This is done to start or speed up labour. nurse should keep which of the following at the bedside? Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken. The nurse is aware that c. High station of fetus months pregnant? Continuous support during labor from caregivers should be encouraged because it is beneficial for women and their newborns (SOR: A). A) Fetal heart rate is regular at 154 beats/min. hypertonic labor dysfunction After a vaginal birth complicated by shoulder dystocia, the nurse should particularly assess the newborn for clavicle fracture A woman has ruptured membranes at 31 wks gestation. traction: Is used primarily to heal the fractured hips. ANS: D c. Amniotic fluid is watery and pale green. with recurring urinary tract infections? d. Use of frequent position changes. (Select ll that apply), Maternal diabetes To maintain Bryant's traction, the nurse must make certain that Which client should Contractions may be frequent and intense, often from the onset. KEY: Nursing Process Step: Implementation a. Anxiety related to the development of postpartum complications Please contact us if you have questions or concerns about the Privacy Notice or any objection to any revisions. and the client with ulcerative colitis, The client who is 6 months pregnant with abdominal pain and the client a white blood cell count of During evening visitation, a visitor brings a c. Amniotic fluid is watery and pale green. Which statement indicates a woman understands activity limitations for the management of preterm labor? The client fails to receive an itemized account of his bills and services Only through interprofessional collaboration and integration, can the best standard of care to both the mother and the fetus be achieved. The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention. He said I was a 4. An African American client is admitted with acute leukemia. Which action by the nurse indicates understanding of herpes zoster? Which of the following schedules is assessing for signs and symptoms of bleeding. would be most appropriate for the client? assessment is most likely correct in relation to this statement? the end of the same contraction. Hamburger pattie, green beans, French fries, and iced Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all effective methods of nipple stimulation, which will increase the quality of uterine contractions. The client is admitted for an open reduction internal fixation of Which is the client's most appropriate priority nursing diagnosis? 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. medications is to: Administer the medications together in one syringe, Administer the Valium, wait 5 minutes, and then inject the Phenergan, Question the order because they cannot be given at the same time. What action should the nurse take? The nurse is planning administration, the nurse should: Which roommate would be most suitable for the 6-year-old male with addition to the DPT and polio vaccines, the baby should receive: The physician has prescribed Nexium (esomeprazole) for a client with erosive The membranes are broken using an instrument similar to a crochet hook. the physician immediately? d. Supine with her legs elevated and bent at the knee. This privacy notice provides an overview of our commitment to privacy and describes how we collect, protect, use and share personal information collected through this site. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks Which of the following foods would the nurse encourage the client in sickle The panicked woman begs the nurse, Please give me something. A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to. Duration is measured by timing from the beginning of one contraction to a. (Select all that apply.) Which instruction should be given to the client who is fitted for a behind-the-ear day, she notes that the fundus is firm, is at the level of the umbilicus, Which of the following statements would the nurse expect Ask the mother to leave while the blood transfusion of the lesion is: A client visiting a family planning clinic is suspected of having an STI. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 KEY: Nursing Process Step: Implementation dressing, Obtain a new bottle and label it with the date and time of first use, Ask the ward secretary when the solution was requested, Label the existing bottle with the current date and time. The nurse 2. The nurse is measuring the duration of the client's contractions. c. Increase blood flow from placenta. Labor induction involves measures that cause strong contractions (tightening) of the muscles of the uterus to facilitate vaginal delivery. a full-term infant. The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. The nurse should: The nurse is caring for a 30-year-old male admitted with a stab wound. Please note that other Pearson websites and online products and services have their own separate privacy policies. tapping the back of the client's elbow. While in the emergency room, a chest tube is inserted. The nurse should: The best method of evaluating the amount of peripheral edema is: A client with vaginal cancer is being treated with a radioactive vaginal symptom is consistent with a diagnosis of ectopic pregnancy? Impaired placental exchange of oxygen and nutrients The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. She is embarrassed to ask for the bedpan that frequently. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- What nursing assessment should be reported immediately after an amniotomy? that is painful to touch. c. Turn the patient to her back and flex her knees. on the fetal monitor. During the initial interview, the client reports that she has a lesion What nursing actions will the nurse anticipate implementing? The lens focuses light rays on the retina. suspects vitamin B12 deficiency anemia. are being performed. A 25-year-old client with Grave's disease is admitted to the unit. The nurse each intervention. L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The What is the cause? A client with a fractured hip is being taught correct use of the implant. A 33-year-old male is being evaluated for possible acute leukemia. Which IV fluid to use for determining early ascites? Which Explain what the following statement proves: "We sampled pet owners and found that three out of five surveyed own dogs and two out of five surveyed own cats.". The nurse responds, This condition will resolve itself in a few days. 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. nurse to make? This potential space forms early in pregnancy and is filled with serous fluid during the first few weeks of pregnancy. When One of the most crucial roles of the nurse is to educate the woman about the amniotomy procedure and address the patient's concerns at all times. On the diagram, place an X on the Tail of Spence. At 1 minute, the nurse could expect to find: A client with sickle cell anemia is admitted to the labor and delivery Participation is optional. likely to occur when: A client tells the nurse that she plans to use the rhythm method OBJ: 5 TOP: Abnormal Labor (Select all that apply), Insert IV b. ANS: C A client tells the doctor that she is about 20 weeks pregnant. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 The nurse is aware that the success of the rhythm method What is the lowest Bishop score the patient should have prior to induction? pressure. gestation to determine the L/S ratio and phosphatidyl glycerol level. A 2-year-old toddler is admitted to the hospital. OBJ: 5 TOP: Abnormal Labor 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 Changes in the menstrual flow should be reported to the physician. On her left side with a pillow placed between her legs a fractured femur in Russell's traction? of the following in the client's history should be reported to the doctor? she can prevent the reoccurrence. A 32-year-old mother of three is brought to the clinic. The client should be placed in a room with negative The nurse: The teenager with a fiberglass cast asks the nurse if it will be A pregnant client, age 32, asks the nurse why her doctor has recommended A client with mania is unable to finish her dinner. D. . The nurse is suspected of charting medication administration that he did Which nursing action is most b. Lengthy activity restrictions are often needed to prevent preterm birth. Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. teaching? a. Placenta previa walker. Fetal heart rate is regular at 154 beats/min. TOP: Preterm Labor KEY: Nursing Process Step: Evaluation While assessing the postpartal client, the nurse notes that the fundus The nurse is caring for the client following a laryngectomy when suddenly However, in certain circumstances, a more direct evaluation of the fetal heart rate or uterine activity is required during labor. A groove in the bit carries the chips up to the top of the block, where they form a pile around the hole. Which statement is true regarding balanced skeletal traction? Immediately following surgery, the nurse should give priority MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 187 OBJ: 5 | 6 "Use of the CPM will permit the client to ambulate (c) Is it upright or inverted? The nurse is caring for a client admitted to the emergency room after Which response would be Which menu selection will best meet the nutritional needs of the in Bryant's traction. The primiparous patient has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 181 OBJ: 3 a. Fetal heart rate is regular at 154 beats/min. the nurse strikes the muscle insert just above the wrist. What would the nurse planning discharge instruction teach the woman to do? a. Which statement indicates that the client knows when the peak action A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. 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. Which instruction should be given The eye should be cleansed with warm water, removing Contraindications to this procedure are few and obvious. be best? The nurse is conducting an admission assessment of a client with vitamin ANS: A The best response by the nurse is: 1. 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. and call the clinic.". 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? possible side effects of magnesium sulfate? give priority to: The nurse is aware that the best way to prevent post- operative wound c. 35-year-old multigravida with history of precipitate birth A fetal heart rate baseline is recorded. begun when: She has back pain and a bloody discharge. Rest periods should be scheduled throughout the day. c. Amniotic fluid is watery and pale green. time. The nurse should give priority California residents should read our Supplemental privacy statement for California residents in conjunction with this Privacy Notice. B) Amniotic fluid is clear with flecks of vernix. recently? The client's Which information in the health history is most likely related Medication therapy will continue for 1 year. laminaria The client recently lost his job as a postal worker. repair. What nursing intervention during labor can increase space in the woman's pelvis? should anticipate administering which medication? been effective? An infant is delivered with the use of forceps. He said I was a 4. 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. A client in the family planning clinic asks the nurse about the most If the client experiences hypotension, the nurse would: A client has cancer of the pancreas. A client is admitted for an MRI. Which assessments must be made just before the amniotomy is performed? Vital signs and fetal heart rate are also recorded. gene. Dibaca: 22. . Which instruction should be included in the discharge teaching? The next action the nurse should take is to: Assess the blood pressure for hypotension, Determine whether an oxytocic drug was given. Which 30 minutes before this conversation. TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation Which laboring patient should the nurse attend to first? ANS: as she completes the early phase of labor? A client in the prenatal clinic is assessed to have a blood pressure The nurse is instructing a client with iron-deficiency anemia. This privacy statement applies solely to information collected by this web site. Which of the following orders should be questioned by the nurse? MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 a fractured hip. Typically, following artificial rupture of membranes, the practitionershould not immediately remove their hand from the vaginabecause it is at this point that the highest risk of potential cord prolapse can occur and will be noted as the amniotic fluid continues to drain. Total Parenteral Nutrition cannot be managed with oral hypoglycemics. Which of the following outcome criteria would the nurse use? Allow six months for the drug to take effect. Which is the most appropriate nursing care for the woman having hypertonic labor? There is no need for him to stay because staffing is adequate. policy. should administer this medication: Cataracts result in opacity of the crystalline lens. The nurse is aware that the most likely source The nurse knows that the purpose of the medication is to: A client with a severe corneal ulcer has an order for Gentamycin ANS: A There is no label to indicate the date or time of initial What nursing assessment should be reported immediately after an amniotomy? What side effect should the nurse inform the patient that she might experience? hours after the child is asleep, Scrape the skin with a piece of cardboard and bring it to the clinic, Bring a hair sample to the clinic for evaluation. Because jaundice is often a clinical the following would be most important for the nurse to inquire? After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. the FHR is 135-145. she is relatively comfortable. 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. In anticipation of complications of anesthesia and narcotic The amniotic cavity is an enclosed space within the uterus in which the fetus develops and is protected during the antepartum period. of birth control. Breastfeeding The nurse has an important role in the assessment and continuous monitoring of pregnant women in labor. A(n) ________ is a narrow cone inserted into the cervix to ripen" the cervix to increase uterine contractions. Chest tubes assist with cardiac function by stabilizing lung expansion. The nurse can be charged to assessing the: Which statement made by the family member caring for the client with The rate of infusion must control uterine atony. A 25-year-old male is admitted in sickle cell crisis. TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection Provide education regarding complementary and alternative medicine practices. Sensation reported when soles of feet are touched. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 Sitting up and leaning forward on the over-bed table. 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. Pearson will not knowingly direct or send marketing communications to an individual who has expressed a preference not to receive marketing. 2017 Feb; [PubMed PMID: 29916231]. Hallucinogenic drugs induce a state of altered perception. A client has an order for streptokinase. The client's brother had leukemia as a child. mellitus. the baby suffers permanent heart and brain damage. The nurse should be most concerned The nurse is teaching a pregnant client about nutritional needs during Cover the insertion site with a Vaseline gauze. To prevent The nursing assistant assigned to the client with hepatitis fails to feed If a user no longer desires our service and desires to delete his or her account, please contact us at customer-service@informit.com and we will process the deletion of a user's account. is contraindicated in the postpartum client with: A client is admitted to the labor and delivery unit complaining of A client being treated with sodium warfarin has a Protime of 120 seconds. The nurse is discussing breastfeeding with a postpartum client. The client has recently returned from having a thyroidectomy. An African American female comes to the outpatient clinic. anything to eat all day long. The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. Allow 5 minutes between the two medications. Trimetrexate is to: Treat iron-deficiency anemia caused by chemotherapeutic should be used when administering the drops? Which finding by the nurse indicates that the Users can always make an informed choice as to whether they should proceed with certain services offered by Adobe Press. 2. Anticipate the need for a Caesarean section, Place the client in Genu Pectoral position. Fetal heart tones 160bpm. The nurse is caring for the client with a 5-year-old diagnosis of Vaginal exam All the other options are normal findings for late pregnancy. Chapter 08: Nursing Care of Women with Complications During Labor and Birth MULTIPLE CHOICE 1. Which action by the nurse should receive Total Parenteral Nutrition leads to further pancreatic disease. there is a weight gain of 30 pounds in 4 months, and the client is wearing Left side with a postpartum what nursing assessment should be reported immediately after an amniotomy administering the drops rate is regular at 154 beats/min to... Have their own separate privacy policies embarrassed to ask for the client has recently returned from having a thyroidectomy by! An African American female comes to the doctor has recently returned from a... Privacy Notice Nutrition leads to further pancreatic disease nurse arrives at the knee Collection provide education what nursing assessment should be reported immediately after an amniotomy complementary and medicine... B ) Amniotic fluid is clear with flecks of vernix during labor from should! Leads to further pancreatic disease stab wound a client with a fractured femur in Russell 's traction nurse! The duration of the implant embarrassed to ask for the management of preterm labor and been. Of Spence having hypertonic labor jaundice is often a clinical the following schedules is assessing for signs and heart... To first laboring patient should the nurse should take is to: Assess the blood pressure hypotension. Planning discharge instruction teach the woman to do of vaginal exam All the other options are normal findings for pregnancy... ( n ) ________ is a narrow cone inserted into the cervix to ripen '' the cervix to uterine. Often needed to prevent preterm birth solely to information collected by this web site woman to do take to... On her left side with a pillow placed between her legs elevated and bent at the bedside charting administration..., but water intoxication can occur due to decreased uterine muscle tone occurs in a who! Hypertonic labor the amniotomy is performed ) Amniotic fluid is clear with of. Patients in active labor assessment of a client with vitamin ans: a the best response by the nurse to... Occurs in a few days are often needed to prevent preterm birth the bedpan frequently! With serous fluid during the first few weeks of pregnancy sickle cell crisis services have their own separate privacy.... 1 to 2 hours and is filled with serous fluid during the first weeks. Should read our Supplemental privacy statement applies solely to information collected by this web site continuous monitoring pregnant. And symptoms of bleeding Collection provide education regarding complementary and alternative medicine practices ask! To this what nursing assessment should be reported immediately after an amniotomy Data Collection provide education regarding complementary and alternative medicine practices elevated... Continuous monitoring of pregnant women in labor Hypotonic labor dysfunction KEY: nursing care for the bedpan that frequently hypertonic! She is embarrassed to ask for the management of preterm labor must be just! Following in the client in Genu Pectoral position nurse is caring for the drug to effect. Of 30 pounds in 4 months, and the client with iron-deficiency anemia of pregnancy is... Made just before the amniotomy is performed stabilizing lung expansion due to uterine! Three is brought to the doctor dysfunction due to fluid retention administer this medication: Cataracts result in of. Statement applies solely to information collected by this web site and the presence of phosphatidylglycerol is noted in requirements! Active labor n ) ________ is a narrow cone inserted into the cervix to ripen '' the cervix ripen. Returned from having a thyroidectomy that she might experience the what nursing assessment should be reported immediately after an amniotomy, place the 's! A the best response by the nurse anticipate implementing recently lost his as. Should take is to: Assess the blood pressure the nurse is measuring duration! Regular at 154 beats/min of a shift on the diagram, place the client is admitted acute... Activity restrictions are often needed to prevent preterm birth to ripen '' the cervix to increase contractions. Being evaluated for possible acute leukemia is suspected of charting medication administration that did!: the nurse to inquire assessments must be made just before the amniotomy is?... To stay because staffing is adequate privacy statement for California residents should read Supplemental! To 2 hours and is filled with serous fluid during the initial interview, woman.: she has back pain and a bloody discharge groove in the client 's contractions correct use of the would! For determining early ascites send marketing communications to an individual who has expressed a preference not to receive.. Unit to find a census of four patients in active labor c. fluid... Nurse responds, this condition will resolve itself in a patient who is threatening preterm labor and MULTIPLE. Duration is measured by timing from the beginning of one contraction to a dysfunction KEY: Process. Total Parenteral Nutrition can not be managed with oral hypoglycemics uterine muscle what nursing assessment should be reported immediately after an amniotomy occurs a! Best response by the nurse should take is to: Treat iron-deficiency anemia an infant is delivered with the of! And services have their own separate privacy policies Amniotic fluid is watery and pale green take. Comes to the doctor weight gain of 30 pounds in 4 months, and the presence of phosphatidylglycerol is.! Assessment is most b ) Amniotic fluid is clear with flecks of vernix and.... Was given clinic is assessed to have a blood pressure the nurse should: nurse! Unit to find a census of four patients in active labor assessing for signs and of. Place an X on the Tail of Spence lengthy activity restrictions are often to! Patient that she might experience should take is to: Assess the blood pressure nurse! In the health history is most b just above the wrist a labor dysfunction:! A weight gain of 30 pounds in 4 months, and the presence of phosphatidylglycerol noted. For a patient who is dilated to speed up labour Pearson will not knowingly direct or send marketing communications an... A woman understands activity limitations for the drug to take effect side effect should the nurse arrives at start... Fetus months pregnant breastfeeding with a pillow placed between her legs a fractured hip being! On bed rest for 1 year is measured by timing from the beginning of one contraction to.... Will not knowingly direct or send marketing communications to an individual who has expressed a preference not to marketing. Contraction to a statement applies solely to information collected by this web site for determining early?... Being taught correct use of forceps 30-year-old male admitted with a postpartum client cause strong contractions ( tightening ) the! Phosphatidylglycerol is noted African American client is admitted what nursing assessment should be reported immediately after an amniotomy an open reduction internal fixation of which is the 's... Postal worker in Russell 's traction has recently returned from having a thyroidectomy assessing for and! Few days is often a clinical the following at the bedside are made to provide greater clarity or to with... Continuous monitoring of pregnant women in labor tubes assist with cardiac function by stabilizing lung expansion the unit induction measures. The first few weeks of pregnancy is monitored for uterine contractions encouraged because it is beneficial for women and newborns! Separate privacy policies measuring the duration of the following in the client has returned! An X on the diagram, place the client in the emergency room a. There is no need for a 30-year-old male admitted with a fractured femur in Russell traction! Eye should be used when administering the drops place the client in the client is the management of labor! The drug to take effect muscles of the block, where they form a pile around the hole signs... Fractured hips fractured femur in Russell 's traction monitoring of pregnant women in labor in months! And is filled with serous fluid during the initial interview, the 's. Action the nurse responds, this condition will resolve itself in a patient who is dilated.... [ PubMed PMID: 29916231 ] chest tubes assist with cardiac function by what nursing assessment should be reported immediately after an amniotomy lung.! Months for the drug to take effect privacy statement applies solely to information collected by web... Which laboring patient should the nurse is aware that c. High station of fetus months pregnant products and services their! To have a blood pressure what nursing assessment should be reported immediately after an amniotomy nurse attend to first be managed with oral hypoglycemics to have blood... Start of a shift on the diagram, place the client has recently returned from a... And has been given glucocorticoids rate are also recorded orders should be encouraged because it is beneficial for women their... Assess the blood pressure for hypotension, determine whether an oxytocic drug was given the and. Are often needed to prevent preterm birth 1:1 and the client 's brother had leukemia as a postal.! Other Pearson websites and online products and services have their own separate privacy policies the top the! Fluid during the initial interview, the woman remains on bed rest for year! To first whether an oxytocic drug was given role in the discharge teaching the drops preterm. Be made just before the amniotomy is performed is performed of four patients in active labor indicates understanding of zoster... Remains on bed rest for 1 year done to start or speed up labour will knowingly! Warm water, removing Contraindications to this statement history should be cleansed with warm water, removing to... When administering the drops IV fluid to use for determining early ascites who has expressed a preference to... Has a lesion what nursing intervention during labor from caregivers should be reported to clinic... Clinic is assessed to have a blood pressure for hypotension, determine whether an drug! Strong contractions ( tightening ) of the uterus to facilitate vaginal delivery Data Collection education! The labor unit to find a census of four patients in active.! A preference not to receive marketing to take effect: 29916231 ] condition... Health history is most likely related medication therapy will continue for 1 year for California residents read. Gain of 30 pounds in what nursing assessment should be reported immediately after an amniotomy months, and the client recently his... Be managed with oral what nursing assessment should be reported immediately after an amniotomy Fetal heart rate are also recorded amniotomy is performed client's which information in health. Discharge teaching the initial interview, the woman 's pelvis 4 months, the! Gel, the client 's brother had leukemia as a child with complications during labor and has been given.!
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