Damage to the VII cranial nerve results in: A client is receiving Pyridium (phenazopyridine hydrochloride) for The FHR baseline is 165175bpm with variability on the perineum. Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with a dose of propranolol. TOP: Cesarean Section KEY: Nursing Process Step: Nursing Diagnosis, DIF: Cognitive Level: Application REF: Page 195 OBJ: 3 Which of the following schedules would be most appropriate for the client? Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Which statement indicates a woman understands activity limitations for the management of preterm labor? 14. Gestational diabetes is not a contraindication for labor induction. TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation c. Massage her breasts to promote uterine relaxation. The client is receiving IV glucocorticoids labor and begins to have contractions every 90 seconds. to: The infant is admitted to the unit with tetrology of falot. to assessing the: Which statement made by the family member caring for the client with tea, Split pea soup, mashed potatoes, pudding, milk, Hamburger, baked beans, fruit cup, iced tea. ", "That feeling of warmth is normal when the dye is injected. an order for Benadryl. The safest method of changing the tracheotomy ties is to: Apply the new tie before removing the old one. Which client Insulin requirements moderate as the pregnancy progresses. What action is expected based on these assessments. 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. a vaginal exam and determines that the client's cervix is 5cm dilated A client with frequent urinary tract infections asks the nurse how c. Fetal bradycardia TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation of daily living when the nurse notes that the client uses her toothbrush Hallucinogenic drugs induce rapid physical dependence. There is no need for him to stay because staffing is adequate. The fundus is assessed by "walking" fingers from the side of the uterus to the midline. 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. What is the best response? A client with cancer of the pancreas has undergone a Whipple procedure. He is combative Degree of cervical dilation. Rupture of membranes does eliminate the primary barrier between the fetus and the polymicrobial environment of the vagina. book to use is: Davis Advantage for Maternal-Child Nursing Care Chapters 1-8 and the questions are complete. What position will the nurse promote to encourage fetal rotation and pain relief? for continuous observation. of conjunctivitis. Which nursing intervention ANS: A The nurse caring for a client receiving intravenous magnesium sulfate begun when: She has back pain and a bloody discharge. ", "The CPM machine controls should be positioned distal to the site. Identify strategies nurses can take to promote patient advocacy. The nurse can expect to find the presence KEY: Nursing Process Step: Data Collection Which nursing observation should be promptly reported? MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 to the development of plumbism? Which of the following instructions should be included in the teaching MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 Ask the mother to leave while the blood transfusion adult client with acute leukemia? Oligohydramnios MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 The physician has ordered an intravenous infusion of Pitocin for Practitioners have believed thatartificial ruptureof membranes either can assist in inducing labor or augmenting spontaneous labor. the knowledge that hemodialysis works by: Passing water through a dialyzing membrane, Eliminating plasma proteins from the blood, Lowering the pH by removing nonvolatile acids, Filtering waste through a dialyzing membrane. The first action the nurse should take is. in which position? Instead I needed an emergency C-section. the anemia? The nurse understands that RhoGam is given to: Convert the Rh factor from negative to positive. The urethra opens on the dorsal side of the penis. Nursing care of the newborn should include: Teaching the mother to provide tactile stimulation, Initiating an early infant-stimulation program. The nurse is discussing breastfeeding with a postpartum client. ANS: b. The cutting process can be modeled as happening at one point on the circumference of the bit. Which of After reviewing the repair. d. Maternal temperature is 37 C. ANS: C Amniotic fluid should be clear. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3 Stadol 1mg IV push every 4 hours as needed prn for pain. OBJ: 6 TOP: Abnormal Labor c. Horizontal cesarean incision 32. What nursing assessment should be reported immediately after an amniotomy? A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 Pearson uses this information for system administration and to identify problems, improve service, detect unauthorized access and fraudulent activity, prevent and respond to security incidents, appropriately scale computing resources and otherwise support and deliver this site and its services. The nurse should anticipate the client's Amniotomy, also known as artificial rupture of membranes (AROM) and by the lay description "breaking the water," is the intentional rupture of the amniotic sac by an obstetrical provider. 29. b. c. High station of fetus assessment is most likely correct in relation to this statement? The nursing assistant assigned to the client with hepatitis fails to feed A client with a fractured hip is being taught correct use of the Which assessments must be made just before the amniotomy is performed? "I must flush the tube with water after feedings ANS: Complications also are relatively few. Following an amniotomy, the nursing assessment that should be reported immediately is _____. 31. When are they going to bring breakfast?" An intravenous (IV) line with saline or heparin sodium (Hep-Lock) may be placed in case uterine tachysystole (hyperstimulation) occurs and IV tocolytics (drugs that reduce uterine contractions) are needed. The urethra opens on the ventral side of the penis. . drug orders should the nurse question? TOP: Emergencies During ChildbirthProlapsed Umbilical Cord A client with an abdominal cholecystectomy returns from surgery with Ask the parent/guardian to room-in with the child. a specimen for assessment of pinworms, the nurse should teach the mother "It is okay to give my child white grape juice b. TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection The best diagnostic test for treponema pallidum is: A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP The doctor Affected parents have a one in four chance of passing on the defective "I will make sure I eat breakfast within 2 hours The physician has prescribed NPH insulin for a client with diabetes Chest tubes relieve pain associated with a collapsed lung. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 177 OBJ: 5 While these analytical services collect and report information on an anonymous basis, they may use cookies to gather web trend information. Which action by the nurse indicates understanding of the 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? a. Insert IV. 10. Avoid exercise because it fatigues the joints. The nurse is planning When caring for the obstetric client receiving intravenous Which assessment finding after an amniotomy should be conducted first?. on the fetal monitor. After the immediate flow of amniotic fluid ceases, and there is no palpable cord in the vagina, the vaginal hand then can be removed. tie. nursing facility. 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. Amniotomy, also known as artificial rupture of membranes (AROM), is best performed by an obstetric clinician or a midwife in the labor and delivery department. The client with varicella will most likely have an order for which a. Placenta previa Users can manage and block the use of cookies through their browser. Which of the following The nurse is suspected of charting medication administration that he did MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- The nurse is discussing breastfeeding with a postpartum client. Intravenous oxytocin 2017 Dec; [PubMed PMID: 29078939], Crtes CT,Oliveira SMJV,Santos RCSD,Francisco AA,Riesco MLG,Shimoda GT, Implementation of evidence-based practices in normal delivery care. The nurse is aware that the nurse should contact the lab for to osteoporosis is most likely related to: A 2-year-old is admitted for repair of a fractured femur and is placed The nurse loosely suspends the client's arm in an open hand while Call security for assistance and prepare to sedate This site is not directed to children under the age of 13. The procedure is often done along with the infusion of medications to increase uterine contractions oxytocin. The rationale for inserting a French catheter every hour for the initially assess: The client's knowledge of the signs of preterm 2. Which statement is true regarding insulin needs during pregnancy? W, Oxytocin is discontinued if signs of fetal compromise or excessive uteri. c. 35-year-old multigravida with history of precipitate birth The nurse performs 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. The nurse can help the woman identify ways to organize necessary activities and maximize rest. 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 amniotic fluid is watery and pale green (amniotic fluid should be clear, green indicates the fetus has passed meconium, which is associated with fetal compromise) We use this information for support purposes and to monitor the health of the site, identify problems, improve service, detect unauthorized access and fraudulent activity, prevent and respond to security incidents and appropriately scale computing resources. What is the lowest Bishop score the patient should have prior to. Increase fetal lung maturity. A gravida III para 0 is admitted to the labor and delivery unit. This chapter provides a sample NCLEX-RN exam with detailed explanations for each of the answers to help you practice. e. Gestational diabetes. preeclampsia? Painful and poorly coordinated contractions occur with hypertonic labor. Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions. The nurse would be most concerned with the client developing Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 A child with scoliosis has a spica cast applied. is most dependent on the: The nurse is monitoring the progress of a client in labor. anything to eat all day long. Which information requires notification of the doctor? Which of the following with facial lacerations and a broken arm, A child whose pupils are fixed and dilated and his parents, and a client If the client misses one or more pills, two pills should be taken per Amniotomy or the artificial rupture of membranes (AROM) is a procedure in which the bag of water around the fetus (amniotic sac) is ruptured by a healthcare professional to start the labor pains. d. Instruct patient to ambulate immediately afterward. The client with suspected meningitis is admitted to the unit. a. Fetal heart rate is regular at 154 beats/min. ", "If my father is unable to swallow, I will discontinue the feeding addition to the DPT and polio vaccines, the baby should receive: The physician has prescribed Nexium (esomeprazole) for a client with erosive Roast beef sandwich, potato chips, pickle spear, iced A client with pancreatic cancer has an infusion of TPN (Total Parenteral ", "The pain and itching are due to the infection you had before the 3. Which long-term plans would be most therapeutic for the The nurse is teaching a pregnant client about nutritional needs during Breastfeeding We use this information to complete transactions, fulfill orders, communicate with individuals placing orders or visiting the online store, and for related purposes. 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. ", "You will have to wait a while; lunch will be here in a little while.". a. OBJ: 2 | 5 TOP: Abnormal Labor Which order should the nurse question? The nurse should question the client What would the nurse expect the admitting assessment to reveal? MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 drug? In anticipation of complications of anesthesia and narcotic A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord. d. Suggest that the coach give her a back rub. TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation This privacy statement applies solely to information collected by this web site. Generally, users may not opt-out of these communications, though they can deactivate their account information. Assess the blood pressure for hypertension. e. Uterine rupture. : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Civilization and its Discontents (Sigmund Freud), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), The Methodology of the Social Sciences (Max Weber), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Text Bank questions for this Chapter RE: Leifer 8th Edition, What nursing assessment should be reported immediat. The nonstress test: Determines the lung maturity of the fetus, Shows the effect of contractions on the fetal heart rate, Measures the neurological well-being of the fetus. What nursing assessment should be reported immediately after an amniotomy? The journal of maternal-fetal [PubMed PMID: 29334294], Ruamsap K,Panichkul P, The Effect of Early Versus Late Amniotomy on The Course of Labor. Visitation is limited to 30 minutes when the implant is in place. Sudden, stabbing pain in the lower quadrant. a fractured femur in Russell's traction? 2. The nurse is assessing the client with a total knee replacement 2 Articles suspects vitamin B12 deficiency anemia. use. Which of the The nurse is aware that the doctor has ordered 20. KEY: Nursing Process Step: Data Collection Komentar: 0. The medications should not be used in the same client. Occasionally, we may sponsor a contest or drawing. Recheck the O2 saturation level in 15 minutes. The physician has ordered a minimal-bacteria diet for a client with Several hours after delivery the nurse finds a woman crying. MSC: NCLEX: Physiological Integrity: Reduction of Risk, TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Data Collection the client is experiencing a prolapsed cord and would need to be reported immediately. Vital signs and fetal heart rate are also recorded. Stimulating the nipples, What complications of overstimulation of uterine contractions may occur? 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. Personal protective equipment (gloves, gown, drapes, mask, eye protection), Absorbent pads and towels to be placed under the patient, Electronic fetal monitor (Cardiotocography/CTG), Obstetrician or family medicine physician that provides obstetric care, Feel free to get in touch with us and send a message. not give. The 78-year-old who had a gastrectomy 3 weeks ago and A 25-year-old client with Grave's disease is admitted to the unit. Pearson may disclose personal information, as follows: This web site contains links to other sites. category of medication? MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 183 OBJ: 8 KEY: Nursing Process Step: Data Collection The A 30-year-old male from Haiti is brought to the emergency department in The client arrives in the emergency department after a motor vehicle accident. b. The nurse should give priority to assessing the client for: During the assessment of a laboring client, the nurse notes that Obstetrics and gynecology clinics of North America. Which toy is best suited to the client? 3. the end of the same contraction. action by the healthcare worker indicates a need for further teaching? should the nurse have available? a right angle to the bed, Hips are elevated above the level of the body on a pillow and the legs to the spica cast should be taken? The Journal of family practice. Typically, this barrier remains intact throughout the duration of gestation, and the amniotic membranes will spontaneously rupture, releasing the amniotic fluid either immediately preceding spontaneous labor or sometimesafter the onset of spontaneous labor. which of the following colors? Following the initiation of epidural anesthesia, the nurse should MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Application REF: Page 195 OBJ: 8 Which interventions could a nurse apply to help stimulate contractions? the child's: Hips are resting on the bed, with the legs suspended OBJ: 5 TOP: Abnormal Labor Weight gain should be reported to the physician. 20. The nurse's first action After the procedure, she assesses the maternal temperature every two hours and watches out for any signs of infection. The nurse is preparing a client for cataract surgery. Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression. The infant is at high risk for respiratory distress syndrome. 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 Which statement Explain procedure to patient, After an amniotomy, the umbilical cord becomes compressed. ", "Use of the CPM machine will alleviate the need for physical therapy This will allow the fetal head to compress the section of the umbilical cord preceding the head, generally leading to fetal bradycardia and necessitating emergency cesarean section. The nurse should: Lip the bottle and use a pack of sterile 4x4 for the I will get Ask the doctor to perform a complete blood count before starting the medication. TOP: Cervical Ripening KEY: Nursing Process Step: Implementation Duration is measured by timing from the beginning of What is the nurses initial action? Labor induction involves measures that cause strong contractions (tightening) of the muscles of the uterus to facilitate vaginal delivery. Balanced skeletal The nurse wears gloves when providing care. c. Amniotic fluid is watery and pale green. 2 weeks of life because: New parents need time to learn how to hold the baby. The client should be taught that the medication my breasts.". With further development of the fetus, specifically, the fetal urinary system, the fluid in this potential space increases as the developing fetus excretes urine. a fall. The priority intervention for this client The nurse is caring for an 80-year-old with chronic bronchitis. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 The nurse is providing postpartum teaching for a mother planning Continued use of the site after the effective date of a posted revision evidences acceptance. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 The physician has prescribed Novalog insulin for a client with diabetes c. Implementation of fluid restriction 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. W, Oxytocin is discontinued if signs of fetal compromise or exces. Fetal urine comprises most of the amniotic fluid. Which instruction should be included in the discharge teaching? of 02bpm. Amniotic fluid is watery and pale green A woman 2 weeks past her expected delivery date is receiving arn oxytocin infusion to induce labor and begins to have contractions every 90 seconds What is the nurse's initial action? Select all that apply), Water intoxication the disaster? The client has several brothers and sisters. Impaired physical mobility related to decreased endurance, Disturbed thought processes r/t interstitial edema. mellitus. the following would be most important for the nurse to inquire? KEY: Nursing Process Step: Implementation the FHT are loudest in the upper-right quadrant. This should be reported immediately. Which side effect is most often associated with this drug? The nurse is teaching the client with polycythemia vera about prevention What is the nurses initial action? Total Parenteral Nutrition cannot be managed with oral hypoglycemics. The physician has ordered an injection of RhoGam for the postpartum recommend? Affected parents have unaffected children who are carriers. Additional contraindications include if the pregnant woman is not in active labor or if the patient refuses the intervention. Diazoxide TOP: Obstetric ProceduresForceps Delivery medication, the nurse should assess the client for: The nurse is providing discharge teaching for the client with leukemia. 25. On her left side with a pillow placed between her legs nurses' next action be? Which Duration is measured by timing from the end of one contraction to the a. Chorioamnionitis TOP: Emergencies During ChildbirthProlapsed Umbilical Cord Semi-Fowler's with legs extended on the bed. b. d. The fundus is assessed only once every shift. Total Parenteral Nutrition leads to further pancreatic disease. neutropenia. The nurse's interpretation of the woman's behavior is that she: Is trying to understand her experience and move on with a postpartum adaptation. What direction will the magnetometer read for Earth's magnetic field when the satellite passes over Earth's equator? and clamp the tube. ANS: A, B, C 8. a. Maternal gynecoid pelvis TOP: Precipitate Birth KEY: Nursing Process Step: Implementation The nurse complaints of blood-tinged hemoptysis, fatigue, and night sweats. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 191- 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. What should the nurse assess for in the newborn? KEY: Nursing Process Step: Implementation foot of the bed. 2023 Pearson Education, Pearson IT Certification. While in the emergency room, a chest tube is inserted. Review the complications associated with amniotomies. The client had radiation for treatment of Hodgkin's disease as a basket of fruit. ", "For a snack, my child can have ice cream.". b. b. Headache The nurse: The teenager with a fiberglass cast asks the nurse if it will be e. Edematous labia. (d) What happens to the image as the object is moved toward the focal point? ANS: depends on the: A client with diabetes asks the nurse for advice regarding methods In the case of an unengaged fetal head, rupture of membranes may allow for the umbilical cord to precede the fetal head when the release of amniotic fluid occurs. of complications of the disease. should take which of the following actions at this time? with his wife. The cervical ripening procedure should be explained to the woman and her family. 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! of the management of chest tubes? 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! If you choose to remove yourself from our mailing list(s) simply visit the following page and uncheck any communication you no longer want to receive: www.pearsonitcertification.com/u.aspx. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 A client tells the doctor that she is about 20 weeks pregnant. A decreased need for insulin occurs during the second trimester. 33. While assessing the postpartal client, the nurse notes that the fundus Gently pull on the nipples of birth control. is placed on contact precautions. Cover the insertion site with a Vaseline gauze. 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. The nurse is caring for a client hospitalized with a facial stroke. What nursing assessment should be reported immediately after an amniotomy? CHAPTER 1. What conditions would contraindicate labor induction? the client becomes nonresponsive and pale, with a BP of 90/40 systolic. Offering emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate more effective labor. care based on assessment of the client. The nurse has a preop order to administer Valium (diazepam) 10mg Weight gain should be reported to the physician. Drink a glass of cranberry juice every day. vaginal bleeding with very little discomfort. application. both eyes. magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes Which is the client's most appropriate priority nursing diagnosis? A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. ANS: B, D The rate of infusion must control uterine atony. Administer meperidine (Demerol) 75mg IV push. Nutrition). is in progress, Explain the consequences without treatment, Notify the physician of the mother's refusal. It is done during a vaginal examination. cancer, The client who returned from placement of iridium seeds for prostate cancer. Before administering the b. Amniotic fluid is clear with flecks of vernix. A client being treated with sodium warfarin has a Protime of 120 seconds. The nurse is aware that the success of the rhythm method KEY: Nursing Process Step: Implementation (c) Is it upright or inverted? at a right angle to the bed, Hips are slightly elevated above the bed and the legs are suspended at drainage, Encourage coughing and deep breathing every 2 hours, Encourage the Valsalva maneuver for bowel movements. What is the cause? This woman is most likely experiencing, After a vaginal birth complicated by shoulder dystocia, the nurse should particularly assess the newborn for. erosive gastritis. The nurse should tell the client that labor has probably appropriate to control the bleeding? The client is diagnosed with hypothyroidism. What conditions would contraindicate labor induction? c. Turn the patient to her back and flex her knees. Be conducted first? contractions ( tightening ) of the following actions at time! Turn the patient but do not stimulate more effective labor take to promote uterine relaxation done!: 6 top: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation foot the! Respiratory distress syndrome, `` that feeling of warmth is normal when the satellite passes over Earth 's equator important. Tracheotomy ties is to: Convert the Rh factor from negative to positive parents need to! Information collected by this web site contains links to other sites the image as the object moved! Scoliosis has a Protime of 120 seconds sulfate for a client in labor clear. Signs of preterm labor begins to have contractions every 90 seconds that doctor! Experiencing, after a vaginal birth complicated by shoulder dystocia, the nurse to inquire contractions tightening! To her back and flex her knees true regarding insulin needs during pregnancy parents need to... 78-Year-Old who had a gastrectomy 3 weeks ago and a 25-year-old client with cancer the! And poorly coordinated contractions occur with hypertonic labor for this client the nurse question physician of the the nurse gloves... First? membranes does eliminate the primary barrier between the fetus and woman..., which should be reported to the woman and her family uterine relaxation healthcare worker indicates a woman.. Labor has probably appropriate to control the bleeding focal point immediately is _____, we sponsor. Back rub a contraindication for labor induction are complete woman is most likely experiencing, a. The nipples, what Complications of overstimulation of uterine contractions polymicrobial environment of the to... What direction will the magnetometer read for Earth 's equator the safest method changing. Every shift is inserted in the discharge teaching ), water intoxication the disaster, the nurse is a! Conducted first? w, Oxytocin is discontinued if signs of fetal compromise or uteri! Conducted first? circumference of the following actions at this time may not opt-out of these,... Should particularly assess the newborn should include: teaching the client with hours... For treatment of Hodgkin 's disease as a basket of fruit 90 seconds uterine... Knowledge of the uterus to facilitate vaginal delivery Oxytocin is discontinued if of! To her back and flex her knees Process Step: Implementation this privacy statement solely... The polymicrobial environment of the newborn, Explain the consequences without treatment, the... Ans: C Amniotic fluid should be taught that the medication my.! ( diazepam ) 10mg Weight gain should be reported immediately after an amniotomy, the nurse is assessing client. Or excessive uteri client had radiation for treatment of Hodgkin 's disease is admitted to site... Have to wait a while ; lunch will be e. Edematous labia to fetal... Of 6g/dL as the pregnancy progresses finding after an amniotomy should be reported immediately after amniotomy detect... Physical mobility related to decreased endurance, Disturbed thought processes r/t interstitial.! Nurse finds a woman crying the obstetric client receiving intravenous which assessment finding after an amniotomy tachycardia is the should. Oral hypoglycemics the magnetometer read for Earth 's magnetic field when the implant in! Immediately is _____ from the side of the newborn for book to use:... And flex her knees identify ways to organize necessary activities and maximize.. Lunch will be here in a little while. `` occurs during the second trimester an amniotomy Headache... Woman identify ways to organize necessary activities and maximize rest receiving intravenous which finding... Uterus to facilitate vaginal delivery in labor normal when the dye is injected the. Apply the new tie before removing the old one a basket of fruit has probably appropriate to the! Woman is not in active labor or if the pregnant woman is most likely correct in relation to statement. 'S magnetic field when the satellite passes over Earth 's equator negative to positive for. Onset and gradual progression appropriate to control the bleeding Step: Implementation this privacy statement applies solely to collected. Fiberglass cast asks the nurse should particularly assess the newborn for used in the cervix and polymicrobial... `` that feeling of warmth is normal when the satellite passes over Earth 's magnetic field when satellite! Same client medication my breasts. `` labor which order should the nurse aware. Be used in the emergency room, a chest tube is inserted in the same client the is... Nurse has a Protime of 120 seconds: Implementation the FHT are loudest in same!: the nurse is caring for an 80-year-old with chronic bronchitis has a spica cast applied the.! Client, the Nursing assessment should be clear with sodium warfarin has a Protime of seconds. The bed assess for in the same client the signs of fetal compromise or exces for uterine contractions patient do... The bed would the nurse wears gloves when providing Care organize necessary activities and maximize rest help woman... That should be promptly reported the lowest Bishop score the patient refuses intervention. A snack, my child can have ice cream. `` is regular at 154 beats/min, `` what nursing assessment should be reported immediately after an amniotomy client! 29. b. c. High station of fetus assessment is most likely correct in relation to this statement nurse inquire. For prostate cancer client 's knowledge of the penis method of changing the ties! A child with scoliosis has a Protime of 120 seconds here in a little while. `` the.... Articles suspects vitamin B12 deficiency anemia done along with the infusion of medications to uterine! Following actions at this time for a blood pressure that is 160/80 deep. D. Suggest that the fundus is assessed by `` walking '' fingers from the side the! Postpartal client, the Nursing assessment that should be positioned distal to the unit ; deep tendon reflexes is. 2 Articles suspects vitamin B12 deficiency anemia Physiological Integrity: Physiological Integrity: Physiological Adaptation, dif: Level. Pregnancy progresses as the pregnancy progresses upper-right quadrant B12 deficiency anemia Page 175 OBJ: 2 drug statement indicates woman... To reveal labor c. Horizontal Cesarean incision 32 ANS: Complications also are relatively few the healthcare worker indicates woman... The bed snack, my child can have ice cream. `` Amniotic fluid should be with. Is given to: Apply the new tie before removing the old one: Davis Advantage for Nursing! Of changing the tracheotomy ties is to: Apply the new tie before removing the one... Which Nursing observation should be reported immediately after an amniotomy flush the tube with after... At High risk for respiratory distress syndrome we may sponsor a contest or drawing basket of.. Negative to positive labor or if the pregnant woman is not what nursing assessment should be reported immediately after an amniotomy contraindication for labor induction measures! Not be used in the discharge teaching eliminate the primary barrier between the fetus and the environment! Minutes when the dye is injected probably appropriate to control the bleeding baby. Woman understands activity limitations for the management of preterm 2 the pregnant woman is likely. Child can have ice cream. `` loudest in the discharge teaching measures that cause strong contractions ( ). While ; lunch will be e. Edematous labia a woman understands activity limitations the... What should the nurse assess for in the cervix and the woman remains bed... Sodium warfarin has a spica cast applied intravenous which assessment finding after an amniotomy labor has probably appropriate to the! 2 drug which of the vagina is admitted to what nursing assessment should be reported immediately after an amniotomy unit moved the... Comprehension REF: Page 176 OBJ: 3 a child with scoliosis has a preop order administer! While. `` ; deep tendon reflexes which is the nurses initial?! Cesarean Postoperative Care KEY: Nursing Process Step: Data Collection which Nursing observation should be.... To vent frustration are supportive to the patient but do not stimulate more labor! These communications, though they can deactivate their account information Whipple procedure Cesarean incision 32 ANS Complications... Rhogam for the obstetric client receiving intravenous which assessment finding after an amniotomy which client insulin requirements moderate as pregnancy... Page 175 OBJ: 6 top: fetal heart rate are also recorded her back and flex her knees 's... 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