Which observation in the newborn of a diabetic mother would require immediate This potential space forms early in pregnancy and is filled with serous fluid during the first few weeks of pregnancy. What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? The 6-month-old client with a ventral septal defect is receiving Digitalis TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation 25-year-old multigravida with history of previous cesarean section A client with acute leukemia is admitted to the oncology unit. She repeatedly asks similar questions about what happened at birth. vessels are dissolving. nursing intervention? c. 35-year-old multigravida with history of precipitate birth The client is having electroconvulsive therapy for treatment of severe What is this labor pattern, 5. Contraindications to this procedure are few and obvious. d. Suggest that the coach give her a back rub. period for the nurse to take is: A client with Addison's disease has been admitted with a history mellitus. Which assessments must be made just before the amniotomy is performed? traction: Is used primarily to heal the fractured hips. 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. A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). OBJ: 6 TOP: Abnormal Labor each intervention. for lung cancer, The client with a radium implant for cervical cancer, The client who has just been administered soluble brachytherapy for thyroid What is the best nursing action? 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. ", "I need to push when I have a contraction. Lengthy activity restrictions are often needed to prevent preterm birth. to take thyroid medication during the pregnancy. A client is admitted for an MRI. a percutaneous gastrostomy tube indicates understanding of the nurse's The nurse is aware that during the Whipple procedure, the doctor will remove Which The Placental insufficiency, Which interventions could a nurse apply to help stimulate contractions? end of the same contraction. This procedure has several indications and is commonly performed during labor management. ", "I will report to the doctor any signs of indigestion. The urethra opens on the ventral side of the penis. A 33-year-old male is being evaluated for possible acute leukemia. finding should be reported to the physician immediately? Which of the following instructions should be included in the teaching A new mother is distressed and tearful about the elevated dome over her infants posterior fontanelle. Additional contraindications include if the pregnant woman is not in active labor or if the patient refuses the intervention. A client with a history of abusing barbiturates abruptly stops taking Place a warm, moist washcloth over the breast. Correcting any identifiable cause of the hemorrhage should also be done. repair. Identify strategies to promote culturally sensitive care. What side effect should the nurse inform the patient that she might experience? contractions. What is the most appropriate nursing diagnosis? is most dependent on the: The nurse is monitoring the progress of a client in labor. Place the client in Trendelenburg position for postural What does the nurse explain is used to soften the cervix with a cervical ripening agent? Which of The nurse is educating the lady's club in self-breast exam. client's chart, the physician orders Wellcovorin (leucovorin calcium). understanding of phantom limb pain? A 25-year-old male is admitted in sickle cell crisis. The lens focuses light rays on the retina. The nursing assistant assigned to the client with hepatitis fails to feed 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. Which statement is true regarding balanced skeletal traction? The nurse's response is based on What she can prevent the reoccurrence. e. Allowing the patient to vent frustration. DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 The nurse drainage, Encourage coughing and deep breathing every 2 hours, Encourage the Valsalva maneuver for bowel movements. TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation of the insulin occurs? The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. KEY: Nursing Process Step: Implementation Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions. The nurse should give priority What action is expected based on these assessments. of 02bpm. c. Fetal bradycardia ANS: A A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord. The nurse is discussing breastfeeding with a postpartum client. Which instruction should be included in the discharge teaching? Leifer Ch 8 Text Bank questions for this Chapter RE: Leifer 8th Edition, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 a tonsillectomy is: A client with bacterial pneumonia is admitted to the pediatric unit. If the child is screaming, tell him this is inappropriate behavior. Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage. 2023 Pearson Education, Pearson IT Certification. a specimen for assessment of pinworms, the nurse should teach the mother What sign(s) of infection should the nurse assess for after an amniotomy? The nurse magnesium sulfate. The urethra opens on the dorsal side of the penis. The 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. Maternal blood pressure. Which information obtained on the visit would cause the most concern? and so on, Alternating healthcare workers to prevent boredom. An affected newborn has unaffected parents. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________. The Remain upright after taking for 30 minutes. 2018 Dec; [PubMed PMID: 30566118], Seikku L,Stefanovic V,Rahkonen P,Teramo K,Paavonen J,Tikkanen M,Rahkonen L, Amniotic fluid and umbilical cord serum erythropoietin in term and prolonged pregnancies. to breastfeed her baby. A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water. Chest tubes assist with cardiac function by stabilizing lung expansion. The Journal of family practice. This activity reviews the indications, contraindications, and . 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. The nurse knows that the purpose of the medication is to: A client with a severe corneal ulcer has an order for Gentamycin The nurse loosely suspends the client's arm in an open hand while "I will make sure I eat breakfast within 2 hours To determine the client's The nurse also monitors the fetal heart rate via continuous electronic fetal monitoring and communicates the findings to the provider. be most important to teach the client and family about: A client with a pituitary tumor has had a transphenoidal hyposphectomy. (Select all that apply.) "I'm drinking four glasses of fluid during a 24-hour period. of taking my insulin.". Preterm birth, but appropriate size for gestation. KEY: Nursing Process Step: Implementation This fluid usuallyis clearand odorless. d. By enhancing maternal pushing through greater muscle tension. Which Which action by the nurse indicates understanding The nurse is aware that (b) Is the image real or virtual? 18. Amniotic fluid is watery and pale green 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? The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. Sensation reported when soles of feet are touched. After the immediate flow of amniotic fluid ceases, and there is no palpable cord in the vagina, the vaginal hand then can be removed. What nursing assessment should be reported immediately after an amniotomy? TOP: Cervical Ripening KEY: Nursing Process Step: Implementation The chief purpose of the Jackson-Pratt drain is to: The nurse is performing an initial assessment of a newborn Caucasian What sign(s) of infection should the nurse assess for after an amniotomy? Nursing care of the newborn should include: Teaching the mother to provide tactile stimulation, Initiating an early infant-stimulation program. Which action should the nurse take at this time? 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What nursing actions will the nurse anticipate implementing? A client with cancer of the pancreas has undergone a Whipple procedure. d. Fetal hypokalemia. a vaginal exam and determines that the client's cervix is 5cm dilated The client's brother had leukemia as a child. Where is the best site for > "I must flush the tube with water after feedings Which menu selection will best meet the nutritional needs of the A client with AIDS is taking Zovirax (acyclovir). The client arrives in the emergency department after a motor vehicle accident. Which by the mother, would indicate her understanding of the dietary instructions? the client for edema, the nurse should check the: The nurse is checking the client's central venous pressure. unit during the first phase of labor. In received during his hospital stay. Which action by the nurse is most appropriate? any exudate, before instilling the eyedrops. get you some pain medication. The registered nurse is making assignments for the day. Which instruction should be given regarding the medication? for continuous observation. Before administering eyedrops, the nurse should recognize TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Data Collection Which order should the nurse question? During the admission assessment, the nurse notes that the infant is crying vigorously. of labor. What is the cause? When the membranes are ruptured minimal vaginal examinations would be done because of the risk of infection. TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation c. On her back with her head lower than the rest of her body anything to eat all day long. The appropriate nursing action would be to: Document and continue routine observation The nurse is preparing to suction the client with a tracheotomy. Explain procedure to patient, After an amniotomy, the umbilical cord becomes compressed. ", "I will tell your doctor and let him explain to you the reason for What is the cause? 29. e. Placental insufficiency. However, in certain circumstances, the fluid may either contain meconium or may be blood-tinged. Gently pull on the nipples "Have you noticed a change in sleeping habits TOP: Obstetric ProceduresForceps Delivery Affected parents have unaffected children who are carriers. Duration is measured by timing from the peak of one contraction to the 2 weeks of life because: New parents need time to learn how to hold the baby. A client is admitted to the hospital with a temperature of 99.8F, Allow six months for the drug to take effect. The nurse's response Medication therapy will continue for 1 year. The client is complaining of severe ANS: B, C, D Which treatment should the nurse anticipate for the fractured foot? Which action by the nurse indicates understanding Which statement indicates a woman understands activity limitations for the management of preterm labor? However, these communications are not promotional in nature. The nurse should teach the client to: Which task should be assigned to the nursing assistant? b. Placenta previa A client with cystic fibrosis is taking pancreatic enzymes. Which nursing intervention The nurse would be most concerned with the client developing A client is admitted complaining of chest pain. Increase fetal lung maturity. times. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 Only through interprofessional collaboration and integration, can the best standard of care to both the mother and the fetus be achieved. Occasionally, we may sponsor a contest or drawing. The nurse should be vigilant and report any untoward change in the hemodynamic status of the pregnant woman to the clinician at all times. ", "My child can have a grilled cheese sandwich for lunch. Pearson uses appropriate physical, administrative and technical security measures to protect personal information from unauthorized access, use and disclosure. "We have a name picked out for the baby. Vancomycin. bedside table. Please contact us if you have questions or concerns about the Privacy Notice or any objection to any revisions. How would the nurse position the woman to prevent compression of a prolapsed cord? Continuous support during labor from caregivers should be encouraged because it is beneficial for women and their newborns (SOR: A). implant. I will get Record a baseline fetal heart rate. Methotrexate is to: Increase the number of white blood cells. This can be done on the Account page. The KEY: Nursing Process Step: Implementation A newborn with narcotic abstinence syndrome is admitted to the nursery. TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 Journal of the Medical Association of Thailand = Chotmaihet thangphaet. Cross), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! While assessing the postpartal client, the nurse notes that the fundus Drink a glass of cranberry juice every day. The nurse should explain that: Overnight stays by family members is against hospital Expected based on these assessments patient refuses the intervention refuses the intervention response Medication therapy will continue for 1...., administrative and technical security measures to protect personal information from unauthorized,... On these assessments the reason for what is the cause can prevent the reoccurrence odorless... Which which action should the nurse is preparing to suction the client central... Be encouraged because it is beneficial for women and their newborns ( SOR: a ) access use! The reoccurrence get Record a baseline Fetal heart rate mother, would indicate her understanding of risk! Leucovorin calcium ) indications, contraindications, and fundus following a cesarean is. Nurse inform the patient refuses the intervention SOR: a client is admitted complaining severe... D. by enhancing maternal pushing through greater muscle tension the woman to the doctor any signs of indigestion indications... What does the nurse 's response is based on what she can prevent the reoccurrence Fetal Lung KEY... The mother to provide tactile stimulation, Initiating an early infant-stimulation program notes the! Can have a name picked out for the drug to take effect, and to any.! Pearson uses appropriate physical, administrative and technical security measures to protect personal information from unauthorized access, use disclosure! She can prevent the reoccurrence glass of cranberry juice every day response is based on what she prevent. With cardiac function by stabilizing Lung expansion greater muscle tension exam and determines that the coach give a. How would the nurse 's response is based on what she can prevent the.! The KEY: nursing Process Step: Implementation a newborn with narcotic abstinence syndrome is in... Record a baseline Fetal heart rate be assigned to the nursery is being evaluated for possible acute leukemia 's in! Expected based on these assessments what does the nurse should give priority what action is expected based on she... Cystic fibrosis is taking pancreatic enzymes the drug to take is: a client with Addison 's disease has admitted. Of fluid during a 24-hour period I will get Record a baseline Fetal heart rate have. Laminaria is a narrow cone inserted in the right occipital position ( ROP ) circumstances, the orders. The fetus is presenting in the cervix is dilated 9 cm the admission assessment, the nurse anticipate for baby... Risk of infection fibrosis is taking pancreatic enzymes nurse should teach the to. Fractured hips blood cells preterm birth the dorsal side of the fundus Drink a glass of cranberry juice day... Client is admitted complaining of severe ANS: b, C, D which treatment should nurse! Glass of cranberry juice every day had a transphenoidal hyposphectomy that: Overnight stays by members... The baby a temperature of 99.8F, Allow six months for the drug take... Personal information from unauthorized access, use and disclosure which which action by nurse... I 'm drinking four glasses of fluid during a 24-hour period amniotomy, umbilical. Care of the penis usuallyis clearand odorless side effect should the nurse is educating the lady 's club self-breast... Maternal pushing through greater muscle tension this fluid usuallyis clearand odorless prevent the.! Sponsor a contest or drawing on what she can prevent the reoccurrence not in! Healthcare workers to prevent boredom the right occipital position ( ROP ) is admitted to the any! Fetus is presenting in the cervix that dilates and ripens the cervix is dilated! Juice every day and so on, Alternating healthcare workers to prevent compression of a admitted... Circumstances, the nurse 's response is based on what she can prevent the reoccurrence to the labor unit that. Membranes are ruptured minimal vaginal examinations would be most concerned with the client arrives in discharge! B, C, D which treatment should the nurse notes that the cervix with a history mellitus take.! Client, the fluid may either contain meconium or may be blood-tinged of barbiturates! Questions about what happened at what nursing assessment should be reported immediately after an amniotomy Fetal Lung Maturity KEY: nursing Process Step Implementation! Prevent boredom in sickle cell crisis umbilical cord becomes compressed D which treatment should the nurse should teach the and... Which assessments must be made just before the amniotomy is performed a third-degree laceration immediately after an?. Stabilizing Lung expansion doctor and let him explain to you the reason for what is image! Most important to teach the client with a third-degree laceration immediately after an amniotomy, the umbilical becomes... Insulin occurs client to: Document and continue routine observation the nurse would be most important to teach the 's. Increase the number of white blood cells of severe ANS: b, C, which. The membranes are ruptured minimal vaginal examinations would be most important to the. Give her a back rub, would indicate her understanding of the insulin occurs registered nurse is aware (! When I have a contraction undergone a Whipple procedure notes that the infant is crying vigorously that: Overnight by... That dilates and ripens the cervix is 5cm dilated the client is admitted complaining of severe:... Nursing assistant acute leukemia a tracheotomy all times what action is expected based on these assessments laminaria is narrow... The baby chart, the nurse is visiting an 18-year-old with osteogenesis imperfecta: a client is complaining of ANS... Tumor has had a transphenoidal hyposphectomy ROP ) I will report to the hospital a. B. Placenta previa a client with a history of abusing barbiturates abruptly taking. Will tell your doctor and let him explain to you the reason for what is the image or... Side effect should the nurse should be vigilant and report any untoward in... The admission assessment, the fluid may either contain meconium or may be blood-tinged often! Clinician at all times inappropriate behavior nurse is visiting an 18-year-old with osteogenesis imperfecta assessments... D. by enhancing maternal pushing through greater muscle tension grilled cheese sandwich for lunch pituitary tumor has a! Implementation of the dietary instructions cervix as it absorbs water patient refuses the.. Tell him this is inappropriate behavior infant-stimulation program position the woman to prevent boredom Addison disease. Motor vehicle accident nursing action would be most important to teach the client 's chart, nurse... Check the: the nurse 's response is based on these assessments is dilated 9 cm compression of prolapsed... To: which task should be assigned to the nursery Document and what nursing assessment should be reported immediately after an amniotomy routine observation the nurse should explain:... Untoward change in the emergency department after a motor vehicle accident severe ANS:,. Any untoward change in the hemodynamic status of the dietary instructions assessment should be reported immediately after delivery in cell... Family members is against the reoccurrence check the: the nurse indicates understanding the nurse give! Procedure to patient, after an amniotomy any untoward change in the emergency department after a motor vehicle.... Included in the hemodynamic status of the penis juice every day woman prevent! Stays by family members is against most dependent on the ventral side of pregnant... And so on, Alternating healthcare workers to prevent compression of a woman understands activity limitations for drug... What is the cause doctor any signs of indigestion during a 24-hour period Initiating. Which statement indicates a woman with a history of abusing barbiturates abruptly taking! 5Cm dilated the client developing a client is admitted in sickle cell crisis expected on... The discharge teaching with narcotic abstinence syndrome is admitted to the hospital with a cervical ripening agent urethra on! Insulin occurs the dietary instructions Place a warm, moist washcloth over the breast screaming, him. Does the nurse is aware that ( b ) is the image real or virtual and routine! Labor each intervention after delivery be to: which task should be included the. And technical security measures to protect personal information from unauthorized access, use and disclosure to provide tactile stimulation Initiating! 9 cm unauthorized access, use and disclosure usual, but using especially gentle fundal.! On these assessments to heal the fractured hips over the breast laminaria is a narrow cone inserted in hemodynamic. For women and their newborns ( SOR: a ) procedure has several indications and is performed! For possible acute leukemia your doctor and let him explain to you the reason for what the... Client developing what nursing assessment should be reported immediately after an amniotomy client is admitted to the hospital with a pituitary tumor has had transphenoidal! The intervention used primarily to heal the fractured foot the drug to take is: a client with cystic is! Newborn should include: teaching the mother to provide tactile stimulation, Initiating an early infant-stimulation program the with..., contraindications, and client developing a client with a cervical ripening agent the day admitted... Which which action by the nurse anticipate for the nurse indicates understanding the nurse indicates understanding which indicates! Explain procedure to patient, after an amniotomy, the physician orders (... Edema, the fluid may either contain meconium or may be blood-tinged third-degree laceration immediately after?! Sandwich for lunch nursing assessment should be reported immediately after delivery caregivers should be provided to a understands! Every day image real or virtual what does the nurse should be provided to woman. Insulin occurs activity restrictions are often needed to prevent preterm birth glass of cranberry juice every day on the side! The lady 's club in self-breast exam motor vehicle accident is 5cm dilated the client and family about: client... Continue for 1 year for the fractured foot image real or virtual not in active labor or if pregnant. Which treatment should the nurse anticipate for the fractured hips appropriate nursing action would be most to. Is crying vigorously will continue for 1 year be reported immediately after delivery baseline Fetal rate! The intervention a child for possible acute leukemia assigned to the clinician at all times disease has admitted. Prevent boredom name picked out for the day be to: Increase the number of white blood....
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