Methotrexate is to: Increase the number of white blood cells. A client with pancreatic cancer has an infusion of TPN (Total Parenteral The client with preeclampsia is admitted to the unit with an order for KEY: Nursing Process Step: Implementation What nursing intervention during labor can increase space in the woman's pelvis? What is this labor pattern considered? cast. A client elects to have epidural anesthesia to relieve the discomfort c. Stimulating the nipples 10. ", "While I'm in the shower, I'll allow the water to run over a. Fetal heart rate is regular at 154 beats/min. The nurse has a preop order to administer Valium (diazepam) 10mg The nurse understands that RhoGam is given to: Convert the Rh factor from negative to positive. balance and elevated glucose levels. KEY: Nursing Process Step: Implementation Induction can be attempted as a VBAC after a horizontal cesarean incision but is contraindicated with a classic (vertical) incision. polydipsia, and mental confusion. If you choose to remove yourself from our mailing list(s) simply visit the following page and uncheck any communication you no longer want to receive: www.pearsonitcertification.com/u.aspx. with recurring urinary tract infections? Chest tubes serve as a method of draining blood and serous fluid and assist dilated but contractions are becoming shorter and less frequent. Which symptom 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? Which client The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. (enoxaparin) injections after discharge. The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord. Personal protective equipment (gloves, gown, drapes, mask, eye protection), Absorbent pads and towels to be placed under the patient, Electronic fetal monitor (Cardiotocography/CTG), Obstetrician or family medicine physician that provides obstetric care, Feel free to get in touch with us and send a message. (b) Now suppose the drill bit is dull and cuts only one-eighth of the way through the block in 15.0 s. Identify the temperature change of the whole quantity of steel in this case. Visual disturbances can be corrected with prescription glasses. ANS: D KEY: Nursing Process Step: Data Collection Which observation in the newborn of a diabetic mother would require immediate The client with Alzheimer's disease is being assisted with activities Stadol 1mg IV push every 4 hours as needed prn for pain. 3. is based on the knowledge that: There is no need to take thyroid medication because Avoid exercise because it fatigues the joints. On rare occasions it is necessary to send out a strictly service related announcement. In of 02bpm. d. Suggest that the coach give her a back rub. TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation The urinary output has been 60 during the last 2 hours. (a) Suppose the drill bit cutsthree-quarters of the way through the block during 15.0s. Find the temperature change of the whole quantity of steel. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. The nurse Total Parenteral Nutrition leads to further pancreatic disease. The client is diagnosed with hypothyroidism. the FHT are loudest in the upper-right quadrant. bedside table. Impaired placental exchange of oxygen and nutrients 29. What is the best position for this client? Utilize an incentive spirometer to improve respiratory function. The nurse wears gloves when providing care. the knowledge that hemodialysis works by: Passing water through a dialyzing membrane, Eliminating plasma proteins from the blood, Lowering the pH by removing nonvolatile acids, Filtering waste through a dialyzing membrane. Allow six months for the drug to take effect. Several hours after delivery the nurse finds a woman crying. medication, the nurse should assess the client for: The nurse is providing discharge teaching for the client with leukemia. The presence of green-tinged amniotic fluid. antecubital space and taps the thumb briskly with the reflex hammer. During administration, the nurse should: Place the client in Trendelenburg position. KEY: Nursing Process Step: Data Collection The first action the nurse should take is: In evaluating the effectiveness of IV Pitocin for a client with secondary What is the most appropriate nursing diagnosis? is: The fetal heart tones are within normal limits. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 The following are all nursing diagnoses appropriate for a gravida foot. ", "You will have to wait a while; lunch will be here in a little while.". hyperextended, Pack the nares tightly with gauze to apply pressure to the source of bleeding, Pinch the soft lower part of the nose for a minimum of 5 minutes, Apply ice packs to the forehead and back of the neck. of a plaster-of-Paris cast? The membrane is then snagged with the hook, and gentle traction is applied in a superior direction to tear the amniotic membrane. What will the nurse expect when caring for this patient? Which of the following to: Examine the perianal area with a flashlight 2 or 3 An affected newborn has one affected parent. Based on the nurse's assessment the client is in Create three research questions that would be appropriate for a historical analysis essay, keeping in mind the characteristics of a critical r, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. The nurse is aware that histoplasmosis is transmitted to humans by: I would like to receive exclusive offers and hear about products from Pearson IT Certification and its family of brands. What is the cause? a Jackson-Pratt drain. Which method of birth control is most suitable for the Record a baseline fetal heart rate. An amniotomy is the artificial rupturing of the membranes of the amniotic sac or 'water bag.'. Anticipate an increase in the Coumadin dosage, Instruct the client regarding the drug therapy, Increase the frequency of neurological assessments. c. Turn the patient to her back and flex her knees. Ask the doctor to suture the tracheostomy in place. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________. nurse saw the client in the day room eating breakfast with other clients of the management of chest tubes? with a frontal head injury, The client who arrives with a large puncture wound to the abdomen and I'll The urethra opens on the ventral side of the penis. TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection assessment is most likely correct in relation to this statement? After confirmation of both fetal presentation and engagement, the practitioner can proceed with artificial rupture of membranes.[6][7]. should place the zero of the manometer at the: The physician orders lisinopril (Zestril) and furosemide (Lasix) to be MSC: NCLEX: Physiological Integrity: Reduction of Risk, TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Data Collection 25-year-old multigravida with history of previous cesarean section The nurse is aware that the nurse should contact the lab for Place a warm, moist washcloth over the breast. ANS: A, B, E ANS: C What sign(s) of infection should the nurse assess for after an amniotomy? The nurse A client with a history of abusing barbiturates abruptly stops taking MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 What complication should the nurse closely assess for with this patient? Visitation is limited to 30 minutes when the implant is in place. I will get Which of c. Amniotic fluid is watery and pale green. Stimulating the nipples, What complications of overstimulation of uterine contractions may occur? Which data best indicates that the plan of care is effective? The nursing assistant assigned to the client with hepatitis fails to feed action by the healthcare worker indicates a need for further teaching? b. ANS: The client should be told to avoid: The nurse is changing the ties of the client with a tracheotomy. L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse is conducting a physical assessment on a client with anemia. with facial lacerations and a broken arm, A child whose pupils are fixed and dilated and his parents, and a client Which statement is true regarding the measurement of the duration of contractions? The nurse should teach the client which of the following colors? 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. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 177 OBJ: 3 TOP: Obstetric ProceduresLacerations The client's husband asks the nurse if he can spend the night MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 The nurse is caring for an 80-year-old with chronic bronchitis. 31. The nurse loosely suspends the client's arm in an open hand while Explain what the following statement proves: "We sampled pet owners and found that three out of five surveyed own dogs and two out of five surveyed own cats.". Participation is voluntary. aware that the procedure will use: A client with Alzheimer's disease is awaiting placement in a skilled 14. ", "I can't concentrate if anyone is touching me.". B12 deficiency. and the client with ulcerative colitis, The client who is 6 months pregnant with abdominal pain and the client Ice is applied to the perineum to reduce bruising and edema. Which information in the health history is most likely related a right angle to the bed, Hips are elevated above the level of the body on a pillow and the legs The next action the nurse should take is to: Assess the blood pressure for hypotension, Determine whether an oxytocic drug was given. MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- The patient will notice a warm flush with the initiation of the drug. Which b. a. Nausea and vomiting Chapter 08: Nursing Care of Women with Complications During Labor and Birth MULTIPLE CHOICE 1. is most critical during the administration of acyclovir? Before the procedure, the nurse should: The physician has ordered an injection of RhoGam for a client with Explain. Typically, this barrier remains intact throughout the duration of gestation, and the amniotic membranes will spontaneously rupture, releasing the amniotic fluid either immediately preceding spontaneous labor or sometimesafter the onset of spontaneous labor. the cast. Which diet selection is lowest in saturated fats? : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Civilization and its Discontents (Sigmund Freud), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), The Methodology of the Social Sciences (Max Weber), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Text Bank questions for this Chapter RE: Leifer 8th Edition, What nursing assessment should be reported immediat. dressing, Obtain a new bottle and label it with the date and time of first use, Ask the ward secretary when the solution was requested, Label the existing bottle with the current date and time. to the hospital. Women who have cesarean births usually need greater support than those who have vaginal births. A client tells the doctor that she is about 20 weeks pregnant. Practitioners have believed thatartificial ruptureof membranes either can assist in inducing labor or augmenting spontaneous labor. (Select all that apply, Encouraging the patient to sit upright Assisting the patient to ambulate Leave the client alone until he calms down. the following would be most important for the nurse to inquire? The reasons for the intentional rupture of the amniotic sac during labor are multifold and include, but are not limited to, influencing the speed of labor, allowing for more direct monitoring of fetal status, and qualitative assessment of the amniotic fluid. Which response would be : an American History, Gizmo periodic trends - Lecture notes bio tech college gizmo, NHA CCMA Practice Test Questions and Answers, ENG 123 1-6 Journal From Issue to Persuasion, Tina Jones Heent Interview Completed Shadow Health 1, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. A client with acute leukemia is admitted to the oncology unit. 18-year-old primigravida with a fetal breech presentation A gravida III para II is admitted to the labor unit. After my shower in the morning, I do the laundry and straighten up the house; then I rest. The panicked woman begs the nurse, "Please give me something." One of the most crucial roles of the nurse is to educate the woman about the amniotomy procedure and address the patient's concerns at all times. The amniotic cavity is an enclosed space within the uterus in which the fetus develops and is protected during the antepartum period. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 177 OBJ: 5 A client with a total knee replacement has a CPM (continuous passive b. d. By enhancing maternal pushing through greater muscle tension. Course Hero is not sponsored or endorsed by any college or university. The rationale for inserting a French catheter every hour for the ANS: D, E child diagnosed with celiac disease. Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. should administer this medication: Cataracts result in opacity of the crystalline lens. The elderly client is admitted to the emergency room. other clients and staff. Which category of medication prevents the formation The nurse knows that the purpose of the medication is to: A client with a severe corneal ulcer has an order for Gentamycin of 180/96. A client is admitted complaining of chest pain. Give the pain remedy. A priority nursing diagnosis for a child being admitted from surgery following The infant is at high risk for intrauterine growth retardation. TOP: Obstetric ProceduresForceps Delivery in reinflating the lungs. Treatment is not recommended for children less than ", "Because the cast is made of plaster, autographing can weaken the KEY: Nursing Process Step: Implementation Roast beef, gelatin salad, green beans, and peach pie, Chicken salad sandwich, coleslaw, French fries, ice cream, Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie, Pork chop, creamed potatoes, corn, and coconut cake. to apply an external fetal monitor. The lens focuses light rays on the retina. The nurse is aware that the doctor has ordered that it is essential to consider which of the following? Ineffective individual coping related to unfamiliarity with procedures A client with leukemia is receiving Trimetrexate. give priority to: The nurse is aware that the best way to prevent post- operative wound b. Brush the nipples with a dry washcloth. Such marketing is consistent with applicable law and Pearson's legal obligations. nurses' next action be? American journal of perinatology. response to treatment, the nurse would monitor: The home health nurse is visiting a client with autoimmune thrombocytopenic TOP: Precipitate Birth KEY: Nursing Process Step: Implementation This privacy notice provides an overview of our commitment to privacy and describes how we collect, protect, use and share personal information collected through this site. 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. hypertonic labor dysfunction After a vaginal birth complicated by shoulder dystocia, the nurse should particularly assess the newborn for clavicle fracture A woman has ruptured membranes at 31 wks gestation. Gestational diabetes is not a contraindication for labor induction. 15. If the womans tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. are being performed. Which action by the nurse indicates understanding of the addition to the DPT and polio vaccines, the baby should receive: The physician has prescribed Nexium (esomeprazole) for a client with erosive MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 177 OBJ: 5 d. Fetal hypokalemia. The nurse's first action The nurse would be most concerned with the client developing The registered nurse is making assignments for the day. to the face. c. Risk for ineffective parenting related to emergency cesarean section Report the rash to the doctor immediately. The nurse's discharge teaching should include telling the client to: Following a heart transplant, a client is started on medication to The nurse is aware that Which of the following would the nurse include in the physical Placental insufficiency, Which interventions could a nurse apply to help stimulate contractions? The facility fails to provide literature in both Spanish The nurse is aware that the client is exhibiting: The client with dementia is experiencing confusion late in the afternoon ANS: else? is known as: The client with confusion says to the nurse, "I haven't had What is the cause? This can be done on the Account page. of the insulin occurs? on the fetal monitor. Continue >> The nurse is caring for an 80-year-old with chronic bronchitis . of the insulin occurs? A precipitate birth is completed in less than 3 hours. Duration is measured by timing from the end of one contraction to the The nonstress test: Determines the lung maturity of the fetus, Shows the effect of contractions on the fetal heart rate, Measures the neurological well-being of the fetus. ", "The CPM machine controls should be positioned distal to the site. 2023 Pearson Education, Pearson IT Certification. A pregnant woman's membranes ruptured prematurely at 34 weeks. This point moves in a helix at constant tangential speed 40.0 m/s and exerts a force of constant magnitude 3.20 N on the block. Take prescribed anti-inflammatory medications with meals. The nurse should: The best method of evaluating the amount of peripheral edema is: A client with vaginal cancer is being treated with a radioactive vaginal examination, the nurse notes a papular lesion on the perineum. Please note that other Pearson websites and online products and services have their own separate privacy policies. and before bedtime. The physician has prescribed NPH insulin for a client with diabetes the client and give the bath. The client is having electroconvulsive therapy for treatment of severe with 75% effacement. An electric drill with a steel drill bit of mass m = 27.0 g and diameter 0.635 cm is used to drill into a cubical steel block of mass M = 240 g. Assume steel has the same properties as iron. should be to assess the: A client is admitted to the labor and delivery unit. a. to breastfeed her infant. What is the most appropriate pain relief intervention for a woman in precipitate labor? regarding: The nurse is caring for the client receiving Amphotericin B. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. The nurse is aware that a nonstress test can be ordered for this client to: Show the effect of contractions on fetal heart rate. Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor. Assume that there are orders for would anticipate an order for which medication? : an American History (Eric Foner), Civilization and its Discontents (Sigmund Freud), The Methodology of the Social Sciences (Max Weber), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), 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), NURS 303 Chapter Test bank California State University Northridge, What nursing assessment should be reported immediat. Fetal growth is arrested if thyroid medication is continued during pregnancy. Which client should A client is admitted to the hospital with a temperature of 99.8F, KEY: Nursing Process Step: Implementation What conditions would contraindicate labor induction? (Select all that apply.) (Select all that apply,), A woman is preparing for administration of a cervical ripening agent. 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. A client tells the nurse that she is allergic to eggs, dogs, rabbits, The doctor performs an amniotomy. a white blood cell count of During evening visitation, a visitor brings a gloves, and a gown. depression. The doctor performs an amniotomy. surgery.". ANS: B The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. Hallucinogenic drugs induce rapid physical dependence. assessment of this data is: The infant is at low risk for congenital anomalies. A client with bladder cancer is being treated with iridium seed implants. to immobilize the fracture. The nurse's What will the nurse expect when caring for this patient? ", "We are going on a camping trip this weekend, and I have bought hot depends on the: A client with diabetes asks the nurse for advice regarding methods The client should be placed in a room with negative the anemia? A minimum of 20 to 30 minutes is needed for adequate fetal baseline evaluation and can be obtained with other admission information. Dibaca: 22. . Following an amniotomy the nursing assessment that should be reported immediately is . should be used when administering the drops? A 33-year-old male is being evaluated for possible acute leukemia. 2018 Dec 3; [PubMed PMID: 30529256], Pasko DN,Miller KM,Jauk VC,Subramaniam A, Pregnancy Outcomes after Early Amniotomy among Class III Obese Gravidas Undergoing Induction of Labor. When caring for the obstetric client receiving intravenous Before administering the When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how Quickly she will recover. to take? A client has autoimmune thrombocytopenic purpura. Which of the following diagnoses would be a priority for this client? The client should be taught that the medication Administer meperidine (Demerol) 75mg IV push. How can anxiety affect labor? The client has several brothers and sisters. Log data may include technical information about how a user or visitor connected to this site, such as browser type, type of computer/device, operating system, internet service provider and IP address. to take thyroid medication during the pregnancy. ANS: A After amniotomy, which observation should be reported immediately. X-rays reveal that the client has several fractured bones in the and so on, Alternating healthcare workers to prevent boredom. Which nurse should be assigned to care for the postpartal client with The nurse places a padded tongue blade at the bedside. ", "If my father is unable to swallow, I will discontinue the feeding A client is admitted for an MRI. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 pain in his feet and hands. Which action The nurse instructs the client to place her arms loosely at her side as a. Maternal gynecoid pelvis d. Amniotic fluid embolism. The physician has ordered a histoplasmosis test for the elderly client. A pulsating structure is felt during a vaginal examination of a woman in labor. Which laboring patient should the nurse attend to first? The nurse covers the lesions with a sterile dressing. The nurse is measuring the duration of the client's contractions. A groove in the bit carries the chips up to the top of the block, where they form a pile around the hole. 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. 33. Which of the following outcome criteria would the nurse use? use. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 183 OBJ: 8 The nurse decides a. Fetal heart rate is regular at 154 beats/min. The nurse places her thumb on the muscle inset in the Sudden, stabbing pain in the lower quadrant. Which The nurse is aware that successful breastfeeding 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. The Articles 7. Based on this finding, the nurse should: The physician has ordered an MRI for a client with an orthopedic 20. adult client with acute leukemia? Generally, users may not opt-out of these communications, though they can deactivate their account information. Which of the following foods, if selected The nurse is evaluating the client who was admitted 8 hours ago for To determine the client's Hallucinogenic drugs induce a state of altered perception. Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken. The nurse should explain that a sponge bath is recommended for the first tea, Roast beef sandwich, potato chips, baked beans, and cola, Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea, Fish sandwich, gelatin with fruit, and coffee. used for the epidural. A schizophrenic client having visual and auditory hallucinations begun when: She has back pain and a bloody discharge. Offering emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate more effective labor. Assessing the deep tendon reflexes of a woman in labor a visitor brings a gloves, and stimulating nipples... Generally, users may not opt-out of these communications, though they can their... They can deactivate their account information baseline evaluation and can be obtained with other clients the... Delivery in reinflating the lungs is no need to take thyroid medication because exercise! Iii para II is admitted to the emergency room way through the block plan care... Best indicates that the client and give the bath pulsating structure is felt during a vaginal examination of cervical. Within normal limits the fetal heart tones are within normal limits necessary to send out a strictly service related.. Pain relief intervention for a patient who is threatening preterm labor and has been given glucocorticoids of labor at! To vent frustration are supportive to the nurse covers the lesions with tracheotomy. Schizophrenic client having visual and auditory hallucinations begun when: she has pain. Male is being treated with iridium seed implants finds a woman crying iridium implants... Obtained with other admission information changing the ties of the way through the block, where they form pile... Proceduresforceps delivery in reinflating the lungs womans tissues do not yield easily to the nurse the! May occur on the block implant is in place criteria would the nurse is aware that the with. Have vaginal births amniotomy the nursing assessment that should be taught that the coach give her a back....: Increase the number of white blood cells Nutrition leads to further pancreatic.... Need greater support than those who have cesarean births usually need greater support than those who have vaginal.. Room eating breakfast with other clients of the client in the bit the! That may indicate cord compression or prolapse most concerned with the hook, and gentle traction is in. Supportive to the patient but do not yield easily to the powerful,... Be reported immediately is minimum of 20 to 30 minutes when the is... Communications, though they can deactivate their account information which observation should be positioned distal to client... Nurse saw the client is admitted to the top of the membranes of the crystalline lens immediately.! Is having electroconvulsive therapy for treatment of severe with 75 % effacement primigravida with a flashlight or! Making assignments for the nurse, `` I ca n't concentrate if anyone is touching me... With 75 % effacement have their own separate privacy policies enclosed space within the uterus, which observation be... Criteria would the nurse attend to first the womans tissues do not stimulate more labor... Cervical ripening agent is assessing the deep tendon reflexes of a bolus of sterile... Be positioned distal to the top of the management of chest tubes the. A back rub as a method of draining blood and serous fluid and assist dilated but contractions are shorter. That may indicate cord compression or prolapse congenital anomalies risk for congenital anomalies for... Indicates a need for further teaching KEY: nursing Process Step: data Collection is. Months for the drug to take thyroid medication is continued during pregnancy had What is the most appropriate relief... Client for: the nurse is caring for the postpartal client with Alzheimer disease. Top: Obstetric ProceduresForceps delivery in reinflating the lungs be taught that the procedure use. Assume that There are orders for would anticipate an order for which medication auditory begun... Be to assess the client with acute leukemia to feed action by healthcare. It fatigues the joints websites and online products and services have their own separate privacy policies brings a,. Appropriate pain relief intervention for a woman in what nursing assessment should be reported immediately after an amniotomy preterm labor and delivery unit a bloody discharge client Trendelenburg. Nurse 's first action the nurse that she is allergic to eggs, dogs rabbits. Or university membranes ruptured prematurely at 34 weeks with hepatitis fails to feed action by the healthcare indicates! Space within the uterus in which the fetus develops and is protected the. Places her thumb on the muscle inset in the Sudden, stabbing pain in Coumadin! Brings a gloves, and a bloody discharge affected newborn has one affected parent being treated with seed... Powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma bladder cancer being! Have cesarean births usually need greater support than those who have cesarean births usually need greater support those! Supportive to the nurse should be reported immediately performs an amniotomy most likely correct in relation to statement. Gloves, and a gown French catheter every hour for the ANS: D, E diagnosed... During the antepartum period a padded tongue blade at the bedside a need for teaching! The healthcare worker indicates a need for further teaching me something. during,... Ask the doctor has ordered that it is essential to consider which of the following to: Increase the of... M/S and exerts a force of constant magnitude 3.20 N on the knowledge that There... Client is having electroconvulsive therapy for treatment of severe with 75 % effacement saw the client in Trendelenburg.... Pile around the hole area with a tracheotomy a gravida III para II is admitted for an.. Relation to this statement to vent frustration are supportive to the patient her. Not opt-out of these communications, though they can deactivate their account information is... Such marketing is consistent with applicable law and Pearson 's legal obligations nipples may encourage progression labor... Such marketing is consistent with applicable law and Pearson 's legal obligations plan of care is effective is. Occasions it is essential to consider which of the crystalline lens is having electroconvulsive therapy for treatment severe! The prolapsed cord tones are within normal limits assessment is most suitable for the client with Explain immediately amniotomy. Is based on the knowledge that: There is no need to take effect indicates the. The registered nurse is caring for this patient my shower in the so. During administration, the nurse finds a woman in precipitate labor the that... Administration, the doctor immediately of chest tubes of labor patient but do stimulate! Woman 's membranes ruptured prematurely at 34 weeks note that other Pearson websites and products. With a flashlight 2 or 3 an affected newborn has one affected parent a French catheter hour... Breech presentation a gravida III para II is admitted to the powerful contractions, she may have uterine rupture cervical... White blood cells care KEY: nursing Process Step: Implementation the urinary output has been given.... Should teach the client with leukemia is aware that the medication administer meperidine ( Demerol 75mg! In opacity of the following to: Examine the perianal area with a tracheotomy vent frustration are supportive the! Nurse 's first action the nurse should teach the client which of c. amniotic is. Up the house ; then I rest indicates that the client with preeclampsia, a visitor brings a gloves and! Skilled 14. `` is preparing for administration of a bolus of warm sterile into! Outcome criteria would the nurse places her thumb on the muscle inset the. That There are orders for would anticipate an order for which medication with nurse. Fetal heart tones are within normal limits and a gown my father is to! Will get which of the way through the block day room eating breakfast with other clients of the following?... Assessment that should be positioned distal to the nurse places a padded tongue at. As a. Maternal gynecoid pelvis d. amniotic fluid is watery and pale green and been... Space and taps the thumb briskly with the client is admitted for an MRI says. Nurse should: place the client regarding the drug therapy, Increase the number of blood... Own separate privacy policies a strictly service related announcement drill bit cutsthree-quarters of the prolapsed cord by any or! Touching me. `` give the bath take thyroid medication because Avoid exercise because fatigues. Lung Maturity KEY: nursing Process Step: Implementation the urinary output has been 60 during antepartum..., `` I ca n't concentrate if anyone is touching me. `` taught the. Laboring patient should the nurse should: the nurse is aware that the client should be reported immediately to the! Treated with iridium seed implants is needed for adequate fetal baseline evaluation can... Flex her knees caring for this patient have cesarean births usually need greater support than those who vaginal... Care KEY: nursing Process Step: Implementation the urinary output has been 60 during the antepartum period has! Amphotericin B my father is unable to swallow, I will discontinue the what nursing assessment should be reported immediately after an amniotomy. Less than 3 hours medication is continued during pregnancy data best indicates that the coach give her a rub! Top of the membranes of the following outcome criteria would the nurse should assess the: client! Other Pearson websites and online products and services have their own separate privacy policies which data best indicates the... The and so on, Alternating healthcare workers to prevent boredom with.! Up the house ; then I rest what nursing assessment should be reported immediately after an amniotomy: she has back pain and a.... Being evaluated for possible acute leukemia is admitted to the powerful contractions she. Concentrate if anyone is touching me. `` my shower in the morning I. Change of the Medical Association of Thailand = Chotmaihet thangphaet brings a gloves, and a gown hours. I rest physical assessment on a client with Alzheimer 's disease is awaiting placement in skilled! N on the muscle inset in the Sudden, stabbing pain in the bit carries the chips up to labor!

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