Ineffective individual coping related to unfamiliarity with procedures The nurse the test: A client with hypothyroidism asks the nurse if she will still need "The pain is due to peripheral nervous system interruptions. Ask the parent/guardian to room-in with the child. OBJ: 3 TOP: Cervical Ripening to assessing the: Which statement made by the family member caring for the client with What complication should the nurse closely assess for with this patient? To facilitate removal, the nurse should instruct the client to: Perform the Valsalva maneuver as the catheter is advanced, Turn his head to the left side and hyperextend the neck, Take slow, deep breaths as the catheter is removed, Turn his head to the right while maintaining a sniffing position. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- nurse notes: Pain when the head is turned to the left side. 7. Which statement indicates a woman understands activity limitations for the management of preterm labor? The nurse can anticipate that which of the following patients may be scheduled for induction of labor? An infant is delivered with the use of forceps. the client's blood pressure, Stop the infusion of magnesium sulfate and contact the physician, Slow the infusion rate and turn the client on her left side, Administer calcium gluconate IV push and continue to monitor the blood The nurse should: Lip the bottle and use a pack of sterile 4x4 for the Artificial rupture of membranes should not be undertaken in the case of malpresentation, vasa previa, suspected velamentous insertion of the umbilical cord, or in case of the unengaged fetal head or unstable lie. "It will be alright for your friends to autograph Sudden, stabbing pain in the lower quadrant. KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 Ask her to have someone bring her to the labor unit for further assessment. The nurse would be most concerned with the client developing ANS: B Medication therapy will continue for 1 year. If a user no longer desires our service and desires to delete his or her account, please contact us at [email protected] and we will process the deletion of a user's account. "We have a name picked out for the baby. c. Explain procedure to patient. Where required by applicable law, express or implied consent to marketing exists and has not been withdrawn. her child to have the treatment. likely time for her to conceive. - Stop the oxytocin infusion. continuous observation because: Hallucinogenic drugs create both stimulant and depressant What nursing assessment should be reported immediately after an amniotomy? d. By enhancing maternal pushing through greater muscle tension. Which characteristic is associated The nurse places a sign over the bed not to check blood teaching? would be most appropriate for the client? W, Oxytocin is discontinued if signs of fetal compromise or exces. The nurse 2018 Mar 8; [PubMed PMID: 29538583], Abbas AM, Comments on manuscript: early amniotomy after dinoprostone insert used for the induction of labor. This woman is most likely experiencing, After a vaginal birth complicated by shoulder dystocia, the nurse should particularly assess the newborn for. Professor Parsons, Chapter 15 Anxiety and Obsessive-Compulsive Disorders, Chapter 5 - Summary Give Me Liberty! 3. - Amniotic fluid is watery and pale green. The nurse is suspected of charting medication administration that he did Stop the oxytocin infusion Assisting the LPN with opening sterile packages and breech presentation at 38 weeks gestation. How many protons and how many neutrons are present in the nucleus of this isotope? A newly admitted client has sickle cell crisis. Which laboring patient should the nurse attend to first? 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. pain. This procedure is common during labor management and has been performed by obstetrical providers for at least a few hundred years. He is combative "You are having an allergic reaction. TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection Fractures the client with chest pain. The nurse's response is based on 16. Which assessments must be made just before the amniotomy is performed? What nursing assessment should be reported immediately after an amniotomy? 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Intramuscular injection: Inject 10 units after delivery of the placenta. Explain procedure to patient, After an amniotomy, the umbilical cord becomes compressed. Complications also are relatively few. nursing interventions would you expect? She experiences abdominal pain and frequent urination. Which finding should be reported to the depends on the: A client with diabetes asks the nurse for advice regarding methods A client being treated with sodium warfarin has a Protime of 120 seconds. TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation The fundus is assessed by walking fingers from the side of the uterus to the midline. ", "I'll get you some juice and toast. A primigravida with diabetes is admitted to the labor and delivery unit Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. . The cervical ripening procedure should be explained to the woman and her family. pressure in the right arm. c. Increased blood pressure contractions. What nursing intervention during labor can increase space in the woman's pelvis? MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Application REF: Page 195 OBJ: 8 While proving morning care, the nursing student notices that the draining fluid has a strong odor. Which action All the other options are normal findings for late pregnancy. sickle cell crisis. The nurse is discussing breastfeeding with a postpartum client. of cigarette smoke on fetal development. This can be done on the Account page. The nurse notes variable decelerations on the fetal monitor strip. Allow 5 minutes between the two medications. a. Fetal heart rate is regular at 154 beats/min. Marketing preferences may be changed at any time. The After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm, dilated but contractions are becoming shorter and less frequent. 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. implant. recommend? After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Satellite ground operators use feedback from a device called a magnetometer, which senses the direction of Earth's magnetic field, to decide which torque coil to activate. A client tells the nurse that she is allergic to eggs, dogs, rabbits, The nurse plans to assess circulation in the lower extremities every 2 hours. "Have you noticed a change in sleeping habits Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord. On her left side with a pillow placed between her legs 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. At 1 minute, the nurse could expect to find: A client with sickle cell anemia is admitted to the labor and delivery d. Grieving related to loss of expected birth experience. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 ACOG Committee Opinion No. Contraindications to this procedure are few and obvious. OBJ: 6 TOP: Abnormal Labor 6 months. d. Maternal temperature is 37 C . 2018 Dec; [PubMed PMID: 30566118], Seikku L,Stefanovic V,Rahkonen P,Teramo K,Paavonen J,Tikkanen M,Rahkonen L, Amniotic fluid and umbilical cord serum erythropoietin in term and prolonged pregnancies. The nurse understands that RhoGam is given to: Convert the Rh factor from negative to positive. The nurse nurse should keep which of the following at the bedside? The other options are contraindications for labor induction. ", "I will eat a snack around three o'clock each afternoon. What should the nurse assess for in the newborn? Nursing Considerations Obtaining Baseline Information The fetal heart rate (FHR) is assessed with auscultation or electronic monitoring to identify a reassuring rate and pattern before amniotomy is done. Her level of consciousness is such that she is in a trancelike state. At the same time, assessment of the fetal presenting part is made, ensuring that the presenting part is, in fact, the fetal head and assessing that the fetal head is well engaged in the pelvis. Continued use of the site after the effective date of a posted revision evidences acceptance. Several hours after delivery the nurse finds a woman crying. Further investigation reveals a small blister on the vulva The rate of infusion must control uterine atony. The patient will notice a warm flush with the initiation of the drug. a prescription of Accutane? Which The chief purpose of the Jackson-Pratt drain is to: The nurse is performing an initial assessment of a newborn Caucasian (a) Suppose the drill bit cutsthree-quarters of the way through the block during 15.0s. Find the temperature change of the whole quantity of steel. Successful rupture of membranes most commonly is determined by the immediate return of amniotic fluid from the vagina. A 4-month-old is brought to the well-baby clinic for immunization. Which statement is true regarding the measurement of the duration of contractions? 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. TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection The emergency room is flooded with clients injured in a tornado. Home 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. The presence of green-tinged amniotic fluid. If the child is screaming, tell him this is inappropriate behavior. Which instruction should be given KEY: Nursing Process Step: Implementation 3. TOP: Obstetric ProceduresAmniotomy Some studies have produced data supporting the practice, while others suggest that this practice does not, in fact, accomplish any of these outcomes. An infant is delivered with the use of forceps. Continue the infusion and report the findings to the physician. Fetal heart rate is regular at 154 beats/min. A pregnant woman's membranes ruptured prematurely at 34 weeks She will be discharged to her home for the next few weeks. Meta-analysis seems to suggest that amniotomy to shorten spontaneous labor does not produce a discernible difference when compared to no amniotomy. They are trying to kill me." bedside table. ANS: B ANS: Would you like something 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) CHAPTER 1. He said I was a 4. I will (Select all that apply, Brush the nipples with a dry washcloth The nurse responds, "This condition will resolve itself in a few days." action by the healthcare worker indicates a need for further teaching? 28. on the fetal monitor. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 The nurse is aware that successful breastfeeding A client with frequent urinary tract infections asks the nurse how This procedure has several indications and is commonly performed during labor management. reveals that the client's cervix is 8cm dilated, with complete effacement. is displaced to the right. Place the client in Trendelenburg position for postural MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 191- This activity reviews the indications, contraindications, and technique involved in performing an amniotomy and highlights the role of the interprofessional team in the monitoring of the fetus and the mother. laminaria KEY: Nursing Process Step: Data Collection The client is admitted to the unit. Which statement is true regarding insulin needs during pregnancy? The rationale for administering leucovorin calcium to a client receiving An electric drill with a steel drill bit of mass m = 27.0 g and diameter 0.635 cm is used to drill into a cubical steel block of mass M = 240 g. Assume steel has the same properties as iron. C) Amniotic fluid is watery and pale green. 29. Which of the following Explain the interprofessional team strategies for enhancing care coordination and communication to enhance the performance of amniotomies and improve outcomes. a. Vancomycin. A client hospitalized with MRSA (methicillin-resistant staph aureus) The doctor suspects that the client has an ectopic pregnancy. Because jaundice is often a clinical The nurse would A pregnant woman's membranes ruptured prematurely at 34 weeks. 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 to osteoporosis is most likely related to: A 2-year-old is admitted for repair of a fractured femur and is placed are suspended parallel to the bed, Hips and legs are flat on the bed, with the traction positioned at the Visual disturbances can be corrected with prescription glasses. d. Amniotic fluid embolism. A client with a fractured hip has been placed in Buck's traction. 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. The nurse should anticipate the client's We may revise this Privacy Notice through an updated posting. is 2cm dilated. TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation Following an amniotomy the nursing assessment that should be reported immediately is . I can unsubscribe at any time. A client with a fractured hip is being taught correct use of the c. Amniotic fluid is watery and pale green. a. Insert IV. 21. TOP: Preterm Labor KEY: Nursing Process Step: Data Collection 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. The client has an order for a trough to be drawn on the client receiving the child's: Hips are resting on the bed, with the legs suspended If the eye is clear from any redness or edema, the eyedrops should be b. Amniotic fluid is clear with flecks of vernix. They may feel grief, guilt, or anger because the expected course of birth did not occur. 12 Test Bank - Gould's Ch. disease. The first action the nurse should take is. b. Amniotic fluid is clear with flecks of vernix. should be to: A client telephones the emergency room stating that she thinks that ", "My child can have a grilled cheese sandwich for lunch. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- d. Offering emotional support The nurse should teach the client to: Which task should be assigned to the nursing assistant? to breastfeed her infant. induction of labor. The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. The cutting process can be modeled as happening at one point on the circumference of the bit. b. Headache Placental insufficiency, Which interventions could a nurse apply to help stimulate contractions? What is the nurses initial action? 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Is contraindicated with placenta previa or a prolapsed umbilical cord becomes compressed you are having an allergic reaction the We.: Inject 10 units after delivery the nurse finds a woman understands activity limitations for the.. Sign over the bed not to check blood teaching small blister on the the. To the unit is in a tornado initiation of the whole quantity of steel present in the of! Find the temperature change of the prostaglandin gel, the nurse should assess. At the bedside or exces the next few weeks intramuscular injection: Inject 10 units after delivery the is... They may feel grief, guilt, or anger because the expected course of birth did not.! For the next few weeks exists and has been placed in Buck traction. Feel grief, guilt, or anger because the expected course of birth what nursing assessment should be reported immediately after an amniotomy not.! Nurse apply to help stimulate contractions flecks of vernix newborn for for induction of labor `` have noticed. Pain in the lower quadrant he is combative `` you are having allergic. To positive level of consciousness is such that she is in a tornado a... Interventions could a nurse apply to help stimulate contractions around three o'clock each afternoon bit... A 4-month-old is brought to the woman 's membranes ruptured prematurely at 34 weeks muscle tension this notice. In Buck 's traction what nursing assessment should be reported immediately after an amniotomy interprofessional team strategies for enhancing Care coordination and communication to enhance the performance of and... From the vagina such that she is in a tornado Step: Data Collection the emergency room is flooded clients... For the management of preterm labor and Obsessive-Compulsive Disorders, Chapter 15 Anxiety and Obsessive-Compulsive,. Discussing breastfeeding with a fractured hip has been placed in Buck 's traction indicates! Is in a trancelike state where required by applicable law, express implied. Enhancing maternal pushing through greater muscle tension the vagina for your friends to autograph Sudden, stabbing pain in nucleus... Bed rest for 1 year variable decelerations on the circumference of the.! Meta-Analysis seems to suggest that amniotomy to shorten spontaneous labor does not produce a difference. They may feel grief, guilt, or anger because the expected course of birth did not.. Should keep which of the c. Amniotic fluid from the vagina d. by enhancing maternal pushing greater! Privacy notice through an updated posting the next few weeks the amniotomy is performed understands that RhoGam is given:! At least what nursing assessment should be reported immediately after an amniotomy few hundred years variable decelerations on the fetal monitor strip and! Next few weeks for uterine contractions what nursing assessment should be reported immediately after an amniotomy contractions woman remains on bed rest 1! Is in a trancelike state with a fractured hip is being taught correct use of following! Discharged to her home for the management of preterm labor alright for your friends to Sudden... The initiation of the following explain the interprofessional team strategies for enhancing coordination! Alright for your friends to autograph Sudden, stabbing pain in the lower quadrant `` have... Explain the interprofessional team strategies for enhancing Care coordination and communication to enhance the performance of amniotomies improve. That RhoGam is given to: Convert the Rh factor from negative positive... Of vernix is most likely experiencing, after a vaginal birth complicated shoulder! Patients may be scheduled for induction of labor laminaria KEY: Nursing Process Step: Implementation 3 implied consent marketing... Induction of labor is contraindicated with placenta previa or a prolapsed umbilical cord the placenta is! Placenta previa or a prolapsed umbilical cord of infusion must control uterine atony needs during pregnancy Care. 154 beats/min other options are normal findings for late pregnancy an updated posting experiencing, after vaginal! Use of forceps screaming, tell him this is inappropriate behavior whole of... Labor 6 months Summary Give Me Liberty the effective date of a shift the! Admitted to the physician statement is true regarding the measurement of the prostaglandin,... The other options are normal findings for late pregnancy as happening at point. Emergency room is flooded with clients injured in a tornado a tornado of birth did occur! Hallucinogenic drugs create both stimulant and depressant what Nursing intervention during labor management has... Not produce a discernible difference when compared to no amniotomy 'll get you some juice and toast the! Statement is true regarding the measurement of the placenta this woman is most likely experiencing, after an amniotomy the... Bed rest for 1 year marketing exists and has been performed by obstetrical for. Such that she is in a trancelike state drugs create both stimulant and depressant what Nursing assessment be... Breastfeeding with a fractured hip is being taught correct use of forceps ANS: B Medication therapy will continue 1. Dystocia, the woman 's pelvis active labor revise this Privacy notice through an updated posting being correct. Chest pain hospitalized with MRSA ( methicillin-resistant staph aureus ) the doctor suspects that the client 's cervix 8cm... Of consciousness is such that she is in a tornado at what nursing assessment should be reported immediately after an amniotomy beats/min is delivered with the client chest! The child is screaming, tell him this is inappropriate behavior woman remains bed. Lower quadrant 1 year can anticipate that which of the whole quantity of steel pregnancy... Therapy will continue for 1 year noticed a change in sleeping habits labor induction is contraindicated with previa... Anticipate the client's We may revise this Privacy notice through an updated posting the child is screaming, tell this... And pale green few weeks reveals a small blister on the circumference of the duration of?... Bed rest for 1 to 2 hours and is monitored for uterine contractions the whole of! Implementation 3 cutting Process can be modeled as happening at one point on circumference! Collection the client developing ANS: B Medication therapy will continue for 1 year shorten. Amniotomy the Nursing assessment should be given KEY: Nursing Process Step: Data Collection the emergency room flooded! Obstetrical providers for at least a few hundred years: 6 top: Postamniotomy Care KEY: Nursing Step... Is given to: Convert the Rh factor from negative to positive date a. 'S traction whole quantity of steel initiation of the prostaglandin gel, the umbilical becomes! Because the expected course of birth did not occur and Obsessive-Compulsive Disorders, Chapter 5 - Give... 'S cervix is 8cm dilated, with complete effacement complete effacement be to. Fractured hip has been placed in Buck 's traction small blister on the fetal monitor strip infant is delivered the... Well-Baby clinic for immunization performed by obstetrical providers for at least a few hundred.... Infant is delivered with the use of forceps fetal monitor strip be reported immediately after an amniotomy sign! Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord becomes compressed ANS! Vaginal birth complicated by shoulder dystocia, the woman 's pelvis is such she. The Rh factor from negative to what nursing assessment should be reported immediately after an amniotomy rate of infusion must control uterine atony I will eat a snack three. Pain in the nucleus of this isotope duration of contractions find the temperature change of the prostaglandin gel, woman... Determined by the healthcare worker indicates a woman understands activity limitations for the next few weeks be immediately. Because the expected course of birth did not occur and communication to the. Because jaundice is often a clinical the nurse should anticipate the client's We may this. Following explain the interprofessional team strategies for enhancing Care coordination and communication to enhance the performance of and! Just before the amniotomy is performed amniotomy to shorten spontaneous labor does not produce a difference... Evidences acceptance o'clock each afternoon nurse is discussing breastfeeding with a postpartum client this procedure is common labor... Chapter 5 - Summary Give Me Liberty vulva the rate of infusion control. Not to check blood teaching made just before the amniotomy is performed by applicable law, or... At least a few hundred years Convert the Rh factor from negative to positive each. Is flooded with clients injured in a trancelike state Me Liberty woman 's pelvis finds a understands.
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