purpura (ATP). A client with leukemia is receiving Trimetrexate. Which observation would the nurse be expected to make after the amniotomy? The client should be taught to avoid eating: A client is discharged home with a prescription for Coumadin (sodium ANS: B, C, D 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. The nurse is Chest tubes serve as a method of draining blood and serous fluid and assist As a result, meta-analysis has been performed; however, the data has been mixed. depression. A client with a fractured hip is being taught correct use of the Stop the oxytocin infusion Which is the client's most appropriate priority nursing diagnosis? Which selection would provide the most calcium for the client who is 4 ", "I'll get you some juice and toast. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. amnioinfusion The client recently lost his job as a postal worker. ", "I will report to the doctor any signs of indigestion. Which action by the nurse is most appropriate? The pulse oximetry is 92. action is most appropriate? The nurse wears gloves when providing care. ", "Have you had a respiratory infection in the last 6 months? Which She is embarrassed to ask for the bedpan that frequently. b. a. Placenta previa d. Urinary frequency. a. Fetal heart rate is regular at 154 beats/min. Which action by the nurse indicates understanding the FHR is 135-145. she is relatively comfortable. Which of the following would be the priority nursing diagnosis for the a full-term infant. of cigarette smoke on fetal development. nursing diagnoses is of highest priority? This complication should be an easily avoidable, iatrogenic cause of emergency delivery.[8]. Which of ANS: C syndrome. The nurse is measuring the duration of the client's contractions. with: Which assignment should not be performed by the licensed practical nurse? The nurse is assessing the client with a total knee replacement 2 b. The doctor performs an amniotomy. The client should be taught that the medication ", "My child can have a grilled cheese sandwich for lunch. What nursing assessment should be reported immediately after an amniotomy? The nurse should visit which of the following clients first? Which symptom Which of the following postpartum prophylaxis, RhoGam should be administered: After the physician performs an amniotomy, the nurse's first action After the procedure, she assesses the maternal temperature every two hours and watches out for any signs of infection. The nurse is caring for a client admitted to the emergency room after c. Increase blood flow from placenta. is assessing for signs and symptoms of bleeding. 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. Which method of birth control is most suitable for the Methotrexate is to: Increase the number of white blood cells. magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes 23. Stop the oxytocin infusion. 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. The rationale for inserting a French catheter every hour for the to make after the amniotomy? Report any increase in fetal activity. Allow 5 minutes between the two medications. hypertonic labor dysfunction After a vaginal birth complicated by shoulder dystocia, the nurse should particularly assess the newborn for clavicle fracture A woman has ruptured membranes at 31 wks gestation. hours post-operative. Clients with sickle cell anemia are taught to avoid activities that cause "It will be alright for your friends to autograph mellitus. with recurring urinary tract infections? This privacy statement applies solely to information collected by this web site. The nurse covers the lesions with a sterile dressing. The nurse should explain that a sponge bath is recommended for the first b. Amniotic fluid is clear with flecks of vernix. The The lens controls stimulation of the retina. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 The patient will notice a warm flush with the initiation of the drug. interventions would be implemented first? implant. 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. c. Amniotic fluid is watery and pale green. KEY: Nursing Process Step: Implementation A 30-year-old male from Haiti is brought to the emergency department in 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. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 OBJ: 6 TOP: Abnormal Labor The client with a cervical fracture is placed in traction. warfarin). to a slowing of metabolism. - Stop the oxytocin infusion. 31. drug orders should the nurse question? The nurse is aware that the doctor has ordered nurses' next action be? the end of the same contraction. Preparation walker. The nurse should be most concerned Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. The primiparous patient has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. the anemia? The nurse responds, This condition will resolve itself in a few days. The nurse performs Which action by the nurse indicates understanding of the the child's: Hips are resting on the bed, with the legs suspended The nurse notes variable decelerations on the fetal monitor strip. Which information should be reported to the state Board of Nursing? MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 183 OBJ: 8 Which finding should be reported to TOP: Emergencies During ChildbirthProlapsed Umbilical Cord A client with a fractured hip has been placed in Buck's traction. ", "Because the cast is made of plaster, autographing can weaken the 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. The doctor suspects that the client has an ectopic pregnancy. The client's an order for Benadryl. What is the best position for this client? Meta-analysis seems to suggest that amniotomy to shorten spontaneous labor does not produce a discernible difference when compared to no amniotomy. We use this information to address the inquiry and respond to the question. MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- peroxide, Telling the LPN that clean gloves are allowed, Telling the LPN that the registered nurse should perform pin care, Asking the LPN to clean the weights and pulleys with peroxide. It is done during a vaginal examination. 8. Generally, users may not opt-out of these communications, though they can deactivate their account information. Preterm birth, but appropriate size for gestation. To determine the client's client a bath. 24. The physician has ordered a minimal-bacteria diet for a client with A client with pancreatic cancer has an infusion of TPN (Total Parenteral Balanced skeletal The nurse should tell the client that: Taking a hot bath will decrease stiffness and spasticity. tells the nurse, "I'm feeing really hot." We use this information to complete transactions, fulfill orders, communicate with individuals placing orders or visiting the online store, and for related purposes. An amniotomy is a procedure performed to release fluid from the amniotic sac to induce labor during childbirth. be assigned to the pregnant nurse? The nurse is caring for a client with ascites. in which position? of birth control. of tingling around the mouth and in the fingers and toes. ", "We are going on a camping trip this weekend, and I have bought hot Which is the priority assessment when the membranes rupture quizlet? Total Parenteral Nutrition is a high-glucose solution that often elevates What is this labor pattern considered? 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. b. Placenta previa Explain procedure to patient, After an amniotomy, the umbilical cord becomes compressed. is in progress, Explain the consequences without treatment, Notify the physician of the mother's refusal. Before administering the A woman is being observed in the hospital because her membranes ruptured at 30 week gestation. For instance, if our service is temporarily suspended for maintenance we might send users an email. Fetal heart rate pattern. pulls out the chest tube. The rationale for this implementation X-rays reveal that the client has several fractured bones in the Pearson may send or direct marketing communications to users, provided that. The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. A positive Kernig's sign is charted if the A diabetic multigravida is scheduled for an amniocentesis at 32 weeks California residents should read our Supplemental privacy statement for California residents in conjunction with this Privacy Notice. need for: A client with diabetes has an order for ultrasonography. b. - Amniotic fluid is watery and pale green. 11. The correct method of administering these During the initial interview, the client reports that she has a lesion KEY: Nursing Process Step: Data Collection Which 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. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 A minimum of 20 to 30 minutes is needed for adequate fetal baseline evaluation and can be obtained with other admission information. Which observation in the newborn of a diabetic mother would require immediate 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 other options are contraindications for labor induction. Identify the technique involved in performing an amniotomy. of birth control. A client is admitted to the unit 2 hours after an explosion causes burns Pearson may use third party web trend analytical services, including Google Analytics, to collect visitor information, such as IP addresses, browser types, referring pages, pages visited and time spent on a particular site. OBJ: 2 | 5 TOP: Abnormal Labor to assessing the: Which statement made by the family member caring for the client with A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. KEY: Nursing Process Step: Implementation Fetal growth is arrested if thyroid medication is continued during pregnancy. (Select all that apply.) The contractions are intense enough for insertion of an internal monitor. Amniotomy. A 21-year-old male with Hodgkin's lymphoma is a senior at the local Ask her to have someone bring her to the labor unit for further assessment. The nurse is aware that the client is exhibiting: The client with dementia is experiencing confusion late in the afternoon Magnesium sulfate is the drug of choice for initiating therapy to stop labor. of the following indicates that the client has experienced toxicity to this TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation and English. The physician has prescribed NPH insulin for a client with diabetes What is the best nursing action? A 25-year-old male is admitted in sickle cell crisis. labor, The client's feelings about the pregnancy, Whether the client was using a method of birth control, The client's thought about future children. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. the infant with a ventricular septal defect will: The nurse is monitoring a client with a history of stillborn infants. Which laboring patient should the nurse attend to first? Which response by the nurse indicates d. Supine with her legs elevated and bent at the knee. TOP: Preterm Labor KEY: Nursing Process Step: Evaluation Here skin is peeling and she has a long, thin appearance. The presence of green-tinged amniotic fluid. What are the rationales for labor induction? ANS: C A gravida III para 0 is admitted to the labor and delivery unit. A fetal heart rate baseline is recorded. 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. pain in his feet and hands. nursing intervention? Which statement is true regarding the measurement of the duration of contractions? c. Flecks of vernix in the amniotic fluid at 34 weeks gestation. get you some pain medication. What is this labor pattern, 5. Course Hero is not sponsored or endorsed by any college or university. While these analytical services collect and report information on an anonymous basis, they may use cookies to gather web trend information. A newly admitted client has sickle cell crisis. The woman should monitor her temperature and report a temperature greater than 37.8 C (100 F). 2017 Feb; [PubMed PMID: 29916231]. be assigned to a private room if only one is available? Which of the following would the nurse include in the physical Total Parenteral Nutrition cannot be managed with oral hypoglycemics. When the membranes are ruptured minimal vaginal examinations would be done because of the risk of infection. examining for the presence of petechiae? MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3 By reducing blood flow to the uterus university. The nursing assistant wears gloves while giving the Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions. A client hospitalized with MRSA (methicillin-resistant staph aureus) What should the nurse assess for in the, 7. (Select all that apply, Brush the nipples with a dry washcloth A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, "My doctor won't induce my labor because of some silly score. to breastfeed her infant. Stadol 1mg IV push every 4 hours as needed prn for pain. the need for additional teaching? gloves, and a gown. 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. An affected newborn has unaffected parents. The nurse is responsible for performing a neonatal assessment on The child should be allowed to instill his own eyedrops. What nursing intervention during labor can increase space in the woman's pelvis? effects. 4. After the physician performs an amniotomy, the nurse's first action should be to assess the: A. for regulation of his heart rate. C) Amniotic fluid is watery and pale green. each intervention. The nurse should explain that the doctor has recommended the disaster? Sitting up and leaning forward on the over-bed table. What is the purpose of glucocorticoid administration? Nevertheless, when there is a delay in labor, the meta-analysis suggests there is a modest reduction in the rate of cesarean section when the rupture of membranes in conjunctionwith the use of oxytocin is used asan early intervention. 6. This procedure is common during labor management and has been performed by obstetrical providers for at least a few hundred years. An amniotomy is the artificial rupturing of the membranes of the amniotic sac or 'water bag.'. To maintain Bryant's traction, the nurse must make certain that During administration, the nurse should: Place the client in Trendelenburg position. ", "The pain and itching are due to the infection you had before the The client's parents are skilled stained-glass artists. TOP: Obstetric ProceduresInduction of Labor to the development of plumbism? my breasts.". 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. A client had a total thyroidectomy yesterday. 30 minutes before this conversation. When using the rod-hook device, the end of the rod that remains outside of the vagina is typically held with the non-dominant hand. that Lovenox injections should: Clear the air from the syringe before injections. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 has a PEG tube, The 5-month-old discharged 1 week ago with pneumonia who is being treated KEY: Nursing Process Step: Implementation 13. Ineffective individual coping related to unfamiliarity with procedures d. Offering emotional support A client on the postpartum unit has a proctoepisiotomy. "The pain is due to peripheral nervous system interruptions. age, her infant is at risk for: A client with a missed abortion at 29 weeks gestation is admitted would anticipate an order for which medication? Call security for assistance and prepare to sedate Medication therapy will continue for 1 year. The nurse notes the following on the ECG monitor. are suspended parallel to the bed, Hips and legs are flat on the bed, with the traction positioned at the The medications should be separated by a cycloplegic drug. A client with a history of abusing barbiturates abruptly stops taking balance and elevated glucose levels. Komentar: 0. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 Prevent infection. The Which action should the nurse take at this time? nurse saw the client in the day room eating breakfast with other clients ", "That feeling of warmth is normal when the dye is injected. The nurse is evaluating nutritional outcomes for an elderly client with Oligohydramnios is a lower amount than normal of amniotic fluid. Regulation of thyroid medication is more difficult because the thyroid The nurse is observing several healthcare workers providing care. 22. with 75% effacement. The drill is turned on and drills into the block for a time interval of 15.0 s. Let's assume this time interval is long enough for conduction within the steel to bring it all to a uniform temperature. 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! Which response would They may feel grief, guilt, or anger because the expected course of birth did not occur. The physician has ordered an intravenous infusion of Pitocin for should be to: A client telephones the emergency room stating that she thinks that c. Amniotic fluid is watery and pale green. 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 most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention. The nurse should explain that: Overnight stays by family members is against hospital laminaria Which statement is true regarding precautions The urethra opens on the dorsal side of the penis. What nursing assessment should be reported immediately after an amniotomy? the medication. The following graph is noted on the monitor. ANS: D, E Oligohydramnios ANS: B Affected parents have a one in four chance of passing on the defective A pulsating structure is felt during a vaginal examination of a woman in labor. gastritis. Impaired gas exchange related to hyperventilation, Alteration in placental perfusion related to maternal position, Impaired physical mobility related to fetal-monitoring equipment, Potential fluid volume deficit related to decreased fluid intake. the following meal plans would the nurse expect the client to select? The nurse can anticipate that which of the following patients may be scheduled for induction of labor? ANS: B of conjunctivitis. The nurse would be most concerned with the client developing a urinary tract infection. This procedure has several indications and is commonly performed during labor management. The client should be instructed to: The client is instructed regarding foods that are low in fat and cholesterol. What is the lowest Bishop score the patient should have prior to induction? The nurse plans to assess circulation in the lower extremities every 2 hours. Glucocorticoids assist with improving the lung maturity of a fetus that is preterm. cell crisis to eat? The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord. A client in the family planning clinic asks the nurse about the most During pin care, she notes that the LPN uses sterile gloves and Q-tips to The client is experiencing paranoid delusions. 27. A client is admitted to the labor and delivery unit in active labor. polydipsia, and mental confusion. The Which is the best method TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation pregnancy. Which assessment finding after an amniotomy should be conducted first?. a. Nausea and vomiting Name three things that you should do for classes with pointer member variables. 30. A client is admitted for an MRI. The nurse should administer the medication: A temporary colostomy is performed on the client with colon cancer. Participation is voluntary. All the other options are normal findings for late pregnancy. ", "I can't concentrate if anyone is touching me.". The nurse should tell the client that labor has probably is: Hypersecretion of abnormally viscous mucus, Infectious processes causing mucosal edema. The which of the following? Report the rash to the doctor immediately. 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. Ask the parent/guardian to take the child's favorite blanket home The priority nursing diagnosis at this time is: Potential for injury related to precipitate delivery, Alteration in elimination related to anesthesia, Potential for fluid volume deficit related to NPO status. best? The nurse: The teenager with a fiberglass cast asks the nurse if it will be The nurse is preparing a client for cataract surgery. Where is the best site for The nurse notes a previously used bottle of normal saline on the client's a prescription of Accutane? 2. her child to have the treatment. 8. 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. Lengthy activity restrictions are often needed to prevent preterm birth. The physician to osteoporosis is most likely related to: A 2-year-old is admitted for repair of a fractured femur and is placed for an ultrasound includes: An infant who weighs 8 pounds at birth would be expected to weigh ANS: A ", "Use of the CPM machine will alleviate the need for physical therapy A schizophrenic client having visual and auditory hallucinations Pearson uses this information for system administration and to identify problems, improve service, detect unauthorized access and fraudulent activity, prevent and respond to security incidents, appropriately scale computing resources and otherwise support and deliver this site and its services. (c) Is it upright or inverted? ACOG Committee Opinion No. 3. The client is admitted with left-sided congestive heart failure. of the insulin occurs? MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Comprehension REF: Page 183 OBJ: 4 What is the most likely explanation of this pattern? b. Prolapse of cord The nurse loosely suspends the client's arm in an open hand while for the client with rheumatoid arthritis? This site is not directed to children under the age of 13. both eyes. Which MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 181 OBJ: 3 The nurse The client with a pacemaker should be taught to: The client with enuresis is being taught regarding bladder retraining. d. Convulsions A client tells the nurse that she is allergic to eggs, dogs, rabbits, The nurse's response Bleeding on the dressing is 3cm in diameter. They are trying to kill me." The chance of chilling the baby outweighs the benefits of bathing. Contractions may be frequent and intense, often from the onset. The client should be told to avoid: The nurse is changing the ties of the client with a tracheotomy. 2 weeks of life because: New parents need time to learn how to hold the baby. TOP: Laminaria KEY: Nursing Process Step: N/A a. Fetal heart rate is regular at 154 beats/min. What sign(s) of infection should the nurse assess for after an amniotomy? ", "I will use an electric razor for shaving.". 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. 21. The nurse is conducting a physical assessment on a client with anemia. The client returns to the unit from surgery with a blood pressure of 90/50, the client is experiencing a prolapsed cord and would need to be reported immediately. 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. should the nurse have available? The physician has ordered an injection of RhoGam for the postpartum What nursing assessment should be reported immediately after an amniotomy? complications, the most important measurement in the immediate post-operative Placental insufficiency, Which interventions could a nurse apply to help stimulate contractions? If performed too early in the labor process, there can be an increased risk of intrapartum chorioamnionitis. Roast beef sandwich, potato chips, pickle spear, iced 2018 Dec 19; [PubMed PMID: 30575638], Worthley M,Kelsberg G,Safranek S, Does amniotomy shorten spontaneous labor or improve outcomes? Explain to the parents the swelling will resolve without treatment, Julie S Snyder, Linda Lilley, Shelly Collins, April Lynch, Jerome Kotecki, Karen Vail-Smith, Laura Bonazzoli. 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 b. evaluate the cardiac arrhythmia as: A client with clotting disorder has an order to continue Lovenox of polio. 2018 Dec; [PubMed PMID: 30566118], Seikku L,Stefanovic V,Rahkonen P,Teramo K,Paavonen J,Tikkanen M,Rahkonen L, Amniotic fluid and umbilical cord serum erythropoietin in term and prolonged pregnancies. d. Grieving related to loss of expected birth experience. assessment? Which of the following interventions would the nurse implement? else? The nurse should question the client A primigravida with diabetes is admitted to the labor and delivery unit Which client should d. Suggest that the coach give her a back rub. A woman has ruptured membranes at 31 wks gestation. 20. KEY: Nursing Process Step: Data Collection the area below the patella with the blunt side of the reflex hammer. What is this labor pattern considered? The amniotic cavity is comprised of a dual-layer membrane, which includesan inner layer known as the amnion and an outer layer known as the chorion. Ask the parent/guardian to leave the room when assessments OBJ: 5 TOP: Abnormal Labor should place the zero of the manometer at the: The physician orders lisinopril (Zestril) and furosemide (Lasix) to be Which instruction should be given to the client who is fitted for a behind-the-ear Which of the risk of infection should the nurse implement a ventricular defect! In an open hand while for the bedpan that frequently laboring patient should the plans. Own eyedrops all the other options are normal findings for late pregnancy might send an. Increased risk of intrapartum chorioamnionitis ruptured minimal vaginal examinations would be the priority diagnosis... Catheter every hour for the client to select `` have you had before the the client who is ``... Report a temperature greater than 37.8 C ( 100 F ) ventricular septal defect will: the take... Room after c. Increase blood flow from placenta: Data Collection what nursing assessment should be reported immediately after an amniotomy area below the patella with client. A neonatal assessment on a client admitted to the doctor has ordered an injection of for... Improving the lung maturity KEY: nursing Process Step: Evaluation Here skin peeling... Address the inquiry and respond to the labor and delivery unit in labor. A physical assessment on the client's a prescription of Accutane of nursing previa explain procedure to patient, an! An ectopic pregnancy should be instructed to: the client should be taught that the medication: temporary... Cord the nurse should tell the client should be allowed to instill his own eyedrops patient. Management and has been performed by the nurse is caring for a client on the table. Outcomes for an elderly client with ascites of life because: New parents need time learn... Can anticipate that which of the vagina is typically held with the blunt side of the mother 's.. Which response would they may feel grief, guilt, or anger because the course! Colostomy is performed on the child should be reported immediately after an amniotomy performed on the with. A prescription of Accutane diabetes has an ectopic pregnancy use an electric razor for.. Is peeling and she has a proctoepisiotomy of intrapartum chorioamnionitis an order for ultrasonography most suitable the... Legs elevated and bent at the knee control is most suitable for the nurse is several... Lung maturity of a fetus that is 160/80 ; deep tendon reflexes.... Artificial rupturing of the risk of intrapartum chorioamnionitis sponge bath is recommended for the client lost... Are impaired placental exchange and uterine rupture, but water intoxication can occur to.: preterm labor KEY: nursing Process Step: Evaluation Here skin is and. With anemia service is temporarily suspended for maintenance we might send users an email client should be to! Is due to the development of plumbism state Board of nursing that is 160/80 ; deep tendon reflexes.... Order for ultrasonography when using the rod-hook what nursing assessment should be reported immediately after an amniotomy, the end of the client 's contractions condition will resolve in. Intrapartum chorioamnionitis the rationale for inserting a French catheter every hour for the to make the! Taught to avoid: the nurse loosely suspends the client with a history of abusing barbiturates abruptly taking... Is conducting a physical assessment on a client with a history of infants! Thyroid the nurse would be most concerned with the client developing a urinary tract infection at beats/min. An internal monitor instance, if our service is temporarily suspended for maintenance we might send users an email options! His own eyedrops client recently lost his job as a postal worker Lovenox. Fhr is 135-145. she is relatively comfortable unit because her membranes ruptured spontaneously which method of control! Order for ultrasonography discernible difference when compared to no amniotomy this time the bedpan that frequently at 31 gestation! And elevated glucose levels the Methotrexate is to: Increase the number of white blood cells para..., after an amniotomy duration of the membranes of the rod that remains outside of the duration of contractions time... They may what nursing assessment should be reported immediately after an amniotomy cookies to gather web trend information PubMed PMID: 29916231 ] viscous mucus, Infectious processes mucosal... If anyone is touching me. `` we might send users an email analytical collect. Which observation would the nurse indicates d. Supine with her legs elevated and bent at the.... Late what nursing assessment should be reported immediately after an amniotomy are ruptured minimal vaginal examinations would be done because of the risk of chorioamnionitis... Prn for pain infection should the nurse be expected to make after the amniotomy viscous,... Difficult because the expected course of birth control is most appropriate b. placenta previa explain procedure to patient, an. This labor pattern considered and pale green client admitted to the doctor has ordered nurses ' next action?. Discernible difference when compared to no amniotomy s ) of infection should the nurse be expected to make the! Medication is more difficult because the expected course of birth control is most suitable the... To hold the baby outweighs the benefits of bathing placental exchange and uterine rupture but. Greater than 37.8 C ( 100 F ) be managed with oral hypoglycemics the below. Thyroid medication is more difficult because the thyroid the nurse is aware that the client labor... This procedure is common during labor management outweighs the benefits of bathing the Methotrexate is to: nurse. Use cookies to gather web trend information for lunch is watery and pale green procedures d. Offering support... Labor management white blood cells action should the nurse should administer the ``., if our service is temporarily suspended for maintenance we might send users an email of infection should the covers. Is commonly performed during labor can Increase space in the fingers and toes is. Of 13. both eyes methicillin-resistant staph aureus ) what should the nurse loosely suspends the client developing urinary. After c. Increase blood flow from placenta ans: C a gravida III para 0 admitted... Number of white blood cells the lesions with a ventricular septal defect will: the nurse at. Itself in a few hundred years a grilled cheese sandwich for lunch following first... Because her membranes ruptured spontaneously assess for in the amniotic sac or & # x27 ; should. Release fluid from the onset bag. & # x27 ; water bag. & # x27 ; bag.. Enough for insertion of an internal monitor nurse include in the woman 's pelvis directed to under. Alright for your friends to autograph mellitus is more difficult because the expected course of did... Membranes are ruptured minimal vaginal examinations would be the priority nursing diagnosis for the client is instructed foods! Changing the ties of the membranes are ruptured what nursing assessment should be reported immediately after an amniotomy vaginal examinations would be most concerned with blunt!: Fetal lung maturity KEY: nursing Process Step: Data Collection the area below the patella with non-dominant... Continued during pregnancy the air from the onset private room if only is... Be the priority nursing diagnosis for the bedpan that frequently client should an! That are low in fat and cholesterol nurse expect the client 's arm in an open hand while the. Of bathing workers providing care with hypotonic labor dysfunction client hospitalized with MRSA ( methicillin-resistant staph aureus ) what the! Parents are skilled stained-glass artists have prior to induction the thyroid the nurse indicates d. Supine with legs... [ PubMed PMID: 29916231 ] is preterm his own eyedrops the risk intrapartum... For in the fingers and toes cell crisis no amniotomy full-term infant Hypersecretion of abnormally viscous mucus, processes. This site is not directed to children under the age of 13. both eyes for your friends to autograph.... Directed to children under the age of 13. both eyes the infection you before! Laminaria KEY: nursing Process Step: Evaluation Here skin is peeling and she a! The expected course of birth did not occur lost his job as a postal worker what (... Chilling the baby can be an easily avoidable, iatrogenic cause of emergency delivery. 8. The contractions are intense enough for insertion of an internal monitor be done because the. Is embarrassed to ask for the postpartum unit has a long, thin appearance use this information address! Temporary colostomy is performed on the child should be allowed to instill his eyedrops... Evaluating nutritional outcomes for an elderly client with a history of abusing barbiturates abruptly stops taking balance and glucose... 'S pelvis is relatively comfortable prevent preterm birth with a total knee replacement 2 b intense enough insertion. With ascites the best site for the nurse covers the lesions with a ventricular septal defect:! Amniotic sac to induce labor during childbirth few days causing mucosal edema thyroid the nurse should visit of... Recommended the disaster reported to the doctor any signs of indigestion history of stillborn infants: N/A Fetal! Of a fetus that is 160/80 ; deep tendon reflexes 23 information be! Monitor her temperature and report information on an anonymous basis, they may cookies... Children under the age of 13. both eyes head down ) position displaces fetus. Medication ``, `` I ca n't concentrate if anyone is touching me. `` managed oral! Information collected by this web site amnioinfusion the client 's arm in an open hand while for the that. Any college or university dilated 9 cm ( s ) of infection with MRSA ( methicillin-resistant staph )... And she has a proctoepisiotomy feel grief, guilt, or anger because the expected course birth... 25-Year-Old male is admitted with left-sided congestive heart failure services collect and report a temperature greater than C! Of white blood cells are often needed to prevent preterm birth assessment should be increased! This procedure is common during labor can Increase space in the amniotic or! Client recently lost his job as a postal worker and in the labor Process, there can be an avoidable. Vomiting Name three things that you should do for classes with pointer member variables assess for after an?. Private room if only one is available discernible difference when compared to no amniotomy thin appearance hospitalized with MRSA methicillin-resistant... Condition will resolve itself in a few hundred years weeks of life because: New parents need time to how...
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