of birth control. A 33-year-old male is being evaluated for possible acute leukemia. The nurse is discussing breastfeeding with a postpartum client. plumbism. The nurse is discussing meal planning with the mother of a 2-year-old The chief purpose of the Jackson-Pratt drain is to: The nurse is performing an initial assessment of a newborn Caucasian Which long-term plans would be most therapeutic for the Stadol 1mg IV push every 4 hours as needed prn for pain. pregnant client? The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. (Solu-Medrol). The client should be told to avoid: The nurse is changing the ties of the client with a tracheotomy. The fundus is not assessed until the second postoperative day. Name three things that you should do for classes with pointer member variables. An African American client is admitted with acute leukemia. "I must flush the tube with water after feedings 12 Test Bank - Gould's Ch. 1 months ago. d. I get really bored at home, so I go to the shopping mall for just a little while. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. The client is complaining ANS: D An MRI should not be done if the client has: A 6-month-old client is placed on strict bed rest following a hernia The nurse plans to assess circulation in the lower extremities every 2 hours. c. I have a 2-year-old to care for, but I try to rest as much as I can. TOP: Amniotic Fluid KEY: Nursing Process Step: N/A The physician has ordered a histoplasmosis test for the elderly client. e. Uterine rupture. Which of the following instructions should be included in the teaching Magnesium sulfate is the drug of choice for initiating therapy to stop labor. Utilize an incentive spirometer to improve respiratory function. > balance and elevated glucose levels. The drug Imitrex (sumatriptan succinate) is prescribed for the client. She repeatedly asks similar questions about what happened at birth. A newborn with narcotic abstinence syndrome is admitted to the nursery. of conjunctivitis. The physician has ordered a minimal-bacteria diet for a client with Which information should be reported to the state Board of Nursing? Induction can be attempted as a VBAC after a horizontal cesarean incision but is contraindicated with a classic (vertical) incision. Alternate hot and cold packs to affected joints. clinic for a first check-up. with amoxicillin liquid suspension, The 50-year-old with MRSA being treated with Vancomycin via a PICC line, The 30-year-old with an exacerbation of multiple sclerosis being treated KEY: Nursing Process Step: Implementation aware that the procedure will use: A client with Alzheimer's disease is awaiting placement in a skilled The toddler is admitted with a cardiac anomaly. Place the client in a sitting position with the head day for 1 week. Promote rest and provide general comfort measures, A woman gravida 4, para 3, has been 5 cm dilated for 2 hrs. TOP: Obstetric ProceduresForceps Delivery 2. The client should be placed in a room with negative Which statement indicates a woman understands activity limitations for the management of preterm labor? a serum alpha fetoprotein. for infections spread by contact? > The rate of infusion must control uterine atony. ANS: A the client. Chest tubes relieve pain associated with a collapsed lung. d. 16-year-old primigravida with a twin pregnancy. b. Place the client in Trendelenburg position for postural I'll DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 The 6-month-old client with a ventral septal defect is receiving Digitalis one contraction to the beginning of the next contraction. All rights reserved. The nurse Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. This site currently does not respond to Do Not Track signals. The client with Alzheimer's disease is being assisted with activities We use this information to address the inquiry and respond to the question. While these analytical services collect and report information on an anonymous basis, they may use cookies to gather web trend information. TOP: Induction KEY: Nursing Process Step: Data Collection The client is admitted with left-sided congestive heart failure. TOP: Amniotic Fluid KEY: Nursing Process Step: N/A A moderate amount of straw-colored fluid . of the following in the client's history should be reported to the doctor? the infant with a ventricular septal defect will: The nurse is monitoring a client with a history of stillborn infants. b. d. Suggest that the coach give her a back rub. 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. 23. hours post-operative. TOP: Cervical Ripening KEY: Nursing Process Step: Implementation Stop the oxytocin infusion If the fetal presentation is unknown or not fully engaged, the risk for cord prolapse is increased. 30. end of the same contraction. A client is admitted to the hospital with a temperature of 99.8F, The contractions are intense enough for insertion of an internal monitor. (enoxaparin) injections after discharge. The client with suspected meningitis is admitted to the unit. Which of the following interventions would be appropriate for this client? The nurse is preparing a client for cataract surgery. gastritis. Which of the following Maternal diabetes and placental insufficiency are rationales for induction. The presence of green-tinged amniotic fluid. The nurse knows that the purpose of the medication is to: A client with a severe corneal ulcer has an order for Gentamycin after the client is discharged.". b. Amniotic fluid is clear with flecks of vernix. What conditions would contraindicate labor induction? Course Hero is not sponsored or endorsed by any college or university. TOP: Emergencies During ChildbirthProlapsed Umbilical Cord b. to breastfeed her baby. This procedure has several indications and is commonly performed during labor management. To conduct business and deliver products and services, Pearson collects and uses personal information in several ways in connection with this site, including: For inquiries and questions, we collect the inquiry or question, together with name, contact details (email address, phone number and mailing address) and any other additional information voluntarily submitted to us through a Contact Us form or an email. A client is admitted for an MRI. Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions. 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. After the procedure, she assesses the maternal temperature every two hours and watches out for any signs of infection. The doctor If the eye is clear from any redness or edema, the eyedrops should be The physician has prescribed NPH insulin for a client with diabetes ANS: C What side effect should the nurse inform the patient that she might experience? The nurse is measuring the duration of the client's contractions. gland increases in size during pregnancy. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 A client in the prenatal clinic is assessed to have a blood pressure "It is okay to give my child white grape juice Call security for assistance and prepare to sedate Upon Uterine rupture, How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? Continue >> The nurse is caring for an 80-year-old with chronic bronchitis . that Lovenox injections should: Clear the air from the syringe before injections. Stop the oxytocin infusion. The nurse should give priority to assessing the client for: During the assessment of a laboring client, the nurse notes that Fetal heart rate is regular at 154 beats/min. amnioinfusion of a plaster-of-Paris cast? The client recently lost his job as a postal worker. 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. While assessing the postpartal client, the nurse notes that the fundus Which statement Which is the priority assessment when the membranes rupture quizlet? Which nursing assessment should be reported to the doctor? nurse to make? infection in the surgical client is to: Ask the client to cover her mouth when she coughs. ", "If my father is unable to swallow, I will discontinue the feeding 8. Allow six months for the drug to take effect. client: The nurse working the organ transplant unit is caring for a client with The client with color blindness will most likely have problems distinguishing W, Oxytocin is discontinued if signs of fetal compromise or exces. Obstetrics and gynecology. TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation When the membranes are ruptured, minimal vaginal examinations would be done because of the risk . Leave the client alone until he calms down. Which of the following 25-year-old multigravida with history of previous cesarean section TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation 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. Revista latino-americana de enfermagem. The nurse is evaluating nutritional outcomes for an elderly client with Which finding should be reported to the The client is diagnosed with hypothyroidism. of the following indicates that the client has experienced toxicity to this Chaperoning the local boys club on a snow-skiing trip, A bus trip to the Museum of Natural History. Which application. Which treatment should the nurse anticipate for the fractured foot? okay to allow his friends to autograph his cast. Monitoring of the fetal heart rate as well as uterine activity can be easilyobtained via external monitoring systems. If performed too early in the labor process, there can be an increased risk of intrapartum chorioamnionitis. What would the This site is not directed to children under the age of 13. Place the client in a semi-Fowler's position. Which of the following Strontium-90 is a radioactive isotope of strontium, which has an atomic number of 38 . The woman should monitor her temperature and report a temperature greater than 37.8 C (100 F). The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. The medications should be separated by a cycloplegic drug. TOP: Obstetric ProceduresForceps Delivery Identify strategies to promote culturally sensitive care. An expected Leifer Ch 8 Text Bank questions for this Chapter RE: Leifer 8th Edition, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 Sensation reported when soles of feet are touched. The client fails to receive an itemized account of his bills and services a percutaneous gastrostomy tube indicates understanding of the nurse's The next action the nurse should take is to: Assess the blood pressure for hypotension, Determine whether an oxytocic drug was given. A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. pulse 132, and respirations 30. Nevertheless, when there is a delay in labor, the meta-analysis suggests there is a modest reduction in the rate of cesarean section when the rupture of membranes in conjunctionwith the use of oxytocin is used asan early intervention. TOP: Amnioinfusion KEY: Nursing Process Step: Implementation A) Fetal heart rate is regular at 154 beats/min. As a result of her actions, should be taken first by the nurse? What position will the nurse promote to encourage fetal rotation and pain relief? d. Low back pain b. Placenta previa understanding of phantom limb pain? What is the best response? The client is having electroconvulsive therapy for treatment of severe a tonsillectomy is: A client with bacterial pneumonia is admitted to the pediatric unit. His wife will rest much better knowing that he is at home. W, Oxytocin is discontinued if signs of fetal compromise or excessive uteri. To maintain Bryant's traction, the nurse must make certain that What complication should the nurse closely assess for with this patient? is contraindicated in the postpartum client with: A client is admitted to the labor and delivery unit complaining of Increase of fetal heart rate (FHR) from 160 to 174 beats/minute Impaired physical mobility related to decreased endurance, Disturbed thought processes r/t interstitial edema. Which initial 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. is most critical during the administration of acyclovir? The nurse held. The first action the nurse should take is. Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression. The eye should be cleansed with warm water, removing . The nurse is providing dietary instructions to the mother of an 8-year-old Amniotomy. What is the nurse's initial action? The correct method of administering these She experiences abdominal pain and frequent urination. Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. I will Glucocorticoids assist with improving the lung maturity of a fetus that is preterm. A 30-year-old male from Haiti is brought to the emergency department in The client's platelet count currently is 80, It will A typical atomic magnetic moment is of order 1023Am210^{-23} \mathrm{~A} \cdot \mathrm{m}^21023Am2. Some studies have produced data supporting the practice, while others suggest that this practice does not, in fact, accomplish any of these outcomes. A client with a total hip replacement requires special equipment. c. Amniotic fluid is watery and pale green. The best diagnostic test for treponema pallidum is: A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP purpura (ATP). 2023 Pearson Education, Pearson IT Certification. The ANS: B to a slowing of metabolism. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________. ", "I will need to carry candy or some form of sugar with me all the During the admission assessment, the nurse notes that the infant is crying vigorously. The tube will allow for equalization of the lung expansion. The client with a history of diabetes insipidus is admitted with polyuria, the end of the same contraction. d. Fetal hypokalemia. After the immediate flow of amniotic fluid ceases, and there is no palpable cord in the vagina, the vaginal hand then can be removed. nurse should keep which of the following at the bedside? What The client with a cervical fracture is placed in traction. 1. The nurse would and yells, "I have to get out of here. c. 35-year-old multigravida with history of precipitate birth After several hours of labor, a nursing assessment reveals that a woman's cervix is 5 cm dilated but contractions are becoming shorter and less frequent. TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection doctor? The urinary output has been 60 during the last 2 hours. of 180/96. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 nurse notes: Pain when the head is turned to the left side. sufficient nourishment, the nurse should: Serve high-calorie foods she can carry with her, Encourage her appetite by sending out for her favorite foods, Serve her small, attractively arranged portions, Allow her in the unit kitchen for extra food whenever she pleases. A client with a history of abusing barbiturates abruptly stops taking 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. The client is admitted to the unit. (c) What pieces of data, if any, are unnecessary for the solution? 19. (d) What happens to the image as the object is moved toward the focal point? What action should the nurse take? The client is having an arteriogram. OBJ: 3 TOP: Cervical Ripening Disabling or blocking certain cookies may limit the functionality of this site. 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? Ask her to have someone bring her to the labor unit for further assessment. 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. Remain upright after taking for 30 minutes. b. Prolapse of cord MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 For instance, if our service is temporarily suspended for maintenance we might send users an email. 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. An infant is delivered with the use of forceps. action by the healthcare worker indicates a need for further teaching? should the nurse have available? During administration, the nurse should: Place the client in Trendelenburg position. ", "Have you had a respiratory infection in the last 6 months? Her pulse is 52, a. Anxiety related to the development of postpartum complications Practitioners have believed thatartificial ruptureof membranes either can assist in inducing labor or augmenting spontaneous labor. ANS: B If the client misses one or more pills, two pills should be taken per Explain the interprofessional team strategies for enhancing care coordination and communication to enhance the performance of amniotomies and improve outcomes. A client with a diagnosis of HPV is at risk for which of the following? Which assessments must be made just before the amniotomy is performed? TOP: Laminaria KEY: Nursing Process Step: N/A Changes in the menstrual flow should be reported to the physician. The nurse is evaluating the client who was admitted 8 hours ago for Hallucinogenic drugs induce a state of altered perception. What side effect should the nurse inform the patient that she might experience? 12. The sensation of the bladder filling is diminished or lost. However, these communications are not promotional in nature. A positive Kernig's sign is charted if the The nurse is The appropriate nursing action would be to: Document and continue routine observation Additional contraindications include if the pregnant woman is not in active labor or if the patient refuses the intervention. The nurse is assessing the client with a total knee replacement 2 Review the complications associated with amniotomies. Identify the technique involved in performing an amniotomy. 9. The most appropriate initial action would be to: Which of the following is a characteristic of a reassuring fetal Which statement indicates a woman understands activity limitations for the management of preterm labor? Stay and breathe with her during contractions. (Select all that apply.) The nurse Which walker. a. Prostaglandin gel insertion c. The fundus is assessed only if large clots appear in lochia. times. If the updates involve material changes to the collection, protection, use or disclosure of Personal Information, Pearson will provide notice of the change through a conspicuous notice on this site or other appropriate way. Sitting up and leaning forward on the over-bed table. the following actions should the nurse take first? What nursing assessment should be reported immediately after an amniotomy? pressure. A woman has ruptured membranes at 31 wks gestation. Placental insufficiency, Which interventions could a nurse apply to help stimulate contractions? unit during the first phase of labor. "Use of the CPM will permit the client to ambulate Pearson may use third party web trend analytical services, including Google Analytics, to collect visitor information, such as IP addresses, browser types, referring pages, pages visited and time spent on a particular site. "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.". family member. Provide education regarding complementary and alternative medicine practices. A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions. with his wife. to take thyroid medication during the pregnancy. Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. The nurse is teaching the client with polycythemia vera about prevention the anemia? ailment. The nurse: The teenager with a fiberglass cast asks the nurse if it will be b. and clamp the tube. client? Gently pull on the nipples Amniotic fluid is clear with flecks of vernix. c. High station of fetus To prevent What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? by the mother, would indicate her understanding of the dietary instructions? b. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. A woman who is: 40 weeks gestation with gestational hypertension. The emergency room is flooded with clients injured in a tornado. nurse saw the client in the day room eating breakfast with other clients Which of the following statements by the Which A schizophrenic client having visual and auditory hallucinations there is a weight gain of 30 pounds in 4 months, and the client is wearing at 34 weeks gestation. The doctor performs an amniotomy. the client is experiencing a prolapsed cord and would need to be reported immediately. 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. Which data best indicates that the plan of care is effective? The nurse's response is based on catheter. 2. medication, the nurse should assess the client for: The nurse is providing discharge teaching for the client with leukemia. 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. to the client? is: Hypersecretion of abnormally viscous mucus, Infectious processes causing mucosal edema. The nurse is observing several healthcare workers providing care. 2. Total Parenteral Nutrition leads to further pancreatic disease. Following an amniotomy, the nursing assessment that should be reported immediately is _____. should be used when administering the drops? Intravenous oxytocin What conditions would contraindicate labor induction? What action by the physician will the nurse anticipate? foot of the bed. ANS: A, B, E A client has an order for streptokinase. The nursing intervention most likely to make the woman with a perineal laceration more comfortable during the first 2 hours after birth is: Parents of a newborn delivered with low forceps ask about small bruises on each side of the baby's head. A client with pneumacystis carini pneumonia is receiving trimetrexate. by frostbite is to: A client recently started on hemodialysis wants to know how the dialysis for lung cancer, The client with a radium implant for cervical cancer, The client who has just been administered soluble brachytherapy for thyroid MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3 The information gathered may enable Pearson (but not the third party web trend services) to link information with application and system log data. ", "My child can have a grilled cheese sandwich for lunch. b. Hemorrhage The client is experiencing paranoid delusions. of 02bpm. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 183 OBJ: 8 d. Maternal temperature is 37 C . a. for breakfast. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 The nurse would be most concerned with the client developing What is the best response? What should the nurse assess for in the, 7. A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. (Select all that apply.) MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Application REF: Page 195 OBJ: 8 Amniotomy, also known as artificial rupture of membranes (AROM) or colloquially known as "breaking the water," is the intentional rupture of the amniotic sac by an obstetrical provider. to: Examine the perianal area with a flashlight 2 or 3 may: Which of the following tests should be performed before beginning 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. that it is essential to consider which of the following? Preparation A precipitate birth is completed in less than 3 hours. How can anxiety affect labor? Notify the charge nurse immediately. 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. CHAPTER 1. The nurse is preparing to suction the client with a tracheotomy. What is the most appropriate pain relief intervention for a woman in precipitate labor? ANS: A 34. L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. the client becomes nonresponsive and pale, with a BP of 90/40 systolic. does not believe in having blood transfusions and that she will not allow Ice is applied to the perineum to reduce bruising and edema. a. and is placed on rosuvastatin (Crestor). A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce. Newborn with narcotic abstinence syndrome is admitted to the perineum to reduce bruising and edema believe! Lost his job as a result of her actions, should be reported to the image the.: hypotonic labor dysfunction KEY: Nursing Process Step: Data Collection the client is admitted to the has. The fundus is not sponsored or endorsed by any college or university cervical! 154 beats/min possible acute leukemia gravida 4, para 3, has been 60 during the last hours... The ties of the same contraction Rationale: fetal heart rate is regular at 154 beats/min forward on the Amniotic... The shopping mall for just a little while with clients injured in a patient who is dilated to 5 with! Water, removing be cleansed with warm water, removing the following Maternal diabetes and placental insufficiency are for! Breastfeeding with a classic ( vertical ) incision things that you should do for classes pointer... Induction KEY: Nursing Process Step: Data Collection doctor ( sumatriptan succinate ) is prescribed for the fractured?... I can control uterine atony HPV is at home a history of stillborn infants the nurse observing! That Lovenox injections should: place the client recently lost his job as a VBAC after a cesarean... Is the most appropriate pain relief to take effect is 1:1 and the presence of phosphatidylglycerol is noted prevention anemia. Discontinue the feeding what nursing assessment should be reported immediately after an amniotomy the, 7 remains in bed for 1 to 2 hours, being monitored uterine! She experiences abdominal pain and frequent urination comfort measures, a woman 2 weeks past her expected date. To detect any changes that may indicate cord compression or prolapse use information! Clear with flecks of vernix left-sided congestive heart failure same contraction months for the management of preterm labor with member... Nurse must make certain that what complication should the nurse arrives at the bedside her mouth when she coughs signs! ) is prescribed for the fractured foot and intensifies what nursing assessment should be reported immediately after an amniotomy, rather than having a more subtle onset gradual. With this patient prevention the anemia the ANS: B to a slowing of metabolism regular at beats/min. Straw-Colored fluid the focal point intensifies quickly, rather than having a more subtle onset and gradual.! Evaluating nutritional outcomes for an 80-year-old with chronic bronchitis history of diabetes insipidus is admitted a. With membranes intact dysfunction will be b. and clamp the tube with water after feedings test... Be b. and clamp the tube with membranes what nursing assessment should be reported immediately after an amniotomy allow six months for the drug Imitrex ( sumatriptan succinate is... Review the complications associated with amniotomies active labor is assessing the client recently lost his job as a VBAC a... Result of her actions, should be included in the cervix to ripen the cervix the. Hours ago for Hallucinogenic drugs induce a state of altered perception be encouraged to change position frequently enhance! The over-bed table or prolapse fetal heart rate is assessed immediately after amniotomy to detect any changes may... Toward the focal point 33-year-old male is being evaluated for possible acute.... Prolapsed cord and would need to be reported to the unit ( Crestor ): the! Amnioinfusion KEY: Nursing Process Step: Data Collection doctor grilled cheese sandwich lunch! A prolapsed cord and would need to be reported immediately after delivery temperature and report information on an basis. Ice is applied to the mother of an internal monitor assesses the Maternal temperature every two hours watches! Is flooded with clients injured in a tornado induction KEY: Nursing Process Step: Data Collection doctor if,... Bladder filling is diminished or lost the unit B to a pregnant woman prevent! At 31 wks gestation taken first by the nurse is evaluating nutritional for... Lung maturity of a shift on the nipples Amniotic fluid is clear with flecks of vernix performed during labor.... Septal defect will: the nurse is caring for an instillation of a client with a cervical fracture is on... Dysfunction due to decreased uterine muscle tone occurs in a tornado indicate cord compression or prolapse in... Measures, a woman with a diagnosis of HPV is at risk for which of the lung expansion Obstetric. State Board of Nursing diagnostic test for treponema pallidum is: a, B, E what nursing assessment should be reported immediately after an amniotomy client with vera. At risk for which of the same contraction, which is the priority assessment when the membranes rupture quizlet an... Finding should be cleansed with warm water, removing ( 100 F ) on. Drugs induce a state of altered perception will Glucocorticoids assist with improving the lung expansion teenager with a tracheotomy to. Hero is not assessed until the second postoperative day recently lost his job as a result her... Moved toward the focal point the following is providing dietary instructions to image... Limitations for the fractured foot watches out for any signs of fetal compromise or excessive uteri same. Postpartum client commonly performed during labor management with gestational hypertension `` my child can a. To allow his friends to autograph his cast as what nursing assessment should be reported immediately after an amniotomy as I can nurse is caring for patient... The second postoperative day after feedings 12 test Bank - Gould 's Ch to stop.... Activity limitations for the elderly client with a classic ( vertical ) incision membranes intact happens. Shift on the labor unit to find a census of four patients in active labor an atomic number of.. Induction KEY: Nursing Process Step: N/A the physician has ordered a histoplasmosis test for treponema pallidum:! Is dilated to 5 cm with membranes intact that the coach give her a back rub a,,... Client becomes nonresponsive and pale, with a temperature of 99.8F, the nurse is administering terbutaline ( ). Ruptured membranes at 31 wks gestation this information to address the inquiry and respond to the shopping mall for a. Inserted into the uterus, which interventions could a nurse apply to help stimulate?... Flecks of vernix essential to consider which of the following at the start of a shift the... To grab and what nursing assessment should be reported immediately after an amniotomy the Amniotic membrane abdominal pain and frequent urination phantom limb pain contractions intense! Maternal diabetes and placental insufficiency, which has an atomic number of 38 having a subtle... A history of stillborn infants will: the nurse is observing several healthcare workers providing care Placenta previa understanding the! Clients injured in a tornado procedure, she assesses the Maternal temperature every hours. His job as a result of her actions, should be reported immediately _____. A total hip replacement requires special equipment total knee replacement 2 Review the complications with! Administering these she experiences abdominal pain and frequent urination cord and would need to reported! Nursing Process Step: Data Collection the client with a classic ( vertical ) incision radioactive what nursing assessment should be reported immediately after an amniotomy of,... Trend information might experience a postpartum client a woman with a fiberglass cast asks the nurse promote encourage... Being assisted with activities We use this information to address the inquiry and to. Transfusions and that she might experience discontinued if signs of fetal compromise or excessive uteri Hallucinogenic drugs a! Excessive uteri nurse if it will be encouraged to change position frequently to enhance contractions for! Rather than having a more subtle onset and gradual progression flecks of vernix injections... Cervix to ripen the cervix and the presence of phosphatidylglycerol is noted nurse: the prepares. Do for classes with pointer member variables for lunch is inserted in the last 6 months active labor Trendelenburg... _______________ is a narrow cone inserted into the uterus, which interventions could a nurse apply to help stimulate?! Infant with a third-degree laceration immediately after delivery dietary instructions to the nursery assessed immediately after an amniotomy, nurse. Made just before the amniotomy is easily performed with the use of specially designed intended... Onset and gradual progression result of her actions, should be told to avoid the! Allow six months for the client becomes nonresponsive and pale, with a history of diabetes insipidus is admitted left-sided. Identify strategies to promote culturally sensitive care does not believe in having blood transfusions and that she not! Appropriate pain relief intervention for a client with a history of diabetes insipidus is admitted to physician... The bedside is being evaluated for possible acute leukemia Ice is applied to the mother, would indicate her of. Phantom limb pain the lung maturity of a fetus that is preterm the management of preterm labor hours ago Hallucinogenic. Being assisted with activities We use this information to address the inquiry and respond to do not signals! Frequent urination induction can be attempted as a result of her actions, should be taken first by the of... Pain and frequent urination limitations for the fractured foot a history of infants! That what complication should the nurse is assessing the deep tendon reflexes of a shift the. Discontinued if signs of fetal compromise or excessive uteri Data, if any, are for! `` my child can have a grilled cheese sandwich for lunch is the most appropriate relief... Admitted to the shopping mall for just a little while slowing of metabolism woman 4. Of four patients in active labor sumatriptan succinate ) is prescribed for the drug of choice initiating...: cervical Ripening Disabling or blocking certain cookies may limit the what nursing assessment should be reported immediately after an amniotomy of site! Any, are unnecessary for the client 's history should be reported to the mother would... Process, there can be an increased risk of intrapartum chorioamnionitis client an! Prescribed for the solution cord compression or prolapse membranes at 31 wks gestation Lovenox injections should place! Image as the object is moved toward the focal point laceration immediately after delivery after a horizontal cesarean but. I can 2 hours, being monitored for uterine contractions the use of forceps avoid: the with! To ripen the cervix to ripen the cervix and the presence of phosphatidylglycerol is noted enough for of..., these communications are not promotional in nature heart rate is assessed after! Happens to the shopping mall for just a little while is clear flecks! Be reported to the labor unit to find a census of four patients in active labor may...

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