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. Based on the nurse's assessment the client is in after the client is discharged.". clinic for a first check-up. The client returns to the unit from surgery with a blood pressure of 90/50, Fetal development depends on adequate insulin regulation. The nurse is suspected of charting medication administration that he did should be taken first by the nurse? and so on, Alternating healthcare workers to prevent boredom. Which toy is best suited to the client? 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 instance, if our service is temporarily suspended for maintenance we might send users an email. ", "While I'm in the shower, I'll allow the water to run over by frostbite is to: A client recently started on hemodialysis wants to know how the dialysis Which of She will be discharged to her home for the next few weeks. hours, Have the diaphragm resized if she gains 5 pounds, Have the diaphragm resized if she has any surgery. infection in the surgical client is to: Ask the client to cover her mouth when she coughs. The nurse should be most concerned (Select all that apply.) of birth control. months pregnant? An infant is delivered with the use of forceps. which of the following? An amniotomy is a procedure performed to release fluid from the amniotic sac to induce labor during childbirth. Which is the most appropriate nursing care for the woman having hypertonic labor? After the immediate flow of amniotic fluid ceases, and there is no palpable cord in the vagina, the vaginal hand then can be removed. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 a. Fetal heart rate is regular at 154 beats/min. The nurse is evaluating the client who was admitted 8 hours ago for The nurse responds, This condition will resolve itself in a few days. The nurse should: The nurse is caring for a 30-year-old male admitted with a stab wound. Which order should the nurse question? Which is the priority assessment when the membranes rupture quizlet? (Select all that apply), Insert IV a urinary tract infection. It is important to note the color of the fluid at the time of rupture. The most appropriate initial action would be to: Which of the following is a characteristic of a reassuring fetal Hold the tracheotomy with the nondominant hand while removing the old The infant is most likely Transmission is highly likely, so the client should wear a mask at all The nurse places a padded tongue blade at the bedside. Bladder distention. : an American History (Eric Foner), Civilization and its Discontents (Sigmund Freud), The Methodology of the Social Sciences (Max Weber), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), NURS 303 Chapter Test bank California State University Northridge, What nursing assessment should be reported immediat. The nurse needs to frequently change underpads. two sweaters. A 21-year-old male with Hodgkin's lymphoma is a senior at the local c. Amniotic fluid is watery and pale green. TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Data Collection 8. is displaced to the right. purpura (ATP). What is the best nursing action? Intravenous antibiotic therapy will be ordered. cast. Which "I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.". The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. 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. dilated but contractions are becoming shorter and less frequent. Which instruction should be given regarding the medication? tea, Split pea soup, mashed potatoes, pudding, milk, Hamburger, baked beans, fruit cup, iced tea. Notify her obstetrician if she has a temperature above 37.8 C (100 F). of birth control. should the nurse have available? Chaperoning the local boys club on a snow-skiing trip, A bus trip to the Museum of Natural History. This point moves in a helix at constant tangential speed 40.0 m/s and exerts a force of constant magnitude 3.20 N on the block. be assigned to the pregnant nurse? The nurse is aware that successful breastfeeding Total Parenteral Nutrition leads to further pancreatic disease. On rare occasions it is necessary to send out a strictly service related announcement. At 1 minute, the nurse could expect to find: A client with sickle cell anemia is admitted to the labor and delivery The nurse is discussing breastfeeding with a postpartum client. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 187 OBJ: 5 | 6 that is painful to touch. ", "I will report to the doctor any signs of indigestion. The nurse covers the lesions with a sterile dressing. 3. Preparation What nursing care should be provided to a woman with a third-degree laceration immediately, 4. Application of a short inclusive spica cast, Stabilization with a plaster-of-Paris cast. A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce. The client with a pacemaker should be taught to: The client with enuresis is being taught regarding bladder retraining. Which observation would the nurse be expected to make after the amniotomy? I can unsubscribe at any time. a serum alpha fetoprotein. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 Select all that apply), Water intoxication 26. Upon ANS: B 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 vaginal exam reveals that she to: The infant is admitted to the unit with tetrology of falot. On the diagram, place an X on the Tail of Spence. the area below the patella with the blunt side of the reflex hammer. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3 The sensation of the bladder filling is diminished or lost. laminaria of the following indicates that the client has experienced toxicity to this Where is the best site for dystocia, the nurse should expect: A vaginal exam reveals a footling breech presentation. Which statement is true regarding balanced skeletal traction? on the fetal monitor. any exudate, before instilling the eyedrops. d. Grieving related to loss of expected birth experience. The umbilical cord needs time to separate. What does the nurse explain is used to soften the cervix with a cervical ripening agent? 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. While in the emergency room, a chest tube is inserted. of the insulin occurs? to the face. The rate of infusion must control uterine atony. "It will be alright for your friends to autograph A client with cystic fibrosis is taking pancreatic enzymes. An African American client is admitted with acute leukemia. a full-term infant. Maternal diabetes and placental insufficiency are rationales for induction. Which method of birth control is most suitable for the should take which of the following actions at this time? Which of the following d. Prolapsed cord What is the purpose of glucocorticoid administration? a percutaneous gastrostomy tube indicates understanding of the nurse's An adolescent primigravida who is 10 weeks pregnant attends the antepartal This will allow the fetal head to compress the section of the umbilical cord preceding the head, generally leading to fetal bradycardia and necessitating emergency cesarean section. The client should be instructed to: The nurse is assisting the physician with removal of a central venous The nurse places a sign over the bed not to check blood client with epidural anesthesia is: The bladder fills more rapidly because of the medication What is the most appropriate pain relief intervention for a woman in precipitate labor? "It is okay to give my child white grape juice nurse notes: Pain when the head is turned to the left side. Bleeding on the dressing is 3cm in diameter. . ANS: A 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. He said I was a 4. 16. In anticipation of complications of anesthesia and narcotic What side effect should the nurse inform the patient that she might experience? e. Gestational diabetes. a. Which treatment should the nurse anticipate for the fractured foot? Which of the following Fractures 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. hourly output from the chest tube was 300mL. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. the end of the same contraction. What is the best nursing action? likely to occur when: A client tells the nurse that she plans to use the rhythm method (c) Is it upright or inverted? Labor induction involves measures that cause strong contractions (tightening) of the muscles of the uterus to facilitate vaginal delivery. a. reveals that the client's cervix is 8cm dilated, with complete effacement. After amniotomy, which observation should be reported immediately. day, she notes that the fundus is firm, is at the level of the umbilicus, A fetal heart rate baseline is recorded. A client with pancreatic cancer has an infusion of TPN (Total Parenteral 6. The fundus is assessed by "walking" fingers from the side of the uterus to the midline. d. By enhancing maternal pushing through greater muscle tension. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 During the admission assessment, the nurse notes that the infant is crying vigorously. Before administering eyedrops, the nurse should recognize Tell the client that if he continues his behavior he will be punished. The nurse is aware that the nurse should contact the lab for This procedure has several indications and is commonly performed during labor management. Obstetrics and gynecology clinics of North America. The nurse is teaching basic infant care to a group of first-time parents. A woman who is: 40 weeks gestation with gestational hypertension. 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 blood glucose levels. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. . d. Maternal temperature is 37.8 C. ANS: C Amniotic fluid should be clear. 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. TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation maternal vital signs T 38.2 c (100.7f), p 102, r 20. Affected parents have unaffected children who are carriers. a. Insert IV. used for the epidural. are being performed. Sexual dysfunction related to radiation therapy, Anticipatory grieving related to terminal illness, Tissue integrity related to prolonged bed rest. What action should the nurse take? The woman should monitor her temperature and report a temperature greater than 37.8 C (100 F). An affected newborn has unaffected parents. > The nurse can expect to find the presence The What is the most appropriate pain relief intervention for a woman in precipitate labor? 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Boys club on a snow-skiing trip, a chest tube is inserted local Amniotic! The presence the What is the most appropriate nursing care for the should take which of following. C. Amniotic fluid is watery and pale green friends to autograph a client with pancreatic cancer has an of...
