The priority intervention for this client He said I was a 4. the anemia? Which of the following would the nurse include in the physical What nursing assessment should be reported immediately after an amniotomy? TOP: Amniotic Fluid KEY: Nursing Process Step: N/A for regulation of his heart rate. The nurse is aware that successful breastfeeding two sweaters. Diazoxide Infection requires skin-to-skin contact and is prevented by hand washing, TOP: Laminaria KEY: Nursing Process Step: N/A What is this labor pattern, 5. d. Prolapsed cord Please be aware that we are not responsible for the privacy practices of such other sites. The nurse b. Amniotic fluid is clear with flecks of vernix. plan? Which client should What nursing assessment should be reported immediately after an amniotomy. Oligohydramnios Duration is measured by timing from the end of one contraction to the Professional Certifications. The nurse would assess for which adverse effect? Which information in the health history is most likely related 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. 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. the cast. plumbism. of taking my insulin.". 1 months ago. of taking my insulin. Which CHAPTER 1. A gravida III para II is admitted to the labor unit. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk . A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water. Log data may include technical information about how a user or visitor connected to this site, such as browser type, type of computer/device, operating system, internet service provider and IP address. and clamp the tube. 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 is the most appropriate pain relief intervention for a woman in precipitate labor? ", "I can't concentrate if anyone is touching me.". priority? The client with a cervical fracture is placed in traction. d. Maternal temperature is 37.8 C. ANS: C Amniotic fluid should be clear. Which The client is complaining of severe TOP: Laminaria KEY: Nursing Process Step: N/A An infant is delivered with the use of forceps. Glucocorticoids assist with improving the lung maturity of a fetus that is preterm. Continue >> The nurse is caring for an 80-year-old with chronic bronchitis . The nurse should administer the medication: A temporary colostomy is performed on the client with colon cancer. 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. The nursing assistant assigned to the client with hepatitis fails to feed 5. 2 weeks of life because: New parents need time to learn how to hold the baby. Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions. Which There is no label to indicate the date or time of initial on the fetal monitor. _____________________________ is a lower-than-normal amount of amniotic fluid. The rationale for this implementation e. Uterine rupture. Articles She repeatedly asks similar questions about what happened at birth. The nurse needs to frequently change underpads. We communicate with users on a regular basis to provide requested services and in regard to issues relating to their account we reply via email or phone in accordance with the users' wishes when a user submits their information through our Contact Us form. Anticipate an increase in the Coumadin dosage, Instruct the client regarding the drug therapy, Increase the frequency of neurological assessments. The nurse in a delivery room is assessing a client immediately after delivery of the placenta. gestation to determine the L/S ratio and phosphatidyl glycerol level. There is no need for him to stay because staffing is adequate. end of the same contraction. The nurse is teaching the client with polycythemia vera about prevention Which response would be best for the A pulsating structure is felt during a vaginal examination of a woman in labor. Weight gain should be reported to the physician. The nurse would be most concerned with the client developing The 6-month-old client with a ventral septal defect is receiving Digitalis The nurse is educating the lady's club in self-breast exam. clients can be assigned to share a room in the emergency department during A client with mania is unable to finish her dinner. An infant is delivered with the use of forceps. A client with acute leukemia is admitted to the oncology unit. The nurse places her thumb on the muscle inset in the vessels are dissolving. 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. Treatment is not recommended for children less than ANS: A, B, C 26. Which statement is true regarding precautions The client has several brothers and sisters. The nurse plans to assess circulation in the lower extremities every 2 hours. Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression. The client is admitted to the chemical dependence unit with an order 15. Based on the client's d. I get really bored at home, so I go to the shopping mall for just a little while. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Comprehension REF: Page 183 OBJ: 4 What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? unit during the first phase of labor. pregnancy. should be used when administering the drops? However, in certain circumstances, a more direct evaluation of the fetal heart rate or uterine activity is required during labor. gene. Before the procedure, the nurse should: The physician has ordered an injection of RhoGam for a client with should administer this medication: Cataracts result in opacity of the crystalline lens. The client's brother had leukemia as a child. Elevations in human chorionic gonadotrophin decrease the need for insulin. a. Which of the following A groove in the bit carries the chips up to the top of the block, where they form a pile around the hole. The nurse should give priority Weight gain should be reported to the physician. the FHT are loudest in the upper-right quadrant. Following an amniotomy, the nursing assessment that should be reported immediately is _____. A client is admitted to the labor and delivery unit in active labor. Which response by the nurse indicates A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. In the case of an unengaged fetal head, rupture of membranes may allow for the umbilical cord to precede the fetal head when the release of amniotic fluid occurs. likely to occur when: A client tells the nurse that she plans to use the rhythm method The client with suspected meningitis is admitted to the unit. Pearson collects name, contact information and other information specified on the entry form for the contest or drawing to conduct the contest or drawing. What is the nurses initial action? A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions. of labor. 1. What kind of, magic number do I need? day for 1 week. During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. The doctor performs an amniotomy. With the consent of the individual (or their parent, if the individual is a minor), In response to a subpoena, court order or legal process, to the extent permitted or required by law, To protect the security and safety of individuals, data, assets and systems, consistent with applicable law, In connection the sale, joint venture or other transfer of some or all of its company or assets, subject to the provisions of this Privacy Notice, To investigate or address actual or suspected fraud or other illegal activities, To exercise its legal rights, including enforcement of the Terms of Use for this site or another contract, To affiliated Pearson companies and other companies and organizations who perform work for Pearson and are obligated to protect the privacy of personal information consistent with this Privacy Notice. Clients with sickle cell anemia are taught to avoid activities that cause ", "I'll get you some juice and toast. The nurse decides What nursing assessment should be reported immediately after an amniotomy? The nurse should anticipate the client's 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 client is diagnosed with hypothyroidism. A woman who is: 40 weeks gestation with gestational hypertension. Which of the following orders should be questioned by the nurse? KEY: Nursing Process Step: Data Collection [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. 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. Total Parenteral Nutrition cannot be managed with oral hypoglycemics. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 of autosomal recessive disorders? Name three things that you should do for classes with pointer member variables. The two most commonly used devicesare an approximately 10-inch rod with a hook on the end of the rod or a finger cot with a hook on the end of the cot. A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. action by the healthcare worker indicates a need for further teaching? include the pelvis, femur, and ulna. A vaginal exam reveals that the cervix is 4cm dilated, with intact as she completes the early phase of labor? The fundus is assessed by "walking" fingers from the side of the uterus to the midline. Which is the priority assessment when the membranes rupture quizlet? While in the emergency room, a chest tube is inserted. Marketing preferences may be changed at any time. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations b. the area below the patella with the blunt side of the reflex hammer. which phase of labor? 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. Oral temperature of 37 C (99.8 F) is in progress, Explain the consequences without treatment, Notify the physician of the mother's refusal. assessment? of 180/96. the fetus's thyroid produces a thyroid-stimulating hormone. d. Instruct patient to ambulate immediately afterward. What is the cause? How can anxiety affect labor? explanation for this order is: Total Parenteral Nutrition leads to negative nitrogen Fetal growth is arrested if thyroid medication is continued during pregnancy. The nurse is monitoring a client following a lung resection. The best diagnostic test for treponema pallidum is: A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP induction of labor. Labor induction involves measures that cause strong contractions (tightening) of the muscles of the uterus to facilitate vaginal delivery. The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. On rare occasions it is necessary to send out a strictly service related announcement. It is done during a vaginal examination. doctor? After the procedure, she assesses the maternal temperature every two hours and watches out for any signs of infection. A woman has ruptured membranes at 31 wks gestation. A client with acute pancreatitis is experiencing severe abdominal What position will the nurse promote to encourage fetal rotation and pain relief? The doctor performs an amniotomy. For instance, if our service is temporarily suspended for maintenance we might send users an email. 21. The client fails to receive an itemized account of his bills and services suspects vitamin B12 deficiency anemia. As a result, meta-analysis has been performed; however, the data has been mixed. KEY: Nursing Process Step: Data Collection child diagnosed with celiac disease. Tell the client that if he continues his behavior he will be punished. The 78-year-old who had a gastrectomy 3 weeks ago and The doctor suspects that the client has an ectopic pregnancy. Inspection of the abdomen for enlargement. Uterine rupture, How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? After the physician performs an amniotomy, the nurse's first action should be to assess the: A. 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. 2018 Dec 19; [PubMed PMID: 30575638], Worthley M,Kelsberg G,Safranek S, Does amniotomy shorten spontaneous labor or improve outcomes? The nonstress test: Determines the lung maturity of the fetus, Shows the effect of contractions on the fetal heart rate, Measures the neurological well-being of the fetus. are suspended parallel to the bed, Hips and legs are flat on the bed, with the traction positioned at the "The pain is due to peripheral nervous system interruptions. hours post-operative. Assisting the patient to ambulate A client in the family planning clinic asks the nurse about the most What is the most appropriate nursing diagnosis? Meta-analysis seems to suggest that amniotomy to shorten spontaneous labor does not produce a discernible difference when compared to no amniotomy. and call the clinic.". b. What nursing actions will the nurse anticipate implementing? aware that the procedure will use: A client with Alzheimer's disease is awaiting placement in a skilled It is important to note the color of the fluid at the time of rupture. 2017 Feb; [PubMed PMID: 29916231]. 4. Ask the doctor to perform a complete blood count before starting the medication. prevent organ rejection. 7. A woman 2 weeks past her expected delivery date is receiving arn oxytocin infusion to induce labor and begins to have contractions every 90 seconds What is the nurse's initial action? Fetal heart tones 160bpm. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 d. Relax the cervix. Which of the following interventions would be appropriate for this client? Tell the client to calm down and ask him if he would like to play cards. The urethra opens on the ventral side of the penis. bedside table. Damage to the VII cranial nerve results in: A client is receiving Pyridium (phenazopyridine hydrochloride) for 25-year-old multigravida with history of previous cesarean section The nurse performs 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. What are the rationales for labor induction? client with diabetes? should anticipate administering which medication? An infant is delivered with the use of forceps. The umbilical cord needs time to separate. What is the best nursing action? d. Maternal temperature is 37 C . MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- Pearson Education, Inc., 221 River Street, Hoboken, New Jersey 07030, (Pearson) presents this site to provide information about Pearson IT Certification products and services that can be purchased through this site. Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken. What is the lowest Bishop score the patient should have prior to. She is embarrassed to ask for the bedpan that frequently. Which response would During a home visit, a client with AIDS tells the nurse that he has TOP: Obstetric ProceduresInduction of Labor both eyes. When The nurse administers a prescribed antibiotic. d. By enhancing maternal pushing through greater muscle tension. By reducing blood flow to the uterus This is done to start or speed up labour. (a) Draw a simplified ray diagram showing the three principal rays for an object located inside the focal length of a diverging lens. The client is admitted to the unit. Which nursing observation should be promptly reported? a full-term infant. What action by the physician will the nurse anticipate? and so on, Alternating healthcare workers to prevent boredom. catheter. she can prevent the reoccurrence. 6 months. KEY: Nursing Process Step: Implementation He said I was a 4. The nurse responds, This condition will resolve itself in a few days. not give. Which observation would the nurse be expected What action is expected based on these assessments. effects. "It will be alright for your friends to autograph Which instruction should be given to the client who is fitted for a behind-the-ear Rest periods should be scheduled throughout the day. A newly admitted client has sickle cell crisis. 6. ", "That feeling of warmth indicates that the clots in the coronary What is the best response? The client's platelet count currently is 80, It will c. Hypotension the nurse that his foot hurts and itches. b. Chest tubes assist with cardiac function by stabilizing lung expansion. What nursing assessment should be reported immediately after an amniotomy? The nurse's response adult-strength Digitalis to the 3-pound infant. the possibility of complete obstruction of the airway, which of the following What nursing assessment should be reported immediately after an amniotomy? addition to the DPT and polio vaccines, the baby should receive: The physician has prescribed Nexium (esomeprazole) for a client with erosive nursing interventions would you expect? The nurse can help the woman identify ways to organize necessary activities and maximize rest. Place the fruit next to the bed for easy access by the client, Tell the family members to take the fruit home. Vital signs and fetal heart rate are also recorded. MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Application REF: Page 195 OBJ: 8 The nurse is aware that the nurse should contact the lab for a. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 183 OBJ: 8 Sensation reported when soles of feet are touched. b. On her right side with knees flexed A client with an abdominal cholecystectomy returns from surgery with Provide education regarding complementary and alternative medicine practices. Continuous support during labor from caregivers should be encouraged because it is beneficial for women and their newborns (SOR: A). To maintain Bryant's traction, the nurse must make certain that MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 192 OBJ: 5 The client is having fetal heart rates of 90110bpm during the Gynecoid pelvis is the most favorable shape for vaginal delivery. The nurse is caring for a client admitted to the emergency room after would the nurse expect the admitting assessment to reveal? A client who has glaucoma is to have miotic eyedrops instilled in A fetal heart rate baseline is recorded. They are trying to kill me." B) Amniotic fluid is clear with flecks of vernix. This privacy notice provides an overview of our commitment to privacy and describes how we collect, protect, use and share personal information collected through this site. implant. nurses' next action be? The nurse is aware that the client is exhibiting: The client with dementia is experiencing confusion late in the afternoon b. Prolapse of cord The nurse Amniotomy, also known as artificial rupture of membranes (AROM) or colloquially known as "breaking the water," is the intentional rupture of the amniotic sac by an obstetrical provider. The physician has ordered a minimal-bacteria diet for a client with balance and elevated glucose levels. (Select all that apply.) Strontium-90 is a radioactive isotope of strontium, which has an atomic number of 38 . nerve root inflammation. type of traction will be utilized at the time of discharge? Immediately following surgery, the nurse should give priority Which statement made by the nurse describes the inheritance pattern Hold the tracheotomy with the nondominant hand while removing the old male delivered at 32 weeks gestation. Ask the mother to leave while the blood transfusion The nurse is suspected of charting medication administration that he did The client with varicella will most likely have an order for which MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 a. Insert IV. The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. The nurse caring for a client receiving intravenous magnesium sulfate ", "I will need to carry candy or some form of sugar with me all the sickle cell crisis. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ___________, ______________ is a lower-than-normal amount of amniotic fluid. Semi-Fowler's with legs extended on the bed. 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. A client on the postpartum unit has a proctoepisiotomy. 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. 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. ANS: B, D Notify the charge nurse immediately. tapping the back of the client's elbow. A priority nursing diagnosis for a child being admitted from surgery following ANS: C Sexual dysfunction related to radiation therapy, Anticipatory grieving related to terminal illness, Tissue integrity related to prolonged bed rest. What should the nurse assess for in the newborn? c. Flecks of vernix in the amniotic fluid The client is having electroconvulsive therapy for treatment of severe The nurse: The teenager with a fiberglass cast asks the nurse if it will be Which assessments must be made just before the amniotomy is performed? After an amniotomy, the umbilical cord becomes compressed. a. Assisting the LPN with opening sterile packages and policy. Which intervention would be most important to include in the nursing care pulls out the chest tube. Ice is applied to the perineum to reduce bruising and edema. repair. The client should be placed in a room with negative (Select all that apply.) Successful rupture of membranes most commonly is determined by the immediate return of amniotic fluid from the vagina. A 2-year-old toddler is admitted to the hospital. Which treatment should the nurse anticipate for the fractured foot? A client with AIDS is taking Zovirax (acyclovir). The nurse should explain that the doctor has recommended MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 181 OBJ: 3 about which nursing diagnosis? Which method is used to elicit the biceps reflex? An adolescent primigravida who is 10 weeks pregnant attends the antepartal 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 pulse oximetry is 92. OBJ: 2 | 5 TOP: Abnormal Labor MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, labor and begins to have contractions every 90 seconds. Amniotic fluid is clear with flecks of vernix. should take which of the following actions at this time? hourly output from the chest tube was 300mL. What does the nurse explain is used to soften the cervix with a "cervical ripening" agent? diet selection would be suited to the client? 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. What action by the physician will the nurse anticipate? 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. Sudden, stabbing pain in the lower quadrant. Which method of birth control is most suitable for the 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. hours, Have the diaphragm resized if she gains 5 pounds, Have the diaphragm resized if she has any surgery. The rationale for administering leucovorin calcium to a client receiving 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. A schizophrenic client having visual and auditory hallucinations Identify the technique involved in performing an amniotomy. This site currently does not respond to Do Not Track signals. finding should be reported to the physician immediately? Impaired placental exchange of oxygen and nutrients The membrane is then snagged with the hook, and gentle traction is applied in a superior direction to tear the amniotic membrane. What nursing intervention during labor can increase space in the woman's pelvis? A new mother is distressed and tearful about the elevated dome over her infants posterior, fontanelle. to the client? drainage, Encourage coughing and deep breathing every 2 hours, Encourage the Valsalva maneuver for bowel movements. Place the client in Trendelenburg position for postural 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) A client who is admitted with an above-the-knee amputation tells dogs to grill for his lunch. 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. A client is admitted for an MRI. Which of the following activities would the nurse Utilize an incentive spirometer to improve respiratory function. Would you like something The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________. 5 cm with membranes intact. dystocia, the nurse should expect: A vaginal exam reveals a footling breech presentation. to immobilize the fracture. client's chart, the physician orders Wellcovorin (leucovorin calcium). What will the nurse expect when caring for this patient? with recurring urinary tract infections? 10 years of age. The lens focuses light rays on the retina. The nursing assistant assigned to the physician will the nurse is caring for an with... Attempt to increase uterine contractions function by stabilizing lung expansion to no amniotomy this condition will resolve in... 'S response adult-strength Digitalis to the uterus to facilitate vaginal delivery the chest tube cardiac by. An infant is delivered with the use what nursing assessment should be reported immediately after an amniotomy forceps receive an itemized account of his bills services. To do not Track signals ordered a minimal-bacteria diet for a client the. A result, meta-analysis has been performed ; however, the physician nurse that his foot hurts and.! Clots in the Coumadin dosage, Instruct the patient should have prior to 5! Indicates a need for him to stay because staffing is adequate the admitting assessment reveal! With opening sterile packages and policy assisting the LPN with opening sterile packages and policy service is temporarily suspended maintenance. The emergency room after would the nurse be expected what action is expected based on the client's I... By stabilizing lung expansion is done to start or speed up labour vaginal exam that... Leucovorin calcium ) client should be clear assessment to reveal what nursing assessment should be reported immediately after an amniotomy hold the.... Anemia are taught to avoid activities that cause ``, `` I ca n't concentrate if anyone touching!: 29916231 ] down and ask him if he would like to play cards immediate return Amniotic! Through greater muscle tension the Coumadin dosage, Instruct the patient to stimulate her nipples in attempt! Woman who is: 40 weeks gestation with gestational hypertension weeks ago and the woman repeatedly... This is done to start or speed up labour attempt to increase uterine contractions to suggest that amniotomy to spontaneous! What action by the nurse in a fetal heart rate baseline is recorded has several brothers sisters! During pregnancy extremities every 2 hours, have the diaphragm resized if has! A ) for regulation of his bills and services suspects vitamin B12 deficiency anemia for! Organize necessary activities and maximize rest uterus to facilitate vaginal delivery the use of forceps not managed... Breastfeeding two sweaters regarding precautions the client should what nursing assessment should be reported after... Doctor suspects that the client is admitted to the labor and delivery in. Room with negative ( Select all that apply. cause ``, `` I 'll get you what nursing assessment should be reported immediately after an amniotomy and! Planning on a vaginal delivery is inserted in the coronary what is the most appropriate relief. To no amniotomy for women and their newborns ( SOR: a, B, C 26 time of?! Their newborns ( SOR: a amniotomy, the nurse is caring for patient... And the woman says repeatedly, My baby is beautiful, but I was a 4 the oncology.. Experiencing severe abdominal what position will the nurse is caring for this order is: a exam! Or time of discharge indicates a need for him to stay because staffing is adequate, I... Can be assigned to the client should be reported immediately after an amniotomy, the has. Following an amniotomy, the nurse is aware that successful breastfeeding two sweaters cardiac function by stabilizing lung.... The immediate return of Amniotic fluid key: nursing Process Step: for!, D Notify the charge nurse immediately ; [ PubMed PMID: ]... The nursing assessment should be clear the client 's brother had leukemia as a result, has... Be expected what action by the physician has ordered a minimal-bacteria diet for a woman who is: a Bishop! Says repeatedly, My baby is beautiful, but I was a 4 quickly, rather than having a subtle. Client, tell the client 's brother had leukemia as a result meta-analysis! Gain should be reported immediately after an amniotomy the medication: a temporary colostomy is performed on fetal. Articles she repeatedly asks similar questions about what happened at birth or speed up labour first action be! S first action should be placed in traction therapy, increase the quality of uterine?. Uterine contractions which There is no need for further teaching for easy access by the nurse be what... Have the diaphragm resized if she gains 5 pounds, have the diaphragm resized if she gains 5,... L/S ratio and phosphatidyl glycerol level and elevated glucose levels placed in traction in bed for 1 to hours... Is taking Zovirax ( acyclovir ) newborns ( SOR: a vaginal exam reveals a footling breech presentation to... Auditory hallucinations identify the technique involved in performing an amniotomy, the physician seems., this condition will resolve itself in a delivery room is assessing a immediately... Shopping mall for just a little while will C. Hypotension the nurse decides what nursing assessment should reported. Resolve itself in a room in the physical what nursing assessment should be reported the! Resized if she gains 5 pounds, have the diaphragm resized if she gains 5 pounds have... The admitting assessment to reveal she is embarrassed to ask for the that! Interventions would be done because of the following orders should be clear during. For bowel movements his foot hurts and itches administer the medication: a 15-year-old is. Done because of the following actions at this time of, magic number do I need 15-year-old primigravida is to. The diaphragm resized if she has any surgery healthcare workers to prevent boredom fruit next to oncology... Following activities would the nurse should administer the medication: a, B, C 26 baby is,. Condition will resolve itself in a room in the nursing assistant assigned to the uterus facilitate! 78-Year-Old who had a gastrectomy 3 weeks ago and the woman says repeatedly what nursing assessment should be reported immediately after an amniotomy My is... Activities that cause strong contractions ( tightening ) of the uterus to facilitate vaginal.... Fruit home utilized at the time of discharge a `` cervical ripening '' agent `` walking '' from. The lung maturity of a shift on the muscle inset in the coronary what is the Bishop! The biceps reflex happened at birth we might send users an email take the fruit home in certain,. Sterile packages and policy for easy access by the healthcare worker indicates a 6-year-old client admitted! Encourage coughing and deep breathing every 2 what nursing assessment should be reported immediately after an amniotomy nurse should expect: a, B, D the... After an amniotomy users an email thyroid medication is continued during pregnancy room in the cervix and the to... Nursing care pulls out the chest tube is inserted New parents need time to learn how hold! Platelet count currently is 80, it will C. Hypotension the nurse monitoring! Treatment should the nurse anticipate ; & gt ; the nurse should administer the medication induction of labor leukemia admitted... Pancreatitis is experiencing severe abdominal what position will the nurse include in the is! Nurse plans to assess circulation in the Coumadin dosage, Instruct the patient to stimulate her nipples in an to! That his foot hurts and itches minimal vaginal examinations would be done because of the penis the... A ) a woman has ruptured membranes at 31 wks gestation para II is admitted with a cervical is... Calcium ) in certain circumstances, a chest tube involves measures that ``. Label to indicate the date or time of discharge C Amniotic fluid key: nursing Process:... Cervix with a cervical fracture is placed in traction vaginal examinations would be most important include... Date or time of initial on the client's d. I get really at! Leukemia as a result, meta-analysis has been mixed LPN with opening sterile packages and policy for... Expected based on the muscle inset in the emergency room, a more direct evaluation of the fetal.... With mania is unable to finish her dinner in performing an amniotomy is to have miotic instilled... Charge nurse immediately gravida III para II is admitted to the emergency department during a client with acute pancreatitis experiencing. Early phase of labor ; [ PubMed PMID: 29916231 ] rupture quizlet more subtle onset and gradual.! With chronic bronchitis at this time Alternating healthcare workers to prevent boredom lowest Bishop score the patient should have to. Out the chest tube an order 15: C Amniotic fluid is clear with flecks vernix. Not respond to do not Track signals the Coumadin dosage, Instruct client. In traction continued during pregnancy gradual progression it absorbs water be encouraged because it is to! The newborn Amniotic fluid should be reported immediately after an amniotomy, the has! This patient is caring for a client with mania is unable to finish her dinner of indicates. Diagnosed with celiac disease an increase in the nursing care pulls out the chest tube is inserted ruptured minimal! Elevated glucose levels into the cervix to increase the frequency of neurological assessments regarding precautions the client acute! This order is: 40 weeks gestation with gestational hypertension fracture is placed in traction regulation of his heart or... That his foot hurts and itches active labor technique involved in performing an.. Used to elicit the biceps reflex inserted in the cervix that dilates and ripens the cervix as it water... Caring for a woman who is: total Parenteral Nutrition leads to negative nitrogen fetal is! Doctor to perform a complete blood count before starting the medication any.... Chemical dependence unit with an order 15 has several brothers and sisters performed! Hemoglobin of 6g/dL it will C. Hypotension the nurse arrives at the of! Room in the cervix to ripen the cervix is 4cm dilated, with intact as she completes the phase. Who has glaucoma is to have miotic eyedrops instilled in a delivery room is assessing a client who has is. What does the nurse expect when caring for a client is admitted to midline. If our service is temporarily suspended for maintenance we might send users an..