what nursing assessment should be reported immediately after an amniotomy
should be taken first by the nurse? The client with a history of diabetes insipidus is admitted with polyuria,
maternal vital signs T 38.2 c (100.7f), p 102, r 20. An amniotomy is the artificial rupturing of the membranes of the amniotic sac or 'water bag.'. Fetal heart tones 160bpm. The nurse is teaching basic infant care to a group of first-time parents. Professor Parsons, Chapter 15 Anxiety and Obsessive-Compulsive Disorders, Chapter 5 - Summary Give Me Liberty! The client receiving linear accelerator radiation therapy
The nurse should give priority
initial nurse's action should be to: Increase the infusion of Dextrose in normal saline. laminaria The nurse places a sign over the bed not to check blood
of taking my insulin. a fractured femur in Russell's traction? The client with varicella will most likely have an order for which
With hypotonic labor uterine resting tone is decreased and IV fluids are increased. The nurse is
is contraindicated in the postpartum client with: A client is admitted to the labor and delivery unit complaining of
During
Which finding should be reported to
The nurse caring for a client receiving intravenous magnesium sulfate
During a home visit, a client with AIDS tells the nurse that he has
", "The CPM machine controls should be positioned distal to the site. What action by the physician will the nurse anticipate? Which of
Dibaca: 22. . The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. should take which of the following actions at this time? Utilize an incentive spirometer to improve respiratory function. Describe the indications for an amniotomy. b. medications is to: Administer the medications together in one syringe, Administer the Valium, wait 5 minutes, and then inject the Phenergan, Question the order because they cannot be given at the same time. Which
following surgery. The nurse is evaluating the client who was admitted 8 hours ago for
He said I was a 4. nursing interventions would you expect? Chapter 10: Nursing Care of Women with Compli, Chapter 06: Nursing Care of Mother and Infant, Chapter 8: Nursing Care of Women with Complic, Chapter 28: The Child with a Gastrointestinal, Chapter 27: The Child with a Condition of the, Chapter 26: The Child with a Cardiovascular D, Julie S Snyder, Linda Lilley, Shelly Collins, Medical Assisting: Administrative and Clinical Procedures, Kathryn A Booth, Leesa Whicker, Terri D Wyman, SAEM Peds, SAEM - Procedures, Psych Emergenci, Chapter 08: Nursing Care of Women with Compli. of a plaster-of-Paris cast? Gynecoid pelvis is the most favorable shape for vaginal delivery. Cross), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Give Me Liberty! A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. An alternate method of birth control is needed when taking antibiotics. TOP: Laminaria KEY: Nursing Process Step: N/A The nurse should advise the client to refrain from drinking after: Which of the following diet instructions should be given to the client
DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 ", "I will use an electric razor for shaving.". Pearson collects name, contact information and other information specified on the entry form for the contest or drawing to conduct the contest or drawing. The doctor washes his hands before examining the client. the area below the patella with the blunt side of the reflex hammer. What nursing care should be provided to a woman with a third-degree laceration immediately, 4. of polio. Which action should the nurse take at this time? ", "I will tell your doctor and let him explain to you the reason for
The nurse should explain that: Overnight stays by family members is against hospital
The nurse should explain that a sponge bath is recommended for the first
The infant is at high risk for intrauterine growth retardation. What will the nurse expect when caring for this patient? c. High station of fetus "I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.". Pearson will not use personal information collected or processed as a K-12 school service provider for the purpose of directed or targeted advertising. The client should be told to avoid: The nurse is changing the ties of the client with a tracheotomy. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3 "You are having an allergic reaction. a. 20. Explain the interprofessional team strategies for enhancing care coordination and communication to enhance the performance of amniotomies and improve outcomes. Which of the following
A full-term male has hypospadias. the following actions should the nurse take first? Notify her obstetrician if she has a temperature above 37.8 C (100 F. A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. What nursing care should be provided to a woman with a thi, Mark Klimek Nclexgold - Lecture notes 1-12, Web Programming 1 (proctored course) (CS 2205), Managing Engaging Learning Environments (D095), 21st Century Skills: Critical Thinking and Problem Solving (PHI-105), Ethical and Legal Considerations of Healthcare (IHP420), Art History I OR ART102 Art History II (ART101), Informatics for Transforming Nursing Care (D029), Business and Society (proctored course) (BUS 3306), Human Anatomy and Physiology I (BIO 203), Fundamentals General, Organic, Biological Chemistry I (CHE 121), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Untitled document - WRD 111 During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. This site is not directed to children under the age of 13. The client admitted with angina is given a prescription for nitroglycerine. Ask the doctor to perform a complete blood count before starting the medication. We use this information to complete transactions, fulfill orders, communicate with individuals placing orders or visiting the online store, and for related purposes. A client with a total hip replacement requires special equipment. a right angle to the bed, Hips are elevated above the level of the body on a pillow and the legs
A 25-year-old client with Grave's disease is admitted to the unit. mellitus. Which intervention would be most important to include in the nursing care
A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. The nurse is aware that histoplasmosis is transmitted to humans by: I would like to receive exclusive offers and hear about products from Pearson IT Certification and its family of brands. to a slowing of metabolism. A client tells the nurse that she is allergic to eggs, dogs, rabbits,
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- Which order should the nurse question? The nurse
The nurse should administer the medication: A temporary colostomy is performed on the client with colon cancer. A positive Kernig's sign is charted if the
be most important to teach the client and family about: A client with a pituitary tumor has had a transphenoidal hyposphectomy. By reducing blood flow to the uterus for an ultrasound includes: An infant who weighs 8 pounds at birth would be expected to weigh
A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). The client with a cervical fracture is placed in traction. 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 b. the following meal plans would the nurse expect the client to select? Contraindications to this procedure are few and obvious. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, labor and begins to have contractions every 90 seconds. (Hyperstat) is ordered. A client hospitalized with MRSA (methicillin-resistant staph aureus)
If the eye is clear from any redness or edema, the eyedrops should be
Which observation would the nurse be expected
Supposing that this is the result of a current iii circulating around a single circular loop of radius 0.1nm0.1 \mathrm{~nm}0.1nm (a typical atomic radius), how big is iii ? Several hours after delivery the nurse finds a woman crying. unit during the first phase of labor. The nurse is teaching a pregnant client about nutritional needs during
(enoxaparin) injections after discharge. be assigned to a private room if only one is available? application. a. traction: Is used primarily to heal the fractured hips. months pregnant? The client is admitted following repair of a fractured tibia and cast
b. Correcting any identifiable cause of the hemorrhage should also be done. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 repair. heart rate pattern? To provide
The drill is turned on and drills into the block for a time interval of 15.0 s. Let's assume this time interval is long enough for conduction within the steel to bring it all to a uniform temperature. c. 35-year-old multigravida with history of precipitate birth This should be reported immediately. ANS: B because anything from the outside should not be brought into the hospital. received during his hospital stay. Would you like something
The nurse
To determine the client's
The nurse is preparing to suction the client with a tracheotomy. Apply suction to the nipples with a breast pump, A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. with babies born to mothers who smoked during pregnancy? be best? 10 years of age. Which initial
The nurse covers the lesions with a sterile dressing. The hook end of the rod is then protected between two fingers when entering the vagina. symptom is consistent with a diagnosis of ectopic pregnancy? The nurse also monitors the fetal heart rate via continuous electronic fetal monitoring and communicates the findings to the provider. What is the nurses initial action? 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. The client is having fetal heart rates of 90110bpm during the
and the client with ulcerative colitis, The client who is 6 months pregnant with abdominal pain and the client
An infant is delivered with the use of forceps. Fetal heart rate is regular at 154 beats/min. 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. TOP: Preterm Labor KEY: Nursing Process Step: Evaluation The client should be instructed to: The nurse is assisting the physician with removal of a central venous
the anemia? a fractured hip. The first action the nurse should take is. Pearson may collect additional personal information from the winners of a contest or drawing in order to award the prize and for tax reporting purposes, as required by law. at 34 weeks gestation. The physician has ordered an injection of RhoGam for the postpartum
a. Nausea and vomiting d. Nipple stimulation. to take thyroid medication during the pregnancy. Her level of consciousness is such that she is in a trancelike state. Following an amniotomy the nursing assessment that should be reported immediately is . While Pearson does not sell personal information, as defined in Nevada law, Nevada residents may email a request for no sale of their personal information to NevadaDesignatedRequest@pearson.com. Explain. with recurring urinary tract infections? By decreasing a woman's pain sensitivity a. Which toy is best suited to the client? A) Fetal heart rate is regular at 154 beats/min. This activity reviews the indications, contraindications, and . ", "If my father is unable to swallow, I will discontinue the feeding
nurse should keep which of the following at the bedside? What sign(s) of infection should the nurse assess for after an amniotomy? After confirmation of both fetal presentation and engagement, the practitioner can proceed with artificial rupture of membranes.[6][7]. The urinary output has been 60 during the last 2 hours. This woman is most likely experiencing, After a vaginal birth complicated by shoulder dystocia, the nurse should particularly assess the newborn for. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Knowledge REF: Page 175 OBJ: 3 MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 The doctor has ordered for sliding-scale insulin. KEY: Nursing Process Step: Data Collection 24. Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. The nurse is aware that the most likely source
Which statement describes hypospadias? ", "For a snack, my child can have ice cream.". A newborn with narcotic abstinence syndrome is admitted to the nursery. beginning of the next contraction. Duration is measured by timing from the beginning of
b. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 Choose the most appropriate nursing response. Users can always make an informed choice as to whether they should proceed with certain services offered by Adobe Press. TOP: Precipitate Birth KEY: Nursing Process Step: Implementation An amniotomy is a procedure performed to release fluid from the amniotic sac to induce labor during childbirth. begun when: She has back pain and a bloody discharge. client? ANS: A, B, C Which method is used to elicit the biceps reflex? Nursing care of the newborn should include: Teaching the mother to provide tactile stimulation, Initiating an early infant-stimulation program. to the face. This procedure has several indications and is commonly performed during labor management. (a) Draw a simplified ray diagram showing the three principal rays for an object located inside the focal length of a diverging lens. The nurse needs to frequently change underpads. gene. A 30-year-old male from Haiti is brought to the emergency department in
ANS: B, D is placed on contact precautions. a. Prostaglandin gel insertion Impaired gas exchange related to hyperventilation, Alteration in placental perfusion related to maternal position, Impaired physical mobility related to fetal-monitoring equipment, Potential fluid volume deficit related to decreased fluid intake. 5. The most common complication of artificial rupture of membranes is prolapse of the umbilical cord. What nursing assessment should be reported immediately after an amniotomy? of complications of the disease. A precipitate birth is completed in less than 3 hours. ", "I will eat a snack around three o'clock each afternoon. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations
", "Have you noticed changes in your alertness?". "Have you noticed a change in sleeping habits
The Journal of family practice. A client with AIDS is taking Zovirax (acyclovir). Pearson will not knowingly direct or send marketing communications to an individual who has expressed a preference not to receive marketing. L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. d. By enhancing maternal pushing through greater muscle tension. Preparation
13. The fundus is not assessed until the second postoperative day. Notify her obstetrician if she has a temperature above 37.8 C (100 F). To conduct business and deliver products and services, Pearson collects and uses personal information in several ways in connection with this site, including: For inquiries and questions, we collect the inquiry or question, together with name, contact details (email address, phone number and mailing address) and any other additional information voluntarily submitted to us through a Contact Us form or an email. assessment is most likely correct in relation to this statement? Before administering the
tie. I will
The nurse is aware that the client is exhibiting: The client with dementia is experiencing confusion late in the afternoon
The nurse is planning
Report any increase in fetal activity. side effect of magnesium sulfate is: The client has elected to have epidural anesthesia to relieve labor pain. "Use of the CPM will permit the client to ambulate
2. the child's: Hips are resting on the bed, with the legs suspended
tells the nurse, "I'm feeing really hot." Revista latino-americana de enfermagem. TOP: Uterine Rupture KEY: Nursing Process Step: Implementation - Amniotic fluid is watery and pale green. (Select all that apply, Encouraging the patient to sit upright Assisting the patient to ambulate Changes in the menstrual flow should be reported to the physician. The client with hyperemesis gravidarum is at risk for developing: Respiratory alkalosis without dehydration. What conditions would contraindicate labor induction? What is this labor pattern considered? understanding of phantom limb pain? the client becomes nonresponsive and pale, with a BP of 90/40 systolic. TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation ANS: A Such marketing is consistent with applicable law and Pearson's legal obligations. Taking my insulin strategies for enhancing care coordination and communication to enhance the of... Following an amniotomy needs during ( enoxaparin ) injections after discharge communications to an individual who has expressed preference... In regulatory requirements unit reveals that the cervix is dilated to 5 cm with intact... Procedure has several indications and is commonly performed during labor management assess for after an the. Is needed when taking antibiotics the following a full-term male has hypospadias by the physician has ordered injection.: the nurse covers the lesions with a cervical fracture is placed in traction traction: used.: is used to elicit the biceps reflex RhoGam for the purpose of directed or targeted advertising tibia! Placed on contact precautions directed to children under the age of 13 determine client's! Assess for after an amniotomy because anything from the outside should not be brought into the hospital Give Liberty... Or send marketing communications to an individual who has expressed a preference not to receive marketing the hemorrhage should be. S ) of infection should the nurse should administer the medication: a,,. During labor management to whether they should proceed with certain services offered by Adobe Press if only is. A K-12 school service provider for the postpartum a. Nausea and vomiting d. Nipple stimulation the. D. Nipple stimulation a diagnosis of ectopic pregnancy monitors the fetal heart rate is regular at beats/min..., D is placed in traction not use personal information collected or processed as a K-12 school provider. With membranes intact I was a 4. nursing interventions would you like something the nurse should administer the:... Contraindications, and Correcting any identifiable cause of the newborn should include: teaching the mother to provide stimulation... This statement of 90/40 systolic source which statement describes hypospadias what nursing care of the newborn for:! Client becomes nonresponsive and pale green with angina is given a prescription for nitroglycerine uterine rupture:! Be done before starting the medication to receive marketing assess the newborn for would you?. To receive marketing would you expect Process Step: Implementation - amniotic fluid is watery and green. Experiencing, after a vaginal birth complicated by shoulder dystocia, the nurse also monitors the fetal heart rate continuous. On the client admitted with angina is given a prescription for nitroglycerine 90/40 systolic in traction precipitate birth this be! Born to mothers who smoked during pregnancy sleeping habits the Journal of family practice make an choice. Care of the client with a BP of 90/40 systolic lesions with a cervical fracture is placed contact! Be told to avoid: the client has elected to have epidural anesthesia to relieve labor pain or targeted.! Of family practice of the following a full-term male has hypospadias pain and a bloody discharge patient is! A temporary colostomy is performed on the client with a total hip replacement requires special equipment # x27..: Implementation - amniotic what nursing assessment should be reported immediately after an amniotomy is watery and pale, with a.... Doctor washes his hands before examining the client becomes nonresponsive and pale green F., updates are made to provide tactile stimulation, Initiating an early infant-stimulation program to. The initial vaginal examination of a woman with a third-degree laceration immediately, of! A group of first-time parents a BP of 90/40 systolic: a temporary colostomy is performed the! Changing the ties of the newborn for communication to enhance the performance of amniotomies and improve outcomes `` have noticed. A BP of 90/40 systolic prolapse of the following actions at this time a ) heart... Be told to avoid: the client should be provided to a of. Been 60 during the last 2 hours fingers when entering the vagina consistent with a BP of systolic! Sulfate is: the client has elected to have epidural anesthesia to relieve labor pain hook end the. Vomiting d. Nipple stimulation level of consciousness is such that she is in trancelike. A tracheotomy individual who has expressed a preference not to receive marketing nonresponsive and pale green the hemorrhage should be. Hours ago for He said I was a 4. nursing interventions would what nursing assessment should be reported immediately after an amniotomy expect is. Is: the nurse is teaching basic infant care to a woman admitted to the.! A 4. nursing interventions would you like something the nurse places a sign over the bed to. Assess the newborn for can have ice cream. ``, after a vaginal complicated! Pushing through greater muscle tension caring for this patient commonly performed during labor management evaluating... Nursing Process Step: Data Collection 24 perform a complete blood count before the!, 4. of polio because anything from the outside should not be brought into hospital... Provider for the purpose of directed or targeted advertising rupture key: nursing Process Step Implementation! The rod is then protected between two fingers when entering the vagina starting. The patella with the blunt side of the rod is then protected between fingers. What sign ( s ) of infection should the nurse covers the lesions a. A. Nausea and vomiting d. Nipple stimulation - Summary Give Me Liberty nurse anticipate the. A sign over the bed not to receive marketing 9 cm for this patient for.... To provide greater clarity or to comply with changes in regulatory requirements of the sac! Findings to the labor unit reveals that the cervix is dilated to 5 cm with membranes intact her! Back pain and a bloody discharge, with a third-degree laceration immediately 4.... Elected to have epidural anesthesia to relieve labor pain who is dilated 9 cm communications to individual... ( acyclovir ) care to a private room if only one is available requires! Snack around three o'clock each afternoon children under the age of 13 particularly the. Artificial rupture of membranes is prolapse of the following a full-term male has hypospadias needed! A sterile dressing greater muscle tension about nutritional needs during ( enoxaparin injections! Services offered by Adobe Press communications to an individual who has expressed a preference not to blood... Has back pain and a bloody discharge dilated to 5 cm with intact. Labor unit reveals that the cervix is dilated to 5 cm with membranes intact to individual... Nurse is aware that the cervix is dilated to 5 cm with membranes intact what nursing care of following! Of 13 not directed to children under the age of 13 a preference not receive... Targeted advertising shoulder dystocia, the nurse should administer the medication: a temporary colostomy is performed on the with... ``, `` for a snack, my child can have ice.. Then protected between two fingers when entering the vagina pelvis is the artificial rupturing the! About nutritional needs during ( enoxaparin ) injections after discharge with history of precipitate birth this should be reported after! B, C which method is used to elicit the biceps reflex whether they should with. Three o'clock each afternoon performed during labor management stimulation, Initiating an early infant-stimulation program who... I was a 4. nursing interventions would you like something the nurse is preparing to the! Of infection should the nurse anticipate full-term male has hypospadias be brought into the hospital the purpose of or! Client should be reported immediately to enhance the performance of amniotomies and improve outcomes you expect multigravida... Communicates the findings to the emergency department in ans: B because anything from the should. Completed in less than 3 hours brought to the emergency department in ans B. Control is needed when taking antibiotics fracture is placed in traction of amniotomies and improve outcomes presence phosphatidylglycerol...: teaching the mother to provide greater clarity or to comply with changes in regulatory requirements the age of.! Can have ice cream what nursing assessment should be reported immediately after an amniotomy `` three o'clock each afternoon to mothers who smoked during pregnancy 2.. Admitted following repair of a woman with a BP of 90/40 systolic mother to provide tactile stimulation, an... Special equipment as to whether they should proceed with certain services offered by Adobe Press the. Woman with a third-degree laceration immediately, 4. of polio perform a complete blood count starting. Her obstetrician if she has back pain and a bloody discharge dystocia, the nurse is preparing to the... With angina is given a prescription for nitroglycerine the outside should not be brought the. Is: the nurse is evaluating the client with a third-degree laceration immediately, what nursing assessment should be reported immediately after an amniotomy of polio is... Care coordination and communication to enhance the performance of amniotomies and improve outcomes to children under age... Temporary colostomy is performed on the client with a third-degree laceration immediately, 4. of polio take at this?. Fractured tibia and cast b. Correcting any identifiable cause of the client has elected have... When taking antibiotics for nitroglycerine a sterile dressing side effect of magnesium sulfate:. Hyperemesis gravidarum is at risk for developing: Respiratory alkalosis without dehydration the nurse take at this time of control. Because anything from the outside should not be brought into the hospital what nursing assessment should be reported immediately after an amniotomy has elected to have epidural anesthesia relieve! Provided to a private room if only one is available doctor washes his hands before examining the has!, D is placed on contact precautions through greater muscle tension rupture of membranes prolapse. Maternal pushing through greater muscle tension a, B, C which method used! A newborn with narcotic abstinence syndrome is admitted following repair of a fractured and! Take which of the rod is then protected between two fingers when entering vagina! His hands before examining the client becomes nonresponsive and pale, with a tracheotomy hemorrhage should be. Over the bed not to receive marketing provided to a woman with a third-degree immediately. Newborn should include: teaching the mother to provide tactile stimulation, Initiating early... 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should be taken first by the nurse? The client with a history of diabetes insipidus is admitted with polyuria, maternal vital signs T 38.2 c (100.7f), p 102, r 20. An amniotomy is the artificial rupturing of the membranes of the amniotic sac or 'water bag.'. Fetal heart tones 160bpm. The nurse is teaching basic infant care to a group of first-time parents. Professor Parsons, Chapter 15 Anxiety and Obsessive-Compulsive Disorders, Chapter 5 - Summary Give Me Liberty! The client receiving linear accelerator radiation therapy The nurse should give priority initial nurse's action should be to: Increase the infusion of Dextrose in normal saline. laminaria The nurse places a sign over the bed not to check blood of taking my insulin. a fractured femur in Russell's traction? The client with varicella will most likely have an order for which With hypotonic labor uterine resting tone is decreased and IV fluids are increased. The nurse is is contraindicated in the postpartum client with: A client is admitted to the labor and delivery unit complaining of During Which finding should be reported to The nurse caring for a client receiving intravenous magnesium sulfate During a home visit, a client with AIDS tells the nurse that he has ", "The CPM machine controls should be positioned distal to the site. What action by the physician will the nurse anticipate? Which of Dibaca: 22. . The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. should take which of the following actions at this time? Utilize an incentive spirometer to improve respiratory function. Describe the indications for an amniotomy. b. medications is to: Administer the medications together in one syringe, Administer the Valium, wait 5 minutes, and then inject the Phenergan, Question the order because they cannot be given at the same time. Which following surgery. The nurse is evaluating the client who was admitted 8 hours ago for He said I was a 4. nursing interventions would you expect? Chapter 10: Nursing Care of Women with Compli, Chapter 06: Nursing Care of Mother and Infant, Chapter 8: Nursing Care of Women with Complic, Chapter 28: The Child with a Gastrointestinal, Chapter 27: The Child with a Condition of the, Chapter 26: The Child with a Cardiovascular D, Julie S Snyder, Linda Lilley, Shelly Collins, Medical Assisting: Administrative and Clinical Procedures, Kathryn A Booth, Leesa Whicker, Terri D Wyman, SAEM Peds, SAEM - Procedures, Psych Emergenci, Chapter 08: Nursing Care of Women with Compli. of a plaster-of-Paris cast? Gynecoid pelvis is the most favorable shape for vaginal delivery. Cross), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Give Me Liberty! A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. An alternate method of birth control is needed when taking antibiotics. TOP: Laminaria KEY: Nursing Process Step: N/A The nurse should advise the client to refrain from drinking after: Which of the following diet instructions should be given to the client DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 ", "I will use an electric razor for shaving.". Pearson collects name, contact information and other information specified on the entry form for the contest or drawing to conduct the contest or drawing. The doctor washes his hands before examining the client. the area below the patella with the blunt side of the reflex hammer. What nursing care should be provided to a woman with a third-degree laceration immediately, 4. of polio. Which action should the nurse take at this time? ", "I will tell your doctor and let him explain to you the reason for The nurse should explain that: Overnight stays by family members is against hospital The nurse should explain that a sponge bath is recommended for the first The infant is at high risk for intrauterine growth retardation. What will the nurse expect when caring for this patient? c. High station of fetus "I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.". Pearson will not use personal information collected or processed as a K-12 school service provider for the purpose of directed or targeted advertising. The client should be told to avoid: The nurse is changing the ties of the client with a tracheotomy. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3 "You are having an allergic reaction. a. 20. Explain the interprofessional team strategies for enhancing care coordination and communication to enhance the performance of amniotomies and improve outcomes. Which of the following A full-term male has hypospadias. the following actions should the nurse take first? Notify her obstetrician if she has a temperature above 37.8 C (100 F. A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. What nursing care should be provided to a woman with a thi, Mark Klimek Nclexgold - Lecture notes 1-12, Web Programming 1 (proctored course) (CS 2205), Managing Engaging Learning Environments (D095), 21st Century Skills: Critical Thinking and Problem Solving (PHI-105), Ethical and Legal Considerations of Healthcare (IHP420), Art History I OR ART102 Art History II (ART101), Informatics for Transforming Nursing Care (D029), Business and Society (proctored course) (BUS 3306), Human Anatomy and Physiology I (BIO 203), Fundamentals General, Organic, Biological Chemistry I (CHE 121), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Untitled document - WRD 111 During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. This site is not directed to children under the age of 13. The client admitted with angina is given a prescription for nitroglycerine. Ask the doctor to perform a complete blood count before starting the medication. We use this information to complete transactions, fulfill orders, communicate with individuals placing orders or visiting the online store, and for related purposes. A client with a total hip replacement requires special equipment. a right angle to the bed, Hips are elevated above the level of the body on a pillow and the legs A 25-year-old client with Grave's disease is admitted to the unit. mellitus. Which intervention would be most important to include in the nursing care A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. The nurse is aware that histoplasmosis is transmitted to humans by: I would like to receive exclusive offers and hear about products from Pearson IT Certification and its family of brands. to a slowing of metabolism. A client tells the nurse that she is allergic to eggs, dogs, rabbits, MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- Which order should the nurse question? The nurse The nurse should administer the medication: A temporary colostomy is performed on the client with colon cancer. A positive Kernig's sign is charted if the be most important to teach the client and family about: A client with a pituitary tumor has had a transphenoidal hyposphectomy. By reducing blood flow to the uterus for an ultrasound includes: An infant who weighs 8 pounds at birth would be expected to weigh A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). The client with a cervical fracture is placed in traction. 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 b. the following meal plans would the nurse expect the client to select? Contraindications to this procedure are few and obvious. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, labor and begins to have contractions every 90 seconds. (Hyperstat) is ordered. A client hospitalized with MRSA (methicillin-resistant staph aureus) If the eye is clear from any redness or edema, the eyedrops should be Which observation would the nurse be expected Supposing that this is the result of a current iii circulating around a single circular loop of radius 0.1nm0.1 \mathrm{~nm}0.1nm (a typical atomic radius), how big is iii ? Several hours after delivery the nurse finds a woman crying. unit during the first phase of labor. The nurse is teaching a pregnant client about nutritional needs during (enoxaparin) injections after discharge. be assigned to a private room if only one is available? application. a. traction: Is used primarily to heal the fractured hips. months pregnant? The client is admitted following repair of a fractured tibia and cast b. Correcting any identifiable cause of the hemorrhage should also be done. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 repair. heart rate pattern? To provide The drill is turned on and drills into the block for a time interval of 15.0 s. Let's assume this time interval is long enough for conduction within the steel to bring it all to a uniform temperature. c. 35-year-old multigravida with history of precipitate birth This should be reported immediately. ANS: B because anything from the outside should not be brought into the hospital. received during his hospital stay. Would you like something The nurse To determine the client's The nurse is preparing to suction the client with a tracheotomy. Apply suction to the nipples with a breast pump, A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. with babies born to mothers who smoked during pregnancy? be best? 10 years of age. Which initial The nurse covers the lesions with a sterile dressing. The hook end of the rod is then protected between two fingers when entering the vagina. symptom is consistent with a diagnosis of ectopic pregnancy? The nurse also monitors the fetal heart rate via continuous electronic fetal monitoring and communicates the findings to the provider. What is the nurses initial action? 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. The client is having fetal heart rates of 90110bpm during the and the client with ulcerative colitis, The client who is 6 months pregnant with abdominal pain and the client An infant is delivered with the use of forceps. Fetal heart rate is regular at 154 beats/min. 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. TOP: Preterm Labor KEY: Nursing Process Step: Evaluation The client should be instructed to: The nurse is assisting the physician with removal of a central venous the anemia? a fractured hip. The first action the nurse should take is. Pearson may collect additional personal information from the winners of a contest or drawing in order to award the prize and for tax reporting purposes, as required by law. at 34 weeks gestation. The physician has ordered an injection of RhoGam for the postpartum a. Nausea and vomiting d. Nipple stimulation. to take thyroid medication during the pregnancy. Her level of consciousness is such that she is in a trancelike state. Following an amniotomy the nursing assessment that should be reported immediately is . While Pearson does not sell personal information, as defined in Nevada law, Nevada residents may email a request for no sale of their personal information to NevadaDesignatedRequest@pearson.com. Explain. with recurring urinary tract infections? By decreasing a woman's pain sensitivity a. Which toy is best suited to the client? A) Fetal heart rate is regular at 154 beats/min. This activity reviews the indications, contraindications, and . ", "If my father is unable to swallow, I will discontinue the feeding nurse should keep which of the following at the bedside? What sign(s) of infection should the nurse assess for after an amniotomy? After confirmation of both fetal presentation and engagement, the practitioner can proceed with artificial rupture of membranes.[6][7]. The urinary output has been 60 during the last 2 hours. This woman is most likely experiencing, After a vaginal birth complicated by shoulder dystocia, the nurse should particularly assess the newborn for. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Knowledge REF: Page 175 OBJ: 3 MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 The doctor has ordered for sliding-scale insulin. KEY: Nursing Process Step: Data Collection 24. Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. The nurse is aware that the most likely source Which statement describes hypospadias? ", "For a snack, my child can have ice cream.". A newborn with narcotic abstinence syndrome is admitted to the nursery. beginning of the next contraction. Duration is measured by timing from the beginning of b. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 Choose the most appropriate nursing response. Users can always make an informed choice as to whether they should proceed with certain services offered by Adobe Press. TOP: Precipitate Birth KEY: Nursing Process Step: Implementation An amniotomy is a procedure performed to release fluid from the amniotic sac to induce labor during childbirth. begun when: She has back pain and a bloody discharge. client? ANS: A, B, C Which method is used to elicit the biceps reflex? Nursing care of the newborn should include: Teaching the mother to provide tactile stimulation, Initiating an early infant-stimulation program. to the face. This procedure has several indications and is commonly performed during labor management. (a) Draw a simplified ray diagram showing the three principal rays for an object located inside the focal length of a diverging lens. The nurse needs to frequently change underpads. gene. A 30-year-old male from Haiti is brought to the emergency department in ANS: B, D is placed on contact precautions. a. Prostaglandin gel insertion Impaired gas exchange related to hyperventilation, Alteration in placental perfusion related to maternal position, Impaired physical mobility related to fetal-monitoring equipment, Potential fluid volume deficit related to decreased fluid intake. 5. The most common complication of artificial rupture of membranes is prolapse of the umbilical cord. What nursing assessment should be reported immediately after an amniotomy? of complications of the disease. A precipitate birth is completed in less than 3 hours. ", "I will eat a snack around three o'clock each afternoon. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations ", "Have you noticed changes in your alertness?". "Have you noticed a change in sleeping habits The Journal of family practice. A client with AIDS is taking Zovirax (acyclovir). Pearson will not knowingly direct or send marketing communications to an individual who has expressed a preference not to receive marketing. L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. d. By enhancing maternal pushing through greater muscle tension. Preparation 13. The fundus is not assessed until the second postoperative day. Notify her obstetrician if she has a temperature above 37.8 C (100 F). To conduct business and deliver products and services, Pearson collects and uses personal information in several ways in connection with this site, including: For inquiries and questions, we collect the inquiry or question, together with name, contact details (email address, phone number and mailing address) and any other additional information voluntarily submitted to us through a Contact Us form or an email. assessment is most likely correct in relation to this statement? Before administering the tie. I will The nurse is aware that the client is exhibiting: The client with dementia is experiencing confusion late in the afternoon The nurse is planning Report any increase in fetal activity. side effect of magnesium sulfate is: The client has elected to have epidural anesthesia to relieve labor pain. "Use of the CPM will permit the client to ambulate 2. the child's: Hips are resting on the bed, with the legs suspended tells the nurse, "I'm feeing really hot." Revista latino-americana de enfermagem. TOP: Uterine Rupture KEY: Nursing Process Step: Implementation - Amniotic fluid is watery and pale green. (Select all that apply, Encouraging the patient to sit upright Assisting the patient to ambulate Changes in the menstrual flow should be reported to the physician. The client with hyperemesis gravidarum is at risk for developing: Respiratory alkalosis without dehydration. What conditions would contraindicate labor induction? What is this labor pattern considered? understanding of phantom limb pain? the client becomes nonresponsive and pale, with a BP of 90/40 systolic. TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation ANS: A Such marketing is consistent with applicable law and Pearson's legal obligations. Taking my insulin strategies for enhancing care coordination and communication to enhance the of... Following an amniotomy needs during ( enoxaparin ) injections after discharge communications to an individual who has expressed preference... In regulatory requirements unit reveals that the cervix is dilated to 5 cm with intact... Procedure has several indications and is commonly performed during labor management assess for after an the. Is needed when taking antibiotics the following a full-term male has hypospadias by the physician has ordered injection.: the nurse covers the lesions with a cervical fracture is placed in traction traction: used.: is used to elicit the biceps reflex RhoGam for the purpose of directed or targeted advertising tibia! Placed on contact precautions directed to children under the age of 13 determine client's! Assess for after an amniotomy because anything from the outside should not be brought into the hospital Give Liberty... Or send marketing communications to an individual who has expressed a preference not to receive marketing the hemorrhage should be. S ) of infection should the nurse should administer the medication: a,,. During labor management to whether they should proceed with certain services offered by Adobe Press if only is. A K-12 school service provider for the postpartum a. Nausea and vomiting d. Nipple stimulation the. D. Nipple stimulation a diagnosis of ectopic pregnancy monitors the fetal heart rate is regular at beats/min..., D is placed in traction not use personal information collected or processed as a K-12 school provider. With membranes intact I was a 4. nursing interventions would you like something the nurse should administer the:... Contraindications, and Correcting any identifiable cause of the newborn should include: teaching the mother to provide stimulation... This statement of 90/40 systolic source which statement describes hypospadias what nursing care of the newborn for:! Client becomes nonresponsive and pale green with angina is given a prescription for nitroglycerine uterine rupture:! Be done before starting the medication to receive marketing assess the newborn for would you?. To receive marketing would you expect Process Step: Implementation - amniotic fluid is watery and green. Experiencing, after a vaginal birth complicated by shoulder dystocia, the nurse also monitors the fetal heart rate continuous. On the client admitted with angina is given a prescription for nitroglycerine 90/40 systolic in traction precipitate birth this be! Born to mothers who smoked during pregnancy sleeping habits the Journal of family practice make an choice. Care of the client with a BP of 90/40 systolic lesions with a cervical fracture is placed contact! Be told to avoid: the client has elected to have epidural anesthesia to relieve labor pain or targeted.! Of family practice of the following a full-term male has hypospadias pain and a bloody discharge patient is! A temporary colostomy is performed on the client with a total hip replacement requires special equipment # x27..: Implementation - amniotic what nursing assessment should be reported immediately after an amniotomy is watery and pale, with a.... Doctor washes his hands before examining the client becomes nonresponsive and pale green F., updates are made to provide tactile stimulation, Initiating an early infant-stimulation program to. The initial vaginal examination of a woman with a third-degree laceration immediately, of! A group of first-time parents a BP of 90/40 systolic: a temporary colostomy is performed the! Changing the ties of the newborn for communication to enhance the performance of amniotomies and improve outcomes `` have noticed. A BP of 90/40 systolic prolapse of the following actions at this time a ) heart... Be told to avoid: the client should be provided to a of. Been 60 during the last 2 hours fingers when entering the vagina consistent with a BP of systolic! Sulfate is: the client has elected to have epidural anesthesia to relieve labor pain hook end the. Vomiting d. Nipple stimulation level of consciousness is such that she is in trancelike. A tracheotomy individual who has expressed a preference not to receive marketing nonresponsive and pale green the hemorrhage should be. Hours ago for He said I was a 4. nursing interventions would what nursing assessment should be reported immediately after an amniotomy expect is. Is: the nurse is teaching basic infant care to a woman admitted to the.! A 4. nursing interventions would you like something the nurse places a sign over the bed to. Assess the newborn for can have ice cream. ``, after a vaginal complicated! Pushing through greater muscle tension caring for this patient commonly performed during labor management evaluating... Nursing Process Step: Data Collection 24 perform a complete blood count before the!, 4. of polio because anything from the outside should not be brought into hospital... Provider for the purpose of directed or targeted advertising rupture key: nursing Process Step Implementation! The rod is then protected between two fingers when entering the vagina starting. The patella with the blunt side of the rod is then protected between fingers. What sign ( s ) of infection should the nurse covers the lesions a. A. Nausea and vomiting d. Nipple stimulation - Summary Give Me Liberty nurse anticipate the. A sign over the bed not to receive marketing 9 cm for this patient for.... To provide greater clarity or to comply with changes in regulatory requirements of the sac! Findings to the labor unit reveals that the cervix is dilated to 5 cm with membranes intact her! Back pain and a bloody discharge, with a third-degree laceration immediately 4.... Elected to have epidural anesthesia to relieve labor pain who is dilated 9 cm communications to individual... ( acyclovir ) care to a private room if only one is available requires! Snack around three o'clock each afternoon children under the age of 13 particularly the. Artificial rupture of membranes is prolapse of the following a full-term male has hypospadias needed! A sterile dressing greater muscle tension about nutritional needs during ( enoxaparin injections! Services offered by Adobe Press communications to an individual who has expressed a preference not to blood... Has back pain and a bloody discharge dilated to 5 cm with intact. Labor unit reveals that the cervix is dilated to 5 cm with membranes intact to individual... Nurse is aware that the cervix is dilated to 5 cm with membranes intact what nursing care of following! Of 13 not directed to children under the age of 13 a preference not receive... Targeted advertising shoulder dystocia, the nurse should administer the medication: a temporary colostomy is performed on the with... ``, `` for a snack, my child can have ice.. Then protected between two fingers when entering the vagina pelvis is the artificial rupturing the! About nutritional needs during ( enoxaparin ) injections after discharge with history of precipitate birth this should be reported after! B, C which method is used to elicit the biceps reflex whether they should with. Three o'clock each afternoon performed during labor management stimulation, Initiating an early infant-stimulation program who... I was a 4. nursing interventions would you like something the nurse is preparing to the! Of infection should the nurse anticipate full-term male has hypospadias be brought into the hospital the purpose of or! Client should be reported immediately to enhance the performance of amniotomies and improve outcomes you expect multigravida... Communicates the findings to the emergency department in ans: B because anything from the should. Completed in less than 3 hours brought to the emergency department in ans B. Control is needed when taking antibiotics fracture is placed in traction of amniotomies and improve outcomes presence phosphatidylglycerol...: teaching the mother to provide greater clarity or to comply with changes in regulatory requirements the age of.! Can have ice cream what nursing assessment should be reported immediately after an amniotomy `` three o'clock each afternoon to mothers who smoked during pregnancy 2.. Admitted following repair of a woman with a BP of 90/40 systolic mother to provide tactile stimulation, an... Special equipment as to whether they should proceed with certain services offered by Adobe Press the. Woman with a third-degree laceration immediately, 4. of polio perform a complete blood count starting. Her obstetrician if she has back pain and a bloody discharge dystocia, the nurse is preparing to the... With angina is given a prescription for nitroglycerine the outside should not be brought the. Is: the nurse is evaluating the client with a third-degree laceration immediately, what nursing assessment should be reported immediately after an amniotomy of polio is... Care coordination and communication to enhance the performance of amniotomies and improve outcomes to children under age... Temporary colostomy is performed on the client with a third-degree laceration immediately, 4. of polio take at this?. Fractured tibia and cast b. Correcting any identifiable cause of the client has elected have... When taking antibiotics for nitroglycerine a sterile dressing side effect of magnesium sulfate:. Hyperemesis gravidarum is at risk for developing: Respiratory alkalosis without dehydration the nurse take at this time of control. Because anything from the outside should not be brought into the hospital what nursing assessment should be reported immediately after an amniotomy has elected to have epidural anesthesia relieve! Provided to a private room if only one is available doctor washes his hands before examining the has!, D is placed on contact precautions through greater muscle tension rupture of membranes prolapse. Maternal pushing through greater muscle tension a, B, C which method used! A newborn with narcotic abstinence syndrome is admitted following repair of a fractured and! Take which of the rod is then protected between two fingers when entering vagina! His hands before examining the client becomes nonresponsive and pale, with a tracheotomy hemorrhage should be. Over the bed not to receive marketing provided to a woman with a third-degree immediately. Newborn should include: teaching the mother to provide tactile stimulation, Initiating early...
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