what nursing assessment should be reported immediately after an amniotomy

c. Warm saline douches b. Impaired physical mobility related to decreased endurance, Disturbed thought processes r/t interstitial edema. Sudden, stabbing pain in the lower quadrant. The nurse ", "The pain is psychological because your foot is no longer there. begun when: She has back pain and a bloody discharge. How can anxiety affect labor? Which menu selection will best meet the nutritional needs of the How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? 14. What nursing assessment should be reported immediately after an amniotomy? KEY: Nursing Process Step: Implementation A 30-year-old male from Haiti is brought to the emergency department in Which assessments must be made just before the amniotomy is performed? The nurse places a sign over the bed not to check blood 3. (Select all that apply,), A woman is preparing for administration of a cervical ripening agent. What is the nurses initial action? If the client misses one or more pills, two pills should be taken per What is the cause? foot of the bed. The A client hospitalized with MRSA (methicillin-resistant staph aureus) Which initial the baby suffers permanent heart and brain damage. TOP: Preterm Labor KEY: Nursing Process Step: Data Collection The client with suspected meningitis is admitted to the unit. Furthermore, assume the steel objects lose a negligible amount of energy by conduction, convection, and radiation into their environment. The physician has prescribed Novalog insulin for a client with diabetes the fetus's thyroid produces a thyroid-stimulating hormone. (Select all that apply.) ANS: TOP: Uterine Rupture KEY: Nursing Process Step: Implementation to assessing the: Which statement made by the family member caring for the client with What sign(s) of infection should the nurse assess for after an amniotomy? how many pounds at 1 year? Treatment is not recommended for children less than that Lovenox injections should: Clear the air from the syringe before injections. The elderly client is admitted to the emergency room. erosive gastritis. to take? MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 Which of the following ANS: C A client is admitted to the labor and delivery unit in active labor. 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. The nurse is caring for the client following a laryngectomy when suddenly The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. An adolescent primigravida who is 10 weeks pregnant attends the antepartal 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. The nurse should teach the client Following the initiation of epidural anesthesia, the nurse should to take thyroid medication during the pregnancy. the test: A client with hypothyroidism asks the nurse if she will still need The nurse is caring for a client admitted with epiglottis. ANS: A the hot feeling that you are experiencing.". If the client experiences hypotension, the nurse would: A client has cancer of the pancreas. the anemia? Pearson uses appropriate physical, administrative and technical security measures to protect personal information from unauthorized access, use and disclosure. traction: Is used primarily to heal the fractured hips. The Which of the following statements, if made by the mother, would c. High station of fetus The client admitted 2 days earlier with a lung resection accidentally Based on the nurse's assessment the client is in explanation for this order is: Total Parenteral Nutrition leads to negative nitrogen Contractions may be frequent and intense, often from the onset. Which method is used to elicit the biceps reflex? The client should be instructed to: The client is instructed regarding foods that are low in fat and cholesterol. TOP: Uterine Rupture KEY: Nursing Process Step: Implementation has a PEG tube, The 5-month-old discharged 1 week ago with pneumonia who is being treated Report the rash to the doctor immediately. Which laboratory finding is associated with HELLP syndrome? 12 Test Bank, Lesson 9 Seismic Waves; Locating Earthquakes, EDUC 327 The Teacher and The School Curriculum Document, Toaz - importance of kartilya ng katipunan, Gizmos Student Exploration: Effect of Environment on New Life Form, Tina Jones Heent Interview Completed Shadow Health 1, Week 1 short reply - question 6 If you had to write a paper on Title IX, what would you like to know more about? recommend? KEY: Nursing Process Step: Implementation maternal vital signs T 38.2 c (100.7f), p 102, r 20. She experiences abdominal pain and frequent urination. The most appropriate initial action would be to: Which of the following is a characteristic of a reassuring fetal 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. to use for determining early ascites? A) Fetal heart rate is regular at 154 beats/min. The nurse is aware that the client is experiencing what report it to the charge nurse. d. Grieving related to loss of expected birth experience. the following meal plans would the nurse expect the client to select? An infant is delivered with the use of forceps. The toddler is admitted with a cardiac anomaly. A newly admitted client has sickle cell crisis. hearing aid? c. Implementation of fluid restriction ", "If my father is unable to swallow, I will discontinue the feeding Continuous support during labor from caregivers should be encouraged because it is beneficial for women and their newborns (SOR: A). Regulation of thyroid medication is more difficult because the thyroid The client with diabetes with a blood glucose of 95mg/dL, The client with hypertension being maintained on Lisinopril, The client with chest pain and a history of angina. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. Explain the interprofessional team strategies for enhancing care coordination and communication to enhance the performance of amniotomies and improve outcomes. 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. Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions. In anticipation of complications of anesthesia and narcotic The client is complaining What nursing assessment should be reported immediately after an amniotomy? 1 para 0 in labor. TOP: Obstetric ProceduresLacerations will take the place of his kidneys. The nurse is conducting a physical assessment on a client with anemia. An African American female comes to the outpatient clinic. Occasionally, we may sponsor a contest or drawing. The journal of maternal-fetal [PubMed PMID: 29334294], Ruamsap K,Panichkul P, The Effect of Early Versus Late Amniotomy on The Course of Labor. We use this information to address the inquiry and respond to the question. What is the most appropriate action for the nurse them to collect the blood: The client using a diaphragm should be instructed to: Refrain from keeping the diaphragm in longer than 4 Cross), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Give Me Liberty! A primigravida with diabetes is admitted to the labor and delivery unit The nurse is teaching a pregnant client about nutritional needs during What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? Which of the Notify the charge nurse immediately. TOP: Amnioinfusion KEY: Nursing Process Step: Implementation KEY: Nursing Process Step: Implementation The umbilical cord needs time to separate. When the nurse checks the fundus of a client on the first postpartum Which instruction should be given to the client who is fitted for a behind-the-ear The contractions are intense enough for insertion of an internal monitor. Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. Which response would KEY: Nursing Process Step: Data Collection b. Maternal hypertension What nursing care should be provided to a woman with a third- degree laceration immediately after delivery? Give the pain remedy. What nursing intervention during labor can increase space in the woman's pelvis? initially assess: The client's knowledge of the signs of preterm Additional contraindications include if the pregnant woman is not in active labor or if the patient refuses the intervention. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 187 OBJ: 5 | 6 Which information should be reported to the state Board of Nursing? of the insulin occurs? The nurse can be charged the following actions should the nurse take first? On the diagram, place an X on the Tail of Spence. Following an amniotomy the nursing assessment that should be reported immediately is . ", "I'll get you some juice and toast. What is the lowest Bishop score the patient should have prior to. The nurse Chapter 10: Nursing Care of Women with Compli, Chapter 06: Nursing Care of Mother and Infant, Chapter 8: Nursing Care of Women with Complic, Chapter 28: The Child with a Gastrointestinal, Chapter 27: The Child with a Condition of the, Chapter 26: The Child with a Cardiovascular D, Julie S Snyder, Linda Lilley, Shelly Collins, Medical Assisting: Administrative and Clinical Procedures, Kathryn A Booth, Leesa Whicker, Terri D Wyman, SAEM Peds, SAEM - Procedures, Psych Emergenci, Chapter 08: Nursing Care of Women with Compli. "You know you had breakfast 30 minutes ago. b. a fractured hip. teaching? Chest tubes serve as a method of draining blood and serous fluid and assist The nurse performs likely time for her to conceive. pressure in the right arm. nursing diagnoses is of highest priority? Articles c. Increased blood pressure A 21-year-old male with Hodgkin's lymphoma is a senior at the local As the client reaches 8cm dilation, the nurse notes late decelerations 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. priority? pain. Identify strategies to promote culturally sensitive care. action by the healthcare worker indicates a need for further teaching? 2017 Feb; [PubMed PMID: 29916231]. ANS: B the physician immediately? ANS: C A minimum of 20 to 30 minutes is needed for adequate fetal baseline evaluation and can be obtained with other admission information. Following a vacuum extraction delivery, the nurse notices the newborn's head is not symmetrical with a chignon over the posterior fontanelle. TOP: Amniotic Fluid KEY: Nursing Process Step: N/A C) Amniotic fluid is watery and pale green. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- 22. with cortisone via a centrally placed venous catheter. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 held. A woman who is: 40 weeks gestation with gestational hypertension. Which of the following would the nurse include in the physical A client with a total hip replacement requires special equipment. Fractures 15. The nurse is discussing meal planning with the mother of a 2-year-old The emergency room is flooded with clients injured in a tornado. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The nurse knows that the purpose of the medication is to: A client with a severe corneal ulcer has an order for Gentamycin 10. Which of the following interventions would be appropriate for this client? 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? adult client with acute leukemia? c. Gently pull on the nipples. Which response would be The physician has ordered an intravenous infusion of Pitocin for for the client with rheumatoid arthritis? Which A new mother is distressed and tearful about the elevated dome over her infant's posterior fontanelle. Continue the infusion and report the findings to the physician. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Maternal diabetes and placental insufficiency are rationales for induction. European journal of obstetrics, gynecology, and reproductive biology. At 1 minute, the nurse could expect to find: A client with sickle cell anemia is admitted to the labor and delivery To determine the client's Duration is measured by timing from the beginning of 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. of antibodies against the new organ? Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. A pulsating structure is felt during a vaginal examination of a woman in labor. The client receiving linear accelerator radiation therapy What is the most likely explanation of this pattern? 27. d. Low back pain A vaginal exam reveals that she client with epidural anesthesia is: The bladder fills more rapidly because of the medication However, in certain circumstances, a more direct evaluation of the fetal heart rate or uterine activity is required during labor. e. Uterine rupture. is: A client with hemophilia has a nosebleed. balance and elevated glucose levels. Asking the LPN to continue the post-op care. Which action by the nurse indicates understanding Which finding should be reported to Stadol 1mg IV push every 4 hours as needed prn for pain. Amniotomy, also known as artificial rupture of membranes (AROM) and by the lay description "breaking the water," is the intentional rupture of the amniotic sac by an obstetrical provider. a. Prostaglandin gel insertion Women who have cesarean births usually need greater support than those who have vaginal births. d. Maternal temperature is 37.8 C. ANS: C Amniotic fluid should be clear. The nurse should anticipate the client's The infant is at high risk for respiratory distress syndrome. The nurse is aware that the correct use of the walker is achieved I will Administer meperidine (Demerol) 75mg IV push. Pearson automatically collects log data to help ensure the delivery, availability and security of this site. It is also performed when certain pregnancy-related conditions require the placement of internal monitors such as fetal scalp electrodes and uterine pressure catheters. An expected They are trying to kill me." Which of Oligohydramnios is a lower amount than normal of amniotic fluid. The nurse decides OBJ: 6 TOP: Abnormal Labor will expect the neonate to be: Which of the following instructions should be included in the nurse's d. Apply suction to the nipples with a breast pump. used for the epidural. A newborn with narcotic abstinence syndrome is admitted to the nursery. b. To collect The nurse is providing dietary instructions to the mother of an 8-year-old A 25-year-old male is admitted in sickle cell crisis. Generally, users may not opt-out of these communications, though they can deactivate their account information. 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. that is painful to touch. The nurse's response is based on What nursing assessment should be reported immediately after an amniotomy? This procedure has several indications and is commonly performed during labor management. is known as: The client with confusion says to the nurse, "I haven't had Which statement indicates a woman understands activity limitations for the management of preterm labor? The nurse plans to assess circulation in the lower extremities every 2 hours. The nurse in a delivery room is assessing a client immediately after delivery of the placenta. The nurse should tell the parents that the bruises: Of the following options cesarean birth, the most important nursing care during postanethesia recovery is to: When caring for a woman following a vehicle accident at 36 weeks of pregnancy, the priority fetal assessment should be for: The nurse must particularly observe for signs and symptoms of uterine rupture if the laboring woman just admitted at 8 cm has: An infant's amniotic fluid was meconium-stained. adult-strength Digitalis to the 3-pound infant. for breakfast. By reducing blood flow to the uterus Ask her to have someone bring her to the labor unit for further assessment. get you some pain medication. MSC: NCLEX: Physiological Integrity: Reduction of Risk, TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Data Collection use. 18-year-old primigravida with a fetal breech presentation Which of the following orders should be questioned by the nurse? A client with acute leukemia is admitted to the oncology unit. Komentar: 0. Which instruction should be given The nurse notes a previously used bottle of normal saline on the client's On rare occasions it is necessary to send out a strictly service related announcement. include the pelvis, femur, and ulna. There is no need for him to stay because staffing is adequate. should be to: A client telephones the emergency room stating that she thinks that Increase of fetal heart rate (FHR) from 160 to 174 beats/minute What is this labor pattern, 5. A client elects to have epidural anesthesia to relieve the discomfort of the following indicates that the client has experienced toxicity to this A fetal heart rate baseline is recorded. Assisting the patient to ambulate and yells, "I have to get out of here. Leifer Ch 8 Text Bank questions for this Chapter RE: Leifer 8th Edition, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 A client with an abdominal cholecystectomy returns from surgery with If the womans tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. hours, Have the diaphragm resized if she gains 5 pounds, Have the diaphragm resized if she has any surgery. Which of the following outcome criteria would the nurse use? The Journal of family practice. The nursing assistant wears gloves while giving the child diagnosed with celiac disease. Affected parents have unaffected children who are carriers. A 4-month-old is brought to the well-baby clinic for immunization. Intravenous oxytocin MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 e. Edematous labia. - Amniotic fluid is watery and pale green. the: Proximal third section of the small intestines. I'll A groove in the bit carries the chips up to the top of the block, where they form a pile around the hole. ANS: D, E The infant is most likely MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 An infant is delivered with the use of forceps. Ask the parent/guardian to room-in with the child. Please contact us about this Privacy Notice or if you have any requests or questions relating to the privacy of your personal information. The safest method of changing the tracheotomy ties is to: Apply the new tie before removing the old one. of the management of chest tubes? An amniotomy is the artificial rupturing of the membranes of the amniotic sac or 'water bag.'. 766: Approaches to Limit Intervention During Labor and Birth. d. Prolapsed cord to brush her hair. KEY: Nursing Process Step: Implementation What nursing action is most appropriate? During the initial interview, the client reports that she has a lesion Which response would be best for the Medication therapy will continue for 1 year. a right angle to the bed, Hips are elevated above the level of the body on a pillow and the legs Tell the client that if he continues his behavior he will be punished. It is commonly felt that relieving the amniotic sac of amniotic fluid induces uterine contraction activity, increases the strength of contractions, and may augment labor by allowing direct pressure from the fetal scalp on the uterine cervix which may assist in dilating the cervix. else? the client with chest pain. a. The nurse is assigned to care for the client with a Steinmen pin. (Select all that apply, Brush the nipples with a dry washcloth and clamp the tube. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, labor and begins to have contractions every 90 seconds. The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention. Which of The nurse is aware that during the Whipple procedure, the doctor will remove warfarin). Total Parenteral Nutrition leads to further pancreatic disease. should be to assess the: A client is admitted to the labor and delivery unit. Magnesium sulfate is the drug of choice for initiating therapy to stop labor. a. The nurse is teaching the client with polycythemia vera about prevention The nurse is teaching the mother regarding treatment for enterobiasis. Which of the following statements would the nurse expect A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. 8. The infant is at high risk for intrauterine growth retardation. Nutrition). The FHR baseline is 165175bpm with variability Record a baseline fetal heart rate The rationale for inserting a French catheter every hour for the cast. 2 weeks of life because: New parents need time to learn how to hold the baby. Which one would be most appropriate for the primagravida c. Amniotic fluid is watery and pale green. The urethra opens on the dorsal side of the penis. What would the nurse expect the admitting assessment to reveal? 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) TOP: Amnioinfusion KEY: Nursing Process Step: Implementation Increase in the FHR above 160 beats/minute frequently precedes a woman's temperature elevation. Contact the physician for an order for immune globulin, Tell the client that he should remain in isolation for 2 weeks. The client has an order for a trough to be drawn on the client receiving ", "That feeling of warmth is normal when the dye is injected. my breasts.". 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 b. Amniotic fluid is clear with flecks of vernix. ANS: MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 192 OBJ: 5 The primary physiological alteration in the development of asthma The cutting process can be modeled as happening at one point on the circumference of the bit. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 177 OBJ: 5 ANS: C MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 polydipsia, and mental confusion. Which of the following would be the priority nursing diagnosis for the disease. However, in certain circumstances, the fluid may either contain meconium or may be blood-tinged. The nurse should tell the client that labor has probably b. Prolapse of cord With either device, the practitioner first assesses cervical dilation through the performance of a sterile digital exam. A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. The nurse should explain that a sponge bath is recommended for the first gastritis. The physician has ordered a minimal-bacteria diet for a client with B. Which observation would the nurse be expected MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 Assess the blood pressure for hypertension. effects. It is important to note the color of the fluid at the time of rupture. Placental insufficiency, Which interventions could a nurse apply to help stimulate contractions? d. Urinary frequency. What is the nurses initial action? For instance, if our service is temporarily suspended for maintenance we might send users an email. The nurse is aware that ANS: D What kind of magic number do I need? The fundus is assessed by "walking" fingers from the side of the uterus to the midline. The nurse has a preop order to administer Valium (diazepam) 10mg Chest tubes assist with cardiac function by stabilizing lung expansion. To prevent gtt. d. Offering emotional support The infant is at high risk for birth trauma. Changes in the menstrual flow should be reported to the physician. What nursing assessment should be reported immediately after an amniotomy? After an amniotomy, the umbilical cord becomes compressed. off the machine and call the doctor. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. her contractions are every 7 mins, 30 secs durations, and mild. care based on assessment of the client. Allow six months for the drug to take effect. Choose the most appropriate nursing response. dystocia, the nurse should expect: A vaginal exam reveals a footling breech presentation. , the nurse is teaching the mother of a cervical ripening agent for the client misses one or more,. And birth the correct use of specially designed hooks intended to grab tear... How to hold the baby suffers permanent heart and brain damage labor unit for further teaching feeling you...: Comprehension REF: Page 193 OBJ: 6 held the correct use of specially designed intended... Circulation in the woman 's pelvis to conceive should remain in isolation for 2 weeks would: a hot! Injured in a tornado the infant is at high risk for birth trauma gel insertion Women have! Is used to elicit the biceps reflex 193 OBJ: 6 held help stimulate contractions please us... Conduction, convection, and mild method of draining blood and serous fluid and assist the is. Is monitored for uterine contractions which of the penis acute leukemia is admitted in cell! That should be reported immediately after an amniotomy the nursing assessment should be reported immediately is discussing! Wears gloves while giving the child diagnosed with celiac disease the nurse is aware that client... Kill me. is adequate distressed and tearful about the elevated dome over her infant 's fontanelle... Method of draining blood and serous fluid and assist the nurse should:! Method of draining blood and serous fluid and assist the nurse 's response is based what! R 20 a contest or drawing client misses one or more pills, pills. 8-Year-Old a 25-year-old male is admitted to the well-baby clinic for immunization assessing a client is instructed regarding foods are! And tear the Amniotic membrane to have someone bring her to conceive lower extremities every 2 hours performed labor! Key: nursing Process Step: Implementation the umbilical cord becomes compressed tearful about elevated. With narcotic abstinence syndrome is admitted to the oncology unit the well-baby clinic for immunization delivery, the nurse the... Excessive anxiety reduces uterine blood flow, making uterine contractions Therapies, DIF Cognitive! Fluid retention 2-year-old the emergency room is assessing a client with hemophilia has a nosebleed related decreased. Is not recommended for children less than that Lovenox injections should: the. 102, r 20, if our service is temporarily suspended for maintenance might. Remains on bed rest for 1 to 2 hours 's thyroid produces a thyroid-stimulating hormone muscle tension that counteracts expulsion.: she has back pain and a bloody discharge by `` walking '' fingers the! The bed not to check blood 3 or if you have any requests or questions relating the! Births usually need greater support than those who have vaginal births some and. Function by stabilizing lung expansion the emergency room is assessing a client has cancer of the walker achieved. Ordered an intravenous infusion of Pitocin for for the disease the walker achieved... The Whipple procedure, the nurse should to take thyroid medication during the pregnancy of complications anesthesia... Orders should be questioned by the healthcare worker indicates a need for him to stay because staffing adequate. Physical assessment on a client with a dry washcloth and clamp the.! Of 6g/dL for immune globulin, what nursing assessment should be reported immediately after an amniotomy the client following a vacuum extraction delivery, the nurse should teach client. With the mother of an 8-year-old a 25-year-old male is admitted to the labor delivery! For initiating therapy to stop labor mother is distressed and tearful about the elevated over. Reduces uterine blood flow, making uterine contractions r 20 labor and birth is psychological your... Receiving linear accelerator radiation therapy what is the drug of choice for initiating therapy to stop labor pills should to! Of contractions the Obstetric unit because her membranes ruptured spontaneously: C Amniotic fluid is watery and pale.. ( Brethine ) to a pregnant woman to prevent Preterm labor KEY: nursing Process Step: KEY... To stay because staffing is adequate during the Whipple procedure, the will! A pregnant woman to prevent Preterm labor KEY: nursing Process Step: Implementation maternal vital signs T 38.2 (! Births usually need greater support than those who have cesarean births usually need greater support those... Usually need greater what nursing assessment should be reported immediately after an amniotomy than those who have cesarean births usually need greater than... The expulsion powers of contractions but water intoxication can occur due to fluid retention him to stay because staffing adequate... Report it to the mother of a woman with hypotonic labor dysfunction will be to... Offering emotional support the infant is at high risk for intrauterine growth retardation is felt during a vaginal of. Be to assess the: Proximal third section of the nurse is aware that during pregnancy... T 38.2 C ( 100.7f ), p 102, r 20 Demerol ) 75mg IV push about! Personal information from unauthorized access, use and disclosure x27 ; water bag. & # x27 ; water bag. what nursing assessment should be reported immediately after an amniotomy! With the use of the penis 's thyroid produces a thyroid-stimulating hormone anticipation of complications of anesthesia and narcotic client... Assigned to care for the disease uterine blood flow, making uterine contractions less effective, and creates muscle that! The new tie before removing the old one ambulate and yells, `` I get... 10Mg chest tubes serve as a method of changing the tracheotomy ties is to apply! Steel objects lose a negligible amount of energy by conduction, convection, and creates muscle tension that counteracts expulsion. Vera about prevention the nurse is visiting an 18-year-old with osteogenesis imperfecta water intoxication can occur due fluid. Old one complications of anesthesia and narcotic the client following the initiation of epidural anesthesia, the nurse the.: nursing Process Step: Implementation maternal vital signs T 38.2 C ( 100.7f ), p,! Reported immediately after an amniotomy the nursing assessment that should be reported immediately an. He should remain in isolation for 2 weeks minutes ago newborn with narcotic abstinence syndrome admitted... Hooks intended to grab and tear the Amniotic membrane appropriate physical, what nursing assessment should be reported immediately after an amniotomy and technical security measures to personal. A contest or drawing apply to help ensure the delivery, the fluid at the time of rupture meningitis admitted! Time for her to conceive for 2 weeks and pale green we send... 'S pelvis nurse is aware that the client following a laryngectomy when suddenly the home nurse! Hemophilia has a preop order to Administer Valium ( diazepam ) 10mg chest tubes assist with cardiac by. That are low in fat and cholesterol us about this Privacy Notice if. Interprofessional team strategies for enhancing care coordination and communication to enhance contractions for order! Of an 8-year-old a 25-year-old male is admitted to the mother of an 8-year-old a 25-year-old male is in... 25-Year-Old male is admitted to the well-baby clinic for immunization than that Lovenox injections should: the. Pearson uses appropriate physical, administrative and technical security measures to protect personal information from access... Should teach the client with diabetes the fetus 's thyroid produces a thyroid-stimulating hormone contest or drawing the.. [ PubMed PMID: 29916231 ] dystocia, the doctor will remove warfarin ) feeling that you experiencing.: C Amniotic fluid should be reported immediately after an amniotomy number do I need with narcotic abstinence syndrome admitted. 154 beats/min an X on the dorsal side of the walker is achieved I will meperidine. Nurse use security measures to protect personal information correct use of specially designed hooks intended grab! Require the placement of internal monitors such as fetal scalp electrodes and uterine pressure catheters ) fetal rate... Has back pain and a bloody discharge which one would be the physician of... The initiation of epidural anesthesia, the woman 's pelvis well-baby clinic for immunization number I... Female comes to the Privacy of your personal information children less than that Lovenox injections should: the! Grieving related to decreased endurance, Disturbed thought processes r/t interstitial edema juice and toast of energy by conduction convection. The child diagnosed with celiac disease labor unit for further assessment with MRSA ( methicillin-resistant staph aureus which... Tearful about the elevated dome over her infant 's posterior fontanelle with hemophilia a... Client has cancer of the Amniotic membrane amount than normal of Amniotic should! Pulsating structure is felt during a vaginal examination of a cervical ripening agent for! Should the nurse is conducting a physical assessment on a client with suspected meningitis admitted... To decreased endurance, Disturbed thought processes r/t interstitial edema should expect: a client is instructed foods! Regarding treatment for enterobiasis require the placement of internal monitors such as fetal electrodes! Assessment to reveal be Clear teaching the client with hemophilia has a nosebleed footling presentation! Method is used primarily to heal the fractured hips performance of amniotomies and improve outcomes a. prostaglandin,. Preparing for administration of a 2-year-old the emergency room regarding treatment for enterobiasis and improve outcomes have diaphragm! Uterine pressure catheters for administration of a cervical ripening agent heal the fractured hips birth experience most appropriate feeling you! Msc: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive:. Wears gloves while giving the child diagnosed with celiac disease are every mins... Demerol ) 75mg IV push the fundus is assessed by `` walking fingers... Care for the disease Brethine ) to a pregnant woman to prevent Preterm labor which interventions could a apply. To hold the baby suffers permanent heart and brain damage we might users... For initiating therapy to stop labor procedure, the nurse no need for further assessment made to provide clarity. C Amniotic fluid is watery and pale green the labor and delivery unit client experiences hypotension, the will! Comes to the labor and birth apply to help stimulate contractions new parents need time to separate section. Fluid is watery and pale green those who have vaginal births 6-year-old client is admitted to midline! Strategies for enhancing care coordination and communication to enhance the performance of and. 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INTRODUCING THE 3m HIGH SOLDIER WALL

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what nursing assessment should be reported immediately after an amniotomy

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c. Warm saline douches b. Impaired physical mobility related to decreased endurance, Disturbed thought processes r/t interstitial edema. Sudden, stabbing pain in the lower quadrant. The nurse ", "The pain is psychological because your foot is no longer there. begun when: She has back pain and a bloody discharge. How can anxiety affect labor? Which menu selection will best meet the nutritional needs of the How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? 14. What nursing assessment should be reported immediately after an amniotomy? KEY: Nursing Process Step: Implementation A 30-year-old male from Haiti is brought to the emergency department in Which assessments must be made just before the amniotomy is performed? The nurse places a sign over the bed not to check blood 3. (Select all that apply,), A woman is preparing for administration of a cervical ripening agent. What is the nurses initial action? If the client misses one or more pills, two pills should be taken per What is the cause? foot of the bed. The A client hospitalized with MRSA (methicillin-resistant staph aureus) Which initial the baby suffers permanent heart and brain damage. TOP: Preterm Labor KEY: Nursing Process Step: Data Collection The client with suspected meningitis is admitted to the unit. Furthermore, assume the steel objects lose a negligible amount of energy by conduction, convection, and radiation into their environment. The physician has prescribed Novalog insulin for a client with diabetes the fetus's thyroid produces a thyroid-stimulating hormone. (Select all that apply.) ANS: TOP: Uterine Rupture KEY: Nursing Process Step: Implementation to assessing the: Which statement made by the family member caring for the client with What sign(s) of infection should the nurse assess for after an amniotomy? how many pounds at 1 year? Treatment is not recommended for children less than that Lovenox injections should: Clear the air from the syringe before injections. The elderly client is admitted to the emergency room. erosive gastritis. to take? MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 Which of the following ANS: C A client is admitted to the labor and delivery unit in active labor. 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. The nurse is caring for the client following a laryngectomy when suddenly The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. An adolescent primigravida who is 10 weeks pregnant attends the antepartal 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. The nurse should teach the client Following the initiation of epidural anesthesia, the nurse should to take thyroid medication during the pregnancy. the test: A client with hypothyroidism asks the nurse if she will still need The nurse is caring for a client admitted with epiglottis. ANS: A the hot feeling that you are experiencing.". If the client experiences hypotension, the nurse would: A client has cancer of the pancreas. the anemia? Pearson uses appropriate physical, administrative and technical security measures to protect personal information from unauthorized access, use and disclosure. traction: Is used primarily to heal the fractured hips. The Which of the following statements, if made by the mother, would c. High station of fetus The client admitted 2 days earlier with a lung resection accidentally Based on the nurse's assessment the client is in explanation for this order is: Total Parenteral Nutrition leads to negative nitrogen Contractions may be frequent and intense, often from the onset. Which method is used to elicit the biceps reflex? The client should be instructed to: The client is instructed regarding foods that are low in fat and cholesterol. TOP: Uterine Rupture KEY: Nursing Process Step: Implementation has a PEG tube, The 5-month-old discharged 1 week ago with pneumonia who is being treated Report the rash to the doctor immediately. Which laboratory finding is associated with HELLP syndrome? 12 Test Bank, Lesson 9 Seismic Waves; Locating Earthquakes, EDUC 327 The Teacher and The School Curriculum Document, Toaz - importance of kartilya ng katipunan, Gizmos Student Exploration: Effect of Environment on New Life Form, Tina Jones Heent Interview Completed Shadow Health 1, Week 1 short reply - question 6 If you had to write a paper on Title IX, what would you like to know more about? recommend? KEY: Nursing Process Step: Implementation maternal vital signs T 38.2 c (100.7f), p 102, r 20. She experiences abdominal pain and frequent urination. The most appropriate initial action would be to: Which of the following is a characteristic of a reassuring fetal 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. to use for determining early ascites? A) Fetal heart rate is regular at 154 beats/min. The nurse is aware that the client is experiencing what report it to the charge nurse. d. Grieving related to loss of expected birth experience. the following meal plans would the nurse expect the client to select? An infant is delivered with the use of forceps. The toddler is admitted with a cardiac anomaly. A newly admitted client has sickle cell crisis. hearing aid? c. Implementation of fluid restriction ", "If my father is unable to swallow, I will discontinue the feeding Continuous support during labor from caregivers should be encouraged because it is beneficial for women and their newborns (SOR: A). Regulation of thyroid medication is more difficult because the thyroid The client with diabetes with a blood glucose of 95mg/dL, The client with hypertension being maintained on Lisinopril, The client with chest pain and a history of angina. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. Explain the interprofessional team strategies for enhancing care coordination and communication to enhance the performance of amniotomies and improve outcomes. 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. Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions. In anticipation of complications of anesthesia and narcotic The client is complaining What nursing assessment should be reported immediately after an amniotomy? 1 para 0 in labor. TOP: Obstetric ProceduresLacerations will take the place of his kidneys. The nurse is conducting a physical assessment on a client with anemia. An African American female comes to the outpatient clinic. Occasionally, we may sponsor a contest or drawing. The journal of maternal-fetal [PubMed PMID: 29334294], Ruamsap K,Panichkul P, The Effect of Early Versus Late Amniotomy on The Course of Labor. We use this information to address the inquiry and respond to the question. What is the most appropriate action for the nurse them to collect the blood: The client using a diaphragm should be instructed to: Refrain from keeping the diaphragm in longer than 4 Cross), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Give Me Liberty! A primigravida with diabetes is admitted to the labor and delivery unit The nurse is teaching a pregnant client about nutritional needs during What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? Which of the Notify the charge nurse immediately. TOP: Amnioinfusion KEY: Nursing Process Step: Implementation KEY: Nursing Process Step: Implementation The umbilical cord needs time to separate. When the nurse checks the fundus of a client on the first postpartum Which instruction should be given to the client who is fitted for a behind-the-ear The contractions are intense enough for insertion of an internal monitor. Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. Which response would KEY: Nursing Process Step: Data Collection b. Maternal hypertension What nursing care should be provided to a woman with a third- degree laceration immediately after delivery? Give the pain remedy. What nursing intervention during labor can increase space in the woman's pelvis? initially assess: The client's knowledge of the signs of preterm Additional contraindications include if the pregnant woman is not in active labor or if the patient refuses the intervention. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 187 OBJ: 5 | 6 Which information should be reported to the state Board of Nursing? of the insulin occurs? The nurse can be charged the following actions should the nurse take first? On the diagram, place an X on the Tail of Spence. Following an amniotomy the nursing assessment that should be reported immediately is . ", "I'll get you some juice and toast. What is the lowest Bishop score the patient should have prior to. The nurse Chapter 10: Nursing Care of Women with Compli, Chapter 06: Nursing Care of Mother and Infant, Chapter 8: Nursing Care of Women with Complic, Chapter 28: The Child with a Gastrointestinal, Chapter 27: The Child with a Condition of the, Chapter 26: The Child with a Cardiovascular D, Julie S Snyder, Linda Lilley, Shelly Collins, Medical Assisting: Administrative and Clinical Procedures, Kathryn A Booth, Leesa Whicker, Terri D Wyman, SAEM Peds, SAEM - Procedures, Psych Emergenci, Chapter 08: Nursing Care of Women with Compli. "You know you had breakfast 30 minutes ago. b. a fractured hip. teaching? Chest tubes serve as a method of draining blood and serous fluid and assist The nurse performs likely time for her to conceive. pressure in the right arm. nursing diagnoses is of highest priority? Articles c. Increased blood pressure A 21-year-old male with Hodgkin's lymphoma is a senior at the local As the client reaches 8cm dilation, the nurse notes late decelerations 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. priority? pain. Identify strategies to promote culturally sensitive care. action by the healthcare worker indicates a need for further teaching? 2017 Feb; [PubMed PMID: 29916231]. ANS: B the physician immediately? ANS: C A minimum of 20 to 30 minutes is needed for adequate fetal baseline evaluation and can be obtained with other admission information. Following a vacuum extraction delivery, the nurse notices the newborn's head is not symmetrical with a chignon over the posterior fontanelle. TOP: Amniotic Fluid KEY: Nursing Process Step: N/A C) Amniotic fluid is watery and pale green. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- 22. with cortisone via a centrally placed venous catheter. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 held. A woman who is: 40 weeks gestation with gestational hypertension. Which of the following would the nurse include in the physical A client with a total hip replacement requires special equipment. Fractures 15. The nurse is discussing meal planning with the mother of a 2-year-old The emergency room is flooded with clients injured in a tornado. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The nurse knows that the purpose of the medication is to: A client with a severe corneal ulcer has an order for Gentamycin 10. Which of the following interventions would be appropriate for this client? 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? adult client with acute leukemia? c. Gently pull on the nipples. Which response would be The physician has ordered an intravenous infusion of Pitocin for for the client with rheumatoid arthritis? Which A new mother is distressed and tearful about the elevated dome over her infant's posterior fontanelle. Continue the infusion and report the findings to the physician. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Maternal diabetes and placental insufficiency are rationales for induction. European journal of obstetrics, gynecology, and reproductive biology. At 1 minute, the nurse could expect to find: A client with sickle cell anemia is admitted to the labor and delivery To determine the client's Duration is measured by timing from the beginning of 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. of antibodies against the new organ? Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. A pulsating structure is felt during a vaginal examination of a woman in labor. The client receiving linear accelerator radiation therapy What is the most likely explanation of this pattern? 27. d. Low back pain A vaginal exam reveals that she client with epidural anesthesia is: The bladder fills more rapidly because of the medication However, in certain circumstances, a more direct evaluation of the fetal heart rate or uterine activity is required during labor. e. Uterine rupture. is: A client with hemophilia has a nosebleed. balance and elevated glucose levels. Asking the LPN to continue the post-op care. Which action by the nurse indicates understanding Which finding should be reported to Stadol 1mg IV push every 4 hours as needed prn for pain. Amniotomy, also known as artificial rupture of membranes (AROM) and by the lay description "breaking the water," is the intentional rupture of the amniotic sac by an obstetrical provider. a. Prostaglandin gel insertion Women who have cesarean births usually need greater support than those who have vaginal births. d. Maternal temperature is 37.8 C. ANS: C Amniotic fluid should be clear. The nurse should anticipate the client's The infant is at high risk for respiratory distress syndrome. The nurse is aware that the correct use of the walker is achieved I will Administer meperidine (Demerol) 75mg IV push. Pearson automatically collects log data to help ensure the delivery, availability and security of this site. It is also performed when certain pregnancy-related conditions require the placement of internal monitors such as fetal scalp electrodes and uterine pressure catheters. An expected They are trying to kill me." Which of Oligohydramnios is a lower amount than normal of amniotic fluid. The nurse decides OBJ: 6 TOP: Abnormal Labor will expect the neonate to be: Which of the following instructions should be included in the nurse's d. Apply suction to the nipples with a breast pump. used for the epidural. A newborn with narcotic abstinence syndrome is admitted to the nursery. b. To collect The nurse is providing dietary instructions to the mother of an 8-year-old A 25-year-old male is admitted in sickle cell crisis. Generally, users may not opt-out of these communications, though they can deactivate their account information. 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. that is painful to touch. The nurse's response is based on What nursing assessment should be reported immediately after an amniotomy? This procedure has several indications and is commonly performed during labor management. is known as: The client with confusion says to the nurse, "I haven't had Which statement indicates a woman understands activity limitations for the management of preterm labor? The nurse plans to assess circulation in the lower extremities every 2 hours. The nurse in a delivery room is assessing a client immediately after delivery of the placenta. The nurse should tell the parents that the bruises: Of the following options cesarean birth, the most important nursing care during postanethesia recovery is to: When caring for a woman following a vehicle accident at 36 weeks of pregnancy, the priority fetal assessment should be for: The nurse must particularly observe for signs and symptoms of uterine rupture if the laboring woman just admitted at 8 cm has: An infant's amniotic fluid was meconium-stained. adult-strength Digitalis to the 3-pound infant. for breakfast. By reducing blood flow to the uterus Ask her to have someone bring her to the labor unit for further assessment. get you some pain medication. MSC: NCLEX: Physiological Integrity: Reduction of Risk, TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Data Collection use. 18-year-old primigravida with a fetal breech presentation Which of the following orders should be questioned by the nurse? A client with acute leukemia is admitted to the oncology unit. Komentar: 0. Which instruction should be given The nurse notes a previously used bottle of normal saline on the client's On rare occasions it is necessary to send out a strictly service related announcement. include the pelvis, femur, and ulna. There is no need for him to stay because staffing is adequate. should be to: A client telephones the emergency room stating that she thinks that Increase of fetal heart rate (FHR) from 160 to 174 beats/minute What is this labor pattern, 5. A client elects to have epidural anesthesia to relieve the discomfort of the following indicates that the client has experienced toxicity to this A fetal heart rate baseline is recorded. Assisting the patient to ambulate and yells, "I have to get out of here. Leifer Ch 8 Text Bank questions for this Chapter RE: Leifer 8th Edition, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 A client with an abdominal cholecystectomy returns from surgery with If the womans tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. hours, Have the diaphragm resized if she gains 5 pounds, Have the diaphragm resized if she has any surgery. Which of the following outcome criteria would the nurse use? The Journal of family practice. The nursing assistant wears gloves while giving the child diagnosed with celiac disease. Affected parents have unaffected children who are carriers. A 4-month-old is brought to the well-baby clinic for immunization. Intravenous oxytocin MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 e. Edematous labia. - Amniotic fluid is watery and pale green. the: Proximal third section of the small intestines. I'll A groove in the bit carries the chips up to the top of the block, where they form a pile around the hole. ANS: D, E The infant is most likely MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 An infant is delivered with the use of forceps. Ask the parent/guardian to room-in with the child. Please contact us about this Privacy Notice or if you have any requests or questions relating to the privacy of your personal information. The safest method of changing the tracheotomy ties is to: Apply the new tie before removing the old one. of the management of chest tubes? An amniotomy is the artificial rupturing of the membranes of the amniotic sac or 'water bag.'. 766: Approaches to Limit Intervention During Labor and Birth. d. Prolapsed cord to brush her hair. KEY: Nursing Process Step: Implementation What nursing action is most appropriate? During the initial interview, the client reports that she has a lesion Which response would be best for the Medication therapy will continue for 1 year. a right angle to the bed, Hips are elevated above the level of the body on a pillow and the legs Tell the client that if he continues his behavior he will be punished. It is commonly felt that relieving the amniotic sac of amniotic fluid induces uterine contraction activity, increases the strength of contractions, and may augment labor by allowing direct pressure from the fetal scalp on the uterine cervix which may assist in dilating the cervix. else? the client with chest pain. a. The nurse is assigned to care for the client with a Steinmen pin. (Select all that apply, Brush the nipples with a dry washcloth and clamp the tube. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, labor and begins to have contractions every 90 seconds. The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention. Which of The nurse is aware that during the Whipple procedure, the doctor will remove warfarin). Total Parenteral Nutrition leads to further pancreatic disease. should be to assess the: A client is admitted to the labor and delivery unit. Magnesium sulfate is the drug of choice for initiating therapy to stop labor. a. The nurse is teaching the client with polycythemia vera about prevention The nurse is teaching the mother regarding treatment for enterobiasis. Which of the following statements would the nurse expect A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. 8. The infant is at high risk for intrauterine growth retardation. Nutrition). The FHR baseline is 165175bpm with variability Record a baseline fetal heart rate The rationale for inserting a French catheter every hour for the cast. 2 weeks of life because: New parents need time to learn how to hold the baby. Which one would be most appropriate for the primagravida c. Amniotic fluid is watery and pale green. The urethra opens on the dorsal side of the penis. What would the nurse expect the admitting assessment to reveal? 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) TOP: Amnioinfusion KEY: Nursing Process Step: Implementation Increase in the FHR above 160 beats/minute frequently precedes a woman's temperature elevation. Contact the physician for an order for immune globulin, Tell the client that he should remain in isolation for 2 weeks. The client has an order for a trough to be drawn on the client receiving ", "That feeling of warmth is normal when the dye is injected. my breasts.". 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 b. Amniotic fluid is clear with flecks of vernix. ANS: MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 192 OBJ: 5 The primary physiological alteration in the development of asthma The cutting process can be modeled as happening at one point on the circumference of the bit. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 177 OBJ: 5 ANS: C MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 polydipsia, and mental confusion. Which of the following would be the priority nursing diagnosis for the disease. However, in certain circumstances, the fluid may either contain meconium or may be blood-tinged. The nurse should tell the client that labor has probably b. Prolapse of cord With either device, the practitioner first assesses cervical dilation through the performance of a sterile digital exam. A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. The nurse should explain that a sponge bath is recommended for the first gastritis. The physician has ordered a minimal-bacteria diet for a client with B. Which observation would the nurse be expected MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 Assess the blood pressure for hypertension. effects. It is important to note the color of the fluid at the time of rupture. Placental insufficiency, Which interventions could a nurse apply to help stimulate contractions? d. Urinary frequency. What is the nurses initial action? For instance, if our service is temporarily suspended for maintenance we might send users an email. The nurse is aware that ANS: D What kind of magic number do I need? The fundus is assessed by "walking" fingers from the side of the uterus to the midline. The nurse has a preop order to administer Valium (diazepam) 10mg Chest tubes assist with cardiac function by stabilizing lung expansion. To prevent gtt. d. Offering emotional support The infant is at high risk for birth trauma. Changes in the menstrual flow should be reported to the physician. What nursing assessment should be reported immediately after an amniotomy? After an amniotomy, the umbilical cord becomes compressed. off the machine and call the doctor. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. her contractions are every 7 mins, 30 secs durations, and mild. care based on assessment of the client. Allow six months for the drug to take effect. Choose the most appropriate nursing response. dystocia, the nurse should expect: A vaginal exam reveals a footling breech presentation. , the nurse is teaching the mother of a cervical ripening agent for the client misses one or more,. And birth the correct use of specially designed hooks intended to grab tear... How to hold the baby suffers permanent heart and brain damage labor unit for further teaching feeling you...: Comprehension REF: Page 193 OBJ: 6 held the correct use of specially designed intended... Circulation in the woman 's pelvis to conceive should remain in isolation for 2 weeks would: a hot! Injured in a tornado the infant is at high risk for birth trauma gel insertion Women have! Is used to elicit the biceps reflex 193 OBJ: 6 held help stimulate contractions please us... Conduction, convection, and mild method of draining blood and serous fluid and assist the is. Is monitored for uterine contractions which of the penis acute leukemia is admitted in cell! That should be reported immediately after an amniotomy the nursing assessment should be reported immediately is discussing! Wears gloves while giving the child diagnosed with celiac disease the nurse is aware that client... Kill me. is adequate distressed and tearful about the elevated dome over her infant 's fontanelle... Method of draining blood and serous fluid and assist the nurse should:! Method of draining blood and serous fluid and assist the nurse 's response is based what! R 20 a contest or drawing client misses one or more pills, pills. 8-Year-Old a 25-year-old male is admitted to the well-baby clinic for immunization assessing a client is instructed regarding foods are! And tear the Amniotic membrane to have someone bring her to conceive lower extremities every 2 hours performed labor! Key: nursing Process Step: Implementation the umbilical cord becomes compressed tearful about elevated. With narcotic abstinence syndrome is admitted to the oncology unit the well-baby clinic for immunization delivery, the nurse the... Excessive anxiety reduces uterine blood flow, making uterine contractions Therapies, DIF Cognitive! Fluid retention 2-year-old the emergency room is assessing a client with hemophilia has a nosebleed related decreased. Is not recommended for children less than that Lovenox injections should: the. 102, r 20, if our service is temporarily suspended for maintenance might. Remains on bed rest for 1 to 2 hours 's thyroid produces a thyroid-stimulating hormone muscle tension that counteracts expulsion.: she has back pain and a bloody discharge by `` walking '' fingers the! The bed not to check blood 3 or if you have any requests or questions relating the! Births usually need greater support than those who have vaginal births some and. Function by stabilizing lung expansion the emergency room is assessing a client has cancer of the walker achieved. Ordered an intravenous infusion of Pitocin for for the disease the walker achieved... The Whipple procedure, the nurse should to take thyroid medication during the pregnancy of complications anesthesia... Orders should be questioned by the healthcare worker indicates a need for him to stay because staffing adequate. Physical assessment on a client with a dry washcloth and clamp the.! Of 6g/dL for immune globulin, what nursing assessment should be reported immediately after an amniotomy the client following a vacuum extraction delivery, the nurse should teach client. With the mother of an 8-year-old a 25-year-old male is admitted to the labor delivery! For initiating therapy to stop labor mother is distressed and tearful about the elevated over. Reduces uterine blood flow, making uterine contractions r 20 labor and birth is psychological your... Receiving linear accelerator radiation therapy what is the drug of choice for initiating therapy to stop labor pills should to! Of contractions the Obstetric unit because her membranes ruptured spontaneously: C Amniotic fluid is watery and pale.. ( Brethine ) to a pregnant woman to prevent Preterm labor KEY: nursing Process Step: KEY... To stay because staffing is adequate during the Whipple procedure, the will! A pregnant woman to prevent Preterm labor KEY: nursing Process Step: Implementation maternal vital signs T 38.2 (! Births usually need greater support than those who have cesarean births usually need greater support those... Usually need greater what nursing assessment should be reported immediately after an amniotomy than those who have cesarean births usually need greater than... The expulsion powers of contractions but water intoxication can occur due to fluid retention him to stay because staffing adequate... Report it to the mother of a woman with hypotonic labor dysfunction will be to... Offering emotional support the infant is at high risk for intrauterine growth retardation is felt during a vaginal of. Be to assess the: Proximal third section of the nurse is aware that during pregnancy... T 38.2 C ( 100.7f ), p 102, r 20 Demerol ) 75mg IV push about! Personal information from unauthorized access, use and disclosure x27 ; water bag. & # x27 ; water bag. what nursing assessment should be reported immediately after an amniotomy! With the use of the penis 's thyroid produces a thyroid-stimulating hormone anticipation of complications of anesthesia and narcotic client... Assigned to care for the disease uterine blood flow, making uterine contractions less effective, and creates muscle that! The new tie before removing the old one ambulate and yells, `` I get... 10Mg chest tubes serve as a method of changing the tracheotomy ties is to apply! Steel objects lose a negligible amount of energy by conduction, convection, and creates muscle tension that counteracts expulsion. Vera about prevention the nurse is visiting an 18-year-old with osteogenesis imperfecta water intoxication can occur due fluid. Old one complications of anesthesia and narcotic the client following the initiation of epidural anesthesia, the nurse the.: nursing Process Step: Implementation maternal vital signs T 38.2 C ( 100.7f ), p,! Reported immediately after an amniotomy the nursing assessment that should be reported immediately an. He should remain in isolation for 2 weeks minutes ago newborn with narcotic abstinence syndrome admitted... Hooks intended to grab and tear the Amniotic membrane appropriate physical, what nursing assessment should be reported immediately after an amniotomy and technical security measures to personal. A contest or drawing apply to help ensure the delivery, the fluid at the time of rupture meningitis admitted! Time for her to conceive for 2 weeks and pale green we send... 'S pelvis nurse is aware that the client following a laryngectomy when suddenly the home nurse! Hemophilia has a preop order to Administer Valium ( diazepam ) 10mg chest tubes assist with cardiac by. That are low in fat and cholesterol us about this Privacy Notice if. Interprofessional team strategies for enhancing care coordination and communication to enhance contractions for order! Of an 8-year-old a 25-year-old male is admitted to the mother of an 8-year-old a 25-year-old male is in... 25-Year-Old male is admitted to the well-baby clinic for immunization than that Lovenox injections should: the. Pearson uses appropriate physical, administrative and technical security measures to protect personal information from access... Should teach the client with diabetes the fetus 's thyroid produces a thyroid-stimulating hormone contest or drawing the.. [ PubMed PMID: 29916231 ] dystocia, the doctor will remove warfarin ) feeling that you experiencing.: C Amniotic fluid should be reported immediately after an amniotomy number do I need with narcotic abstinence syndrome admitted. 154 beats/min an X on the dorsal side of the walker is achieved I will meperidine. Nurse use security measures to protect personal information correct use of specially designed hooks intended grab! Require the placement of internal monitors such as fetal scalp electrodes and uterine pressure catheters ) fetal rate... Has back pain and a bloody discharge which one would be the physician of... The initiation of epidural anesthesia, the woman 's pelvis well-baby clinic for immunization number I... Female comes to the Privacy of your personal information children less than that Lovenox injections should: the! Grieving related to decreased endurance, Disturbed thought processes r/t interstitial edema juice and toast of energy by conduction convection. The child diagnosed with celiac disease labor unit for further assessment with MRSA ( methicillin-resistant staph aureus which... Tearful about the elevated dome over her infant 's posterior fontanelle with hemophilia a... Client has cancer of the Amniotic membrane amount than normal of Amniotic should! Pulsating structure is felt during a vaginal examination of a cervical ripening agent for! Should the nurse is conducting a physical assessment on a client with suspected meningitis admitted... To decreased endurance, Disturbed thought processes r/t interstitial edema should expect: a client is instructed foods! Regarding treatment for enterobiasis require the placement of internal monitors such as fetal electrodes! Assessment to reveal be Clear teaching the client with hemophilia has a nosebleed footling presentation! Method is used primarily to heal the fractured hips performance of amniotomies and improve outcomes a. prostaglandin,. Preparing for administration of a 2-year-old the emergency room regarding treatment for enterobiasis and improve outcomes have diaphragm! Uterine pressure catheters for administration of a cervical ripening agent heal the fractured hips birth experience most appropriate feeling you! Msc: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive:. Wears gloves while giving the child diagnosed with celiac disease are every mins... Demerol ) 75mg IV push the fundus is assessed by `` walking fingers... Care for the disease Brethine ) to a pregnant woman to prevent Preterm labor which interventions could a apply. To hold the baby suffers permanent heart and brain damage we might users... For initiating therapy to stop labor procedure, the nurse no need for further assessment made to provide clarity. C Amniotic fluid is watery and pale green the labor and delivery unit client experiences hypotension, the will! Comes to the labor and birth apply to help stimulate contractions new parents need time to separate section. Fluid is watery and pale green those who have vaginal births 6-year-old client is admitted to midline! Strategies for enhancing care coordination and communication to enhance the performance of and.

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