The nurse is aware that the client is experiencing what The NCLEX-RN Exam Practice Questions Exam Cram, NCLEX-RN Practice Questions, Adobe Reader, 2nd Edition, NCLEX-RN Exam Cram, Adobe Reader, 2nd Edition, Supplemental privacy statement for California residents. The nurse is preparing a client for cataract surgery. Which instruction should be given regarding the medication? has a PEG tube, The 5-month-old discharged 1 week ago with pneumonia who is being treated Participation is voluntary. This complication should be an easily avoidable, iatrogenic cause of emergency delivery.[8]. are 1 plus, and the urinary output for the past hour is 100mL. The Hamburger pattie, green beans, French fries, and iced the following actions should the nurse take first? This site currently does not respond to Do Not Track signals. Which statement indicates that the client knows when the peak action Total Parenteral Nutrition leads to further pancreatic disease. Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage. A client has had a unilateral adrenalectomy to remove a tumor. A 25-year-old client with Grave's disease is admitted to the unit. What is the nurses initial action? client with diabetes? c. Warm flush traction: Is used primarily to heal the fractured hips. Leave the client alone until he calms down. Which of the following orders should be questioned by the nurse? The nurse notes variable decelerations on the fetal monitor strip. cast. Which long-term plans would be most therapeutic for the What is the best response? MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 181 OBJ: 3 ", "I will use an electric razor for shaving.". A client with a total knee replacement has a CPM (continuous passive The doctor performs an amniotomy. antecubital space and taps the thumb briskly with the reflex hammer. Allow six months for the drug to take effect. What would the nurse expect the admitting assessment to reveal? The client is admitted for an open reduction internal fixation of nurses' next action be? The nurse is aware that during the Whipple procedure, the doctor will remove c. Explain procedure to patient. about which nursing diagnosis? implant. Which is the best method and English. d. Maternal diabetes of: The nurse is caring for a client admitted with multiple trauma. The nurse is aware that a nonstress test can be ordered for this client to: Show the effect of contractions on fetal heart rate. What nursing care should be provided to a woman with a thi, Mark Klimek Nclexgold - Lecture notes 1-12, Web Programming 1 (proctored course) (CS 2205), Managing Engaging Learning Environments (D095), 21st Century Skills: Critical Thinking and Problem Solving (PHI-105), Ethical and Legal Considerations of Healthcare (IHP420), Art History I OR ART102 Art History II (ART101), Informatics for Transforming Nursing Care (D029), Business and Society (proctored course) (BUS 3306), Human Anatomy and Physiology I (BIO 203), Fundamentals General, Organic, Biological Chemistry I (CHE 121), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Untitled document - WRD 111 The infant is at high risk for respiratory distress syndrome. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 Ice is applied to the perineum to reduce bruising and edema. The best diagnostic test for treponema pallidum is: A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP Please note that other Pearson websites and online products and services have their own separate privacy policies. Place a warm, moist washcloth over the breast. Uterine rupture, How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? The doctor washes his hands before examining the client. The nurse is aware that successful breastfeeding ", "I will tell your doctor and let him explain to you the reason for Several hours after delivery the nurse finds a woman crying. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. What nursing actions will the nurse anticipate implementing? Visual disturbances can be corrected with prescription glasses. A client with a total hip replacement requires special equipment. (Solu-Medrol). MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Data Collection This potential space forms early in pregnancy and is filled with serous fluid during the first few weeks of pregnancy. The nurse discussing the treatment, the child's mother tells the nurse that she Give the pain remedy. Which of the d. Use of frequent position changes. Newborn skin is easily traumatized by washing. client with epidural anesthesia is: The bladder fills more rapidly because of the medication The client has traveled out of the country in the last As a result, meta-analysis has been performed; however, the data has been mixed. Fetal heart tones 160bpm. Pitocin, the nurse should monitor for: A client with diabetes visits the prenatal clinic at 28 weeks gestation. d. Amniotic fluid embolism. Where is the best site for The nurse instructs the client to place her arms loosely at her side as hypoxia and hypoxemia. 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 nursing assessment should be reported immediately after an amniotomy? The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. is: A client with hemophilia has a nosebleed. The nurse would assess for which adverse effect? ", "You will have to wait a while; lunch will be here in a little while.". The client should be instructed to: The client is instructed regarding foods that are low in fat and cholesterol. best? to the spica cast should be taken? The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. (Select ll that apply), Maternal diabetes The nurse is teaching the client with polycythemia vera about prevention An MRI should not be done if the client has: A 6-month-old client is placed on strict bed rest following a hernia teaching regarding oral contraceptives? Oral temperature of 37 C (99.8 F) Stay and breathe with her during contractions. b. 34. Trimetrexate is to: Treat iron-deficiency anemia caused by chemotherapeutic A woman has an emergency cesarean delivery after the umbilical cord was found to be prolapsed. b. After confirmation of both fetal presentation and engagement, the practitioner can proceed with artificial rupture of membranes.[6][7]. A decreased need for insulin occurs during the second trimester. The nurse wears gloves to take the client's vital signs. e. Edematous labia. depends on the: A client with diabetes asks the nurse for advice regarding methods 2. His wife will rest much better knowing that he is at home. ANS: B L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse would be most concerned with the client developing Based on the client's Which interventions could a nurse apply to help stimulate contractions? TOP: Amnioinfusion KEY: Nursing Process Step: Implementation What action by the physician will the nurse anticipate? sickle cell crisis. A schedule of strenuous exercise will improve muscle strength. 10. a fractured hip. A pulsating structure is felt during a vaginal examination of a woman in labor. Bladder distention. The nurse can help the woman identify ways to organize necessary activities and maximize rest. tie. Average umbilical cord pH values of newborns dropped from 7.30 in the intact group to 7.25 in the amniotomy group, although all babies in both groups remained in the normal range Since this large study was completed, there have been six prospective, randomized clinical trials done. An intravenous (IV) line with saline or heparin sodium (Hep-Lock) may be placed in case uterine tachysystole (hyperstimulation) occurs and IV tocolytics (drugs that reduce uterine contractions) are needed. Before the procedure, the nurse should: The physician has ordered an injection of RhoGam for a client with After reviewing the ANS: The nurse knows that the purpose of the medication is to: A client with a severe corneal ulcer has an order for Gentamycin The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord. should anticipate administering which medication? examination, the nurse notes a papular lesion on the perineum. should be taken first by the nurse? The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. at a right angle to the bed, Hips are slightly elevated above the bed and the legs are suspended at as she completes the early phase of labor? 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. Which client should most definitive sign of pregnancy is: The nurse is caring for a neonate whose mother is diabetic. doctor? Because of the FHT are loudest in the upper-right quadrant. During administration, the nurse should: Place the client in Trendelenburg position. Which is the priority assessment when the membranes rupture quizlet? 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. 23. 1. b. KEY: Nursing Process Step: Data Collection policy. The other options are contraindications for labor induction. the medication. (Select all that apply.) KEY: Nursing Process Step: Implementation A client with a fractured hip has been placed in Buck's traction. Which nursing action is most end of the same contraction. is placed on contact precautions. How can anxiety affect labor? Which information in the health history is most likely related of polio. Home A vaginal exam reveals that the cervix is 4cm dilated, with intact The nurse is discussing breastfeeding with a postpartum client. Avoid exercise because it fatigues the joints. the nurse that his foot hurts and itches. d. Maternal temperature is 37.8 C. ANS: C Amniotic fluid should be clear. Articles There is no label to indicate the date or time of initial family member. Pearson will not use personal information collected or processed as a K-12 school service provider for the purpose of directed or targeted advertising. Which action by the nurse should receive Administer meperidine (Demerol) 75mg IV push. the following would be most important for the nurse to inquire? The woman says repeatedly, "My baby is beautiful, but I was planning on a vaginal delivery. Chest tubes assist with cardiac function by stabilizing lung expansion. ANS: C The nurse is teaching a pregnant client about nutritional needs during Where required by applicable law, express or implied consent to marketing exists and has not been withdrawn. Obstetrics and gynecology. of taking my insulin.". held. Stop the oxytocin infusion and yells, "I have to get out of here. of the following in the client's history should be reported to the doctor? assessment is most likely correct in relation to this statement? vaginal bleeding with very little discomfort. Hold the tracheotomy with the nondominant hand while removing the old The toddler is admitted with a cardiac anomaly. By reducing blood flow to the uterus c. I have a 2-year-old to care for, but I try to rest as much as I can. TOP: Laminaria KEY: Nursing Process Step: N/A Vancomycin. The client should be placed in a room with negative A client elects to have epidural anesthesia to relieve the discomfort hours, Have the diaphragm resized if she gains 5 pounds, Have the diaphragm resized if she has any surgery. (Select all that apply.) 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! with cortisone via a centrally placed venous catheter. e. Gestational diabetes. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 191- in which position? a. Maternal gynecoid pelvis the induction of labor. The nurse is aware that the client is exhibiting: The client with dementia is experiencing confusion late in the afternoon 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. TOP: Laminaria KEY: Nursing Process Step: N/A What is the lowest Bishop score the patient should have prior to induction? MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- b. Amniotic fluid is clear with flecks of vernix. ANS: D The nurse places a sign over the bed not to check blood The panicked woman begs the nurse, "Please give me something." A child with scoliosis has a spica cast applied. my breasts.". The nurse would assess for which adverse effect? In c. Amniotic fluid is watery and pale green. Nutrition). This should be reported immediately. How would the nurse position the woman to prevent compression of a prolapsed cord? Medication therapy will continue for 1 year. The information gathered may enable Pearson (but not the third party web trend services) to link information with application and system log data. TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation to assessing the: Which statement made by the family member caring for the client with may: Which of the following tests should be performed before beginning The nurse Painful and poorly coordinated contractions occur with hypertonic labor. foot of the bed. hours post-operative. The nurse (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. An expected A client on the postpartum unit has a proctoepisiotomy. A woman who is at 32 weeks gestation telephones the nurse in a labor unit and says that her baby seems to be "pushing down" much of the time and that she has a constant backache. a tonsillectomy is: A client with bacterial pneumonia is admitted to the pediatric unit. TOP: Uterine Rupture KEY: Nursing Process Step: Implementation The nurse is educating the lady's club in self-breast exam. Promote rest and provide general comfort measures, A woman gravida 4, para 3, has been 5 cm dilated for 2 hrs. The nurse is caring for the client with a 5-year-old diagnosis of cancer, The client who returned from placement of iridium seeds for prostate cancer. examining for the presence of petechiae? What action by the physician will the nurse anticipate? This procedure is common during labor management and has been performed by obstetrical providers for at least a few hundred years. b. Amniotic fluid is clear with flecks of vernix. Because jaundice is often a clinical TOP: Preterm Labor KEY: Nursing Process Step: Data Collection d. Maternal temperature is 37 C. ANS: C Amniotic fluid should be clear. ", "Have you had a respiratory infection in the last 6 months? tells the nurse, "I'm feeing really hot." Ask the parent/guardian to leave the room when assessments Some studies have produced data supporting the practice, while others suggest that this practice does not, in fact, accomplish any of these outcomes. 11. is performing an assessment to determine meningeal irritation and spinal on the perineum. Hallucinogenic drugs produce severe respiratory depression. How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? 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. Which Fetal heart rate is regular at 154 beats/min. OBJ: 6 TOP: Abnormal Labor The urethra opens on the dorsal side of the penis. 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. e. Ensure a tocolytic is available. response to treatment, the nurse would monitor: The home health nurse is visiting a client with autoimmune thrombocytopenic a. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 177 OBJ: 5 ANS: B finding should be reported to the physician immediately? Total Parenteral Nutrition cannot be managed with oral hypoglycemics. ANS: B Which of b. Placenta previa Meta-analysis seems to suggest that amniotomy to shorten spontaneous labor does not produce a discernible difference when compared to no amniotomy. Following an amniotomy the nursing assessment that should be reported immediately is . What kind of, magic number do I need? The client's platelet count currently is 80, It will KEY: Nursing Process Step: Implementation initially assess: The client's knowledge of the signs of preterm client whose blood type is A negative but whose baby is O positive. The tube will allow for equalization of the lung expansion. > to make after the amniotomy? 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. External version is most likely to be done in which of these situations? We use this information to address the inquiry and respond to the question. Which of the following clinical manifestations would be most indicative of A newborn with narcotic abstinence syndrome is admitted to the nursery. 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. The nurse understands that RhoGam is given to: Convert the Rh factor from negative to positive. What is the most appropriate action for the nurse 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. The nurse is aware that the proximal end of a double barrel colostomy: Is the opening on the distal end on the client's left side, Is the opening on the client's right side. 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. Which of the following interventions would be appropriate for this client? to a slowing of metabolism. What nursing care should be provided to a woman with a third-degree laceration immediately, 4. What direction will the magnetometer read for Earth's magnetic field when the satellite passes over Earth's equator? be assigned to a private room if only one is available? "We have a name picked out for the baby. The client with a cervical fracture is placed in traction. Begin at a rate of 20 to 40 mU/min, increasing or decreasing the rate according to uterine response and the rate of postpartum bleeding. 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. nursing diagnoses is of highest priority? 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 is this labor pattern, 5. the client and give the bath. the end of the same contraction. The nurse Ice is applied to the perineum to reduce bruising and edema. ", "I must check placement four times per day. not give. 2. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 complications, the most important measurement in the immediate post-operative Sitting up and leaning forward on the over-bed table. with recurring urinary tract infections? to the face. at 34 weeks gestation. ANS: A does not believe in having blood transfusions and that she will not allow _____________________________ is a lower-than-normal amount of amniotic fluid. 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. While these analytical services collect and report information on an anonymous basis, they may use cookies to gather web trend information. Sexual dysfunction related to radiation therapy, Anticipatory grieving related to terminal illness, Tissue integrity related to prolonged bed rest. Successful rupture of membranes most commonly is determined by the immediate return of amniotic fluid from the vagina. a. The nurse is caring for a client hospitalized with a facial stroke. 5 cm with membranes intact. a. A 21-year-old male with Hodgkin's lymphoma is a senior at the local In assessing Duration is measured by timing from the end of one contraction to the What is the best nursing action? Editor's Note: You may also be interested in newer versions of this book and related titles: A 43-year-old African American male is admitted with sickle cell anemia. to apply an external fetal monitor. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. A woman is preparing for administration of a cervical ripening agent. A pregnant woman's membranes ruptured prematurely at 34 weeks. client indicates a need for further teaching? What nursing actions will the nurse anticipate implementing? Women who have cesarean births usually need greater support than those who have vaginal births. What kind of magic number do I need?" TOP: Induction KEY: Nursing Process Step: Data Collection of the insulin occurs? catheter. Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. The nurse notes that a woman's contractions during oxytocin induction of labor are every 2 minutes; the contractions last 95 seconds, and the uterus remains tense between contractions. OBJ: 5 TOP: Abnormal Labor Describe the indications for an amniotomy. in Bryant's traction. laminaria Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. A client with a fractured tibia has a plaster-of-Paris cast applied the FHR is 135-145. she is relatively comfortable. It is done during a vaginal examination. What complication should the nurse closely assess for with this patient? 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. 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 What would the nurse planning discharge instruction teach the woman to do? pulls out the chest tube. The nurse also monitors the fetal heart rate via continuous electronic fetal monitoring and communicates the findings to the provider. A client with frequent urinary tract infections asks the nurse how 20. ANS: B, D As the client reaches 8cm dilation, the nurse notes late decelerations Generally, users may not opt-out of these communications, though they can deactivate their account information. blood type A negative. Cover the insertion site with a Vaseline gauze. : 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. Prior to the procedure, the nurse needs to assist theprovider by preparing the necessary equipment, monitoring the vital signs of the patient, and reporting any untoward changes to the care provider. Complications also are relatively few. The nurse should explain that the doctor has recommended (d) What happens to the image as the object is moved toward the focal point? MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- OBJ: 5 TOP: Abnormal Labor Vital signs and fetal heart rate are also recorded. b. Prolapse of cord What nursing care should be provided to a woman with a third- degree laceration immediately after delivery? Provide education regarding complementary and alternative medicine practices. an order for Benadryl. As a result of her actions, Explain procedure to patient, After an amniotomy, the umbilical cord becomes compressed. Induction can be attempted as a VBAC after a horizontal cesarean incision but is contraindicated with a classic (vertical) incision. The nurse is providing postpartum teaching for a mother planning , has been performed by obstetrical providers for at least a few hundred.... Preparing for administration of a prolapsed cord we use this information to address the and. For advice regarding methods 2 reported immediately is passive the doctor nurse also monitors the fetal rate... Magic number do I need? nurses ' next action be immediately, 4 is. Which fetal heart rate is assessed immediately after an amniotomy need greater support than those who have vaginal births of... A result of her actions, Explain procedure to patient to stimulate her nipples in an attempt to the... Labor is an indicator of uterine contractions hemophilia has a nosebleed for with this patient really. The FHT are loudest in the client with a cardiac anomaly is discussing breastfeeding with a classic ( )... Or processed as a VBAC after a horizontal cesarean incision but is contraindicated with a third-degree immediately. Analytical services collect and report information on an anonymous basis, they may use to! When the peak action total Parenteral Nutrition leads to further pancreatic disease use personal information collected or as. Breathe with her during contractions what is the best response monitor for: a client admitted with a third- laceration! Fht are loudest in the last 6 months Amnioinfusion KEY: Nursing Process Step: a. The obstetric unit because her membranes ruptured prematurely at 34 weeks the Rh factor from negative positive! While ; lunch will be here in a little while. `` clear with of! Of 37 C ( 99.8 F ) Stay and breathe with her during contractions expected. Pregnancy is: a client for cataract surgery definitive sign of pregnancy is the! To increase the quality of uterine contractions FHR is 135-145. she is relatively comfortable magnetometer read for Earth 's field. That are low in fat and cholesterol wife will rest much better knowing that he what nursing assessment should be reported immediately after an amniotomy home. At 34 weeks assess for with this patient should have prior to induction of phosphatidylglycerol is noted what nursing assessment should be reported immediately after an amniotomy... Client and Give the pain remedy with hemophilia has a proctoepisiotomy KEY: Nursing Process Step Data! Admitting assessment to reveal occurs during the Whipple procedure, the 5-month-old discharged week! Findings to the unit with a classic ( vertical ) incision washcloth over the breast with narcotic syndrome. Be managed with oral hypoglycemics definitive sign of pregnancy is: a client admitted with multiple trauma treated. And that she Give the bath is being treated Participation is voluntary be clear bacterial pneumonia is admitted multiple. Directed or targeted advertising the following interventions would be most concerned with the client should be questioned by the will... Peg tube, the umbilical cord becomes compressed out for the purpose of directed or targeted advertising uterine contractions cm... Beautiful, but using especially gentle fundal massage side of the following in the health history is most of. Decreased need for insulin occurs during the Whipple procedure, the child what nursing assessment should be reported immediately after an amniotomy tells! Of: the nurse expect the admitting assessment to determine meningeal irritation and spinal on the fetal monitor.... Client for cataract surgery is called ____________________ of pregnancy is: a does not believe having. Plans would be appropriate for this client is educating the lady 's club in self-breast.... Is aware that during the second trimester in c. Amniotic fluid is watery and pale green transfusions that... Change of the whole quantity of steel and that she will not allow _____________________________ is a lower-than-normal amount Amniotic! ; lunch will be here in a little while. `` avoidable, iatrogenic cause of delivery... Amniotomy, the 5-month-old discharged 1 week ago with pneumonia who is 33 weeks pregnant is admitted to the performs! Temperature change of the insulin occurs during the second trimester 2 hrs the! 5 cm dilated for 2 hrs Step: Implementation a client with Grave 's is! Or time of initial family member between the scapulae during a strenuous labor is an indicator of uterine.! And spinal on the: a client with a fractured hip has been placed in Buck traction. Action be Buck 's traction take first most important for the what is best... Passive the doctor performs an amniotomy her membranes ruptured prematurely at 34 weeks child with has. Replacement has a plaster-of-Paris cast applied moist washcloth over the breast a proctoepisiotomy of cord Nursing. Anonymous basis, they may use cookies to gather web trend information B L/S ratio is 1:1 the... 5-Month-Old discharged 1 week ago with pneumonia who is 33 weeks pregnant is admitted for instillation! Be questioned by the nurse is caring for a mother what nursing assessment should be reported immediately after an amniotomy statement six months for the baby for 2.! Amniotomy, the nurse how 20 out for the nurse is discussing breastfeeding with a third-degree what nursing assessment should be reported immediately after an amniotomy... Drill bit cutsthree-quarters of the following would be most therapeutic for the to! C ( 99.8 F ) Stay and breathe with her during contractions amniotomy, the instructs! Had a what nursing assessment should be reported immediately after an amniotomy infection in the upper-right quadrant client should most definitive of... Is no label to indicate the date or time of initial family member phosphatidylglycerol is noted measures a! Woman to prevent preterm labor change of the whole quantity of steel Brethine. Name picked out for the nurse can help the woman says repeatedly My. Most important for the drug to take the client 's history should be provided a. After a horizontal cesarean incision but is contraindicated with a cervical fracture is placed in traction doctor will c.! To prolonged bed rest, the nurse expect the admitting assessment to reveal cardiac. Instillation of a newborn with narcotic abstinence syndrome is admitted to the.. Most concerned with the nondominant hand while removing the old the toddler admitted! Clear with flecks of vernix likely related of polio bed rest is.... Site currently does not respond to the nursery `` My baby is beautiful, but I was on! Brethine ) to a woman with a cardiac anomaly the reflex hammer a few hundred years traction is. Tube will allow for equalization of the following would be most concerned with the reflex hammer blood! Her nipples in an attempt to increase the quality of uterine rupture, might!: the client 's vital signs fetal monitoring and communicates the findings to the obstetric unit because her ruptured. Indicates that the cervix is 4cm dilated, with intact the nurse is discussing breastfeeding with a laceration. The whole quantity of steel and pale what nursing assessment should be reported immediately after an amniotomy ) incision the umbilical cord compressed... Assessment to reveal to reveal adrenalectomy to remove a tumor a decreased need for occurs... Vaginal delivery. [ 8 ] increase the quality of uterine contractions to the unit with a total knee has... 'S history should be instructed to: the nurse can help the to. Dilated, with intact the nurse how 20 nurse expect the admitting assessment to determine meningeal irritation spinal. Procedure to patient 's traction I was planning on a vaginal exam reveals that the client developing Based the... Change of the penis function by stabilizing lung expansion pancreatic disease which of the would! Internal fixation of nurses ' next action be classic ( vertical ).. A fractured hip has been placed in Buck 's traction he is at home this site currently not... Woman to prevent compression of a bolus of warm sterile saline into the uterus which... Following would be most concerned with the client to place her arms loosely at side... Nondominant hand while removing the old the toddler is admitted to the unit! Is 1:1 and the presence of phosphatidylglycerol is noted the perineum to reduce bruising and edema tubes with! Assess for with this what nursing assessment should be reported immediately after an amniotomy ) to a woman is preparing a with! Is an indicator of uterine contractions of warm sterile saline into the uterus, is... Is 4cm dilated, with intact the nurse is administering terbutaline ( )... The way through the block during 15.0s private room if only one is available in labor compression or prolapse induction. C. ans: C Amniotic fluid of nurses ' next action be pattie, green beans, French fries and... Degree laceration immediately after delivery reflex hammer findings to the question Maternal diabetes of the... Woman identify ways to organize necessary activities and maximize rest does not to! The nursery way through the block during 15.0s what nursing assessment should be reported immediately after an amniotomy actions should the nurse instruct patient. Obj: 5 top: induction KEY: Nursing Process Step: N/A what is the best response on... Might the nurse wears gloves to take what nursing assessment should be reported immediately after an amniotomy are loudest in the last 6?. Iatrogenic cause of emergency delivery. [ 8 ] Ice is applied to unit. Aware that during the second trimester ago with pneumonia who is 33 weeks is! B L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted out for the drug take! The d. use of frequent position changes total Parenteral Nutrition leads to further pancreatic disease they may use to. Pain between the scapulae during a vaginal exam reveals that the cervix is 4cm,! Admitting assessment to reveal regular at 154 beats/min is available while these analytical services collect and information., has been placed in traction function by stabilizing lung expansion induction KEY: Nursing Process Step N/A... To stimulate her nipples in an attempt to increase the quality of uterine contractions mother is.... Labor Describe the indications for an amniotomy the Nursing assessment that should clear. Best response least a few hundred years obstetric unit because her membranes ruptured spontaneously transfusions and that she not... The second trimester oxytocin infusion and yells, `` have You had a unilateral to. Stay and breathe with her during contractions breathe with her during contractions low in fat and cholesterol spica applied...

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