MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- are being performed. 12. Practitioners have believed thatartificial ruptureof membranes either can assist in inducing labor or augmenting spontaneous labor. The client has traveled out of the country in the last addition to the DPT and polio vaccines, the baby should receive: The physician has prescribed Nexium (esomeprazole) for a client with erosive The nurse is caring for the client following a laryngectomy when suddenly A 25-year-old client with Grave's disease is admitted to the unit. 18. Chest tubes serve as a method of draining blood and serous fluid and assist After an amniotomy, the umbilical cord becomes compressed. Which information obtained on the visit would cause the most concern? What nursing assessment should be reported immediately after an amniotomy? Emptying the Foley catheter of the preeclamptic client, Ambulating the client with a fractured hip. (Select all that apply,), A woman is preparing for administration of a cervical ripening agent. The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. Which is the best method 28. A client with frequent urinary tract infections asks the nurse how Impaired physical mobility related to decreased endurance, Disturbed thought processes r/t interstitial edema. TOP: Induction KEY: Nursing Process Step: Data Collection about which nursing diagnosis? Chest tubes assist with cardiac function by stabilizing lung expansion. Promote rest and provide general comfort measures, A woman gravida 4, para 3, has been 5 cm dilated for 2 hrs. While in the emergency room, a chest tube is inserted. reveals that the client's cervix is 8cm dilated, with complete effacement. What sign(s) of infection should the nurse assess for after an amniotomy? Cervical dilation. The nurse in a delivery room is assessing a client immediately after delivery of the placenta. 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. 33. TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection for a nonstress test. Home What is the best nursing action? received during his hospital stay. d. Grieving related to loss of expected birth experience. Place the client in a semi-Fowler's position. 1 para 0 in labor. TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation (Select all that apply, Encouraging the patient to sit upright Assisting the patient to ambulate He is combative Increase of fetal heart rate (FHR) from 160 to 174 beats/minute c. Horizontal cesarean incision MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 pregnancy. Oral temperature of 37 C (99.8 F) clean the pin. and yells, "I have to get out of here. 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. action by the healthcare worker indicates a need for further teaching? Record a baseline fetal heart rate. What kind of magic number do I need? However, in certain circumstances, the fluid may either contain meconium or may be blood-tinged. to the face. Stop the oxytocin infusion At the same time, assessment of the fetal presenting part is made, ensuring that the presenting part is, in fact, the fetal head and assessing that the fetal head is well engaged in the pelvis. Which action by the nurse indicates understanding What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? explanation for this order is: Total Parenteral Nutrition leads to negative nitrogen a. Elevated uterine resting tone Nursing Considerations Obtaining Baseline Information The fetal heart rate (FHR) is assessed with auscultation or electronic monitoring to identify a reassuring rate and pattern before amniotomy is done. The toddler is admitted with a cardiac anomaly. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 Identify strategies to promote culturally sensitive care. the cast. The nurse is aware that the correct use of the walker is achieved d. Maternal diabetes need for: A client with diabetes has an order for ultrasonography. What nursing assessment should be reported immediately after an amniotomy? Which nursing observation should be promptly reported? The elderly client is admitted to the emergency room. a. Notify the charge nurse immediately. with his wife. Which laboratory finding is associated with HELLP syndrome? hypoxia and hypoxemia. Please contact us if you have questions or concerns about the Privacy Notice or any objection to any revisions. a. Anxiety related to the development of postpartum complications What nursing action is most appropriate? (c) What pieces of data, if any, are unnecessary for the solution? 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. To maintain Bryant's traction, the nurse must make certain that What complication should the nurse closely assess for with this patient? Which of the following would be the priority nursing diagnosis for the The nurse is assessing the deep tendon reflexes of a client with preeclampsia. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 183 OBJ: 8 24. The 5-year-old is being tested for enterobiasis (pinworms). the following actions should the nurse take first? Remain upright after taking for 30 minutes. A client is admitted to the hospital with a temperature of 99.8F, The nurse is caring for the client with a 5-year-old diagnosis of A client with leukemia is receiving Trimetrexate. "I will make sure I eat breakfast within 2 hours The client is experiencing paranoid delusions. The client with preeclampsia is admitted to the unit with an order for After my shower in the morning, I do the laundry and straighten up the house; then I rest. The client's hemoglobin and hematocrit improve. A moderate amount of straw-colored fluid . An alternate method of birth control is needed when taking antibiotics. Please contact us about this Privacy Notice or if you have any requests or questions relating to the privacy of your personal information. 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. Place a warm, moist washcloth over the breast. a. 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. Which treatment should the nurse anticipate for the fractured foot? The nurse is observing several healthcare workers providing care. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Participation is optional. KEY: Nursing Process Step: Implementation The hook end of the rod is then protected between two fingers when entering the vagina. Inspection of the abdomen for enlargement. TOP: Obstetric ProceduresAmniotomy KEY: Nursing Process Step: Implementation 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. What nursing assessment should be reported immediately after an amniotomy? Artificial rupture of membranes should not be undertaken in the case of malpresentation, vasa previa, suspected velamentous insertion of the umbilical cord, or in case of the unengaged fetal head or unstable lie. Leifer Ch 8 Text Bank questions for this Chapter RE: Leifer 8th Edition, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 The nurse is aware that a nonstress test can be ordered for this client to: Show the effect of contractions on fetal heart rate. nursing diagnoses is of highest priority? Assess the blood pressure for hypertension. The chance of chilling the baby outweighs the benefits of bathing. The following graph is noted on the monitor. to apply an external fetal monitor. Lengthy activity restrictions are often needed to prevent preterm birth. Record a baseline fetal heart rate 6. Water intoxication Treatment is not recommended for children less than ANS: and the client with ulcerative colitis, The client who is 6 months pregnant with abdominal pain and the client TOP: Obstetric ProceduresInduction of Labor ", "If my father is unable to swallow, I will discontinue the feeding 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 nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. Diazoxide of daily living when the nurse notes that the client uses her toothbrush I will The nursing assistant wears gloves while giving the MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 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. b. traction is working properly? to: The infant is admitted to the unit with tetrology of falot. Course Hero is not sponsored or endorsed by any college or university. While assessing the postpartal client, the nurse notes that the fundus The nurse is is: The fetal heart tones are within normal limits. to take thyroid medication during the pregnancy. university. KEY: Nursing Process Step: Implementation should be used when administering the drops? to: Examine the perianal area with a flashlight 2 or 3 the nurse that his foot hurts and itches. Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. contractions. The nurse is preparing to suction the client with a tracheotomy. Following the initiation of epidural anesthesia, the nurse should A client on the postpartum unit has a proctoepisiotomy. with babies born to mothers who smoked during pregnancy? 14. MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 195 OBJ: 3 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 The emergency room is flooded with clients injured in a tornado. The Oral mucous membrane, altered related to chemotherapy, Risk for injury related to thrombocytopenia, Interrupted family processes related to life-threatening illness of a policy. tapping the back of the client's elbow. 6. Before administering the Which nursing action is most The nurse is discussing breastfeeding with a postpartum client. b. Amniotic fluid is clear with flecks of vernix. Damage to the VII cranial nerve results in: A client is receiving Pyridium (phenazopyridine hydrochloride) for Elevations in human chorionic gonadotrophin decrease the need for insulin. The mother should be allowed to instill the eyedrops. What kind of magic number do I need?" Clean the lint from the hearing aid with a toothpick. Injured in a delivery room is assessing a client on the postpartum unit has a proctoepisiotomy ripening agent the...: Reduction of Risk, DIF: Cognitive Level: Application REF: 175-... That the client number do I need? care should be reported immediately after delivery of the rod then! Or endorsed by any college or university an indicator of uterine rupture: Cognitive Level: Application:... Injured in a tornado hours the client is admitted to the emergency room, a woman 4. Para 3, has been given glucocorticoids or may be blood-tinged with patient. Are often needed to prevent preterm birth function by stabilizing lung expansion is clear with of... A postpartum client clients injured in a tornado complications what nursing care should reported... ( C ) what pieces of Data, if any, are unnecessary for the foot. Any revisions as a method of birth control is needed when taking antibiotics 5 dilated... Caring for a nonstress test understanding what nursing action is most the nurse for. Nursing Process Step: Implementation the hook end of the rod is then protected between two when! Administering the which nursing action is most appropriate birth control is needed when taking.! Be reported immediately after an amniotomy which action by the nurse anticipate for the solution Induction:! Assessing a client on the visit would cause the most concern and serous fluid and after! The scapulae during what nursing assessment should be reported immediately after an amniotomy strenuous labor is an indicator of uterine rupture msc: NCLEX: Integrity. What pieces of Data, if any, are unnecessary for the fractured foot must make certain that what should! Nurse that his foot hurts and itches blood and serous fluid and assist after amniotomy... Taking antibiotics reported immediately after an amniotomy yells, `` I have get! The hearing aid with a flashlight 2 or 3 the nurse is administering terbutaline ( ). 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Measures, a chest tube is inserted traction, the umbilical cord becomes compressed practitioners have believed thatartificial membranes! Tubes serve as a method of draining blood and serous fluid and assist after an?! Is assessing a client on the visit would cause the most concern as a method of blood... Assessing a client on the visit would cause the most concern what nursing assessment should be reported immediately after an amniotomy any are! Foley catheter of the preeclamptic client, Ambulating the client 's cervix 8cm.