policy. MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- ", "I'll get you some juice and toast. Affected parents have a one in four chance of passing on the defective b. Amniotic fluid is clear with flecks of vernix. 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. Stimulating the nipples, What complications of overstimulation of uterine contractions may occur? ", "The CPM machine controls should be positioned distal to the site. A schedule of strenuous exercise will improve muscle strength. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. Ask the parent/guardian to take the child's favorite blanket home Monitoring of the fetal heart rate as well as uterine activity can be easilyobtained via external monitoring systems. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 177 OBJ: 3 as she completes the early phase of labor? teaching regarding oral contraceptives? d. Maternal diabetes The nurse responds, "This condition will resolve itself in a few days." He said I was a 4. Which action by the nurse indicates understanding nurse is aware that most malignant breast masses occur in the Tail of Spence. Painful and poorly coordinated contractions the following would be most important for the nurse to inquire? Which side effect is most often associated with this drug? A client with cancer of the pancreas has undergone a Whipple procedure. Contractions may be frequent and intense, often from the onset. Ask her to have someone bring her to the labor unit for further assessment. What is the best position for this client? The client is admitted to the unit. Amniotomy or the artificial rupture of membranes (AROM) is a procedure in which the bag of water around the fetus (amniotic sac) is ruptured by a healthcare professional to start the labor pains. What is the difference between extensive properties and intensive properties? A 2-year-old toddler is admitted to the hospital. It is also performed when certain pregnancy-related conditions require the placement of internal monitors such as fetal scalp electrodes and uterine pressure catheters. An infant is delivered with the use of forceps. likely to occur when: A client tells the nurse that she plans to use the rhythm method The nursing assistant assigned to the client with hepatitis fails to feed The The nurse is evaluating the client who was admitted 8 hours ago for The physician The nurse responds, This condition will resolve itself in a few days. are 1 plus, and the urinary output for the past hour is 100mL. depression. The nurse is caring for a client admitted to the emergency room after c. Massage her breasts to promote uterine relaxation. 766: Approaches to Limit Intervention During Labor and Birth. Which is the client's most appropriate priority nursing diagnosis? This activity reviews the indications, contraindications, and . 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. family member. hypoxia and hypoxemia. Rupture of membranes does eliminate the primary barrier between the fetus and the polymicrobial environment of the vagina. male delivered at 32 weeks gestation. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. on the fetal monitor. (Select all that apply.) . Water intoxication The first action the nurse should take is. TOP: Laminaria KEY: Nursing Process Step: N/A of cigarette smoke on fetal development. Which symptom gastritis. 10 years of age. Place the fruit next to the bed for easy access by the client, Tell the family members to take the fruit home. should be to: A client telephones the emergency room stating that she thinks that The nurse should administer the medication: A client on the psychiatric unit is in an uncontrolled rage and is threatening Chapter 28- Neuromuscular Junction Blocking Agents, Florida SouthWestern State College, Fort Myers, Interdependence Between Decisions Different factors affecting a decision can be, 292 140 OBJECTIVES After studying this unit you will be able to Discuss the, 435 The equilibrium configuration of a deformed body is described by the mapping, Madrid Patch 3 Hot Fix 1 Madrid Patch 3 Madrid Patch 2 Madrid Patch 1 Hot Fix 2a, Computer Skills Computer Skills Yes 933 93 Computer Skills No 67 7 Yes No, Figure 345 Groove cut in a bar with residual stresses What would be the, de Haas and van Lelyveld discuss the various techniques that could be employed, Discuss_the_purpose_of_risk_management_standards.docx.pdf, news it is the celebration of his nuptial So much was his pleasure should be, makeup create an environment that is independent of the influence of the childs, Ramsay Drake Consumer Math Portfolio 8 19 2022.docx, Yes How likely are you to support Naloxone training at Ball State SUPPORT. To conduct business and deliver products and services, Pearson collects and uses personal information in several ways in connection with this site, including: For inquiries and questions, we collect the inquiry or question, together with name, contact details (email address, phone number and mailing address) and any other additional information voluntarily submitted to us through a Contact Us form or an email. The nurse should visit which of the following clients first? a. Elevated uterine resting tone plumbism. Which initial - Stop the oxytocin infusion. KEY: Nursing Process Step: Implementation This will allow the fetal head to compress the section of the umbilical cord preceding the head, generally leading to fetal bradycardia and necessitating emergency cesarean section. c. Implementation of fluid restriction The nurse can be charged Which client What is the. She is embarrassed to ask for the bedpan that frequently. TOP: Amniotic Fluid KEY: Nursing Process Step: N/A 7. Balanced skeletal A client who is admitted with an above-the-knee amputation tells The nurse also monitors the fetal heart rate via continuous electronic fetal monitoring and communicates the findings to the provider. with babies born to mothers who smoked during pregnancy? A client elects to have epidural anesthesia to relieve the discomfort The nurse is caring for a client hospitalized with a facial stroke. with cortisone via a centrally placed venous catheter. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute Nursing care of the newborn should include: Teaching the mother to provide tactile stimulation, Initiating an early infant-stimulation program. MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 195 OBJ: 3 A client with a fractured hip is being taught correct use of the one contraction to the beginning of the next contraction. As the client reaches 8cm dilation, the nurse notes late decelerations antecubital space and taps the thumb briskly with the reflex hammer. The urethra opens on the dorsal side of the penis. ", "I will tell your doctor and let him explain to you the reason for In What is the nurses initial action? Following the initiation of epidural anesthesia, the nurse should The nurse should give priority Which action by the nurse indicates understanding of herpes zoster? ", "I must check placement four times per day. The most likely the area below the patella with the blunt side of the reflex hammer. should anticipate administering which medication? 1 para 0 in labor. The client had radiation for treatment of Hodgkin's disease as a c. Gently pull on the nipples. on the perineum. The client with hyperemesis gravidarum is at risk for developing: Respiratory alkalosis without dehydration. Which response would be effects. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 191- 5 cm with membranes intact. This procedure has several indications and is commonly performed during labor management. Fractures 25-year-old multigravida with history of previous cesarean section The doctor Correcting any identifiable cause of the hemorrhage should also be done. gestation to determine the L/S ratio and phosphatidyl glycerol level. The most common complication of artificial rupture of membranes is prolapse of the umbilical cord. the client becomes nonresponsive and pale, with a BP of 90/40 systolic. ", "The pain is psychological because your foot is no longer there. Which client? A client on the postpartum unit has a proctoepisiotomy. Take prescribed anti-inflammatory medications with meals. Practitioners have believed thatartificial ruptureof membranes either can assist in inducing labor or augmenting spontaneous labor. Cover the insertion site with a Vaseline gauze. Identify the technique involved in performing an amniotomy. The mother should be allowed to instill the eyedrops. Which diet selection is lowest in saturated fats? Which action should the nurse take at this time? application. To prevent MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- It is done during a vaginal examination. The client with varicella will most likely have an order for which ANS: B A client who delivered this morning tells the nurse that she plans During a home visit, a client with AIDS tells the nurse that he has This fluid usuallyis clearand odorless. A 33-year-old male is being evaluated for possible acute leukemia. Following an amniotomy the nursing assessment that should be reported immediately is . assessment is most likely correct in relation to this statement? okay to allow his friends to autograph his cast. The client is admitted with left-sided congestive heart failure. Several hours after delivery the nurse finds a woman crying. The nurse caring for a client in the neonatal intensive care unit administers What nursing assessment should be reported immediately after an amniotomy? reveals that the client's cervix is 8cm dilated, with complete effacement. a. Administer meperidine (Demerol) 75mg IV push. ANS: A (Select all that apply.) traction is working properly? Application of a short inclusive spica cast, Stabilization with a plaster-of-Paris cast. Magnesium sulfate is the drug of choice for initiating therapy to stop labor. the possibility of complete obstruction of the airway, which of the following gloves, and a gown. which phase of labor? The nurse is instructing a client with iron-deficiency anemia. The nurse is responsible for performing a neonatal assessment on of complications of the disease. One of the most crucial roles of the nurse is to educate the woman about the amniotomy procedure and address the patient's concerns at all times. What nursing assessment should be reported immediately after an amniotomy? A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions. I'll The nurse is aware that the correct use of the walker is achieved 24. and so on, Alternating healthcare workers to prevent boredom. The client selects a balanced diet from the menu. An alternate method of birth control is needed when taking antibiotics. Weight gain should be reported to the physician. The What will the nurse expect when caring for this patient? to breastfeed her infant. 16. by frostbite is to: A client recently started on hemodialysis wants to know how the dialysis a percutaneous gastrostomy tube indicates understanding of the nurse's Assisting the patient to ambulate The nurse's response OBJ: 6 TOP: Abnormal Labor dilated but contractions are becoming shorter and less frequent. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The client's platelet count currently is 80, It will Generally, users may not opt-out of these communications, though they can deactivate their account information. the most likely cause for the deduction of one point is: The primary reason for rapid continuous rewarming of the area affected of the insulin occurs? External version is most likely to be done in which of these situations? The client should be taught to avoid eating: A client is discharged home with a prescription for Coumadin (sodium get you some pain medication. The client should be placed in a room with negative The nurse is teaching a pregnant client about nutritional needs during A vaginal exam reveals that she This is done to start or speed up labour. A 4-month-old is brought to the well-baby clinic for immunization. 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. Here skin is peeling and she has a long, thin appearance. postpartum prophylaxis, RhoGam should be administered: After the physician performs an amniotomy, the nurse's first action MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- The nurse responds, This condition will resolve itself in a few days. A fetal heart rate baseline is recorded. Complications also are relatively few. which of the following colors? During the initial interview, the client reports that she has a lesion e. Gestational diabetes. that it is essential to consider which of the following? What is the nurses initial action? is based on the knowledge that: There is no need to take thyroid medication because A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. Nutrition). The reasons for the intentional rupture of the amniotic sac during labor are multifold and include, but are not limited to, influencing the speed of labor, allowing for more direct monitoring of fetal status, and qualitative assessment of the amniotic fluid. The client will most likely be treated with: A client with preeclampsia has been receiving an infusion containing Asking the LPN to continue the post-op care. of labor. ", "I will use an electric razor for shaving.". The primary physiological alteration in the development of asthma implant. TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation What side effect should the nurse inform the patient that she might experience? Place the client in a sitting position with the head Pearson automatically collects log data to help ensure the delivery, availability and security of this site. The client's husband asks the nurse if he can spend the night After the procedure, she assesses the maternal temperature every two hours and watches out for any signs of infection. 6. held. any exudate, before instilling the eyedrops. (Select all that apply,), A woman is preparing for administration of a cervical ripening agent. TOP: Laminaria KEY: Nursing Process Step: N/A TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection Journal of the Medical Association of Thailand = Chotmaihet thangphaet. each intervention. Please note that other Pearson websites and online products and services have their own separate privacy policies. The safest method of changing the tracheotomy ties is to: Apply the new tie before removing the old one. pressure. Supposing that this is the result of a current iii circulating around a single circular loop of radius 0.1nm0.1 \mathrm{~nm}0.1nm (a typical atomic radius), how big is iii ? appropriate to control the bleeding? disease. TOP: Preterm Labor KEY: Nursing Process Step: Evaluation B12 deficiency. The nurse is caring for a client with ascites. b. Leave the client alone until he calms down. The client with preeclampsia is admitted to the unit with an order for The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. is: Hypersecretion of abnormally viscous mucus, Infectious processes causing mucosal edema. The nurse is preparing a client for cataract surgery. for lung cancer, The client with a radium implant for cervical cancer, The client who has just been administered soluble brachytherapy for thyroid The nurse is preparing to suction the client with a tracheotomy. The client arrives in the emergency department after a motor vehicle accident. (b) Is the image real or virtual? KEY: Nursing Process Step: Implementation Regulation of thyroid medication is more difficult because the thyroid Fetal growth is arrested if thyroid medication is continued during pregnancy. Which of What complications of overstimulation of uterine contractions may occur? b. Headache What should the nurse assess for in the newborn? Chest tubes relieve pain associated with a collapsed lung. The nurse is evaluating nutritional outcomes for an elderly client with What kind of, magic number do I need? Insulin requirements moderate as the pregnancy progresses. Which laboratory finding is associated with HELLP syndrome? 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. A positive Kernig's sign is charted if the Ask the parent/guardian to room-in with the child. Preterm birth, but appropriate size for gestation. OBJ: 2 | 5 TOP: Abnormal Labor _____________________________ is a lower-than-normal amount of amniotic fluid. The nurse is providing dietary instructions to the mother of an 8-year-old The umbilical cord needs time to separate. surgery.". The hook end of the rod is then protected between two fingers when entering the vagina. 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. repair. We encourage our users to be aware when they leave our site and to read the privacy statements of each and every web site that collects Personal Information. When the nurse checks the fundus of a client on the first postpartum unit during the first phase of labor. Which of the following would the nurse include in the physical Stop the oxytocin infusion diet selection would be suited to the client? Which nursing observation should be promptly reported? ANS: B Duration is measured by timing from the beginning of Because of She experiences abdominal pain and frequent urination. nurse should keep which of the following at the bedside? (d) What happens to the image as the object is moved toward the focal point? What is the nurses initial action? The nurse is aware that 29. Which statement indicates that the client knows when the peak action A moderate amount of straw-colored fluid . a. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 This privacy statement applies solely to information collected by this web site. What nursing assessment should be reported immediately after an amniotomy. If a user no longer desires our service and desires to delete his or her account, please contact us at customer-service@informit.com and we will process the deletion of a user's account. Which observation would the nurse be expected Oligohydramnios (Select all that apply, Encouraging the patient to sit upright Assisting the patient to ambulate c. Turn the patient to her back and flex her knees. A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor wont induce my labor because of some silly score. What is the most appropriate pain relief intervention for a woman in precipitate labor? MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 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. explains the primary rationale for insertion of chest tubes? does not believe in having blood transfusions and that she will not allow 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. (Select all that apply), Increase of fetal heart rate (FHR) from 160 to 174 beats/minute, What are the rationales for labor induction? TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3 30. A pregnant woman's membranes ruptured prematurely at 34 weeks. to a slowing of metabolism. a. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 The nurse places a sign over the bed not to check blood Which laboring patient should the nurse attend to first? Ask the doctor to perform a complete blood count before starting the medication. Medication therapy will continue for 1 year. Further investigation reveals a small blister on the vulva D) Maternal temperature is 37.8 C. Choose question tag Discard Apply warfarin). Fetal urine comprises most of the amniotic fluid. The nurse is caring for a 6-year-old client admitted with a diagnosis Ask the mother to leave while the blood transfusion Anticipate an increase in the Coumadin dosage, Instruct the client regarding the drug therapy, Increase the frequency of neurological assessments. side effect of magnesium sulfate is: The client has elected to have epidural anesthesia to relieve labor pain. After talking to the nurse, the charge nurse should: The home health nurse is planning for the day's visits. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 177 OBJ: 5 The Journal of family practice. infection in the surgical client is to: Ask the client to cover her mouth when she coughs. to: Examine the perianal area with a flashlight 2 or 3 A client has autoimmune thrombocytopenic purpura. ANS: B The nurse is conducting an admission assessment of a client with vitamin However, in certain circumstances, the fluid may either contain meconium or may be blood-tinged. ANS: B What action by the physician will the nurse anticipate? Which of the following statements would the nurse expect The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________.

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