dl 9.8-13.7
BLOOD CELLS AND TO  ADVISE THE PATIENT TO NOT MASSAGE THE RBC 10^6/ul 3.1-4.44
COUNT DETERMINE IF THE PUNCTURE SITE AFTER COLLECTING THE BLOOD HCT % 28-39
HEMATOCRIT LEVEL. TO PREVENT BRUISES. MCV fl 91-99
MCH pg 27-32
MCHC g/dl 33-37
RETICS % of RBCs 0.2-2.0
PLT *10^3/ul 150-450
WBC *10^3/ul 5000-13000
 TEST SIGNIFICANCE
EXTERNAL ELECTRIC IT IS USED TO EVALUATE THE
FETAL MONITORING FETUS OR TO CHECK THE FETAL
WELL-BEING DURING THE
LABOR. IT IS ALSO USED TO
CHECK THE PLACENTA TO MAKE
SURE THAT IT IS GIVING THE
BABY THE ENOUGH OXYGEN.
CONTRACTION USED TO MEASURE THE BABY’S
STRESS TEST HEART RATE DURING UTERINE
CONTRACTIONS.
IT MAKES SURE THAT THE BABY
CAN GET THE OXYGEN THAT THE
BABY NEEDS FROM THE
PLACENTA DURING LABOR.
NURSING CONSIDERATIONS & PROCEDURE RESULTS
 USING A HANDHELD DOPPLER, THE NORMAL
NURSE WILL LISTEN TO THE FETAL  BABY’S HEART RATE IS 110 TO 160
HEARTBEAT.  BABY’S HEART RATE INCREASES WHEN
 THE GEL IS APPLIED TO THE PATIENT’S THE BABY MOVES AND WHEN THE
ABDOMEN TO ACT AS THE MEDIUM FOR UTERUS CONTRACTS
THE ULTRASOUND TRANSDUCER.  THE BABY’S HEART RATE DROPS DURING
 THE ULTRASOUND TRANSDUCER IS A CONTRACTION BUT QUICKLY GOES
ATTACHED TO THE ABDNOMEN WITH BACK TO NORMAL AFTER THE
STRAPS AND TRANSMITS THE FETAL CONTRACTION IS OVER.
HEARTBEAT TO A RECORDER. THE FETAL
HEART RATE IS DISPLAYED ON A ABNORMAL
SCREEN AND PRINTED ONTO SPECIAL  BABY’S HEART RATE IS LESS THAN 110
PAPER. BEATS PER MINUTE
 DURING CONTRACTIONS, AN EXTERNAL  BABY’S HEART RATE IS MORE THAN 160
TOCODYNAMOMETER (A MONITORING BEATS PER MINUTE
DEVICE THAT IS PLACED OVER THE TOP  UTERINE CONTRACTIONS ARE WEAK OR
OF THE UTERUS WITH A BELT) CAN IRREGULAR DURING LABOR.
RECORD THE PATTERNS OF
CONTRACTIONS.
 THE PATIENT SHOULD BE ASKED NOT TO NORMAL
EAT OR DRINK ANYTHING FOR SIX TO  NORMAL RESULT ARE CALLED NEGATIVE
EIGHT HOURS BEFORE THE  BABY’S HEART RATE DOES NOT GET
PROCEDURE. SLOWER OR DECELERATE AND STAY LOW
 PATIENT SHOULD BE POSITIONED ON AFTER THE CONTRACTION OR LATE
HER LEFT SIDE. DECELERATIONS.
 A PAIR OF BELT IS WRAPPED AROUND  BABY IS EXPECTED TO BE ABLE TO
THE ABDOMEN. HANDLE THE STRESS OF THE LABOR IF
 ONE BELT USES DOPPLER TO DETECT THERE ARE NO LATE DECELERATIONS IN
THE FETAL HEART RATE. THE BABY’S HEART RATE DURING THE
 THE OTHER BELT MEASURES THE THREE CONTRACTIONS IN A 10 MINUTE
LENGTH OF THE CONTRACTIONS AND PERIOD.
THE TIME BETWEEN THEM.
 THE TEST WILL LASTS UNTIL THE ABNORMAL
PATIENT HAD THREE CONTRACTIONS IN  ABNORMAL RESULT ARE CALLED
A TEN MINUTE PERIOD, EACH LASTING POSITIVE
40-60 SECONDS. THE PROCEDURE CAN  BABY’S HEART RATE GETS SLOWER OR
 TAKE UP TO 2 HOURS. DECELERATES AND STAYS SLOW AFTER
THE CONTRACTION OR LATE

 IF THE PATIENT DOESN’T HAVE ANY DECELERATIONS.

CONTRACTIONS FOR THE FIRST 15
MINS, THE NURSE MAY ADMINISTER
OXYTOCIN IN AN IV OR ASK THE PATIENT
TO STIMULATE HER NIPPLES WHICH
RELEASES NATURAL OXYTOCIN.
 LATE DECELERATIONS MEAN THAT THE
BABY MIGHT HAVE PROBLEMS DURING
NORMAL LABOR.

ABDOMINAL USED TO MONITOR FETAL  THE PATIENT SHOULD BE ADVISED TO

ULTRASOUND GROWTH AND POSITION DRINK MORE WATER TO MAKE THE
BLADDER FULL. TELL THE PATIENT NOT
TO VOID BEFORE THE PROCEDURE.
 THE NURSE SHOULD ASK THE MOTHER
IF SHE PUT ANYTHING ON HER
ABDOMEN LIKE POWDER, LOTION ETC.
IF THE PATIENT SAID YES, THE NURSE
SHOULD WIPE IT OFF BEFORE PUTTING
THE GEL (THE GEL WILL HELP THE
SOUND WAVES TRAVEL PROPERLY).
 THE NURSE WILL PLACE A TRANSDUCER
ONTO THE BELLY TO CAPTURE THE
IMAGES ONTO THE ULTRASOUND
SCREEN.
 AFTER THE PROCEDURE, THE NURSE
SHOULD WIPE OFF THE GEL AND TELL
THE PATIENT THAT SHE CAN NOW
EMPTY HER BLADDER.

MODIFIED IT IS A SIMPLE AND PAINLESS
BIOPHYSICAL TEST THAT IS PERFORMED
PROFILE DURING PREGNANCY TO ASSESS
THE BABY’S WELL BEING
ESPECIALLY WHETHER THE
BABY’S GETTING ENOUGH
OXYGEN.
 THE NURSE SHOULD ADVISED THE
PATIENT TO EAT A MEAL JUST BEFORE
THE TEST TO STIMULATE THE BABY TO
MOVE AROUND MORE.
 ALSO, ADVISE THE PATIENT TO USE THE
BATHROOM BEFOREHAND BECAUSE
THE TEST MAY TAKE UP TO AN HOUR.
 THE TEST WILL START WITH AN
ULTRASOUND TO OBSERVE THE BABY’S
EACH OF THE FIVE COMPONENTS (BODY
MOVEMENTS, MUSCLE TONE, BREATHING
MOVEMENTS, HEARTBEAT AND AMNIOTIC FLUID)
IS ASSIGNED A SCORE OF EITHER 0 (ABNORMAL)
TO 2 (NORMAL).
THE 5 COMPONENTS WILL BE ADDED UP FOR A
TOTAL SCORE RANGING FROM 0 TO 10.
TOTAL SCORE OF 8 TO 10 IS NORMAL.
MOVEMENT, MUSCLE TONE, BREATHING TOTAL SCORE OF 6 IS CONSIDERED
MOVEMENTS AND THE AMOUNT OF BORDERLINE.

TOTAL SCORE OF BELOW 6 IS ABNORMAL.

FLUID SURROUNDING THE BABY.
AMOUNT OF AMNIOTIC FLUID SCORES 0 – THE
BABY NEEDS TO DELIVER RIGHT AWAY.