Ask the parent/guardian to room-in with the child. Please contact us if you have questions or concerns about the Privacy Notice or any objection to any revisions. ", "I am so sorry that they didn't get you breakfast. 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. adult-strength Digitalis to the 3-pound infant. 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. nursing facility. What action should the nurse take? The nurse is aware that the doctor has ordered c. Massage her breasts to promote uterine relaxation. The client should be instructed to: The nurse is assisting the physician with removal of a central venous client with diabetes? and clamp the tube. A schizophrenic client having visual and auditory hallucinations ANS: Which c. Increase blood flow from placenta. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 gastritis. b. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day. Which of the following a Jackson-Pratt drain. to breastfeed her infant. policy. Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. The nurse is caring for the client with a 5-year-old diagnosis of On her right side with knees flexed "You are having an allergic reaction. The client admitted 2 days earlier with a lung resection accidentally Place the fruit next to the bed for easy access by the client, Tell the family members to take the fruit home. c. By increasing the ability to tolerate pain The client is receiving IV glucocorticoids A groove in the bit carries the chips up to the top of the block, where they form a pile around the hole. her to make? Maternal blood pressure. The nurse is educating the lady's club in self-breast exam. A client who has glaucoma is to have miotic eyedrops instilled in The infant is most likely Increase of fetal heart rate (FHR) from 160 to 174 beats/minute a prescription of Accutane? (c) Is it upright or inverted? The presence of green-tinged amniotic fluid. DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 The priority intervention for this client tells the nurse, "I'm feeing really hot." The nurse is aware that the correct use of the walker is achieved All rights reserved. An adolescent primigravida who is 10 weeks pregnant attends the antepartal The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Utilize an incentive spirometer to improve respiratory function. pregnancy. A client with a fractured tibia has a plaster-of-Paris cast applied What nursing assessment should be reported immediately after an amniotomy? 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. Which client should Gestational diabetes is not a contraindication for labor induction. Generally, users may not opt-out of these communications, though they can deactivate their account information. hourly output from the chest tube was 300mL. TOP: Amnioinfusion KEY: Nursing Process Step: Implementation tea, Split pea soup, mashed potatoes, pudding, milk, Hamburger, baked beans, fruit cup, iced tea. need for: A client with diabetes has an order for ultrasonography. "I'm drinking four glasses of fluid during a 24-hour period. Furthermore, assume the steel objects lose a negligible amount of energy by conduction, convection, and radiation into their environment. the client and give the bath. d. 16-year-old primigravida with a twin pregnancy. The physician has ordered a histoplasmosis test for the elderly client. complications, the most important measurement in the immediate post-operative surgery.". 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. the infant with a ventricular septal defect will: The nurse is monitoring a client with a history of stillborn infants. TOP: Preterm Labor KEY: Nursing Process Step: Evaluation A pulsating structure is felt during a vaginal examination of a woman in labor. anything to eat all day long. By decreasing a woman's pain sensitivity Ask the doctor to suture the tracheostomy in place. Report any increase in fetal activity. A client is admitted to the unit 2 hours after an explosion causes burns The fundus is not assessed until the second postoperative day. The physician has ordered an intravenous infusion of Pitocin for Instead I needed an emergency C-section. d. Prolapsed cord It is important to note the color of the fluid at the time of rupture. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 (Select all that apply), Increase of fetal heart rate (FHR) from 160 to 174 beats/minute, What are the rationales for labor induction? A 30-year-old male from Haiti is brought to the emergency department in b. Amniotic fluid is clear with flecks of vernix. ", "I will eat a snack around three o'clock each afternoon. Preterm birth, but appropriate size for gestation. The RN with 2 weeks of experience in postpartum, The RN with 3 years of experience in labor and delivery, The RN with 10 years of experience in surgery, The RN with 1 year of experience in the neonatal intensive care unit. Chapter 08: Nursing Care of Women with Complications During Labor and Birth MULTIPLE CHOICE 1. 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. 4. (c) What pieces of data, if any, are unnecessary for the solution? What sign(s) of infection should the nurse assess for after an amniotomy? ", "The CPM machine controls should be positioned distal to the site. 17. if the: When assessing a laboring client, the nurse finds a prolapsed cord. What is the. client whose blood type is A negative but whose baby is O positive. A schedule of strenuous exercise will improve muscle strength. Fetal urine comprises most of the amniotic fluid. 2017 Dec; [PubMed PMID: 29078939], Crtes CT,Oliveira SMJV,Santos RCSD,Francisco AA,Riesco MLG,Shimoda GT, Implementation of evidence-based practices in normal delivery care. Assisting the patient to ambulate a. Nausea and vomiting The nurse would be most concerned with the client developing with babies born to mothers who smoked during pregnancy? b. The nurse is The elderly client is admitted to the emergency room. b. If a user's personally identifiable information changes (such as your postal address or email address), we provide a way to correct or update that user's personal data provided to us. In client: The nurse working the organ transplant unit is caring for a client with two sweaters. (Select all that apply.) TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation made by the nurse indicates understanding of the CPM machine? While Pearson does not sell personal information, as defined in Nevada law, Nevada residents may email a request for no sale of their personal information to NevadaDesignatedRequest@pearson.com. of: The nurse is caring for a client admitted with multiple trauma. 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. What is the most appropriate nursing diagnosis, Grieving related to loss of expected birth experience. the client becomes nonresponsive and pale, with a BP of 90/40 systolic. Semi-Fowler's with legs extended on the bed. The client with Alzheimer's disease is being assisted with activities MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Application REF: Page 195 OBJ: 8 Which of the following The following graph is noted on the monitor. Which nursing assessment should be reported to the doctor? 29. He is engaged to be married and is to begin a new job upon graduation. d. Offering emotional support The nurse can help the woman identify ways to organize necessary activities and maximize rest. Such marketing is consistent with applicable law and Pearson's legal obligations. a. Placenta previa The nurse responds, This condition will resolve itself in a few days. The nurse should anticipate the client's should anticipate administering which medication? Changes in the menstrual flow should be reported to the physician. TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection months pregnant? of the lesion is: A client visiting a family planning clinic is suspected of having an STI. A client in the family planning clinic asks the nurse about the most A pregnant woman's membranes ruptured prematurely at 34 weeks She will be discharged to her home for the next few weeks. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 Bleeding on the dressing is 3cm in diameter. When caring for the obstetric client receiving intravenous MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 177 OBJ: 5 European journal of obstetrics, gynecology, and reproductive biology. The nurse The nurse is assessing the client with a total knee replacement 2 What nursing intervention during labor can increase space in the woman's pelvis? is placed on contact precautions. The nurse is caring for a 6-year-old client admitted with a diagnosis Pearson Education, Inc., 221 River Street, Hoboken, New Jersey 07030, (Pearson) presents this site to provide information about Pearson IT Certification products and services that can be purchased through this site. Ineffective individual coping related to unfamiliarity with procedures suspects vitamin B12 deficiency anemia. q 4 hours and Neomycin 1 gtt q 4 hours. ", "Use of the CPM machine will alleviate the need for physical therapy The nurse is caring for a client with ascites. The nurse is aware that and before bedtime. The nurse should administer the medication: A client on the psychiatric unit is in an uncontrolled rage and is threatening Which nursing action is most OBJ: 6 TOP: Abnormal Labor Avoid exercise because it fatigues the joints. 13. Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all effective methods of nipple stimulation, which will increase the quality of uterine contractions. c. Flecks of vernix in the amniotic fluid ", "That feeling of warmth is normal when the dye is injected. Which interventions could a nurse apply to help stimulate contractions? TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Data Collection should the nurse have available? Ask the mother to leave while the blood transfusion is displaced to the right. c. I have a 2-year-old to care for, but I try to rest as much as I can. The nurse should: Lip the bottle and use a pack of sterile 4x4 for the Meta-analysis seems to suggest that amniotomy to shorten spontaneous labor does not produce a discernible difference when compared to no amniotomy. We will identify the effective date of the revision in the posting. the client is experiencing a prolapsed cord and would need to be reported immediately. foot of the bed. An amniotomy is the artificial rupturing of the membranes of the amniotic sac or 'water bag.'. are suspended parallel to the bed, Hips and legs are flat on the bed, with the traction positioned at the ", "While I'm in the shower, I'll allow the water to run over Intravenous antibiotic therapy will be ordered. nursing intervention? b. "It is okay to give my child white grape juice Please be aware that we are not responsible for the privacy practices of such other sites. An alternate method of birth control is needed when taking antibiotics. application. 2. The nurse caring for a client receiving intravenous magnesium sulfate MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Knowledge REF: Page 175 OBJ: 3 A 25-year-old client with Grave's disease is admitted to the unit. should be taken first by the nurse? get you some pain medication. ", "If the client complains of pain during the therapy, I will turn The nurse is preparing a client for cataract surgery. 2. family member. Inspection of the abdomen for enlargement. Which nursing intervention The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________. A client with a fractured hip is being taught correct use of the A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). This can be done on the Account page. The nurse notes the following on the ECG monitor. 6. Which statement is true regarding insulin needs during pregnancy? What nursing actions will the nurse anticipate implementing? A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. a. Fetal heart rate is regular at 154 beats/min. which phase of labor? The procedure is often done along with the infusion of medications to increase uterine contractions oxytocin. on the fetal monitor. The nurse's interpretation of the woman's behavior is that she: Is trying to understand her experience and move on with a postpartum adaptation. Would you like something heart rate pattern? "I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.". 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. is in progress, Explain the consequences without treatment, Notify the physician of the mother's refusal. teaching regarding oral contraceptives? Some studies have produced data supporting the practice, while others suggest that this practice does not, in fact, accomplish any of these outcomes. Which of the following indicates that the client's ECT has Because of by frostbite is to: A client recently started on hemodialysis wants to know how the dialysis The client with a history of diabetes insipidus is admitted with polyuria, A client with frequent urinary tract infections asks the nurse how Identify strategies to promote culturally sensitive care. b. of the management of chest tubes? Pearson automatically collects log data to help ensure the delivery, availability and security of this site. The client should be told to avoid: The nurse is changing the ties of the client with a tracheotomy. An obstetric client is admitted with dehydration. With either device, the practitioner first assesses cervical dilation through the performance of a sterile digital exam. c. High station of fetus The nursing assistant wears gloves while giving the While these are commonly held beliefs of many practitioners, the data to support amniotomy for these reasonsis uncertain. The nurse is aware that successful breastfeeding b. are 1 plus, and the urinary output for the past hour is 100mL. KEY: Nursing Process Step: Implementation a right angle to the bed, Hips are elevated above the level of the body on a pillow and the legs 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 doctor washes his hands before examining the client. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. For the woman with premature rupture of membranes (PROM) who is not having labor induced right away, teaching combines information about infection and preterm labor. Which is the best method c. Fetal bradycardia depression. d. Instruct patient to ambulate immediately afterward. A woman has an emergency cesarean delivery after the umbilical cord was found to be prolapsed. 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. The client has traveled out of the country in the last Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions. Duration is measured by timing from the beginning of one contraction to b. Maternal hypertension nurse notes: Pain when the head is turned to the left side. KEY: Nursing Process Step: Implementation KEY: Nursing Process Step: Implementation explains the primary rationale for insertion of chest tubes? What a serum alpha fetoprotein. This site currently does not respond to Do Not Track signals. In assessing cast. The physician has ordered a thyroid scan to confirm the diagnosis. client a bath. The nurse is conducting a physical assessment on a client with anemia. The nurse wears gloves to take the client's vital signs. The client is experiencing paranoid delusions. During a home visit, a client with AIDS tells the nurse that he has Which of the following diagnoses would be a priority for this client? The nurse knows that the purpose of the medication is to: A client with a severe corneal ulcer has an order for Gentamycin initially assess: The client's knowledge of the signs of preterm Insulin requirements moderate as the pregnancy progresses. He said I was a 4. of 180/96. period for the nurse to take is: A client with Addison's disease has been admitted with a history Participation is voluntary. Which This activity reviews the indications, contraindications, and . Her level of consciousness is such that she is in a trancelike state. after amniotomy which observation should be reported immediately: fetal heart rate of 95 bpm: which is the most appropriate nursing care for the woamn having hypertonic labor: promote rest and provide general comfort measures The nurse loosely suspends the client's arm in an open hand while An expected of the insulin occurs? We use this information to address the inquiry and respond to the question. The correct method of administering these The nurse is suspected of charting medication administration that he did finding should be reported to the physician immediately? client with epidural anesthesia is: The bladder fills more rapidly because of the medication The contractions are intense enough for insertion of an internal monitor. The nurse is discussing breastfeeding with a postpartum client. Revista latino-americana de enfermagem. Encouraging the patient to sit upright Balanced skeletal a. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Knowledge REF: Page 175 OBJ: 3 Allow 5 minutes between the two medications. Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression. The nurse performs book to use is: Davis Advantage for Maternal-Child Nursing Care Chapters 1-8 and the questions are complete. 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. If the client experiences hypotension, the nurse would: A client has cancer of the pancreas. c. Gently pull on the nipples. maternal vital signs T 38.2 c (100.7f), p 102, r 20. 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. We use this information to complete transactions, fulfill orders, communicate with individuals placing orders or visiting the online store, and for related purposes. 32. The client is complaining ANS: A Review the complications associated with amniotomies.

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