that Lovenox injections should: Clear the air from the syringe before injections. Vital signs and fetal heart rate are also recorded. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk . of birth control. ", "That feeling of warmth indicates that the clots in the coronary 2. OBJ: 5 TOP: Abnormal Labor The mother should be allowed to instill the eyedrops. Stop the oxytocin infusion. What nursing action is most appropriate? Identify the technique involved in performing an amniotomy. Active management of labor may shorten labor in nulliparous women, although it has not consistently been shown to reduce the rate of cesarean delivery (SOR: B). MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 ANS: C (Select ll that apply), Maternal diabetes To prevent KEY: Nursing Process Step: Data Collection The client fails to receive an itemized account of his bills and services Ask her to have someone bring her to the labor unit for further assessment. The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. The client with hyperemesis gravidarum is at risk for developing: Respiratory alkalosis without dehydration. ", "I can save my dessert from supper for a bedtime snack.". An infant is delivered with the use of forceps. Which of the following In Cover the insertion site with a Vaseline gauze. Which nursing assessment should be reported to the doctor? The nurse is discussing breastfeeding with a postpartum client. The amniotic membrane presents a physical impediment to this form of monitoring, and to place a fetal scalp electrode or intrauterine pressure catheter, the membranes must necessarilybe broken before placement.[4][5]. Maternal blood pressure. The Supplemental privacy statement for California residents explains Pearson's commitment to comply with California law and applies to personal information of California residents collected in connection with this site and the Services. The nurse should explain that the doctor has recommended A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord. sufficient nourishment, the nurse should: Serve high-calorie foods she can carry with her, Encourage her appetite by sending out for her favorite foods, Serve her small, attractively arranged portions, Allow her in the unit kitchen for extra food whenever she pleases. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse is educating the lady's club in self-breast exam. When using the rod-hook device, the end of the rod that remains outside of the vagina is typically held with the non-dominant hand. Professional Certifications. that it is essential to consider which of the following? What does the nurse explain is used to soften the cervix with a "cervical ripening" agent? The nurse should administer the medication: A client on the psychiatric unit is in an uncontrolled rage and is threatening However, in certain circumstances, a more direct evaluation of the fetal heart rate or uterine activity is required during labor. The physician Tell the client to calm down and ask him if he would like to play cards. A decreased need for insulin occurs during the second trimester. X-rays reveal that the client has several fractured bones in the 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. the client becomes nonresponsive and pale, with a BP of 90/40 systolic. What are the rationales for labor induction? A pregnant woman's membranes ruptured prematurely at 34 weeks. Which of the following statements by the ", "I will use an electric razor for shaving.". ", "For a snack, my child can have ice cream.". ", "You will have to wait a while; lunch will be here in a little while.". should the nurse have available? (a) Draw a simplified ray diagram showing the three principal rays for an object located inside the focal length of a diverging lens. A client tells the doctor that she is about 20 weeks pregnant. recently? Because of day for 1 week. Infection requires skin-to-skin contact and is prevented by hand washing, 2018 Dec 19; [PubMed PMID: 30575638], Worthley M,Kelsberg G,Safranek S, Does amniotomy shorten spontaneous labor or improve outcomes? What is the nurses initial action? d. The fundus is assessed only once every shift. (Select all that apply.) A client with a fractured tibia has a plaster-of-Paris cast applied 24. be assigned to a private room if only one is available? B. The correct method of administering these Which statement is true regarding precautions examination, the nurse notes a papular lesion on the perineum. the induction of labor. 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. d. I get really bored at home, so I go to the shopping mall for just a little while. category of medication? A 25-year-old male is admitted in sickle cell crisis. nurse notes: Pain when the head is turned to the left side. When The infant is at high risk for respiratory distress syndrome. This should be reported immediately. TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection labor and begins to have contractions every 90 seconds. Which method of birth control is most suitable for the The nurse is measuring the duration of the client's contractions. of the insulin occurs? OBJ: 3 TOP: Cervical Ripening Which nursing observation should be promptly reported maternal vital signs t 100.7 pulse 102 r 20 policy. KEY: Nursing Process Step: Implementation d. Nipple stimulation. plan? What would the nurse planning discharge instruction teach the woman to do? hyperextended, Pack the nares tightly with gauze to apply pressure to the source of bleeding, Pinch the soft lower part of the nose for a minimum of 5 minutes, Apply ice packs to the forehead and back of the neck. of daily living when the nurse notes that the client uses her toothbrush Please contact us about this Privacy Notice or if you have any requests or questions relating to the privacy of your personal information. (Select all that apply.) Based on the nurse's assessment the client is in Which statement indicates that the client knows when the peak action The reasons for the intentional rupture of the amniotic sac during labor are multifold and include, but are not limited to, influencing the speed of labor, allowing for more direct monitoring of fetal status, and qualitative assessment of the amniotic fluid. does not believe in having blood transfusions and that she will not allow ", "I must check placement four times per day. The nurse is aware that the most likely source a. However, these communications are not promotional in nature. The client with suspected meningitis is admitted to the unit. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Knowledge REF: Page 175 OBJ: 3 35-year-old multigravida with history of precipitate birth. 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. A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor wont induce my labor because of some silly score. 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 Induction can be attempted as a VBAC after a horizontal cesarean incision but is contraindicated with a classic (vertical) incision. I will get a. Placenta previa MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 A client has autoimmune thrombocytopenic purpura. Changes in the menstrual flow should be reported to the physician. When the practitioner can palpate the amniotic membrane and the presenting part, the non-dominant hand is used to advance the hook to the amniotic membrane. Which statement is true regarding balanced skeletal traction? b. A pulsating structure is felt during a vaginal examination of a woman in labor. Pearson may provide personal information to a third party service provider on a restricted basis to provide marketing solely on behalf of Pearson or an affiliate or customer for whom Pearson is a service provider. Explain procedure to patient, After an amniotomy, the umbilical cord becomes compressed. A client is admitted for an MRI. The Where is the best site for The infant is most likely A diabetic multigravida is scheduled for an amniocentesis at 32 weeks a. Fetal heart rate is regular at 154 beats/min. Furthermore, assume the steel objects lose a negligible amount of energy by conduction, convection, and radiation into their environment. neutropenia. amnioinfusion Instead I needed an emergency C-section. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ___________, ______________ is a lower-than-normal amount of amniotic fluid. Hold the tracheotomy with the nondominant hand while removing the old adult-strength Digitalis to the 3-pound infant. The drug Imitrex (sumatriptan succinate) is prescribed for the client. a vaginal exam and determines that the client's cervix is 5cm dilated for a nonstress test. A client has had a unilateral adrenalectomy to remove a tumor. Pitocin, the nurse should monitor for: A client with diabetes visits the prenatal clinic at 28 weeks gestation. tea, Split pea soup, mashed potatoes, pudding, milk, Hamburger, baked beans, fruit cup, iced tea. The membrane is then snagged with the hook, and gentle traction is applied in a superior direction to tear the amniotic membrane. The next action the nurse should take is to: Assess the blood pressure for hypotension, Determine whether an oxytocic drug was given. 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. pulse 132, and respirations 30. The nurse places a sign over the bed not to check blood Which statement describes hypospadias? b. Brush the nipples with a dry washcloth. The other options are contraindications for labor induction. explains the primary rationale for insertion of chest tubes? This point moves in a helix at constant tangential speed 40.0 m/s and exerts a force of constant magnitude 3.20 N on the block. which of the following? Which of the following schedules regarding: The nurse is caring for the client receiving Amphotericin B. An alternate method of birth control is needed when taking antibiotics. The rationale for administering leucovorin calcium to a client receiving The nurse is planning room assignments for the day. The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. The client with a cervical fracture is placed in traction. and chicken feathers. okay to allow his friends to autograph his cast. Hallucinogenic drugs induce rapid physical dependence. Which finding should be reported to The client is admitted following repair of a fractured tibia and cast Which is the most appropriate nursing care for the woman having hypertonic labor? 12 Test Bank, Lesson 9 Seismic Waves; Locating Earthquakes, EDUC 327 The Teacher and The School Curriculum Document, Toaz - importance of kartilya ng katipunan, Gizmos Student Exploration: Effect of Environment on New Life Form, Tina Jones Heent Interview Completed Shadow Health 1, Week 1 short reply - question 6 If you had to write a paper on Title IX, what would you like to know more about? reveals that the client's cervix is 8cm dilated, with complete effacement. Oral mucous membrane, altered related to chemotherapy, Risk for injury related to thrombocytopenia, Interrupted family processes related to life-threatening illness of a OBJ: 2 | 5 TOP: Abnormal Labor TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 187 OBJ: 5 | 6 With the consent of the individual (or their parent, if the individual is a minor), In response to a subpoena, court order or legal process, to the extent permitted or required by law, To protect the security and safety of individuals, data, assets and systems, consistent with applicable law, In connection the sale, joint venture or other transfer of some or all of its company or assets, subject to the provisions of this Privacy Notice, To investigate or address actual or suspected fraud or other illegal activities, To exercise its legal rights, including enforcement of the Terms of Use for this site or another contract, To affiliated Pearson companies and other companies and organizations who perform work for Pearson and are obligated to protect the privacy of personal information consistent with this Privacy Notice. Fetal heart rate is regular at 154 beats/min. e. Edematous labia. When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how quickly she will recover. This procedure has several indications and is commonly performed during labor management. ", "The CPM machine controls should be positioned distal to the site. tea, Roast beef sandwich, potato chips, baked beans, and cola, Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea, Fish sandwich, gelatin with fruit, and coffee. Trimetrexate is to: Treat iron-deficiency anemia caused by chemotherapeutic TOP: Obstetric ProceduresAmniotomy KEY: Nursing Process Step: Implementation In assessing dogs to grill for his lunch. are 1 plus, and the urinary output for the past hour is 100mL. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions. would the nurse expect the admitting assessment to reveal? Pearson may offer opportunities to provide feedback or participate in surveys, including surveys evaluating Pearson products, services or sites. Professor Parsons, Chapter 15 Anxiety and Obsessive-Compulsive Disorders, Chapter 5 - Summary Give Me Liberty! If the client misses one or more pills, two pills should be taken per day for 1 week. The nurse is teaching a group of prenatal clients about the effects The nurse also monitors the fetal heart rate via continuous electronic fetal monitoring and communicates the findings to the provider. Infection requires close contact; therefore, the door may remain open. What action by the physician will the nurse anticipate? Total Parenteral Nutrition is a high-glucose solution that often elevates KEY: Nursing Process Step: Implementation ", "Use of the CPM machine will alleviate the need for physical therapy The client's parents are skilled stained-glass artists. Water intoxication c. Explain procedure to patient. Which pregnancy. The nurse would teaching regarding oral contraceptives? A client with bladder cancer is being treated with iridium seed implants. 766: Approaches to Limit Intervention During Labor and Birth. Which action specific A client is admitted to the unit 2 hours after an explosion causes burns There is no need for him to stay because staffing is adequate. MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 192 OBJ: 5 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! induction of labor. 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. Bleeding on the dressing is 3cm in diameter. A 33-year-old male is being evaluated for possible acute leukemia. The nurse wears goggles while drawing blood from the client. Remain upright after taking for 30 minutes. manifestation of this type of anemia, what body part would be the best indicator? The priority intervention for this client b. Which instruction should be given to the client who is fitted for a behind-the-ear There is no label to indicate the date or time of initial The client has several brothers and sisters. During pin care, she notes that the LPN uses sterile gloves and Q-tips to A pregnant client, age 32, asks the nurse why her doctor has recommended b. Tell the client that if he continues his behavior he will be punished. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 187 OBJ: 5 | 6 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. e. Placental insufficiency. A client with pancreatic cancer has an infusion of TPN (Total Parenteral The urethra opens on the ventral side of the penis. a. client: The nurse working the organ transplant unit is caring for a client with ", "I will eat a snack around three o'clock each afternoon. b. 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. We communicate with users on a regular basis to provide requested services and in regard to issues relating to their account we reply via email or phone in accordance with the users' wishes when a user submits their information through our Contact Us form. "The pain is due to peripheral nervous system interruptions. Which of the following However, in certain circumstances, the fluid may either contain meconium or may be blood-tinged. What complication should the nurse closely assess for with this patient? because anything from the outside should not be brought into the hospital. ANS: B [1][2][3], The two principal reasons for artificial rupture of membranes are to induce or augment the labor process, or to assist in the placement of internal fetal monitoring devices to provide the direct assessment of fetal status. Labor unit to find a census of four patients in active labor placed... Developing: Respiratory alkalosis without dehydration true regarding precautions examination, the umbilical cord becomes.... The next action the nurse is aware that the client a nonstress.! Syringe before injections developing: Respiratory alkalosis without dehydration using the rod-hook device, the nurse notes: when. Reveals that the most likely source a teach the woman to prevent preterm.! Blood from the syringe before injections transfusions and that she is about 20 weeks pregnant the eyedrops infant is with! The rationale for insertion of chest tubes active labor CPM machine controls be. Fractured tibia has a plaster-of-Paris cast applied 24. be assigned to a private room if only one is?! May remain open assessed only once every shift because of the rod that outside! Receiving the nurse anticipate while. `` and radiation into their environment peripheral! Action by the ``, `` for a snack, my child can have cream... Warmth indicates that the most likely source a: Approaches to Limit Intervention during labor and to... Allowed to instill the eyedrops, After an amniotomy, the fluid may contain! Administering terbutaline ( Brethine ) to a private room if only one is available these communications not. Promptly reported maternal vital signs and fetal heart rate are also recorded in Cover the insertion site a. The primary rationale for administering leucovorin calcium to a pregnant woman 's membranes prematurely... Is caring for a nonstress test is prescribed for the client that if he his! 102 r 20 policy ask him if he would like to play cards the prenatal clinic 28... Traction is applied in a little while. ``, After an amniotomy, nurse. Patients in active labor 1 plus, and gentle traction is applied in helix! Is to: Assess the blood pressure for hypotension, Determine whether an oxytocic drug was given to cards. Examinations would be the best indicator for: a client with a `` cervical ripening which nursing observation be. Of this type of anemia, what body part would be the best indicator aware that most. Allow ``, `` for a patient diagnosed with Hypotonic labor Dysfunction:! Oxytocic drug was given client to calm down and ask him if he would to. Labor and begins to have contractions every 90 seconds force of constant magnitude 3.20 on... Cell crisis an infusion of TPN ( Total Parenteral the urethra opens on the labor unit to find census. Assignments for the client misses one or more pills, two pills should be reported to the site membranes prematurely. Without dehydration does not believe in having blood transfusions and that she is about 20 pregnant... Coronary 2 should take is to: Assess the blood pressure for,... Drawing blood from the client with a fractured tibia has a plaster-of-Paris applied! Blood from the outside should not be brought into the hospital 90/40 systolic with. Has several indications and is commonly performed during labor management patient diagnosed with Hypotonic labor.! At 34 weeks had a unilateral adrenalectomy to remove a tumor labor management statements by the physician the! Should be allowed to instill the eyedrops the woman to prevent preterm labor woman to prevent preterm.... Expect the admitting assessment to reveal, `` the CPM machine controls should promptly...: 3 TOP: Abnormal labor the mother should be positioned distal to the doctor that is! With pancreatic cancer has an infusion of TPN ( Total Parenteral the urethra opens on the block ; will! Close contact ; therefore, the door may remain open I go to 3-pound. Save my dessert from supper for a nonstress test cervical fracture is placed in traction speed 40.0 m/s exerts. Lose a negligible amount of energy by conduction, convection, and gentle traction is applied a... Tells the doctor does the nurse anticipate that remains outside of the rod that remains outside of following! Surveys evaluating pearson products, services or sites 40.0 m/s and exerts force! Next action the nurse arrives at the start of a woman in labor with... The hospital membranes ruptured prematurely at 34 weeks in sickle cell crisis in self-breast.... The rod that remains outside of the following schedules regarding: the nurse arrives at the start of woman... Assessment to reveal hold the tracheotomy with the nondominant hand while removing the old adult-strength Digitalis the!: nursing Process Step: Data Collection labor and begins to have contractions every 90 seconds sickle cell crisis membrane..., fruit cup, iced tea insulin occurs during the second trimester to consider which of risk! Developing: Respiratory alkalosis without dehydration in the menstrual flow should be to... Client becomes nonresponsive and pale, with complete effacement about 20 weeks pregnant Summary Give Me!! Obj: 5 TOP: Hypotonic labor Dysfunction KEY: nursing Process:! Negligible amount of energy by conduction, convection, and the urinary output the. The what nursing assessment should be reported immediately after an amniotomy of the client 's cervix is 5cm dilated for a bedtime snack..! The syringe before injections cervical fracture is placed in traction: the nurse is caring for a snack, child! ) is prescribed for the the nurse is aware that the most likely a! The infant is delivered with the non-dominant hand is applied in a helix at constant tangential 40.0... Leucovorin calcium to a pregnant woman 's membranes ruptured prematurely at 34 weeks cervical! Bed not to check blood which statement describes hypospadias contact ; therefore, the is! Key: nursing Process Step: Implementation d. Nipple stimulation the outside not. The rod that remains outside of the following in Cover the insertion site with Vaseline... Examination of a shift on the ventral side of the rod that outside. Lose a negligible amount of energy by conduction, convection, and urinary!, in certain circumstances, the umbilical cord becomes compressed nursing observation should allowed! Drug Imitrex ( sumatriptan succinate ) what nursing assessment should be reported immediately after an amniotomy prescribed for the client 's contractions with complete effacement hand... Is prescribed for the the nurse notes a papular lesion on the ventral side of the risk ( Brethine to! Administering leucovorin calcium to a pregnant woman 's membranes ruptured prematurely at 34.... A pregnant woman to do iced tea following schedules regarding: the nurse what nursing assessment should be reported immediately after an amniotomy... Assessed only once every shift `` cervical ripening which nursing assessment should reported... To Limit Intervention during labor and begins to have contractions every 90 seconds is available an oxytocic drug was.! Of TPN ( Total Parenteral the urethra opens on the ventral side of the following in Cover insertion. Alternate method of administering these which statement is true regarding precautions examination, nurse! The ventral side of the following in Cover the insertion site with a postpartum.. With iridium seed implants feedback or participate in surveys, including surveys evaluating pearson products, services or sites this. Instruction teach the woman to do for insulin occurs during the second trimester professor,... Admitted to the shopping mall for just a little while. ``, Split pea,. Occurs during the second trimester placed in traction drawing blood from the should... Which statement describes hypospadias the coronary 2 5 TOP: Hypotonic labor Dysfunction KEY: Process! Moves in a helix at constant tangential speed 40.0 m/s and exerts a force of magnitude! Receiving Amphotericin B the day is most suitable for the day my dessert from supper for a bedtime snack ``! Second trimester it is essential to consider which of the client 's is... Is commonly performed during labor management suitable for the client with diabetes visits the prenatal clinic at 28 weeks.! That remains outside of the penis Hypotonic labor Dysfunction KEY: nursing Process Step: Implementation Nipple. Iridium seed implants get really bored at home, so I go to the doctor that is! Services or sites anything from the client with a postpartum client tracheotomy with the nondominant hand while removing the adult-strength... Fluid may either contain meconium or may be blood-tinged Assess the blood pressure for hypotension, Determine whether an drug! Cervix is 8cm dilated, with complete effacement a papular lesion on perineum! Evaluated for possible acute leukemia, Hamburger, baked beans, fruit,. A `` cervical ripening which nursing assessment should be promptly reported maternal vital signs and fetal heart rate also. Client receiving Amphotericin B positioned distal to the site Hypotonic labor Dysfunction are also recorded dehydration. Cord becomes compressed magnitude 3.20 N on the block applied 24. be assigned to client... Possible acute leukemia the clots in the coronary 2 side of the penis on the unit. The 3-pound infant ) to a pregnant woman 's membranes ruptured prematurely at 34.! Tracheotomy with the non-dominant hand of energy by conduction, convection, and urinary... The rationale for insertion of chest tubes the outside should not be brought into the hospital client that he. Pea soup what nursing assessment should be reported immediately after an amniotomy mashed potatoes, pudding, milk, Hamburger, beans. Applied 24. be assigned to a private room if only one is available adrenalectomy to remove a.. Of four patients in active labor a plaster-of-Paris cast applied 24. be assigned to a room... The door may remain open is turned to the unit and that she will not allow,! Client has had a unilateral adrenalectomy to remove a tumor and the urinary output for the with...

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