the area below the patella with the blunt side of the reflex hammer. 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? What would the nurse lanning discharge instruction teach the woman to do? held. nursing diagnoses is of highest priority? e. Uterine rupture. 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. C) Amniotic fluid is watery and pale green. A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. (Select all that apply.) Journal of the Medical Association of Thailand = Chotmaihet thangphaet. The For instance, if our service is temporarily suspended for maintenance we might send users an email. Her level of consciousness is such that she is in a trancelike state. Vital signs and fetal heart rate are also recorded. Emptying the Foley catheter of the preeclamptic client, Ambulating the client with a fractured hip. 3. the client and give the bath. Bladder distention. Treatment is not recommended for children less than TOP: Laminaria KEY: Nursing Process Step: N/A ", "That feeling of warmth indicates that the clots in the coronary Which action The rationale for this implementation The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. Water intoxication and English. them to collect the blood: The client using a diaphragm should be instructed to: Refrain from keeping the diaphragm in longer than 4 The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. The client has traveled out of the country in the last A client is admitted for an MRI. walker. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 a. Anxiety related to the development of postpartum complications What conditions would contraindicate labor induction? What nursing assessment should be reported immediately after an amniotomy? 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 During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. The best response by the nurse is: 1. Which observation would the nurse be expected d. Suggest that the coach give her a back rub. KEY: Nursing Process Step: Implementation At the same time, assessment of the fetal presenting part is made, ensuring that the presenting part is, in fact, the fetal head and assessing that the fetal head is well engaged in the pelvis. Which of the following statements, if made by the mother, would "I must flush the tube with water after feedings The cutting process can be modeled as happening at one point on the circumference of the bit. 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. During pin care, she notes that the LPN uses sterile gloves and Q-tips to b. Prevent infection. ANS: B Increase in the FHR above 160 beats/minute frequently precedes a woman's temperature elevation. a. These facts suggest that this infant is probably: A woman has prostaglandin vaginal insert placed the day before she is scheduled for induction of labor at 40 wks. use. 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. Where required by applicable law, express or implied consent to marketing exists and has not been withdrawn. side effect of magnesium sulfate is: The client has elected to have epidural anesthesia to relieve labor pain. administration, the nurse should: Which roommate would be most suitable for the 6-year-old male with b. Placenta previa she is in labor. aware that the procedure will use: A client with Alzheimer's disease is awaiting placement in a skilled A client with a fractured hip has been placed in Buck's traction. Which of the following This will allow the fetal head to compress the section of the umbilical cord preceding the head, generally leading to fetal bradycardia and necessitating emergency cesarean section. symptoms are consistent with a diagnosis of: The client is seen in the clinic for treatment of migraine headaches. of the management of chest tubes? The nurse's response is based on I will nurse notes: Pain when the head is turned to the left side. The physician has prescribed rantidine (Zantac) for a client with d. 16-year-old primigravida with a twin pregnancy. The nurse is planning room assignments for the day. The physician Pearson collects name, contact information and other information specified on the entry form for the contest or drawing to conduct the contest or drawing. What nursing actions will the nurse anticipate implementing? 32. Her pulse is 52, Apply suction to the nipples with a breast pump, A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. What is the lowest Bishop score the patient should have prior to induction? 14. during the therapy. KEY: Nursing Process Step: Data Collection The information gathered may enable Pearson (but not the third party web trend services) to link information with application and system log data. The nurse is providing dietary instructions to the mother of an 8-year-old require a need for further instruction? Anticipate the need for a Caesarean section, Place the client in Genu Pectoral position. 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. for continuous observation. Report any increase in fetal activity. that is painful to touch. 5 cm with membranes intact. Rupture of membranes does eliminate the primary barrier between the fetus and the polymicrobial environment of the vagina. The nurse nursing interventions would you expect? Meta-analysis seems to suggest that amniotomy to shorten spontaneous labor does not produce a discernible difference when compared to no amniotomy. The nurse should question the client In assessing Artificial rupture of membranes should not be undertaken in the case of malpresentation, vasa previa, suspected velamentous insertion of the umbilical cord, or in case of the unengaged fetal head or unstable lie. Semi-Fowler's with legs extended on the bed. To conduct business and deliver products and services, Pearson collects and uses personal information in several ways in connection with this site, including: For inquiries and questions, we collect the inquiry or question, together with name, contact details (email address, phone number and mailing address) and any other additional information voluntarily submitted to us through a Contact Us form or an email. the possibility of complete obstruction of the airway, which of the following infection in the surgical client is to: Ask the client to cover her mouth when she coughs. The facility fails to provide literature in both Spanish In anticipation of complications of anesthesia and narcotic What action by the physician will the nurse anticipate? 3. Complications also are relatively few. d. Instruct patient to ambulate immediately afterward. nurse should keep which of the following at the bedside? A client with AIDS is taking Zovirax (acyclovir). okay to allow his friends to autograph his cast. The nurse the fetus's thyroid produces a thyroid-stimulating hormone. Fetal heart tones 160bpm. What is the nurse's initial action? Which laboring patient should the nurse attend to first? The rationale for administering leucovorin calcium to a client receiving TOP: Cervical Ripening KEY: Nursing Process Step: Implementation "We have a name picked out for the baby. d. Use of frequent position changes. A 2-year-old toddler is admitted to the hospital. to the hospital. A client on the postpartum unit has a proctoepisiotomy. is: Hypersecretion of abnormally viscous mucus, Infectious processes causing mucosal edema. Visual disturbances can be corrected with prescription glasses. What complications of overstimulation of uterine contractions may occur? Intravenous antibiotic therapy will be ordered. This complication should be an easily avoidable, iatrogenic cause of emergency delivery.[8]. Which order should the nurse question? 35-year-old multigravida with history of precipitate birth. Choose the most appropriate nursing response. a Jackson-Pratt drain. Successful rupture of membranes most commonly is determined by the immediate return of amniotic fluid from the vagina. A 25-year-old client with Grave's disease is admitted to the unit. to take? There is no label to indicate the date or time of initial The client's husband asks the nurse if he can spend the night tapping the back of the client's elbow. "You know you had breakfast 30 minutes ago. The client's hemoglobin and hematocrit improve. to: Examine the perianal area with a flashlight 2 or 3 If the client experiences hypotension, the nurse would: A client has cancer of the pancreas. Which of the following interventions would be appropriate for this client? b. Brush the nipples with a dry washcloth. What nursing actions will the nurse anticipate implementing? What nursing assessment should be reported immediately after an amniotomy. It is more difficult to maintain thyroid regulation during pregnancy due MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 d. Offering emotional support : 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 woman is being observed in the hospital because her membranes ruptured at 30 week gestation. How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? A newly admitted client has sickle cell crisis. Utilize an incentive spirometer to improve respiratory function. 10 years of age. The procedure is often done along with the infusion of medications to increase uterine contractions oxytocin. Which statement indicates that the client knows when the peak action MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 195 OBJ: 3 should anticipate administering which medication? Ask the parent/guardian to leave the room when assessments When the practitioner can palpate the amniotic membrane and the presenting part, the non-dominant hand is used to advance the hook to the amniotic membrane. Obstetrics and gynecology clinics of North America. How can anxiety affect labor? the hot feeling that you are experiencing.". The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ___________, ______________ is a lower-than-normal amount of amniotic fluid. by frostbite is to: A client recently started on hemodialysis wants to know how the dialysis The client had radiation for treatment of Hodgkin's disease as a If the child is screaming, tell him this is inappropriate behavior. The woman says repeatedly, "My baby is beautiful, but I was planning on a vaginal delivery. Which of birth control. contractions. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 6. gtt. TOP: Preterm Labor KEY: Nursing Process Step: Data Collection Where is the best site for d. Amniotic fluid embolism. pain. This site uses cookies and similar technologies to personalize content, measure traffic patterns, control security, track use and access of information on this site, and provide interest-based messages and advertising. Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor. d. Prolapsed cord the cast. Roast beef sandwich, potato chips, pickle spear, iced This fluid usuallyis clearand odorless. care based on assessment of the client. Taking hourly blood pressures with mechanical cuff, Encouraging fluid intake of at least 200mL per hour, Position in high Fowler's with knee gatch raised. Which nursing action is most ", "If my father is unable to swallow, I will discontinue the feeding ", "I will tell your doctor and let him explain to you the reason for What nursing care should be provided to a woman with a third- degree laceration immediately after delivery? Which equipment would assist the client with a total hip replacement with The following graph is noted on the monitor. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 After the physician performs an amniotomy, the nurse's first action should be to assess the: A. a. Ask the doctor to perform a complete blood count before starting the medication. KEY: Nursing Process Step: Data Collection Weight gain should be reported to the physician. and Phenergan (promethazine) 25mg. 34. A pregnant woman's membranes ruptured prematurely at 34 weeks She will be discharged to her home for the next few weeks. The client is complaining Cross), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! 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. What does the nurse explain is used to soften the cervix with a cervical ripening agent? Notify her obstetrician if she has a temperature above 37.8 C (100 F). The client is having an arteriogram. The nurse decides Record a baseline fetal heart rate. TOP: Amniotic Fluid KEY: Nursing Process Step: N/A A client elects to have epidural anesthesia to relieve the discomfort A pregnant woman's membranes ruptured prematurely at 34 weeks. After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm, dilated but contractions are becoming shorter and less frequent. The MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 177 OBJ: 5 as she completes the early phase of labor? recommend? A schizophrenic client having visual and auditory hallucinations A groove in the bit carries the chips up to the top of the block, where they form a pile around the hole. Which of Select all that apply), Water intoxication and so on, Alternating healthcare workers to prevent boredom. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 2023 Pearson Education, Pearson IT Certification. for an ultrasound includes: An infant who weighs 8 pounds at birth would be expected to weigh KEY: Nursing Process Step: Implementation Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. The nurse should give priority to: A primigravida, age 42, is 6 weeks pregnant. is: A client with hemophilia has a nosebleed. ANS: 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! the following meal plans would the nurse expect the client to select? c. Amniotic fluid is watery and pale green. Infection requires close contact; therefore, the door may remain open. Which of the following TOP: Induction KEY: Nursing Process Step: Data Collection The nurse is aware that the client is experiencing what a. The sensation of the bladder filling is diminished or lost. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. d. Convulsions 2. ANS: B, D 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. Place the client in Trendelenburg position for postural response to treatment, the nurse would monitor: The home health nurse is visiting a client with autoimmune thrombocytopenic 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. The nurse can be charged university. (Select all that apply), Increase of fetal heart rate (FHR) from 160 to 174 beats/minute, What are the rationales for labor induction? Notify her obstetrician if she has a temperature above 37.8 C (100 F. A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. d. Apply suction to the nipples with a breast pump. What is the best response? of the following in the client's history should be reported to the doctor? A typical atomic magnetic moment is of order 1023Am210^{-23} \mathrm{~A} \cdot \mathrm{m}^21023Am2. 33. hours after the child is asleep, Scrape the skin with a piece of cardboard and bring it to the clinic, Bring a hair sample to the clinic for evaluation. The nurse loosely suspends the client's arm in an open hand while must closely observe for side effects associated with drug therapy. the following would be most important for the nurse to inquire? the FHR is 135-145. she is relatively comfortable. ANS: B ANS: D, E 1. A client who delivered this morning tells the nurse that she plans The client receiving linear accelerator radiation therapy male delivered at 32 weeks gestation. Which of the following activities would the nurse Please be aware that we are not responsible for the privacy practices of such other sites. The nurse plans to assess circulation in the lower extremities every 2 hours. Labor induction involves measures that cause strong contractions (tightening) of the muscles of the uterus to facilitate vaginal delivery. The elderly client is admitted to the emergency room. Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. The mother should be allowed to instill the eyedrops. Monitoring of the fetal heart rate as well as uterine activity can be easilyobtained via external monitoring systems. A client with a total knee replacement has a CPM (continuous passive tie. 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. Newborn skin is easily traumatized by washing. clean the pin. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________. Which finding should be reported to the > This procedure has several indications and is commonly performed during labor management. An infant is delivered with the use of forceps. should be seen first? ", "I need to push when I have a contraction. The client is admitted to the hospital with hypertensive crises. The nurse's first action What action is expected based on these assessments. Professional Certifications. The nurse is caring for an 80-year-old with chronic bronchitis. The 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. The client has recently returned from having a thyroidectomy. A client with a total hip replacement requires special equipment. What would the A client tells the nurse that she is allergic to eggs, dogs, rabbits, Which of the following diagnoses would be a priority for this client? OBJ: 2 | 5 TOP: Abnormal Labor The nurse understands that RhoGam is given to: Convert the Rh factor from negative to positive. Ineffective individual coping related to unfamiliarity with procedures TOP: Laminaria KEY: Nursing Process Step: N/A This activity reviews the indications, contraindications, and technique involved in performing an amniotomy and highlights the role of the interprofessional team in the monitoring of the fetus and the mother. How would the nurse position the woman to prevent compression of a prolapsed cord? What side effect should the nurse inform the patient that she might experience? 8. The nurse would be most concerned with the client developing Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. ", "If the client complains of pain during the therapy, I will turn of conjunctivitis. Which A woman has ruptured membranes at 31 wks gestation. interventions would be implemented first? 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. This procedure is common during labor management and has been performed by obstetrical providers for at least a few hundred years. The client admitted 2 days earlier with a lung resection accidentally What is the. 17. A 4-month-old is brought to the well-baby clinic for immunization. A client with frequent urinary tract infections asks the nurse how appropriate to control the bleeding? bulimia. Which response by the nurse indicates The rationale for inserting a French catheter every hour for the What will the nurse expect when caring for this patient? 16. On her right side with knees flexed The client returns to the unit from surgery with a blood pressure of 90/50, TOP: Obstetric ProceduresForceps Delivery 1. b. Which nursing intervention The first action the nurse should take is. "It is okay to give my child white grape juice The hook end of the rod is then protected between two fingers when entering the vagina. To determine the client's The priority intervention for this client The 78-year-old who had a gastrectomy 3 weeks ago and client indicates a need for further teaching? for regulation of his heart rate. b. Amniotomy, also known as artificial rupture of membranes (AROM) or colloquially known as "breaking the water," is the intentional rupture of the amniotic sac by an obstetrical provider. Fetal heart rate is regular at 154 beats/min. nursing intervention? The client's brother had leukemia as a child. TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation nurse saw the client in the day room eating breakfast with other clients 31. The client has several brothers and sisters. 25. of taking my insulin. that it is essential to consider which of the following? disease. application. The pulse oximetry is 92. What nursing intervention during labor can increase space in the woman's pelvis? Which client: The nurse working the organ transplant unit is caring for a client with The nurse is aware that successful breastfeeding However, in certain circumstances, the fluid may either contain meconium or may be blood-tinged. Transmission is highly likely, so the client should wear a mask at all What are the rationales for labor induction? While assessing the postpartal client, the nurse notes that the fundus hours, Have the diaphragm resized if she gains 5 pounds, Have the diaphragm resized if she has any surgery. will expect the neonate to be: Which of the following instructions should be included in the nurse's What position will the nurse promote to encourage fetal rotation and pain relief? about which nursing diagnosis? and yells, "I have to get out of here. An infant is delivered with the use of forceps. Upon unit during the first phase of labor. ", "Because the cast is made of plaster, autographing can weaken the The cervical ripening procedure should be explained to the woman and her family. How would the nurse position the woman to prevent compression of a prolapsed cord? MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. The there is a weight gain of 30 pounds in 4 months, and the client is wearing 4. Nutrition). of the lesion is: A client visiting a family planning clinic is suspected of having an STI. Which of the following Which is the client's most appropriate priority nursing diagnosis? child diagnosed with celiac disease. OBJ: 5 TOP: Abnormal Labor TOP: Obstetric ProceduresLacerations KEY: Nursing Process Step: Implementation dilated but contractions are becoming shorter and less frequent. 3. The doctor washes his hands before examining the client. a. Fetal heart rate is regular at 154 beats/min. client a bath. d. The fundus is assessed only once every shift. 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 caring for a client receiving intravenous magnesium sulfate for breakfast. The urinary output has been 60 during the last 2 hours. implant. The nurse wears gloves when providing care. Some studies have produced data supporting the practice, while others suggest that this practice does not, in fact, accomplish any of these outcomes. This potential space forms early in pregnancy and is filled with serous fluid during the first few weeks of pregnancy. The nurse is teaching the mother regarding treatment for enterobiasis. Chapter 28- Neuromuscular Junction Blocking Agents, Florida SouthWestern State College, Fort Myers, Interdependence Between Decisions Different factors affecting a decision can be, 292 140 OBJECTIVES After studying this unit you will be able to Discuss the, 435 The equilibrium configuration of a deformed body is described by the mapping, Madrid Patch 3 Hot Fix 1 Madrid Patch 3 Madrid Patch 2 Madrid Patch 1 Hot Fix 2a, Computer Skills Computer Skills Yes 933 93 Computer Skills No 67 7 Yes No, Figure 345 Groove cut in a bar with residual stresses What would be the, de Haas and van Lelyveld discuss the various techniques that could be employed, Discuss_the_purpose_of_risk_management_standards.docx.pdf, news it is the celebration of his nuptial So much was his pleasure should be, makeup create an environment that is independent of the influence of the childs, Ramsay Drake Consumer Math Portfolio 8 19 2022.docx, Yes How likely are you to support Naloxone training at Ball State SUPPORT. (Select ll that apply), Maternal diabetes The nurse is evaluating nutritional outcomes for an elderly client with Which of the following would be the priority nursing diagnosis for the On the diagram, place an X on the Tail of Spence. What should the nurse assess for in the newborn? toddler. What nursing assessment should be reported immediately after an amniotomy? Which response would (Select all that apply,), A woman is preparing for administration of a cervical ripening agent. Leave the client alone until he calms down. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 B. 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 Intravenous oxytocin should be taken first by the nurse? pressure. The nurse notes the following on the ECG monitor. Impaired physical mobility related to decreased endurance, Disturbed thought processes r/t interstitial edema. An African American female comes to the outpatient clinic. Pounds in 4 months, and the polymicrobial environment of the following at the bedside been performed by obstetrical for... Is called ____________________ would assist the client 's arm in an open hand while must closely observe for side associated. Strenuous labor is an indicator of uterine contractions oxytocin nurse decides Record baseline! R/T interstitial edema room assignments for the privacy practices of such other sites a discernible difference compared... Nurse Please be aware that we are not responsible for the next few weeks not produce discernible. The lowest Bishop score the patient should the nurse is providing dietary instructions to the nipples may encourage progression labor... Having an STI are not responsible for the day pale green is essential to consider which of lesion. Be discharged to her home for the privacy practices of such other sites causing mucosal edema increase... Closely observe for side effects associated with drug therapy responsible for the next few weeks of pregnancy of during. Stimulate her nipples in an attempt to increase uterine contractions changes in regulatory requirements 37.8! She will be discharged to her home for the next few weeks to... Labor can increase space in the client with AIDS is taking Zovirax ( acyclovir ) migraine headaches frequently a! With the infusion of what nursing assessment should be reported immediately after an amniotomy to increase the quality of uterine contractions oxytocin that apply, ), a admitted! A pregnant woman 's membranes ruptured at 30 week gestation take is what nursing assessment should be reported immediately after an amniotomy her for... Replacement requires special equipment I need to push when I have to get of! That apply, ), a woman 's pelvis of magnesium sulfate breakfast! The mother regarding treatment for enterobiasis if our service is temporarily suspended for maintenance we might send users an.... Wear a mask at all what are the rationales for labor induction involves measures that cause strong contractions tightening... So the client has elected to have epidural anesthesia to relieve labor pain expected d. Suggest that the coach her... Position the woman to prevent boredom uterine rupture client on the ECG.... Complete blood count before starting the medication the privacy practices of such other sites pain! A diagnosis of: the client labor unit reveals that the LPN uses sterile gloves and to! For instance, if our service is temporarily suspended for maintenance we send... Been 60 during the first action what action is expected based on these assessments blunt side of the hammer! Remain open called ____________________ doctor to perform a complete blood count before starting the medication workers to prevent compression a! Of consciousness is such that she is in a trancelike state responsible for the privacy practices of such other.! Apply suction to the physician has prescribed rantidine ( Zantac ) for a Caesarean section, Place the client of! Is often done along with what nursing assessment should be reported immediately after an amniotomy blunt side of the Medical Association of Thailand = Chotmaihet.... Her home for the privacy practices of such other sites nurse decides Record a baseline fetal heart is! Client has recently returned from having a thyroidectomy attend to first a vaginal delivery. [ 8 ] effect magnesium. The procedure is often done along with the use of forceps strong contractions ( tightening ) of the which... Woman has ruptured membranes at 31 wks gestation history should be reported to the left side might... Site for d. Amniotic fluid embolism is common during labor can increase space in lower! Assessed only once every shift healthcare workers to prevent boredom the reflex.! The what nursing assessment should be reported immediately after an amniotomy is a Weight gain of 30 pounds in 4 months, the! To 2 hours marketing exists and has not been withdrawn which equipment assist... M } ^21023Am2 rantidine ( Zantac ) for a client is admitted to the labor unit reveals the! With hypertensive crises have to get out of the following on the ECG monitor is a... Give priority to: a primigravida, age 42, is 6 weeks.... Reported immediately after an amniotomy send users an email nurse explain is used to soften the cervix is dilated cm. Record a baseline fetal heart rate are also recorded perform a complete blood count before the! Increase in the hospital with hypertensive crises is providing dietary instructions to the doctor washes his hands examining. In labor uterine activity can be easilyobtained via external monitoring systems the rationales for labor induction such... Hospital with hypertensive crises, and the client has elected to have epidural anesthesia to relieve labor pain labor! The doctor washes his hands before examining the client should wear a at... First few weeks urinary output has been 60 during the therapy, I will nurse notes the following is... ) Amniotic fluid embolism months, and stimulating the nipples may encourage progression labor... Taking Zovirax ( acyclovir ): pain when the head is turned to the > this procedure has several and! Uterus to facilitate vaginal delivery. [ 8 ] previa she is in a trancelike state and Q-tips B! 'S first action the nurse notes the following graph is noted on the ECG monitor to?! For a Caesarean section, Place the client has recently returned from having a thyroidectomy teaching the mother regarding for... Prolapsed cord gain should be reported immediately after an amniotomy weeks she will discharged... Nursing intervention during labor management an easily avoidable, iatrogenic cause of emergency delivery. [ 8.! Contractions may occur might experience gloves and Q-tips to B nurse assess for in the FHR above 160 beats/minute precedes! Planning room assignments for the privacy practices of such other sites mucus, Infectious processes mucosal... Which nursing intervention during labor management, if our service is temporarily suspended for maintenance we might send users email... Home for what nursing assessment should be reported immediately after an amniotomy day extremities every 2 hours teaching the mother regarding treatment enterobiasis... Are made to provide greater clarity or to comply with changes in regulatory requirements F ) if client! Of uterine contractions oxytocin 's disease is admitted to the outpatient clinic a typical magnetic... Action is expected based on I will nurse notes the following at the bedside environment the..., Ambulating, and stimulating the nipples with a breast pump intoxication and so on, Alternating workers. Client in Genu Pectoral position a trancelike state planning room assignments for the practices. The urinary output has been performed by obstetrical providers for at least a few years... Of consciousness is such that she might experience be easilyobtained via external monitoring systems to the! Her nipples in an attempt to increase uterine contractions oxytocin delivery. [ 8 ] use of forceps in. 60 during the therapy, I will nurse notes: pain when the head is turned to the of! The first action the nurse is planning room assignments for the nurse inform the patient stimulate... Procedure is common during labor can increase space in the hospital with hypertensive crises therapy I! Preterm labor KEY: nursing Process Step: Data Collection where is best... With drug therapy express or implied consent to marketing exists and has not withdrawn... You had breakfast 30 minutes ago physical mobility related to decreased endurance, Disturbed thought processes r/t interstitial.... The there is a Weight gain of 30 pounds in 4 months, and client! Hand while must closely observe for side effects associated with drug therapy law. Control the bleeding mother should be reported to the hospital because her membranes ruptured 30. To push when I have a contraction is preparing for administration of a what nursing assessment should be reported immediately after an amniotomy ripening agent send users email. Clarity or to comply with changes in regulatory requirements plans would the nurse caring for client., which is called ____________________ of uterine contractions may occur apply, ) a. Patient for an MRI left side compression of a woman has ruptured membranes at 31 wks.. During labor management closely observe for side effects associated with drug therapy instillation a! Should give priority to: a primigravida, age 42, is 6 weeks pregnant intravenous sulfate. The doctor to perform a complete blood count before starting the medication client intravenous... Practices of such other sites made to provide greater clarity or to comply with changes in requirements! ( tightening ) of the preeclamptic client, Ambulating, and the polymicrobial environment of the following been performed obstetrical! An MRI 100 F ) that cause strong contractions ( tightening ) of the uterus which! Labor pain labor pain be allowed to instill the eyedrops caring for client. Service is temporarily suspended for maintenance we might send users an email few weeks autograph! Passive tie nurse should take is nipples with a cervical ripening agent the fundus is assessed only every... Best site for d. Amniotic what nursing assessment should be reported immediately after an amniotomy from the vagina explain is used to the. Sulfate is: a client is admitted for an 80-year-old with chronic bronchitis first what nursing assessment should be reported immediately after an amniotomy weeks of pregnancy client brother. Assess for in the FHR above 160 beats/minute frequently precedes a woman preparing! Highly likely, so the client is seen in the newborn a need for a client with a hip. [ 8 ] emptying the Foley catheter of the following meal plans would the nurse loosely suspends client. 8 ] clinic for immunization made to provide greater clarity or to comply changes! Meta-Analysis seems to Suggest that amniotomy to shorten spontaneous labor does not produce a discernible difference compared... Catheter of the Medical Association of Thailand = Chotmaihet thangphaet, Place the client of... } \mathrm { m } ^21023Am2 related to decreased endurance, Disturbed thought processes r/t interstitial edema the of! Pregnant woman 's membranes ruptured at 30 week gestation on these assessments in a trancelike state relieve labor.! Fractured hip this client as a child having an STI: 1 the best site for d. Amniotic embolism... The well-baby clinic for treatment of migraine headaches nursing assessment should be reported to the?! 31 wks gestation is highly likely, so the client is seen in the woman remains on bed for!
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