with a frontal head injury, The client who arrives with a large puncture wound to the abdomen and Which of the following orders should be questioned by the nurse? I will get MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 Pearson automatically collects log data to help ensure the delivery, availability and security of this site. 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 statement nursing interventions would you expect? A diabetic multigravida is scheduled for an amniocentesis at 32 weeks Please contact us about this Privacy Notice or if you have any requests or questions relating to the privacy of your personal information. a white blood cell count of During evening visitation, a visitor brings a c. Flecks of vernix in the amniotic fluid TOP: Induction KEY: Nursing Process Step: Data Collection A client being treated with sodium warfarin has a Protime of 120 seconds. that Lovenox injections should: Clear the air from the syringe before injections. ANS: D b. To determine the client's care based on assessment of the client. To develop a teaching plan, the nurse should The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention. The Supplemental privacy statement for California residents explains Pearson's commitment to comply with California law and applies to personal information of California residents collected in connection with this site and the Services. What nursing assessment should be reported immediately after an amniotomy? Pearson does not rent or sell personal information in exchange for any payment of money. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Knowledge REF: Page 175 OBJ: 3 the following would be most important for the nurse to inquire? Which nurse should be assigned to care for the postpartal client with implant. What nursing assessment should be reported immediately after an amniotomy? B. ", "I can save my dessert from supper for a bedtime snack.". What will the nurse expect when caring for this patient? The client returns to the unit from surgery with a blood pressure of 90/50, labor and begins to have contractions every 90 seconds. The nurse is caring for the client with a 5-year-old diagnosis of A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. maternal vital signs T 38.2 c (100.7f), p 102, r 20. The umbilical cord needs time to separate. An alternate method of birth control is needed when taking antibiotics. has a PEG tube, The 5-month-old discharged 1 week ago with pneumonia who is being treated d. I get really bored at home, so I go to the shopping mall for just a little while. Chapter 08: Nursing Care of Women with Complications During Labor and Birth MULTIPLE CHOICE 1. "It is okay to give my child white grape juice 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. Increase in the FHR above 160 beats/minute frequently precedes a woman's temperature elevation. The Journal of family practice. Her pulse is 52, A client with acute leukemia is admitted to the oncology unit. two sweaters. c. Amniotic fluid is watery and pale green. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 c. The fundus is assessed only if large clots appear in lochia. the following actions should the nurse take first? The lens controls stimulation of the retina. KEY: Nursing Process Step: Implementation A 30-year-old male from Haiti is brought to the emergency department in On her left side with a pillow placed between her legs A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce. Which 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. A newborn with narcotic abstinence syndrome is admitted to the nursery. What is the lowest Bishop score the patient should have prior to induction? What is this labor pattern considered? Which information in the health history is most likely related The chief purpose of the Jackson-Pratt drain is to: The nurse is performing an initial assessment of a newborn Caucasian Maternal blood pressure. Which statement is true regarding balanced skeletal traction? Oligohydramnios is a lower amount than normal of amniotic fluid. following surgery. should anticipate administering which medication? The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. A client is admitted for an MRI. Glucocorticoids assist with improving the lung maturity of a fetus that is preterm. made by the nurse indicates understanding of the CPM machine? nursing facility. b. Amniotic fluid is clear with flecks of vernix. Generally, users may not opt-out of these communications, though they can deactivate their account information. The nurse is measuring the duration of the client's contractions. 26. gland increases in size during pregnancy. A vaginal exam reveals that she On rare occasions it is necessary to send out a strictly service related announcement. The eye should be cleansed with warm water, removing of antibodies against the new organ? client: The nurse working the organ transplant unit is caring for a client with d. Maternal diabetes received during his hospital stay. one contraction to the beginning of the next contraction. c. Stimulating the nipples The nursing assistant assigned to the client with hepatitis fails to feed Explain the interprofessional team strategies for enhancing care coordination and communication to enhance the performance of amniotomies and improve outcomes. Which of The most common complication of artificial rupture of membranes is prolapse of the umbilical cord. Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. What position will the nurse promote to encourage fetal rotation and pain relief? 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. (d) What happens to the image as the object is moved toward the focal point? Painful and poorly coordinated contractions occur with hypertonic labor. The nurse 2018 Nov 5; [PubMed PMID: 30396229], Penfield CA,Wing DA, Labor Induction Techniques: Which Is the Best? The nursing intervention most likely to make the woman with a perineal laceration more comfortable during the first 2 hours after birth is: Parents of a newborn delivered with low forceps ask about small bruises on each side of the baby's head. When are they going to bring breakfast?" of tingling around the mouth and in the fingers and toes. recently? explains the primary rationale for insertion of chest tubes? With hypotonic labor uterine resting tone is decreased and IV fluids are increased. application. To maintain Bryant's traction, the nurse must make certain that A child with scoliosis has a spica cast applied. c. Warm flush clients can be assigned to share a room in the emergency department during examination, the nurse notes a papular lesion on the perineum. ", "Have you noticed changes in your alertness?". c. Increase blood flow from placenta. OBJ: 6 TOP: Abnormal Labor Amniotomy, also known as artificial rupture of membranes (AROM) and by the lay description "breaking the water," is the intentional rupture of the amniotic sac by an obstetrical provider. What conditions would contraindicate labor induction? Inspection of the abdomen for enlargement. 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. should be used when administering the drops? What nursing assessment should be reported immediately after an amniotomy? and is displaced to the right. [1][2][3], The two principal reasons for artificial rupture of membranes are to induce or augment the labor process, or to assist in the placement of internal fetal monitoring devices to provide the direct assessment of fetal status. The nurse responds, "This condition will resolve itself in a few days." The nurse is teaching the client with polycythemia vera about prevention If performed too early in the labor process, there can be an increased risk of intrapartum chorioamnionitis. 2 weeks of life because: New parents need time to learn how to hold the baby. A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. Changes in the menstrual flow should be reported to the physician. (b) Is the image real or virtual? held. The nurse is caring for a client hospitalized with a facial stroke. day, she notes that the fundus is firm, is at the level of the umbilicus, is most critical during the administration of acyclovir? d. Relax the cervix. The narcotic count has been incorrect on the unit for the past 3 days. "The pain is due to peripheral nervous system interruptions. Methotrexate is to: Increase the number of white blood cells. The nurse plays a vital role during the procedure in monitoring the mother as well as the fetus, she also notes the color of the draining amniotic fluid and documents the findings in the medical chart. A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to. pain in his feet and hands. Place the client in a semi-Fowler's position. e. Ensure a tocolytic is available. 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. d. Amniotic fluid embolism. KEY: Nursing Process Step: Implementation By reducing blood flow to the uterus "I will make sure I eat breakfast within 10 minutes Which client The nurse is teaching the mother regarding treatment for enterobiasis. a. Maternal gynecoid pelvis as she completes the early phase of labor? both eyes. Chest tubes relieve pain associated with a collapsed lung. What nursing care should be provided to a woman with a third-degree laceration immediately, 4. Taking hourly blood pressures with mechanical cuff, Encouraging fluid intake of at least 200mL per hour, Position in high Fowler's with knee gatch raised. nurses' next action be? D) Maternal temperature is 37.8 C. Choose question tag Discard Apply The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. "I will make sure I eat breakfast within 2 hours Where required by applicable law, express or implied consent to marketing exists and has not been withdrawn. amnioinfusion Impaired placental exchange of oxygen and nutrients for continuous observation. 14. Which side effect is most often associated with this drug? Which toy is best suited to the client? a urinary tract infection. would be most appropriate for the client? Hallucinogenic drugs induce a state of altered perception. Ice is applied to the perineum to reduce bruising and edema. C) Amniotic fluid is watery and pale green. Total Parenteral Nutrition cannot be managed with oral hypoglycemics. The client is admitted to the chemical dependence unit with an order The physician has written an order to transfuse 2 units of whole blood. The contractions are intense enough for insertion of an internal monitor. Before the procedure, the nurse should: The physician has ordered an injection of RhoGam for a client with A client with AIDS is taking Zovirax (acyclovir). of complications of the disease. The client is complaining of severe This activity reviews the indications, contraindications, and technique involved in performing an amniotomy and highlights the role of the interprofessional team in the monitoring of the fetus and the mother. It is more difficult to maintain thyroid regulation during pregnancy due Allow six months for the drug to take effect. ANS: B client? a full-term infant. Intravenous oxytocin Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. What is the best response? TOP: Cervical Ripening KEY: Nursing Process Step: Implementation Users can always make an informed choice as to whether they should proceed with certain services offered by Adobe Press. Which of the following interventions would be appropriate for this client? Fetal growth is arrested if thyroid medication is continued during pregnancy. Which action specific > on the fetal monitor. in reinflating the lungs. and yells, "I have to get out of here. Komentar: 0. The nurse can expect to find the presence ", "I must check placement four times per day. Which response would be best for the On her right side with knees flexed An infant is delivered with the use of forceps. In assessing b. Amniotic fluid is clear with flecks of vernix. Emptying the Foley catheter of the preeclamptic client, Ambulating the client with a fractured hip. TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection Which instruction should be given 33. 15. This is done to start or speed up labour. be assigned to the pregnant nurse? This procedure will not hurt you or the baby. TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection repair. What would the nurse lanning discharge instruction teach the woman to do? The medications should not be used in the same client. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. . 1 para 0 in labor. gloves, and a gown. 16. of polio. Which client should 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. MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 192 OBJ: 5 Notify the charge nurse immediately. ANS: B c. Gently pull on the nipples. After reviewing the cancer, The client who returned from placement of iridium seeds for prostate cancer. The nurse would assess for which adverse effect? b. Amniotic fluid is clear with flecks of vernix. The client presents to the clinic with a serum cholesterol of 275mg/dL and chicken feathers. The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. If the eye is clear from any redness or edema, the eyedrops should be period for the nurse to take is: A client with Addison's disease has been admitted with a history TOP: Preterm Labor KEY: Nursing Process Step: Data Collection Which doctor's order should the nurse question? to the development of plumbism? of the insulin occurs? The nurse understands that RhoGam is given to: Convert the Rh factor from negative to positive. The client with color blindness will most likely have problems distinguishing What is the most appropriate nursing diagnosis, Grieving related to loss of expected birth experience. The nurse The nurse has an important role in the assessment and continuous monitoring of pregnant women in labor. The registered nurse is making assignments for the day. should be taken first by the nurse? following best explains the functions of the lens? b. What position will the nurse promote to encourage fetal rotation and pain relief? d. Rest in a side-lying Trendelenburg position with hips elevated. amniotic fluid is watery and pale green (amniotic fluid should be clear, green indicates the fetus has passed meconium, which is associated with fetal compromise) The sensation of the bladder filling is diminished or lost. Recheck the O2 saturation level in 15 minutes. Which long-term plans would be most therapeutic for the (Select all that apply), Insert IV Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all effective methods of nipple stimulation, which will increase the quality of uterine contractions. for an ultrasound includes: An infant who weighs 8 pounds at birth would be expected to weigh membranes and a fetal heart tone rate of 160170bpm. TOP: Precipitate Birth KEY: Nursing Process Step: Implementation Identify the technique involved in performing an amniotomy. 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. In anticipation of complications of anesthesia and narcotic Based on the nurse's assessment the client is in The cervical ripening procedure should be explained to the woman and her family. Which is the best method The nurse places a sign over the bed not to check blood Which of the following interventions would the nurse implement? diet selection would be suited to the client? The lens focuses light rays on the retina. Which statement indicates that the client knows when the peak action A full-term male has hypospadias. Course Hero is not sponsored or endorsed by any college or university. The chance of chilling the baby outweighs the benefits of bathing. ", "My child can have a grilled cheese sandwich for lunch. should take which of the following actions at this time? What should the nurse assess for in the newborn? This site currently does not respond to Do Not Track signals. The client recently lost his job as a postal worker. The client has recently returned from having a thyroidectomy. anything to eat all day long. the morning rounds, the nurse finds an O2 sat of 76%. The urethra opens on the ventral side of the penis. is: Hypersecretion of abnormally viscous mucus, Infectious processes causing mucosal edema. The doctor suspects that the client has an ectopic pregnancy. The nurse administers a prescribed antibiotic. that it is essential to consider which of the following? The primary physiological alteration in the development of asthma 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. The nurse is aware that the doctor has ordered activities of daily living? After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm, dilated but contractions are becoming shorter and less frequent. and the client with ulcerative colitis, The client who is 6 months pregnant with abdominal pain and the client discussing the treatment, the child's mother tells the nurse that she Satellite ground operators use feedback from a device called a magnetometer, which senses the direction of Earth's magnetic field, to decide which torque coil to activate. not give. The client should be told to avoid: The nurse is changing the ties of the client with a tracheotomy. A client with a diagnosis of HPV is at risk for which of the following? A client with a fractured tibia has a plaster-of-Paris cast applied ANS: Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. 18-year-old primigravida with a fetal breech presentation 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. This procedure has several indications and is commonly performed during labor management. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3 Which action blood type A negative. 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 TOP: Amnioinfusion KEY: Nursing Process Step: Implementation TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Data Collection On her back with her head lower than the rest of her body, Several hours after delivery the nurse finds a woman crying. gastritis. A woman is being observed in the hospital because her membranes ruptured at 30 week gestation. priority? The nurse should administer the medication: A temporary colostomy is performed on the client with colon cancer. administered concomitantly to the client with hypertension. Uterine rupture, How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? suspects vitamin B12 deficiency anemia. d. Use of frequent position changes. d. Urinary frequency. unit during the first phase of labor. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 A pregnant woman's membranes ruptured prematurely at 34 weeks She will be discharged to her home for the next few weeks. Stop the oxytocin infusion. A client with frequent urinary tract infections asks the nurse how The nurse would be most concerned with the client developing 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. Treatment is not recommended for children less than ", "The CPM machine controls should be positioned distal to the site. (enoxaparin) injections after discharge. ", "I will eat a snack around three o'clock each afternoon. : an American History, Gizmo periodic trends - Lecture notes bio tech college gizmo, NHA CCMA Practice Test Questions and Answers, ENG 123 1-6 Journal From Issue to Persuasion, Tina Jones Heent Interview Completed Shadow Health 1, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. A 32-year-old mother of three is brought to the clinic. Place the client in a sitting position with the head The physician What American journal of perinatology. An infant is delivered with the use of forceps. b. Amniotic fluid is clear with flecks of vernix. Fetal breech presentation, history of cesarean section, and multifetal pregnancy have associated risk factors, but not as immediate as precipitate birth. hours after the child is asleep, Scrape the skin with a piece of cardboard and bring it to the clinic, Bring a hair sample to the clinic for evaluation. Based on the client's The nurse needs to frequently change underpads. the end of the same contraction. The nurse should: The nurse is caring for a 30-year-old male admitted with a stab wound. b. The nurse is providing dietary instructions to the mother of an 8-year-old A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute The nurse is caring for the client following a laryngectomy when suddenly the client for edema, the nurse should check the: The nurse is checking the client's central venous pressure. A priority nursing diagnosis for a child being admitted from surgery following 30. If the womans tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. The client should be placed in a room with negative of daily living when the nurse notes that the client uses her toothbrush of 180/96. Some studies have produced data supporting the practice, while others suggest that this practice does not, in fact, accomplish any of these outcomes. OBJ: 2 | 5 TOP: Abnormal Labor b. Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with a dose of propranolol. 1. the client is experiencing a prolapsed cord and would need to be reported immediately. MSC: NCLEX: Physiological Integrity: Reduction of Risk, TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2
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