how many pounds at 1 year? The nurse has an important role in the assessment and continuous monitoring of pregnant women in labor. else? Drink a glass of cranberry juice every day. Lengthy activity restrictions are often needed to prevent preterm birth. A client being treated with sodium warfarin has a Protime of 120 seconds. The priority nursing action is to: Take the woman's temperature; report it and the fluid odor to the RN. 2. ", "If the client complains of pain during the therapy, I will turn
Impaired physical mobility related to decreased endurance, Disturbed thought processes r/t interstitial edema. Painful and poorly coordinated contractions occur with hypertonic labor. ANS: A Amniotic fluid is clear with flecks of verni, Continue the infusion and report the findings to the phy, What nursing care should be provided to a woman with a thi, N334- Trach Suctioning and Care Performance Checklist-Revised, Leifer Ch 10 Text Bank questions for this Chapter RE: Leifer 8th Edition, Operating Systems 1 (proctored course) (CS 2301), Educational Psychology and Development of Children Adolescents (D094), Strategic Decision Making and Management (BUS 5117), Medical Surgical 1 (MURS_3144_01_UG_MAIN_MEDICAL-SURGICALNURSING1), Preparation For Professional Nursing (NURS 211), Management of Adult Health II (NURSE362), Concepts of Medical Surgical Nursing (NUR 170), Complex Concepts Of Adult Health (RNSG 1443), Professional Nursing Practicum (NUR - 4836C), 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), Dr. Yost - Exam 1 Lecture Notes - Chapter 18, ECO 201 - Chapter 2 Thinking like economist part 1, Kami Export - Madeline Gordy - Paramecium Homeostasis, Ch. She repeatedly asks similar questions about what happened at birth. a. This site uses cookies and similar technologies to personalize content, measure traffic patterns, control security, track use and access of information on this site, and provide interest-based messages and advertising. The chance of chilling the baby outweighs the benefits of bathing. The client should be instructed to: The nurse is assisting the physician with removal of a central venous
MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 Which is the most appropriate teaching immediately after the procedure, call your nurse if you notice fluid leaking form your vagina. 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. Here skin is peeling and she has a long, thin appearance. Which instruction should be given regarding the medication? 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. An alternate method of birth control is needed when taking antibiotics. clinic for a first check-up. vessels are dissolving. An affected newborn has unaffected parents. An infant's Apgar score is 9 at 5 minutes. A client who is admitted with an above-the-knee amputation tells
MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 complaints of blood-tinged hemoptysis, fatigue, and night sweats. Which instruction should be included in the discharge teaching? TOP: Obstetric ProceduresForceps Delivery Begin at a rate of 20 to 40 mU/min, increasing or decreasing the rate according to uterine response and the rate of postpartum bleeding. Which of the following indicates that the client's ECT has
Which
Gynecoid pelvis is the most favorable shape for vaginal delivery. What side effect should the nurse inform the patient that she might experience? A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. (c) What pieces of data, if any, are unnecessary for the solution? The nurse is providing dietary instructions to the mother of an 8-year-old
The membranes are broken using an instrument similar to a crochet hook. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 183 OBJ: 8 following best explains the functions of the lens? Transmission is highly likely, so the client should wear a mask at all
2018 Dec 3; [PubMed PMID: 30529256], Pasko DN,Miller KM,Jauk VC,Subramaniam A, Pregnancy Outcomes after Early Amniotomy among Class III Obese Gravidas Undergoing Induction of Labor. 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. clients can be assigned to share a room in the emergency department during
The nurse is evaluating nutritional outcomes for an elderly client with
The client arrives in the emergency department after a motor vehicle accident. initially assess: The client's knowledge of the signs of preterm
8. ", "I must check placement four times per day. administered concomitantly to the client with hypertension. Leifer Ch 8 Text Bank questions for this Chapter RE: Leifer 8th Edition, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 a prescription of Accutane? of complications of the disease. Successful rupture of membranes most commonly is determined by the immediate return of amniotic fluid from the vagina. To maintain Bryant's traction, the nurse must make certain that
d. Prolapsed cord to take thyroid medication during the pregnancy. ANS: B a. Breastfeeding
MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 should administer this medication: Cataracts result in opacity of the crystalline lens. purpura (ATP). d. Maternal temperature is 37 C . The client with a history of diabetes insipidus is admitted with polyuria,
Assume that there are orders for
(Select all that apply.) If the womans tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. Which of the following activities would the nurse
pregnancy. The nurse is discussing breastfeeding with a postpartum client. 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. 2. times. each intervention. At 1 minute, the nurse could expect to find: A client with sickle cell anemia is admitted to the labor and delivery
basket of fruit. Which
The nurse should advise the client to refrain from drinking after: Which of the following diet instructions should be given to the client
The nurse notes variable decelerations on the fetal monitor strip. This chapter provides a sample NCLEX-RN exam with detailed explanations for each of the answers to help you practice. Duration is measured by timing from the beginning of
discussing the treatment, the child's mother tells the nurse that she
The nurse
A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions. Which of the client's statements indicates
24. What should the nurse assess for in the newborn? If the client misses one or more pills, two pills should be taken per day for 1 week. The most common complication of artificial rupture of membranes is prolapse of the umbilical cord. Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions. b. Headache Fetal development depends on adequate insulin regulation. initial nurse's action should be to: Increase the infusion of Dextrose in normal saline. Which laboring patient should the nurse attend to first? What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? Treatment is not recommended for children less than
c. On her back with her head lower than the rest of her body The nurse is teaching the client with polycythemia vera about prevention
Identify strategies to promote culturally sensitive care. client with diabetes? ANS: C side effect of magnesium sulfate is: The client has elected to have epidural anesthesia to relieve labor pain. should place the zero of the manometer at the: The physician orders lisinopril (Zestril) and furosemide (Lasix) to be
doctor? Gently pull on the nipples I'll
should the nurse have available? ANS: C received during his hospital stay. Ice is applied to the perineum to reduce bruising and edema. The tube will allow for equalization of the lung expansion. The following are all nursing diagnoses appropriate for a gravida
finding should be reported to the physician immediately? 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. 20. The physician has prescribed NPH insulin for a client with diabetes
With either device, the practitioner first assesses cervical dilation through the performance of a sterile digital exam. Hallucinogenic drugs induce a state of altered perception. Vital signs and fetal heart rate are also recorded. What is the most appropriate nursing diagnosis, Grieving related to loss of expected birth experience. she is in labor. A client with a total hip replacement requires special equipment. d. Fetal hypokalemia. MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 192 OBJ: 5 Bladder distention. The client selects a balanced diet from the menu. c. Gently pull on the nipples. Upon
end of the same contraction. Rupture of membranes does eliminate the primary barrier between the fetus and the polymicrobial environment of the vagina. should anticipate administering which medication? b. Maternal hypertension must closely observe for side effects associated with drug therapy. The priority intervention for this client
A client with pancreatic cancer has an infusion of TPN (Total Parenteral
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. Painful and poorly coordinated contractions A client with an abdominal cholecystectomy returns from surgery with
Which laboring patient should the nurse attend to first? 18. OBJ: 6 TOP: Abnormal Labor The client fails to receive an itemized account of his bills and services
the test: A client with hypothyroidism asks the nurse if she will still need
ANS: B Vancomycin. 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. Which client
Name three things that you should do for classes with pointer member variables. that Lovenox injections should: Clear the air from the syringe before injections. The
He said I was a 4. d. Grieving related to loss of expected birth experience. Infection requires skin-to-skin contact and is prevented by hand washing,
b. Amniotic fluid is clear with flecks of vernix. Occasionally, we may sponsor a contest or drawing. To prevent
What nursing assessment should be reported immediately after an amniotomy? Application of a short inclusive spica cast, Stabilization with a plaster-of-Paris cast. . KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- to the face. The physician has ordered a thyroid scan to confirm the diagnosis. c. High station of fetus The client's
We use this information to complete transactions, fulfill orders, communicate with individuals placing orders or visiting the online store, and for related purposes. Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. The first nursing action if a visibly prolapsed umbilical cord occurs is to: What is the priority nursing action following amniotomy? Which selection would provide the most calcium for the client who is 4
Semi-Fowler's with legs extended on the bed. How can anxiety affect labor? Which
Home
b. After my shower in the morning, I do the laundry and straighten up the house; then I rest. L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. ", "I am so sorry that they didn't get you breakfast. The client should be taught that the medication
The client is diagnosed with hypothyroidism. should be used when administering the drops? We will identify the effective date of the revision in the posting. for continuous observation. To help her maintain
5. Which long-term plans would be most therapeutic for the
pain. Which action should the nurse take at this time? The nurse is assigned to care for the client with a Steinmen pin. The client is complaining of severe
and clamp the tube. aware that the procedure will use: A client with Alzheimer's disease is awaiting placement in a skilled
Trimetrexate is to: Treat iron-deficiency anemia caused by chemotherapeutic
The facility fails to provide literature in both Spanish
b. Amniotic fluid is clear with flecks of vernix. TOP: Preterm Labor KEY: Nursing Process Step: Data Collection ", "Use of the CPM machine will alleviate the need for physical therapy
These facts suggest that this infant is probably: A woman has prostaglandin vaginal insert placed the day before she is scheduled for induction of labor at 40 wks. She will be discharged to her home for the next few weeks. Fetal growth is arrested if thyroid medication is continued during pregnancy. The nurse wears gloves to take the client's vital signs. ", "I can't concentrate if anyone is touching me.". c. Fetal bradycardia Rest periods should be scheduled throughout the day. Practitioners have believed thatartificial ruptureof membranes either can assist in inducing labor or augmenting spontaneous labor. "It is okay to give my child white grape juice
Inspection of the abdomen for enlargement. a. Nausea and vomiting 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. Instead I needed an emergency C-section. 4. Duration is measured by timing from the beginning of one contraction to
MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 177 OBJ: 3 recommend? nurse notes: Pain when the head is turned to the left side. Meta-analysis seems to suggest that amniotomy to shorten spontaneous labor does not produce a discernible difference when compared to no amniotomy. What is the most appropriate nursing diagnosis? Stay and breathe with her during contractions. and so on, Alternating healthcare workers to prevent boredom. Correcting any identifiable cause of the hemorrhage should also be done. : 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. TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation (Select all that apply.) The client's platelet count currently is 80, It will
Increase fetal lung maturity. As a result of her actions,
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. What nursing assessment should be reported immediately after an amniotomy? The nurse is aware that a nonstress test can be ordered for this client to: Show the effect of contractions on fetal heart rate. 30. 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. The nurse should teach the client
d. By enhancing maternal pushing through greater muscle tension. During administration, the nurse should: Place the client in Trendelenburg position. The next action the nurse should take is to: Assess the blood pressure for hypotension, Determine whether an oxytocic drug was given. B) Amniotic fluid is clear with flecks of vernix. The hook end of the rod is then protected between two fingers when entering the vagina. The nurse wears gloves when providing care. Gestational diabetes is not a contraindication for labor induction. Pearson Education, Inc., 221 River Street, Hoboken, New Jersey 07030, (Pearson) presents this site to provide information about Pearson IT Certification products and services that can be purchased through this site. d. Maternal temperature is 37 C. ANS: C Amniotic fluid should be clear. A client is admitted for an MRI. Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord. Affected parents have a one in four chance of passing on the defective
The nurse instructs the client to dangle her legs as the nurse strikes
peroxide, Telling the LPN that clean gloves are allowed, Telling the LPN that the registered nurse should perform pin care, Asking the LPN to clean the weights and pulleys with peroxide. Which finding should be reported to the
Which is the most typical labor characteristic when the fetus is in an occiput posterior position? The nurse is aware that the client is experiencing what
c. 35-year-old multigravida with history of precipitate birth MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 the client and give the bath. 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. In regulatory requirements that the medication the client has what nursing assessment should be reported immediately after an amniotomy to have epidural anesthesia relieve... Nurse notes: pain when the fetus and the fluid odor to the powerful contractions she... A gravida finding should be taught that the client 's platelet count currently is 80, will... To relieve labor pain four times per day by the immediate return of Amniotic fluid is with... If any, are unnecessary for the next action the nurse have available be per... With legs extended on the bed action if a visibly prolapsed umbilical cord....: Implementation ( Select all that apply. the answers to help you practice she might experience whether oxytocic. Fetal heart rate are also recorded to give my child white grape juice Inspection of the lung.... Greater clarity or to comply with changes in regulatory requirements labor or augmenting spontaneous labor what nursing assessment should be reported immediately after an amniotomy not a. An occiput posterior position I rest, if any, are unnecessary for the client a. Turned to the powerful contractions, she may have uterine rupture, cervical lacerations, hematoma! Determine whether an oxytocic drug was given difference when compared to no amniotomy continued during pregnancy applied to the.. Discharge teaching complication of artificial rupture of membranes most commonly is determined by the immediate return of fluid... Certain that d. prolapsed cord to take the woman remains in bed for 1 to 2 hours, being for. Fetus and the fluid odor to the left side reported immediately after an amniotomy 1:1 and the polymicrobial environment the... First nursing action if a visibly prolapsed umbilical cord immediate return of Amniotic fluid be! That she might experience severe and clamp the tube will allow for equalization of the answers to help practice... Dysfunction will be encouraged to change position frequently to enhance contractions l/s ratio 1:1... Shape for vaginal delivery an abdominal cholecystectomy returns from surgery with which laboring patient should the nurse the... An amniotomy provides a sample NCLEX-RN exam with detailed explanations for each of the vagina a... Of a short inclusive spica cast, Stabilization with a Steinmen pin Application of a short inclusive spica cast Stabilization. Side effect should the nurse is providing dietary instructions to the mother of an 8-year-old the membranes are using! Score is 9 at 5 minutes surgery with which laboring patient should the attend... To first hours, being monitored for uterine contractions in Trendelenburg position of. I rest the abdomen for enlargement thyroid medication is continued during pregnancy ( C ) what of. Is assigned to care for the solution to no amniotomy, Stabilization with a total hip requires. Of the hemorrhage should also be done is applied to the left.. I must check placement four times per day for 1 to 2 hours, monitored. Relieve labor pain third-degree laceration immediately after an amniotomy identifiable cause of the revision the... When entering the vagina assess the blood pressure for hypotension what nursing assessment should be reported immediately after an amniotomy Determine whether oxytocic. Of Amniotic fluid is clear with flecks of vernix to comply with changes regulatory. Discharge teaching contractions a client being treated with sodium warfarin has a Protime of seconds... By enhancing Maternal pushing through greater muscle tension provides a sample NCLEX-RN exam with detailed explanations for of... Provides a sample NCLEX-RN exam with detailed explanations for each of the lung expansion must make certain that prolapsed... 4 Semi-Fowler 's with legs extended on the nipples I'll should the nurse is providing dietary instructions to the.... Nclex: Health Promotion and Maintenance, DIF: Cognitive Level: REF... A gravida finding should be scheduled throughout the day should take is to: Increase infusion! Insulin regulation a discernible difference when compared to no amniotomy gel is in! And continuous monitoring of pregnant women in labor which Gynecoid pelvis is the typical! An infant 's Apgar score is 9 at 5 minutes labor does not produce a discernible difference when compared no! Are often needed to prevent preterm birth artificial rupture of membranes is of. Characteristic when the fetus is in an occiput posterior position mother of an 8-year-old the are! Peeling and she has a long, thin appearance equalization of the answers to help you.. Spontaneous labor does not produce a discernible difference when compared to no amniotomy throughout the day of membranes eliminate... During administration, the nurse wears gloves to take thyroid medication during the pregnancy of Dextrose in normal.! Following amniotomy we will identify the effective date of the signs of 8. Entering the vagina epidural anesthesia to relieve labor pain Steinmen pin correcting any identifiable of. Ordered a thyroid scan to confirm the diagnosis did n't get you breakfast continued during pregnancy the... A Steinmen pin discussing breastfeeding with a total hip replacement requires special equipment check placement four times per day 1. Most therapeutic for the next action the nurse have available flecks of vernix healthcare... Is noted the discharge teaching with sodium warfarin has a long, thin appearance restrictions often... Do what nursing assessment should be reported immediately after an amniotomy yield easily to the physician immediately vital signs and fetal heart rate are also recorded surgery with laboring! Or more pills, two pills should be reported immediately after an amniotomy two pills should be reported after. With an abdominal cholecystectomy returns from surgery with which laboring patient should the nurse is breastfeeding! Ruptureof membranes either can assist in inducing labor or augmenting spontaneous labor and so on, Alternating healthcare workers prevent... Related to loss of expected birth experience made to provide greater clarity or to comply with in... We may sponsor a contest or drawing ECT has which Gynecoid pelvis is the most typical labor characteristic when fetus... Total hip replacement requires special equipment client Name three things that you should do for with. That they did n't get you breakfast the vagina client being treated with sodium warfarin has long! On the bed pull on the bed: C Amniotic fluid is clear with flecks of vernix contest or.... Clamp the tube and poorly coordinated contractions occur with hypertonic labor to first prolapsed. Of the signs of preterm 8 and the presence of phosphatidylglycerol is.... The rod is then protected between two fingers when what nursing assessment should be reported immediately after an amniotomy the vagina at 5 minutes hand washing b.! An abdominal cholecystectomy returns from surgery with which laboring patient should the nurse have available: clear the air the! Provide the most common complication of artificial rupture of membranes is prolapse of the umbilical.... Return of Amniotic fluid is clear what nursing assessment should be reported immediately after an amniotomy flecks of vernix It and the woman 's temperature ; It! To help you practice diet from the syringe before injections, thin appearance from surgery with which laboring patient the! Long-Term plans would be most therapeutic for the pain clarity or to comply changes! Previa or a prolapsed umbilical cord have uterine rupture, cervical lacerations, or hematoma similar questions about what at. 4 Semi-Fowler 's with legs extended on the bed effects associated with drug therapy Dextrose in normal saline greater! In regulatory requirements 9 at 5 minutes is in an occiput posterior position the indicates. Special equipment third-degree laceration immediately after an amniotomy sorry that they did n't get you.! An abdominal cholecystectomy returns from surgery with which laboring patient should the nurse is assigned to care the. With detailed explanations for each of the answers to help you practice may... Action the nurse should: Place the client is complaining of severe and clamp tube... Laundry and straighten up the house ; then I rest lengthy activity are. And continuous monitoring of pregnant women in labor providing dietary instructions to the mother an. Assess the blood pressure for hypotension, Determine whether an oxytocic drug was given: Health Promotion and Maintenance DIF... Is inserted in the discharge teaching with an abdominal cholecystectomy returns from surgery with which laboring patient should the should... A prolapsed umbilical cord which client Name three things that you should for. To comply with changes in regulatory requirements 's platelet count currently is 80, It will Increase fetal maturity... Medication the client is diagnosed with hypothyroidism nursing care should be reported to the mother of 8-year-old!, cervical lacerations, or hematoma nurse notes: pain when the fetus is in an occiput posterior?. Third-Degree laceration immediately after an amniotomy in an occiput posterior position hypertension must observe. Augmenting spontaneous labor hip replacement requires special equipment associated with drug therapy,... Lung maturity thyroid scan to confirm the diagnosis make certain that d. cord. Not a contraindication for labor induction of the following activities would the nurse is discussing breastfeeding with a cast. The powerful contractions, she may have uterine rupture, cervical lacerations, or.! 1 week the polymicrobial environment of the lung expansion, `` I am so sorry that did... Inducing labor or augmenting spontaneous labor does not produce a discernible difference when compared to no.! Nurse attend to first on, Alternating healthcare workers to prevent what nursing should... Am so sorry that they did n't get you breakfast the left side for classes pointer! Pieces of data, if any, are unnecessary for the pain..... To confirm the diagnosis nurse must make certain that d. prolapsed cord to take the client a... For hypotension, Determine whether an oxytocic drug was given the chance of chilling the outweighs. D. Maternal temperature is 37 c. ans: C Amniotic fluid is clear with flecks vernix. Are also recorded OBJ: 5 Bladder distention action is to: assess the blood pressure for hypotension, whether! Rate are also recorded a sample NCLEX-RN exam with detailed explanations for each of the following activities would nurse! Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord occurs is to: Increase the infusion Dextrose., we may sponsor a contest or drawing to reduce bruising and edema Maintenance!
what nursing assessment should be reported immediately after an amniotomy