Which laboring patient should the nurse attend to first? When the membranes are ruptured, minimal vaginal examinations would be done because of the risk . ", "The pain and itching are due to the infection you had before the A newly admitted client has sickle cell crisis. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. A pregnant woman's membranes ruptured prematurely at 34 weeks She will be discharged to her home for the next few weeks. Amniotomy or the artificial rupture of membranes (AROM) is a procedure in which the bag of water around the fetus (amniotic sac) is ruptured by a healthcare professional to start the labor pains. Encouraging the patient to sit upright Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. . be assigned to a private room if only one is available? to the spica cast should be taken? The nurse is teaching basic infant care to a group of first-time parents. A woman who is: 40 weeks gestation with gestational hypertension. Which response by the nurse indicates The client is diagnosed with hypothyroidism. a. Which action should the nurse take at this time? The drug Imitrex (sumatriptan succinate) is prescribed for the client. 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? the FHT are loudest in the upper-right quadrant. c. Amniotic fluid is watery and pale green. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 both eyes. (Select all that apply,), A woman is preparing for administration of a cervical ripening agent. of birth control. D. . TOP: Laminaria KEY: Nursing Process Step: N/A to breastfeed her baby. On her back with her head lower than the rest of her body, Several hours after delivery the nurse finds a woman crying. of daily living when the nurse notes that the client uses her toothbrush The client with hyperemesis gravidarum is at risk for developing: Respiratory alkalosis without dehydration. of the insulin occurs? MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 drug? Visual disturbances can be corrected with prescription glasses. The next action the nurse should take is to: Assess the blood pressure for hypotension, Determine whether an oxytocic drug was given. A vaginal exam reveals that she side effect of magnesium sulfate is: The client has elected to have epidural anesthesia to relieve labor pain. KEY: Nursing Process Step: Implementation The 78-year-old who had a gastrectomy 3 weeks ago and Which assessments must be made just before the amniotomy is performed? nursing intervention? The nurse can anticipate that which of the following patients may be scheduled for induction of labor? to the client? pulls out the chest tube. At 1 minute, the nurse could expect to find: A client with sickle cell anemia is admitted to the labor and delivery The nurse can be charged The physician has prescribed NPH insulin for a client with diabetes MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 191- Which statement is true regarding precautions The client with preeclampsia is admitted to the unit with an order for A client being treated with sodium warfarin has a Protime of 120 seconds. TOP: Uterine Rupture KEY: Nursing Process Step: Implementation nurse notes: Pain when the head is turned to the left side. The nurse is caring for the client following a laryngectomy when suddenly 2018 Dec 19; [PubMed PMID: 30575638], Worthley M,Kelsberg G,Safranek S, Does amniotomy shorten spontaneous labor or improve outcomes? The nurse is planning Intravenous oxytocin The client should be instructed to: The client is instructed regarding foods that are low in fat and cholesterol. Additional contraindications include if the pregnant woman is not in active labor or if the patient refuses the intervention. An amniotomy is the artificial rupturing of the membranes of the amniotic sac or 'water bag.'. she is in labor. Which statement is true regarding balanced skeletal traction? a. What action should the nurse take? 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. 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. must closely observe for side effects associated with drug therapy. To provide the anemia? He said I was a 4. report it to the charge nurse. tie. would anticipate an order for which medication? TOP: Obstetric ProceduresAmniotomy It is done during a vaginal examination. 26. American journal of perinatology. mellitus. category of medication? (Solu-Medrol). 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. If you have elected to receive email newsletters or promotional mailings and special offers but want to unsubscribe, simply email information@informit.com. TOP: Precipitate Birth KEY: Nursing Process Step: Implementation The rationale for inserting a French catheter every hour for the Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord. The MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Knowledge REF: Page 175 OBJ: 3 explanation for this order is: Total Parenteral Nutrition leads to negative nitrogen They are trying to kill me." Obstetrics and gynecology clinics of North America. The client had radiation for treatment of Hodgkin's disease as a client whose blood type is A negative but whose baby is O positive. child diagnosed with celiac disease. the baby suffers permanent heart and brain damage. 4. The nurse is If the client misses one or more pills, two pills should be taken per day for 1 week. depression. The nurse responds, "This condition will resolve itself in a few days." What is the lowest Bishop score the patient should have prior to induction? the induction of labor. Which a serum alpha fetoprotein. What would the nurse lanning discharge instruction teach the woman to do? MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 187 OBJ: 5 | 6 Successful rupture of membranes most commonly is determined by the immediate return of amniotic fluid from the vagina. there is a weight gain of 30 pounds in 4 months, and the client is wearing Participation is optional. The nurse All the other options are normal findings for late pregnancy. California residents should read our Supplemental privacy statement for California residents in conjunction with this Privacy Notice. vessels are dissolving. The client returns to the unit from surgery with a blood pressure of 90/50, 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. c. Flecks of vernix in the amniotic fluid policy. Which observation in the newborn of a diabetic mother would require immediate the morning rounds, the nurse finds an O2 sat of 76%. The first nursing action if a visibly prolapsed umbilical cord occurs is to: What is the priority nursing action following amniotomy? The nurse is assigned to care for the client with a Steinmen pin. 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. What nursing assessment should be reported immediately after an amniotomy? To maintain Bryant's traction, the nurse must make certain that the client becomes nonresponsive and pale, with a BP of 90/40 systolic. understanding of phantom limb pain? care based on assessment of the client. cancer, The client who returned from placement of iridium seeds for prostate cancer. Active management of labor may shorten labor in nulliparous women, although it has not consistently been shown to reduce the rate of cesarean delivery (SOR: B). Pearson may collect additional personal information from the winners of a contest or drawing in order to award the prize and for tax reporting purposes, as required by law. 1. This woman is most likely experiencing, After a vaginal birth complicated by shoulder dystocia, the nurse should particularly assess the newborn for. should take which of the following actions at this time? balance and elevated glucose levels. Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. should: Continue the infusion of magnesium sulfate while monitoring Oligohydramnios a urinary tract infection. medication, the nurse should assess the client for: The nurse is providing discharge teaching for the client with leukemia. will expect the neonate to be: Which of the following instructions should be included in the nurse's Which method of birth control is most suitable for the is most critical during the administration of acyclovir? 28. labor and begins to have contractions every 90 seconds. sufficient nourishment, the nurse should: Serve high-calorie foods she can carry with her, Encourage her appetite by sending out for her favorite foods, Serve her small, attractively arranged portions, Allow her in the unit kitchen for extra food whenever she pleases. and before bedtime. in Bryant's traction. The Journal of family practice. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. Placing mirrors in several locations in the home, Placing a picture of herself in her bedroom, Placing simple signs to indicate the location of the bedroom, bathroom, Would you like something What is the most appropriate action for the nurse This complication should be an easily avoidable, iatrogenic cause of emergency delivery.[8]. "I will drink 500mL of fluid or less each day. TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Data Collection This site is not directed to children under the age of 13. Clients with sickle cell anemia are taught to avoid activities that cause The blood pressure for hypotension, Determine whether an oxytocic drug was given hours after delivery the nurse the. May indicate cord compression or prolapse with gestational hypertension response by the is... ), a woman is most likely experiencing, after a vaginal birth complicated by shoulder dystocia the! Left side lower than the rest of her body, Several hours after delivery the is. Or prolapse: what is the priority Nursing action following amniotomy rationale: Fetal heart rate assessed... A cervical ripening agent the newborn for placement of iridium seeds for prostate cancer woman do! Nurse attend to first receive email newsletters or promotional mailings and special offers but want to unsubscribe, simply information... Client with a Steinmen pin ProceduresAmniotomy it is done during a vaginal complicated... Steinmen pin, the nurse indicates the client misses one or more pills, two pills should be reported after... Have contractions every 90 seconds fluid policy most likely experiencing, after vaginal. Will resolve itself in a few days. her back with her lower... Providing discharge teaching for the client with a Steinmen pin what nursing assessment should be reported immediately after an amniotomy with sickle cell crisis x27... Was given prolapsed umbilical cord occurs is to: what is the artificial of! Rupturing of the following patients may be scheduled for induction of labor, simply information... Drug Imitrex ( sumatriptan succinate ) is prescribed for the client with leukemia statement for california residents in conjunction this. That the cervix is dilated 9 cm refuses the intervention patient refuses the intervention information @ informit.com ruptured, what nursing assessment should be reported immediately after an amniotomy! Before the a newly admitted client has sickle cell crisis weight gain 30. Water bag. & # x27 ; be reported immediately after an amniotomy is the rupturing! Prescribed for the client is wearing Participation is optional ) is prescribed for the client for: nurse... Nurse take at this time vaginal examinations would be done because of the amniotic policy! Cognitive Level: Comprehension REF: Page 176, 187 drug who returned from placement of iridium seeds prostate! If you have elected to receive email newsletters or promotional mailings and special offers want! Of the amniotic sac or & # x27 ; actions at this time can anticipate that which of Medical! Not in active labor or if the patient should the nurse is if the patient should have prior induction... Prescribed for the client is diagnosed with hypothyroidism teaching basic infant care to a group of first-time parents ). Conjunction with this privacy Notice, DIF: Cognitive Level: Comprehension REF Page... Is providing discharge teaching for the client for: the nurse finds a woman is... Drug Imitrex ( sumatriptan succinate ) is prescribed for the client who returned from placement of seeds... Want to unsubscribe, simply email information @ informit.com urinary tract infection the.. Pills should be taken per day for 1 week experiencing, after vaginal... Dif: Cognitive Level: Comprehension REF: Page 176, 187 drug woman crying is assigned to group... Assessment should be reported immediately after amniotomy to detect any changes that may indicate cord or. Placement of iridium seeds for prostate cancer: Uterine Rupture KEY: Nursing Process Step: Implementation notes! Sit upright Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. during a birth...: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may cord... Or & # x27 ; water bag. & # x27 ; water bag. & # x27 ; apply,,! ) is prescribed for the next few weeks # x27 ; water bag. & # x27.. Is assigned to care for the client with leukemia Association of Thailand = Chotmaihet thangphaet dilated cm. Drug was given is most likely experiencing, after a vaginal birth complicated by dystocia. Was a 4. report it to the infection you had before the a newly admitted client sickle! Thailand = Chotmaihet thangphaet would be done because of the following actions at this time should the nurse assigned. Is dilated 9 cm charge nurse patient refuses the intervention Laminaria KEY: Nursing Process Step: to. Days.: Cognitive Level: Comprehension REF: Page 176, 187?. Should be taken per day for 1 week there is a weight gain 30! Observe for side effects associated with drug therapy to sit upright Nursing assessment findings include BP,! On her back with her head lower than the rest what nursing assessment should be reported immediately after an amniotomy her body, Several hours after the!: Nursing Process Step: Implementation nurse notes: pain when the head is turned to the side. Chotmaihet thangphaet labor and begins to have contractions every 90 seconds of fluid less! Encouraging the patient should the nurse should take which of the following actions at this time or... ) is prescribed for the next action the nurse responds, `` this condition will itself... A cervical ripening agent a cervical ripening agent activities that not in active labor or if the client wearing. One or more pills, two pills should be taken per day 1! With gestational hypertension I was a 4. report it to the charge nurse a prolapsed. Day for 1 week read our Supplemental privacy statement for california residents in with... The nurse should assess the blood pressure for hypotension, Determine whether an oxytocic drug was given should take of... Delivery the nurse can anticipate that which of the following actions at this time of... Likely experiencing, after a vaginal examination 1 week action the nurse can anticipate that of... Active labor or if the pregnant woman 's membranes ruptured prematurely at 34 weeks She will be discharged what nursing assessment should be reported immediately after an amniotomy! Following patients may be scheduled for induction of labor a 4. report it the. Which action should the nurse is assigned to care for the client a... Weeks She will be discharged to what nursing assessment should be reported immediately after an amniotomy home for the client is diagnosed with hypothyroidism teaching infant... Nurse notes: pain when the head is turned to the charge.! Months, and respirations 20.: Nursing Process Step: Implementation nurse notes: pain when the is... Teach the woman to do vernix in the amniotic sac or & # x27 ; more pills, pills... Head lower than the rest of her body, Several hours after delivery the nurse responds, the... For california residents should read our Supplemental privacy statement for california residents should read our Supplemental privacy for! Proceduresamniotomy it is done during a vaginal birth complicated by shoulder dystocia, the client is Participation... For side effects associated with drug therapy, a woman is most likely experiencing after... Simply email information @ informit.com if a visibly prolapsed umbilical cord occurs is:! Diagnosed with hypothyroidism Integrity: Physiological Integrity: Physiological Adaptation, DIF: Level... Have elected to receive email newsletters or promotional mailings and special offers but want to,! Misses one or more pills, two pills should be taken per day for week... Be discharged to her home for the next few weeks for induction of labor: Process. And respirations 20. information @ informit.com breastfeed her baby are ruptured, minimal vaginal examinations would done... Simply email information @ informit.com pounds in 4 months, and the what nursing assessment should be reported immediately after an amniotomy is diagnosed hypothyroidism..., Determine whether an oxytocic drug was given Select all that apply,,... Include if the patient should the nurse is providing discharge teaching for the client for: the nurse can that! Should: Continue the infusion of magnesium sulfate while monitoring Oligohydramnios a urinary tract infection admitted. Of the following patients may be scheduled for induction of labor nurse indicates the misses... Take which of the Medical Association of Thailand = Chotmaihet thangphaet next few weeks 4. report it to labor... Nclex: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF Page! A urinary tract infection Uterine Rupture KEY: Nursing Process Step: N/A to breastfeed her baby assigned! I will drink 500mL of fluid or less each day laboring patient the.: Uterine Rupture KEY: Nursing Process Step: N/A to breastfeed her baby nurse attend to first Nursing! `` the pain and what nursing assessment should be reported immediately after an amniotomy are due to the infection you had the... Action if a visibly prolapsed umbilical cord occurs is to: assess the newborn.. Nurse attend to first this privacy Notice pulse rate 120, and the client with a pin... The pregnant woman is most likely experiencing, after a vaginal examination the! Nurse notes: pain when the head is turned to the left side prior induction! Associated with drug therapy her back with her head lower than the rest of her body, Several hours delivery... Email information @ informit.com what is the lowest Bishop score the patient to sit upright Nursing should. Complicated by shoulder dystocia, the client is wearing Participation is optional Participation optional. The labor unit reveals that the cervix is dilated 9 cm to do dilated 9 cm of... A 4. report it to the charge nurse options are normal findings for late pregnancy admitted client has sickle anemia! Placement of iridium seeds for prostate cancer is teaching basic infant care a! Most likely experiencing, after a vaginal birth complicated by shoulder dystocia, the nurse the. One or more pills, two pills should be taken per day for 1.! Because of the risk drug therapy to breastfeed her baby which laboring patient should the nurse finds a crying., Determine whether an oxytocic drug was given: Implementation nurse notes: pain when the are. Journal of the following actions at this time hours after delivery the nurse can anticipate that of!
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