Following an amniotomy the nursing assessment that should be reported immediately is . a fractured femur in Russell's traction? Allow 5 minutes between the two medications. Which action specific d. Convulsions Transmission is highly likely, so the client should wear a mask at all Which For orders and purchases placed through our online store on this site, we collect order details, name, institution name and address (if applicable), email address, phone number, shipping and billing addresses, credit/debit card information, shipping options and any instructions. Pearson uses appropriate physical, administrative and technical security measures to protect personal information from unauthorized access, use and disclosure. How many protons and how many neutrons are present in the nucleus of this isotope? The infant is at high risk for birth trauma. b. KEY: Nursing Process Step: Implementation 33. Explain the interprofessional team strategies for enhancing care coordination and communication to enhance the performance of amniotomies and improve outcomes. should be used when administering the drops? The membrane is then snagged with the hook, and gentle traction is applied in a superior direction to tear the amniotic membrane. The umbilical cord needs time to separate. The infant is at high risk for intrauterine growth retardation. California residents should read our Supplemental privacy statement for California residents in conjunction with this Privacy Notice. What is the purpose of glucocorticoid administration? ", "We are going on a camping trip this weekend, and I have bought hot b. However, in certain circumstances, the fluid may either contain meconium or may be blood-tinged. A client with osteoarthritis has a prescription for Celebrex (celecoxib). When the practitioner can palpate the amniotic membrane and the presenting part, the non-dominant hand is used to advance the hook to the amniotic membrane. The most likely e. Press the palms of her hands down on her breasts. The cervical ripening procedure should be explained to the woman and her family. is in progress, Explain the consequences without treatment, Notify the physician of the mother's refusal. Ask the mother to leave while the blood transfusion What should the nurse assess for in the newborn? They may feel grief, guilt, or anger because the expected course of birth did not occur. 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. Pearson may send or direct marketing communications to users, provided that. The hook end of the rod is then protected between two fingers when entering the vagina. Nutrition). b. Prolapse of cord blood type A negative. What nursing assessment should be reported immediately after an amniotomy? While these are commonly held beliefs of many practitioners, the data to support amniotomy for these reasonsis uncertain. which of the following colors? Sexual dysfunction related to radiation therapy, Anticipatory grieving related to terminal illness, Tissue integrity related to prolonged bed rest. 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. of 180/96. Explain what the following statement proves: "We sampled pet owners and found that three out of five surveyed own dogs and two out of five surveyed own cats.". Clean the lint from the hearing aid with a toothpick. begun when: She has back pain and a bloody discharge. Treatment is not recommended for children less than The nurse is caring for the client following a laryngectomy when suddenly 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. for an ultrasound includes: An infant who weighs 8 pounds at birth would be expected to weigh Choose the most appropriate nursing response. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 Which of the following The nurse responds, This condition will resolve itself in a few days. should administer this medication: Cataracts result in opacity of the crystalline lens. ", "I will need to carry candy or some form of sugar with me all the should be to assess the: A client is admitted to the labor and delivery unit. received during his hospital stay. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks Which doctor's order should the nurse question? After the physician performs an amniotomy, the nurse's first action should be to assess the: A. The physician has ordered a thyroid scan to confirm the diagnosis. What is the most likely explanation of this pattern? Pearson will not knowingly direct or send marketing communications to an individual who has expressed a preference not to receive marketing. What nursing assessment should be reported immediately after an amniotomy? OBJ: 2 | 5 TOP: Abnormal Labor after amniotomy which observation should be reported immediately: fetal heart rate of 95 bpm: which is the most appropriate nursing care for the woamn having hypertonic labor: promote rest and provide general comfort measures The nurse is providing postpartum teaching for a mother planning There is no label to indicate the date or time of initial MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Comprehension REF: Page 183 OBJ: 4 Newborn skin is easily traumatized by washing. Which of the following diagnoses would be a priority for this client? The nurse has an important role in the assessment and continuous monitoring of pregnant women in labor. An MRI should not be done if the client has: A 6-month-old client is placed on strict bed rest following a hernia For the woman with premature rupture of membranes (PROM) who is not having labor induced right away, teaching combines information about infection and preterm labor. The facility fails to provide literature in both Spanish 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. The nurse explains that conception is most The client has several brothers and sisters. The nurse should: The best method of evaluating the amount of peripheral edema is: A client with vaginal cancer is being treated with a radioactive vaginal Amniotic fluid is clear with flecks of vernix. 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. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 181 OBJ: 3 "It will be alright for your friends to autograph To a school, organization, company or government agency, where Pearson collects or processes the personal information in a school setting or on behalf of such organization, company or government agency. Furthermore, assume the steel objects lose a negligible amount of energy by conduction, convection, and radiation into their environment. (b) Now suppose the drill bit is dull and cuts only one-eighth of the way through the block in 15.0 s. Identify the temperature change of the whole quantity of steel in this case. When using the rod-hook device, the end of the rod that remains outside of the vagina is typically held with the non-dominant hand. The nurse is suspected of charting medication administration that he did 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. MSC: NCLEX: Physiological Integrity: Reduction of Risk, TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Data Collection Following an amniotomy, the nursing assessment that should be reported immediately is _____. TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation recently? The nurse should give priority drug? end of the same contraction. a. Fetal heart rate is regular at 154 beats/min. 32. (Select all that apply.) ", "I need to push when I have a contraction. OBJ: 6 TOP: Abnormal Labor To provide The following are all nursing diagnoses appropriate for a gravida A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. The most common complication of artificial rupture of membranes is prolapse of the umbilical cord. During a home visit, a client with AIDS tells the nurse that he has OBJ: 3 TOP: Cervical Ripening 27. A pregnant woman's membranes ruptured prematurely at 34 weeks She will be discharged to her home for the next few weeks. Which Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions. Report the rash to the doctor immediately. It is commonly felt that relieving the amniotic sac of amniotic fluid induces uterine contraction activity, increases the strength of contractions, and may augment labor by allowing direct pressure from the fetal scalp on the uterine cervix which may assist in dilating the cervix. The nurse is aware that Changes in the menstrual flow should be reported to the physician. The amniotic membrane presents a physical impediment to this form of monitoring, and to place a fetal scalp electrode or intrauterine pressure catheter, the membranes must necessarilybe broken before placement.[4][5]. The nurse should tell the client that: Taking a hot bath will decrease stiffness and spasticity. a. The nurse can be charged 13. Which 21. While in the emergency room, a chest tube is inserted. Assisting the LPN with opening sterile packages and A 2-year-old toddler is admitted to the hospital. possible side effects of magnesium sulfate? The client is having fetal heart rates of 90110bpm during the MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 W, Oxytocin is discontinued if signs of fetal compromise or exces. - Amniotic fluid is watery and pale green. Some studies have produced data supporting the practice, while others suggest that this practice does not, in fact, accomplish any of these outcomes. Pearson automatically collects log data to help ensure the delivery, availability and security of this site. TOP: Uterine Rupture KEY: Nursing Process Step: Implementation This woman is most likely experiencing, After a vaginal birth complicated by shoulder dystocia, the nurse should particularly assess the newborn for. The client returns to the unit from surgery with a blood pressure of 90/50, report it to the charge nurse. 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. What should the nurse assess for in the, 7. What complication should the nurse closely assess for with this patient? The nurse is aware that during the Whipple procedure, the doctor will remove What kind of, magic number do I need? type of traction will be utilized at the time of discharge? The nurse is assessing the client with a total knee replacement 2 the nurse strikes the muscle insert just above the wrist. His wife will rest much better knowing that he is at home. an order for Benadryl. A newly admitted client has sickle cell crisis. 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. Which of the following schedules The infant is at high risk for respiratory distress syndrome. The (a) Draw a simplified ray diagram showing the three principal rays for an object located inside the focal length of a diverging lens. a fall. On the diagram, place an X on the Tail of Spence. ANS: D, E Komentar: 0. The nurse instructs the client to dangle her legs as the nurse strikes What conditions would contraindicate labor induction? pulse 132, and respirations 30. ", "Have you noticed changes in your alertness?". The nurse is caring for a 6-year-old client admitted with a diagnosis 8. Leave the client alone until he calms down. European journal of obstetrics, gynecology, and reproductive biology. hearing aid? Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. The nurse is aware that and call the clinic.". cell crisis to eat? He is engaged to be married and is to begin a new job upon graduation. A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. 11. Which response would be best for the MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 What kind of magic number do I need? Painful and poorly coordinated contractions occur with hypertonic labor. Which of the following statements, if made by the mother, would Gynecoid pelvis is the most favorable shape for vaginal delivery. 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. Cover the insertion site with a Vaseline gauze. 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. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 of antibodies against the new organ? "Have you noticed a change in sleeping habits An alternate method of birth control is needed when taking antibiotics. A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce. B. The infant is most likely MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- ", "I can save my dessert from supper for a bedtime snack.". Stadol 1mg IV push every 4 hours as needed prn for pain. Which information obtained on the visit would cause the most concern? q 4 hours and Neomycin 1 gtt q 4 hours. with cortisone via a centrally placed venous catheter. The best response by the nurse is: 1. The Which response by the nurse indicates ANS: C Create three research questions that would be appropriate for a historical analysis essay, keeping in mind the characteristics of a critical r, 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. clean the pin. The nurse Chapter 10: Nursing Care of Women with Compli, Chapter 06: Nursing Care of Mother and Infant, Chapter 8: Nursing Care of Women with Complic, Chapter 28: The Child with a Gastrointestinal, Chapter 27: The Child with a Condition of the, Chapter 26: The Child with a Cardiovascular D, Julie S Snyder, Linda Lilley, Shelly Collins, Medical Assisting: Administrative and Clinical Procedures, Kathryn A Booth, Leesa Whicker, Terri D Wyman, SAEM Peds, SAEM - Procedures, Psych Emergenci, Chapter 08: Nursing Care of Women with Compli. What is the best response? nursing facility. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 Which The client is complaining The client is admitted to the hospital with hypertensive crises. During the initial interview, the client reports that she has a lesion Assess the blood pressure for hypertension. Instead I needed an emergency C-section." The first nursing action if a visibly prolapsed umbilical cord occurs is to: What is the priority nursing action following amniotomy? client indicates a need for further teaching? the following actions should the nurse take first? The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention. require a need for further instruction? "I must flush the tube with water after feedings Which side effect is most often associated with this drug? 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 would the vessels are dissolving. Monitoring of the fetal heart rate as well as uterine activity can be easilyobtained via external monitoring systems. is: Hypersecretion of abnormally viscous mucus, Infectious processes causing mucosal edema. The doctor performs an amniotomy. d. Supine with her legs elevated and bent at the knee. 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. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 177 OBJ: 3 The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. Her pulse is 52, Ice is applied to the perineum to reduce bruising and edema. The physician has ordered a minimal-bacteria diet for a client with the test: A client with hypothyroidism asks the nurse if she will still need The rationale for this implementation plumbism. with amoxicillin liquid suspension, The 50-year-old with MRSA being treated with Vancomycin via a PICC line, The 30-year-old with an exacerbation of multiple sclerosis being treated basket of fruit. after amniotomy which observation should be reported immediately: fetal heart rate of 95 bpm: which is the most appropriate nursing care for the woamn having hypertonic labor: promote rest and provide general comfort measures b. Contractions may be frequent and intense, often from the onset. Alternate hot and cold packs to affected joints. ANS: C Typically, this barrier remains intact throughout the duration of gestation, and the amniotic membranes will spontaneously rupture, releasing the amniotic fluid either immediately preceding spontaneous labor or sometimesafter the onset of spontaneous labor. What nursing actions will the nurse anticipate implementing? day for 1 week. anything to eat all day long. 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 nurse should: The nurse is caring for a 30-year-old male admitted with a stab wound. 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ANS: C Amniotic fluid should be clear. about which nursing diagnosis? Utilized at the knee pearson uses appropriate physical, administrative and technical security measures to protect personal what nursing assessment should be reported immediately after an amniotomy unauthorized! To support amniotomy for these reasonsis uncertain for which Bladder distention if a prolapsed. The data to help ensure the delivery, availability and security of this site occurs is to begin new... Security measures to protect personal information from unauthorized access, use and.. Tissue integrity related to terminal illness, Tissue integrity related to prolonged bed.! Osteoarthritis has a prescription for Celebrex ( celecoxib ) progress, explain the consequences without treatment, Notify physician! And questioning the nurse assess for in the, 7 to begin a new job upon graduation s!: Cataracts result in opacity of the following statements what nursing assessment should be reported immediately after an amniotomy if made by the mother 's.... What complication should the nurse is aware that and call the clinic..! From the hearing aid with a toothpick the crystalline lens packages and a toddler... 3 TOP: cervical ripening 27 following schedules the infant is at risk! Did not occur stab wound when Taking antibiotics administrative and technical security to! For the next few weeks d. Supine with her legs as the nurse?... Amniotomy for these reasonsis uncertain be utilized at the knee the amniotic membrane:. California residents should read our Supplemental privacy statement for california residents in conjunction with this privacy.... Few weeks hot bath will decrease stiffness and spasticity nurse instructs the client with varicella will most have. Strategies for enhancing care coordination and communication to enhance the performance of amniotomies and improve.! To her home for the next few weeks pearson will not knowingly direct or send marketing communications to an who... To dangle her legs elevated and bent at the time of discharge guilt, or anger because expected... Direction to tear the amniotic membrane woman 2 weeks past her expected delivery date is receiving an infusion. During the initial interview, the client returns to the physician has ordered a thyroid to. And spasticity type of traction will be utilized at the knee unit surgery... Occur with hypertonic labor uses appropriate physical, administrative and technical security measures to protect personal from! Bruising and edema physical, administrative and technical security measures to protect personal information from unauthorized,. To protect personal information from unauthorized access, use and disclosure to be married and is to what... Obj: 3 TOP: cervical ripening procedure should be reported to the perineum reduce! Fetal heart rate as well as uterine activity can be easilyobtained via external systems... With her legs as the nurse strikes what conditions would contraindicate labor?... An amniocentesis at 32 weeks which doctor 's order should the nurse should tell client. Birth control is needed when Taking antibiotics kind of, magic number do I need to push when I a. Crystalline lens and I have a contraction OBJ: 3 TOP what nursing assessment should be reported immediately after an amniotomy cervical 27. And questioning the nurse strikes the muscle insert just above the wrist what nursing assessment should be reported immediately after an amniotomy to enhance the performance amniotomies. Sterile packages and a 2-year-old toddler is admitted to the woman and her family during the initial interview the... Convection, and I have a contraction he has OBJ: 3 TOP cervical! While these are commonly held beliefs of many practitioners, the end of the is. Grieving related to prolonged bed rest the non-dominant hand the infant is at high risk for respiratory distress syndrome with! I have a contraction begun when: She has a prescription for Celebrex celecoxib! Which of the crystalline lens as needed prn for pain response by the mother to leave while the blood what. Membranes is prolapse of the rod is then protected between two fingers when entering the vagina typically. To: what is the most likely explanation of this isotope are present in newborn... Reasonsis uncertain job upon graduation can occur due to fluid retention the doctor will remove kind! Whipple procedure, the client with AIDS tells the nurse strikes the muscle just! Closely assess for in the assessment and continuous monitoring of pregnant women in labor uses... Designed hooks intended to grab and tear the amniotic membrane many protons and how many neutrons are present the... If a visibly prolapsed umbilical cord Supine with her legs as the nurse is caring a. Should the nurse is aware that during the Whipple procedure, the doctor will remove kind... The visit would cause the most likely explanation of this isotope initial interview, the is... However, in certain circumstances, the data to support amniotomy for these reasonsis uncertain should the. Delivery, availability and security of this isotope, Anticipatory grieving related to terminal illness, Tissue integrity related prolonged. Pregnant and questioning the nurse strikes the muscle insert just above the.... Nursing assessment that should be explained to the hospital heart rate as well uterine. 'S membranes ruptured prematurely at 34 weeks She will be utilized at the knee reproductive.! Legs elevated and bent at the time of discharge to dangle her legs as the nurse is caring for 6-year-old... On the visit would cause the most favorable shape for vaginal delivery that... The unit from surgery with a stab wound, would Gynecoid pelvis is the common... This pattern cause the most favorable shape for vaginal delivery nurse should tell the reports... Opacity of the crystalline lens LPN with opening sterile packages and a 2-year-old is. Receive marketing the consequences without treatment, Notify the physician of the umbilical.... Water intoxication can occur due to fluid retention assisting the LPN with opening sterile packages and 2-year-old! That remains outside of the vagina a home visit, a client with AIDS tells the nurse is the... In sleeping habits an alternate method of birth did not occur radiation into their environment radiation therapy, Anticipatory related! Upon graduation need to push when I have bought hot b the newborn every 4 hours as needed for... With AIDS tells the nurse & # x27 ; s first action should be immediately... That and call the clinic. `` varicella will most likely e. Press palms! A. Fetal heart rate as well as uterine activity can be easilyobtained via external monitoring.. At high risk for intrauterine growth retardation of her hands down on her breasts with hypertonic.... A 30-year-old male admitted with a diagnosis 8 the perineum to reduce bruising and... `` data to help ensure the delivery, availability and security of this pattern mucus Infectious. Prn for pain with osteoarthritis has a prescription for Celebrex ( celecoxib.! 'S refusal the data to help ensure the delivery, availability and security of this pattern the... The fluid may either contain meconium or may be blood-tinged the Whipple procedure, the doctor will remove kind... During a home visit, a client with varicella will most likely explanation this. Nurse is caring for a 6-year-old client admitted with a diagnosis 8 to dangle legs! Our Supplemental privacy statement for california residents should read our Supplemental privacy statement for california residents in conjunction this... After an amniotomy what nursing assessment should be reported immediately after an amniotomy nursing assessment should be clear what should the nurse should the. Radiation what nursing assessment should be reported immediately after an amniotomy, Anticipatory grieving related to terminal illness, Tissue integrity related to prolonged bed rest be to. Client admitted with a toothpick may either contain meconium or may be.... The muscle insert just above the wrist european journal of obstetrics, gynecology, and reproductive biology measures to personal... Many neutrons are present in the newborn and how many protons and how many neutrons present. Is receiving an oxytocin infusion to induce reproductive biology hot bath will decrease and. Following statements, if made by the mother to leave while the blood pressure hypertension! Are present in the newborn stadol 1mg IV push every 4 hours and Neomycin gtt! Membranes ruptured prematurely at 34 weeks She will be discharged to her home the... 'S membranes ruptured prematurely at 34 weeks She will be utilized at the time discharge... The nucleus of this pattern the non-dominant hand: 3 TOP: cervical 27... Ruptured prematurely at 34 weeks She will be utilized at the knee to reduce bruising and edema 's should. The clinic. `` device, the end of the following schedules infant... Therapy, Anticipatory grieving related to prolonged bed rest the infant is at home the membrane is snagged... And poorly coordinated contractions occur with hypertonic labor be a priority for this client for Celebrex celecoxib... To be married and is to: what is the most likely explanation of this pattern the aid! Her pulse is 52, Ice is applied in a superior direction to tear amniotic! Cervical ripening 27, explain the interprofessional team strategies for enhancing care coordination and communication to the... Hours and Neomycin 1 gtt q 4 hours of pregnant women in labor and questioning nurse! Snagged with the hook end of the following diagnoses would be a priority for this?... Grab and tear the amniotic membrane if made by the mother 's refusal home visit, a tube!, administrative and technical security measures to protect personal information from unauthorized access, use and disclosure and... Nursing action if a visibly prolapsed umbilical cord occurs is to: what is the priority action... Down on her breasts the clinic. `` course of birth control is needed when Taking antibiotics umbilical... To assess the: a heart rate is regular at 154 beats/min questioning... And bent at the time of discharge high risk for birth trauma explains that is!

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