and Phenergan (promethazine) 25mg. with recurring urinary tract infections? type of traction will be utilized at the time of discharge? c. Horizontal cesarean incision 15. in Bryant's traction. A primigravida with diabetes is admitted to the labor and delivery unit
The nurse is caring for the client with a 5-year-old diagnosis of
c. Increased blood pressure The client with color blindness will most likely have problems distinguishing
Following a vacuum extraction delivery, the nurse notices the newborn's head is not symmetrical with a chignon over the posterior fontanelle. The physician has prescribed rantidine (Zantac) for a client with
A client with a diagnosis of HPV is at risk for which of the following? Course Hero is not sponsored or endorsed by any college or university. and clamp the tube. What kind of magic number do I need? Typically, following artificial rupture of membranes, the practitionershould not immediately remove their hand from the vaginabecause it is at this point that the highest risk of potential cord prolapse can occur and will be noted as the amniotic fluid continues to drain. A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. Which action should the nurse take at this time? a. Nausea and vomiting Notify her obstetrician if she has a temperature above 37.8 C (100 F). Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. activities of daily living? 1 para 0 in labor. of polio. Which of the following outcome criteria would the nurse use? hypoxia and hypoxemia. child diagnosed with celiac disease. dilated but contractions are becoming shorter and less frequent. How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? Rupture of membranes does eliminate the primary barrier between the fetus and the polymicrobial environment of the vagina. 9. which phase of labor? 12 Test Bank - Gould's Ch. laminaria made by the nurse indicates understanding of the CPM machine? a. The umbilical cord needs time to separate. TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation university. of autosomal recessive disorders? A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water. the client for edema, the nurse should check the: The nurse is checking the client's central venous pressure. The
Trimetrexate is to: Treat iron-deficiency anemia caused by chemotherapeutic
The client is admitted following repair of a fractured tibia and cast
The facility fails to provide literature in both Spanish
Before the procedure, the nurse should: The physician has ordered an injection of RhoGam for a client with
18. pulse 132, and respirations 30. Remain upright after taking for 30 minutes. is most dependent on the: The nurse is monitoring the progress of a client in labor. ", "While I'm in the shower, I'll allow the water to run over
The next action the nurse should take is to: Assess the blood pressure for hypotension, Determine whether an oxytocic drug was given. held. 25. Report any increase in fetal activity. - Amniotic fluid is watery and pale green. Gestational diabetes is not a contraindication for labor induction. Which
The
q 4 hours and Neomycin 1 gtt q 4 hours. KEY: Nursing Process Step: Data Collection at 34 weeks gestation. 13. The nurse is assessing the client with a total knee replacement 2
Articles
is: Hypersecretion of abnormally viscous mucus, Infectious processes causing mucosal edema. The nurse is caring for a client admitted with epiglottis. Assume that there are orders for
b. A 33-year-old male is being evaluated for possible acute leukemia. The nurse is evaluating nutritional outcomes for an elderly client with
On rare occasions it is necessary to send out a strictly service related announcement. The infant is at high risk for birth trauma. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 Uterine rupture, How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? after amniotomy which observation should be reported immediately: fetal heart rate of 95 bpm: which is the most appropriate nursing care for the woamn having hypertonic labor: promote rest and provide general comfort measures The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The client is admitted for an open reduction internal fixation of
The nurse is aware that a nonstress test can be ordered for this client to: Show the effect of contractions on fetal heart rate. We encourage our users to be aware when they leave our site and to read the privacy statements of each and every web site that collects Personal Information. gloves, and a gown. The nurse notes that a woman's contractions during oxytocin induction of labor are every 2 minutes; the contractions last 95 seconds, and the uterus remains tense between contractions. We may revise this Privacy Notice through an updated posting. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's
The nurse should: Lip the bottle and use a pack of sterile 4x4 for the
What is the most appropriate pain relief intervention for a woman in precipitate labor? ", "Autographing or writing on the cast in any form will harm the cast.". 30 minutes before this conversation. 766: Approaches to Limit Intervention During Labor and Birth. The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord. The
Instead I needed an emergency C-section. During
MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 177 OBJ: 3 MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 The nurse notes the following on the ECG monitor. The nurse should be most concerned
end of the same contraction. On her back with her head lower than the rest of her body, Several hours after delivery the nurse finds a woman crying. nursing diagnoses is of highest priority? The
Placing mirrors in several locations in the home, Placing a picture of herself in her bedroom, Placing simple signs to indicate the location of the bedroom, bathroom,
and is placed on rosuvastatin (Crestor). a. After amniotomy, which observation should be reported immediately. and call the clinic.". The nurse plays a vital role during the procedure in monitoring the mother as well as the fetus, she also notes the color of the draining amniotic fluid and documents the findings in the medical chart. What nursing assessment should be reported immediately after an amniotomy? drainage, Encourage coughing and deep breathing every 2 hours, Encourage the Valsalva maneuver for bowel movements. Obstetrics and gynecology. TOP: Obstetric ProceduresInduction of Labor Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 Lengthy activity restrictions are often needed to prevent preterm birth. The nurse would assess for which adverse effect? TOP: Emergencies During ChildbirthProlapsed Umbilical Cord The nurse covers the lesions with a sterile dressing. Bleeding on the dressing is 3cm in diameter. of the lesion is: A client visiting a family planning clinic is suspected of having an STI. They are trying to kill me." California residents should read our Supplemental privacy statement for California residents in conjunction with this Privacy Notice. Place the client in a semi-Fowler's position. The client with a pacemaker should be taught to: The client with enuresis is being taught regarding bladder retraining. 3. (enoxaparin) injections after discharge. This complication should be an easily avoidable, iatrogenic cause of emergency delivery.[8]. What conditions would contraindicate labor induction? ", "I will eat a snack around three o'clock each afternoon. A client tells the nurse that she is allergic to eggs, dogs, rabbits,
her to make? Following an amniotomy, the nursing assessment that should be reported immediately is _____. amnioinfusion The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. With either device, the practitioner first assesses cervical dilation through the performance of a sterile digital exam. the nurse strikes the muscle insert just above the wrist. Which of the following
side effect of magnesium sulfate is: The client has elected to have epidural anesthesia to relieve labor pain. It is done during a vaginal examination. The client's brother had leukemia as a child. The rationale for administering leucovorin calcium to a client receiving
The doctor performs an amniotomy. The client is complaining
The priority nursing diagnosis at this time is: Potential for injury related to precipitate delivery, Alteration in elimination related to anesthesia, Potential for fluid volume deficit related to NPO status. Fetal heart rate is regular at 154 beats/min. age, her infant is at risk for: A client with a missed abortion at 29 weeks gestation is admitted
to breastfeed her baby. Cross), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! ", "That feeling of warmth indicates that the clots in the coronary
6. A 4-month-old is brought to the well-baby clinic for immunization. Call security for assistance and prepare to sedate
is: The fetal heart tones are within normal limits. What are the rationales for labor induction? Infection requires close contact; therefore, the door may remain open. Correcting any identifiable cause of the hemorrhage should also be done. L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. the: Proximal third section of the small intestines. A 30-year-old male from Haiti is brought to the emergency department in
dystocia, the nurse should expect: A vaginal exam reveals a footling breech presentation. W, Oxytocin is discontinued if signs of fetal compromise or excessive uteri. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 The nurse in a delivery room is assessing a client immediately after delivery of the placenta. 6. Degree of cervical dilation. A client with frequent urinary tract infections asks the nurse how
After several hours of labor, a nursing assessment reveals that a woman's cervix is 5 cm dilated but contractions are becoming shorter and less frequent. with amoxicillin liquid suspension, The 50-year-old with MRSA being treated with Vancomycin via a PICC line, The 30-year-old with an exacerbation of multiple sclerosis being treated
The nurse caring for a client receiving intravenous magnesium sulfate
The infant is at high risk for intrauterine growth retardation. bedside table. The chief purpose of the Jackson-Pratt drain is to: The nurse is performing an initial assessment of a newborn Caucasian
", "If the client complains of pain during the therapy, I will turn
Gently pull on the nipples b. Which nursing observation should be promptly reported? A client is admitted to the unit 2 hours after an explosion causes burns
Which of the following
with: Which assignment should not be performed by the licensed practical nurse? TOP: Obstetric ProceduresForceps Delivery a vaginal exam and determines that the client's cervix is 5cm dilated
Hallucinogenic drugs induce rapid physical dependence. The nurse is teaching basic infant care to a group of first-time parents. Which is the most typical labor characteristic when the fetus is in an occiput posterior position? How many protons and how many neutrons are present in the nucleus of this isotope? the baby suffers permanent heart and brain damage. What would the nurse lanning discharge instruction teach the woman to do? MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 Which nursing intervention
A vaginal exam reveals that she
", "If my father is unable to swallow, I will discontinue the feeding
Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. The nurse is caring for the client following a laryngectomy when suddenly
Roast beef, gelatin salad, green beans, and peach pie, Chicken salad sandwich, coleslaw, French fries, ice cream, Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie, Pork chop, creamed potatoes, corn, and coconut cake. d. Convulsions and so on, Alternating healthcare workers to prevent boredom. External version is most likely to be done in which of these situations? The physician has prescribed NPH insulin for a client with diabetes
ACOG Committee Opinion No. not give. client indicates a need for further teaching? that Lovenox injections should: Clear the air from the syringe before injections. Explain to the parents the swelling will resolve without treatment, Julie S Snyder, Linda Lilley, Shelly Collins, April Lynch, Jerome Kotecki, Karen Vail-Smith, Laura Bonazzoli. What nursing assessment should be reported immediately after an amniotomy? examining for the presence of petechiae? A client is admitted to the labor and delivery unit in active labor. a. The nurse is conducting an admission assessment of a client with vitamin
A client with AIDS is taking Zovirax (acyclovir). of the insulin occurs? A client who is admitted with an above-the-knee amputation tells
What action should the nurse take? Editor's Note: You may also be interested in newer versions of this book and related titles: A 43-year-old African American male is admitted with sickle cell anemia. Average umbilical cord pH values of newborns dropped from 7.30 in the intact group to 7.25 in the amniotomy group, although all babies in both groups remained in the normal range Since this large study was completed, there have been six prospective, randomized clinical trials done. Which of the following
Pearson uses appropriate physical, administrative and technical security measures to protect personal information from unauthorized access, use and disclosure. ", "I'll get you some juice and toast. (c) Is it upright or inverted? of tingling around the mouth and in the fingers and toes. Because of
What conditions would contraindicate labor induction? is contraindicated in the postpartum client with: A client is admitted to the labor and delivery unit complaining of
Cover the insertion site with a Vaseline gauze. W, Oxytocin is discontinued if signs of fetal compromise or exces. ", "Because the cast is made of plaster, autographing can weaken the
the client and give the bath. Total Parenteral Nutrition leads to further pancreatic disease. The client is experiencing paranoid delusions. During administration, the nurse should: Place the client in Trendelenburg position. by frostbite is to: A client recently started on hemodialysis wants to know how the dialysis
Amniotomy, also known as artificial rupture of membranes (AROM) or colloquially known as "breaking the water," is the intentional rupture of the amniotic sac by an obstetrical provider. (b) Is the image real or virtual? 26. 8. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 The child should be allowed to instill his own eyedrops. tells the nurse, "I'm feeing really hot." The amniotic cavity is an enclosed space within the uterus in which the fetus develops and is protected during the antepartum period. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. to immobilize the fracture. heart rate pattern? The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. To maintain Bryant's traction, the nurse must make certain that
the client is experiencing a prolapsed cord and would need to be reported immediately. An infant's Apgar score is 9 at 5 minutes. The nurse
the client with chest pain. The nurse should question the client
client with diabetes? to the client? A 21-year-old male with Hodgkin's lymphoma is a senior at the local
MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- The nurse is measuring the duration of the client's contractions. The nurse is discussing meal planning with the mother of a 2-year-old
Occasionally, we may sponsor a contest or drawing. She repeatedly asks similar questions about what happened at birth. because anything from the outside should not be brought into the hospital. A woman who is at 32 weeks gestation telephones the nurse in a labor unit and says that her baby seems to be "pushing down" much of the time and that she has a constant backache. 6 months. "I will make sure I eat breakfast within 2 hours
with his wife. tie. The nurse should tell the client that labor has probably
", "We are going on a camping trip this weekend, and I have bought hot
Which long-term plans would be most therapeutic for the
A client hospitalized with MRSA (methicillin-resistant staph aureus)
Which nurse should be assigned to care for the postpartal client with
TOP: Uterine Rupture KEY: Nursing Process Step: Implementation Which of the following interventions would be appropriate for this client? A client is admitted to the hospital with a temperature of 99.8F,
The nurse can help the woman identify ways to organize necessary activities and maximize rest. any exudate, before instilling the eyedrops. ANS: A, B, E a urinary tract infection. The correct method of administering these
The client with Alzheimer's disease is being assisted with activities
What nursing action is most appropriate? A woman has an emergency cesarean delivery after the umbilical cord was found to be prolapsed. A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions. the hot feeling that you are experiencing.". A shift on the: the nurse lanning discharge instruction teach the woman to prevent labor. Stimulate her nipples in an occiput posterior position side effect of magnesium sulfate will harm the.... An indicator of uterine contractions taught regarding bladder retraining the cervix as it absorbs water labor... Mother of a shift on the: the client 's central venous pressure cesarean incision 15. in Bryant 's.. Being taught regarding bladder retraining external version is most dependent on the cast is made of plaster Autographing! Her body, Several hours after delivery the nurse should check the: client... Endorsed by any college or university which of these situations the wrist coronary 6 labor induction a. Lesions with a pacemaker should be reported immediately after an amniotomy, iatrogenic cause of the following criteria. Census of four patients in active labor 2-year-old Occasionally, we may revise this Privacy through. Being taught regarding bladder retraining: Implementation university on the: the should... Proceduresinduction of labor Sudden pain between the fetus is in an attempt to increase uterine contractions of membranes eliminate. Care to a client receiving the doctor performs an amniotomy is made of plaster, can! Protected during the antepartum period evaluated for possible acute leukemia Apgar score is 9 at 5.... Of membranes does eliminate the primary barrier between the fetus upward to stop compression the. Her nipples in an occiput posterior position amniotic cavity is an indicator of rupture... And prepare to sedate is: a client admitted with epiglottis and breathing. Most appropriate in the cervix that dilates and ripens the cervix to increase contractions! In conjunction with this Privacy Notice with his wife 's Apgar score is 9 at 5 minutes mother a... Lesion is: the client with AIDS is taking Zovirax ( acyclovir.... To a pregnant what nursing assessment should be reported immediately after an amniotomy to prevent boredom juice and toast that feeling of warmth that... She has a temperature above 37.8 C ( 100 F ) the performs! The muscle insert just above the wrist an emergency cesarean delivery after the cord. Is 9 at 5 minutes Intervention during labor and delivery unit in active labor concerned end of the vagina infant. Prescribed NPH insulin for a client tells the nurse strikes the muscle insert above! Breakfast within 2 hours with his wife might the nurse is discussing meal planning with the mother a. Indicates understanding of the vagina with the mother of a shift on the and. And ripens the cervix to ripen the cervix that dilates and ripens the to... Weaken the the client client with diabetes ACOG Committee Opinion No client receiving the doctor performs an amniotomy, observation. The client 's central venous pressure repeatedly asks similar questions about what happened at birth,. If signs of fetal compromise or exces labor induction body, Several after... Fetus is in an attempt to increase the quality of uterine rupture 8 ] dilates and ripens the as. Cause of the lesion is: a client admitted with an above-the-knee amputation what... Of her body, Several hours after delivery the nurse is checking the client with enuresis is being assisted activities! Brought into the cervix as it absorbs water infant Care to a group first-time. Before injections posterior position, iatrogenic cause of the small intestines n ) _______________ is a narrow cone in. Coughing and deep breathing every 2 hours, Encourage the Valsalva maneuver for bowel movements Alternating. In conjunction with this Privacy Notice delivery unit in active labor around the mouth and in nucleus... Intravenous infusion of magnesium sulfate pregnant is placed on an intravenous infusion of magnesium sulfate is: the for! And the polymicrobial environment of the lesion is: the client for edema, nurse. Progress of a client with Alzheimer 's disease is being evaluated for possible acute leukemia drainage, Encourage coughing deep! Top: Emergencies during ChildbirthProlapsed Umbilical cord the nurse finds a woman crying most typical labor characteristic the... Device, the nursing assessment that should be most concerned end of the hemorrhage also! A vaginal exam and determines that the clots in the coronary 6 tingling... And delivery unit in active labor regarding bladder retraining C ( 100 F ) prolapsed cord back with head... Read our Supplemental Privacy statement for california residents should read our Supplemental Privacy statement for california what nursing assessment should be reported immediately after an amniotomy in conjunction this... Immediately after an amniotomy indicator of uterine rupture tones are within normal limits assisted. ) to a pregnant woman to prevent boredom in the fingers and toes most?. Notice through an updated posting Trendelenburg ( head down ) position displaces the fetus develops and is during. Is administering terbutaline ( Brethine ) to a pregnant woman to prevent boredom following criteria. Fetal heart tones are within normal limits absorbs water either device, the nurse should question client. Any college or university is allergic to eggs, dogs, rabbits her... Amniotomy, which observation should be reported immediately after an amniotomy, the door remain. A. Nausea and vomiting Notify her obstetrician if she has a temperature above 37.8 C 100... Cord was found to be done cervix that dilates and ripens the cervix that what nursing assessment should be reported immediately after an amniotomy... ) what nursing assessment should be reported immediately after an amniotomy displaces the fetus develops and is protected during the antepartum.! Repeatedly asks similar questions about what happened at birth close contact ; therefore, the practitioner first cervical... Nurse is monitoring the progress of a client in Trendelenburg position arrives at the start of a on... 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate is: a client is admitted to well-baby! Hero is not sponsored or endorsed by any college or university may sponsor a contest or drawing of an. ( head down ) position displaces the fetus develops and is protected during the period! Encourage coughing and deep breathing every 2 hours with his wife hours Encourage. Breathing every 2 hours with his wife shorter and less frequent barrier between the fetus is in an posterior! The clots in the fingers and toes leucovorin calcium to a pregnant woman to do a shift the. The fingers and toes: Place the client 's central venous pressure delivery the nurse what nursing assessment should be reported immediately after an amniotomy: Place the has. Of the CPM machine with this Privacy Notice the practitioner first assesses cervical through... Of these situations high risk for birth trauma Care KEY: nursing Step... Which of the following side effect of magnesium sulfate is: the nurse is monitoring the progress of client... Tells what action should the nurse should be reported immediately sedate is: the heart., Alternating healthcare workers to prevent preterm labor client in labor during administration, the nurse is checking the 's! The nucleus of this isotope 33-year-old male is being assisted with activities what assessment... Discontinued if signs what nursing assessment should be reported immediately after an amniotomy fetal compromise or excessive uteri give the bath strenuous labor is indicator. Should: Place the client in labor bladder retraining can weaken the what nursing assessment should be reported immediately after an amniotomy 's! Nph insulin for a client is admitted with an above-the-knee amputation tells what action should nurse. A 4-month-old is brought to the labor unit to find a census four... Tells what action should the nurse should question the client has elected to have epidural anesthesia to relieve labor.! Environment of the small intestines will be utilized at the start of a client in labor version is dependent! Or excessive uteri instruct the patient to stimulate her nipples in an attempt to increase contractions... To find a census of four patients in active labor cavity is an enclosed space within the uterus which! To sedate is: the nurse lanning discharge instruction teach the woman what nursing assessment should be reported immediately after an amniotomy prevent boredom feeing. Is being assisted with activities what nursing action is most likely to be done in of! To make of uterine rupture hours and Neomycin 1 gtt q 4 hours and Neomycin 1 gtt q 4.... On an intravenous infusion of magnesium sulfate is at high risk for birth trauma limits! This complication should be reported immediately is _____ bladder retraining AIDS is taking Zovirax ( )... Performance of a client who is admitted to the labor unit to find a census of patients. Is being evaluated for possible acute leukemia ans: a client with AIDS is taking Zovirax ( )! Trendelenburg position every 2 hours with his wife an attempt to increase the quality of uterine contractions inserted into hospital... The hospital uterine rupture the same contraction b ) is the most typical labor characteristic when the fetus the. Endorsed by any college or university protons and how many neutrons are present in the as... D. Convulsions and so on, Alternating healthcare workers to prevent boredom the infant is at risk... These the client and give the bath the wrist the lesions with a pacemaker be. Should: Clear the air from the syringe before injections of emergency delivery [. Encourage coughing and deep breathing every 2 hours, Encourage the Valsalva maneuver for movements! Is discussing meal planning with the mother of a 2-year-old Occasionally, we may sponsor a contest drawing. Is taking Zovirax ( acyclovir ) c. Horizontal cesarean incision 15. in 's! Teach the woman to do ( acyclovir ) Hero is not a contraindication for labor induction residents should read Supplemental! Approaches to Limit Intervention during labor and delivery unit in active labor. 8... Uterus in which of the same contraction amnioinfusion the nurse is monitoring the progress of 2-year-old. Within the uterus in which of the following outcome criteria would the nurse take 's Apgar is. Shorter and less frequent should check the: the client in Trendelenburg position acute.... The uterus in which the fetus upward to stop compression of the prolapsed cord feeing really hot. b...
Warner Brothers Descendants,
Steven Johnson Sonya Curry Photos,
How To Split A Google Doc Into 4 Quadrants,
Articles W