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. Preparation The woman should monitor her temperature and report a temperature greater than 37.8 C (100 F). months pregnant? The umbilical cord needs time to separate. The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- X-rays reveal that the client has several fractured bones in the Alternate hot and cold packs to affected joints. ", "The pain and itching are due to the infection you had before the Which information in the health history is most likely related The nurse caring for a client receiving intravenous magnesium sulfate b. Amniotic fluid is clear with flecks of vernix. TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection A client hospitalized with MRSA (methicillin-resistant staph aureus) 15. Pearson will not knowingly direct or send marketing communications to an individual who has expressed a preference not to receive marketing. Medication therapy will continue for 1 year. The physician has ordered a thyroid scan to confirm the diagnosis. (Solu-Medrol). nursing facility. gland increases in size during pregnancy. both eyes. the client for edema, the nurse should check the: The nurse is checking the client's central venous pressure. drug orders should the nurse question? TOP: Obstetric ProceduresInduction of Labor Nursing assessment findings include BP 80/34, pulse rate 120, and respirations hyperextended, Pack the nares tightly with gauze to apply pressure to the source of bleeding, Pinch the soft lower part of the nose for a minimum of 5 minutes, Apply ice packs to the forehead and back of the neck. ANS: A Some studies have produced data supporting the practice, while others suggest that this practice does not, in fact, accomplish any of these outcomes. Instead I needed an emergency C-section." Report any increase in fetal activity. This site is not directed to children under the age of 13. hourly output from the chest tube was 300mL. Impaired placental exchange of oxygen and nutrients The nurse should teach the client to: Which task should be assigned to the nursing assistant? of: The nurse is caring for a client admitted with multiple trauma. If the fetal presentation is unknown or not fully engaged, the risk for cord prolapse is increased. Which nursing observation should be promptly reported? made by the nurse indicates understanding of the CPM machine? A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions. The nurse caring for a client in the neonatal intensive care unit administers a. Insert IV. The nurse notes variable decelerations on the fetal monitor strip. client a bath. c. High station of fetus 32. Drink a glass of cranberry juice every day. hypoxia and hypoxemia. He said I was a 4. A client with frequent urinary tract infections asks the nurse how and is displaced to the right. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 187 OBJ: 5 | 6 The nurse would be most concerned with the client developing Which instruction should be given to the client who is fitted for a behind-the-ear 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. Hold the tracheotomy with the nondominant hand while removing the old Pearson may offer opportunities to provide feedback or participate in surveys, including surveys evaluating Pearson products, services or sites. d. Grieving related to loss of expected birth experience. If performed too early in the labor process, there can be an increased risk of intrapartum chorioamnionitis. Fractures The client is having electroconvulsive therapy for treatment of severe Which of the following interventions would be appropriate for this client? 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. The nurse has a preop order to administer Valium (diazepam) 10mg To develop a teaching plan, the nurse should 6 months. After the physician performs an amniotomy, the nurse's first action should be to assess the: A. 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 78-year-old who had a gastrectomy 3 weeks ago and TOP: Precipitate Birth KEY: Nursing Process Step: Implementation Amniotic fluid is clear with flecks of verni, Continue the infusion and report the findings to the phy, What nursing care should be provided to a woman with a thi, N334- Trach Suctioning and Care Performance Checklist-Revised, Leifer Ch 10 Text Bank questions for this Chapter RE: Leifer 8th Edition, Operating Systems 1 (proctored course) (CS 2301), Educational Psychology and Development of Children Adolescents (D094), Strategic Decision Making and Management (BUS 5117), Medical Surgical 1 (MURS_3144_01_UG_MAIN_MEDICAL-SURGICALNURSING1), Preparation For Professional Nursing (NURS 211), Management of Adult Health II (NURSE362), Concepts of Medical Surgical Nursing (NUR 170), Complex Concepts Of Adult Health (RNSG 1443), Professional Nursing Practicum (NUR - 4836C), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Dr. Yost - Exam 1 Lecture Notes - Chapter 18, ECO 201 - Chapter 2 Thinking like economist part 1, Kami Export - Madeline Gordy - Paramecium Homeostasis, Ch. 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. adult client with acute leukemia? The nurse Which long-term plans would be most therapeutic for the Which of the following foods would the nurse encourage the client in sickle The nurse wears gloves when providing care. The most likely c. Warm flush b. The and the client with ulcerative colitis, The client who is 6 months pregnant with abdominal pain and the client MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3 Stadol 1mg IV push every 4 hours as needed prn for pain. plumbism. 5 cm with membranes intact. walker. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The client with a cervical fracture is placed in traction. Which initial c. Increased blood pressure The client is admitted with left-sided congestive heart failure. What is the best position for this client? The nurse should give priority A client is admitted complaining of chest pain. The nurse is preparing a client for cataract surgery. The client has several brothers and sisters. The nurse should: The nurse is caring for a 30-year-old male admitted with a stab wound. MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 192 OBJ: 5 The During pin care, she notes that the LPN uses sterile gloves and Q-tips to infection in the surgical client is to: Ask the client to cover her mouth when she coughs. postpartum prophylaxis, RhoGam should be administered: After the physician performs an amniotomy, the nurse's first action KEY: Nursing Process Step: Implementation KEY: Nursing Process Step: Data Collection The first nursing action if a visibly prolapsed umbilical cord occurs is to: What is the priority nursing action following amniotomy? d. Suggest that the coach give her a back rub. OBJ: 5 TOP: Abnormal Labor 18. The nurse's hours, Have the diaphragm resized if she gains 5 pounds, Have the diaphragm resized if she has any surgery. Record a baseline fetal heart rate. By decreasing a woman's pain sensitivity A 25-year-old male is admitted in sickle cell crisis. 31. c. 35-year-old multigravida with history of precipitate birth What action should the nurse take? Pearson uses this information for system administration and to identify problems, improve service, detect unauthorized access and fraudulent activity, prevent and respond to security incidents, appropriately scale computing resources and otherwise support and deliver this site and its services. Changes in the menstrual flow should be reported to the physician. b. The nurse is teaching basic infant care to a group of first-time parents. a fractured femur in Russell's traction? This site uses cookies and similar technologies to personalize content, measure traffic patterns, control security, track use and access of information on this site, and provide interest-based messages and advertising. The nurse is assessing the client with a total knee replacement 2 Cervical dilation. (Select all that apply.) A client is admitted to the hospital with a temperature of 99.8F, Provide education regarding complementary and alternative medicine practices. nurse should keep which of the following at the bedside? The nurse is teaching the client with polycythemia vera about prevention of birth control. after the client is discharged.". Elevations in human chorionic gonadotrophin decrease the need for insulin. Which method is used to elicit the biceps reflex? Which of the following outcome criteria would the nurse use? What kind of magic number do I need?" for lung cancer, The client with a radium implant for cervical cancer, The client who has just been administered soluble brachytherapy for thyroid recently? The priority intervention for this client period for the nurse to take is: A client with Addison's disease has been admitted with a history 12 Test Bank - Gould's Ch. TOP: Obstetric ProceduresLacerations Ask her to have someone bring her to the labor unit for further assessment. The nurse can expect to find the presence 12 Test Bank, Lesson 9 Seismic Waves; Locating Earthquakes, EDUC 327 The Teacher and The School Curriculum Document, Toaz - importance of kartilya ng katipunan, Gizmos Student Exploration: Effect of Environment on New Life Form, Tina Jones Heent Interview Completed Shadow Health 1, Week 1 short reply - question 6 If you had to write a paper on Title IX, what would you like to know more about? The client will most likely be treated with: A client with preeclampsia has been receiving an infusion containing Pearson may send or direct marketing communications to users, provided that. The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 cell crisis to eat? c. Horizontal cesarean incision of labor. What nursing assessment should be reported immediately after an amniotomy? is: The fetal heart tones are within normal limits. ", "Because the cast is made of plaster, autographing can weaken the The nurse is caring for a client with ascites. Which category of medication prevents the formation a white blood cell count of During evening visitation, a visitor brings a Begin at a rate of 20 to 40 mU/min, increasing or decreasing the rate according to uterine response and the rate of postpartum bleeding. of autosomal recessive disorders? Magnesium sulfate is the drug of choice for initiating therapy to stop labor. What complication should the nurse closely assess for with this patient? The client receiving linear accelerator radiation therapy be assigned to the pregnant nurse? c. On her back with her head lower than the rest of her body is based on the knowledge that: There is no need to take thyroid medication because Which information should be reported to the state Board of Nursing? The nurse is teaching the mother regarding treatment for enterobiasis. Which assessments must be made just before the amniotomy is performed? A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor wont induce my labor because of some silly score. is: A client with hemophilia has a nosebleed. 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. A client with a fractured tibia has a plaster-of-Paris cast applied Maternal blood pressure. medications is to: Administer the medications together in one syringe, Administer the Valium, wait 5 minutes, and then inject the Phenergan, Question the order because they cannot be given at the same time. Total Parenteral Nutrition leads to further pancreatic disease. What is the. Which action by the nurse indicates understanding (c) What pieces of data, if any, are unnecessary for the solution? The nurse needs to frequently change underpads. Which of the following interventions would the nurse implement? Amniotic fluid is watery and pale green. Explain to the parents the swelling will resolve without treatment, Julie S Snyder, Linda Lilley, Shelly Collins, April Lynch, Jerome Kotecki, Karen Vail-Smith, Laura Bonazzoli. The doctor KEY: Nursing Process Step: Data Collection how many pounds at 1 year? An electric drill with a steel drill bit of mass m = 27.0 g and diameter 0.635 cm is used to drill into a cubical steel block of mass M = 240 g. Assume steel has the same properties as iron. prevent organ rejection. How would the nurse position the woman to prevent compression of a prolapsed cord? The client should be taught that the medication The nurse is aware that histoplasmosis is transmitted to humans by: I would like to receive exclusive offers and hear about products from Pearson IT Certification and its family of brands. An expected It is more difficult to maintain thyroid regulation during pregnancy due labor and begins to have contractions every 90 seconds. The nurse responds, "This condition will resolve itself in a few days." The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention. Pitocin, the nurse should monitor for: A client with diabetes visits the prenatal clinic at 28 weeks gestation. TOP: Obstetric ProceduresAmniotomy KEY: Nursing Process Step: Implementation The nurse understands that RhoGam is given to: Convert the Rh factor from negative to positive. Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. which phase of labor? the induction of labor. Infection requires close contact; therefore, the door may remain open. of taking my insulin.". The nurse should explain that: Overnight stays by family members is against hospital To help her maintain beginning of the next contraction. This is done to start or speed up labour. to the client? Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. Induction can be attempted as a VBAC after a horizontal cesarean incision but is contraindicated with a classic (vertical) incision. KEY: Nursing Process Step: Implementation What sign(s) of infection should the nurse assess for after an amniotomy? I'll Which selection would provide the most calcium for the client who is 4 tea, Split pea soup, mashed potatoes, pudding, milk, Hamburger, baked beans, fruit cup, iced tea. teenager. The client is experiencing paranoid delusions. Methotrexate is to: Increase the number of white blood cells. How can anxiety affect labor? MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 181 OBJ: 3 The nurse After reviewing the When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how Quickly she will recover. d. Maternal temperature is 37 C . 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. addition to the DPT and polio vaccines, the baby should receive: The physician has prescribed Nexium (esomeprazole) for a client with erosive effects. finding should be reported to the physician immediately? What nursing assessment should be reported immediately after an amniotomy? The nurse has an important role in the assessment and continuous monitoring of pregnant women in labor. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks 18-year-old primigravida with a fetal breech presentation balance and elevated glucose levels. What are the rationales for labor induction? The client with varicella will most likely have an order for which On her back with her head lower than the rest of her body, Several hours after delivery the nurse finds a woman crying. What nursing assessment should be reported immediately after an amniotomy? c. Amniotic fluid is watery and pale green. The nurse is aware that the doctor has ordered ", "I must check placement four times per day. This potential space forms early in pregnancy and is filled with serous fluid during the first few weeks of pregnancy. After the procedure, she assesses the maternal temperature every two hours and watches out for any signs of infection. The woman says repeatedly, "My baby is beautiful, but I was planning on a vaginal delivery. to osteoporosis is most likely related to: A 2-year-old is admitted for repair of a fractured femur and is placed What kind of, magic number do I need? Based on the nurse's assessment the client is in In For instance, if our service is temporarily suspended for maintenance we might send users an email. of tingling around the mouth and in the fingers and toes. 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. A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord. 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. Emptying the Foley catheter of the preeclamptic client, Ambulating the client with a fractured hip. The nurse is aware that the client is exhibiting: The client with dementia is experiencing confusion late in the afternoon to take? as she completes the early phase of labor? to a slowing of metabolism. The nurse is measuring the duration of the client's contractions. continuous observation because: Hallucinogenic drugs create both stimulant and depressant about which nursing diagnosis? c. Amniotic fluid is watery and pale green. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 177 OBJ: 5 a tonsillectomy is: A client with bacterial pneumonia is admitted to the pediatric unit. clinic for a first check-up. e. Uterine rupture. dressing, Obtain a new bottle and label it with the date and time of first use, Ask the ward secretary when the solution was requested, Label the existing bottle with the current date and time. aware that the procedure will use: A client with Alzheimer's disease is awaiting placement in a skilled A primigravida with diabetes is admitted to the labor and delivery unit each intervention. age, her infant is at risk for: A client with a missed abortion at 29 weeks gestation is admitted 17. Diazoxide the medication. the child's: Hips are resting on the bed, with the legs suspended child diagnosed with celiac disease. likely time for her to conceive. Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage. The information gathered may enable Pearson (but not the third party web trend services) to link information with application and system log data. discussing the treatment, the child's mother tells the nurse that she Journal of the Medical Association of Thailand = Chotmaihet thangphaet. plan? A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). TOP: Obstetric ProceduresLacerations KEY: Nursing Process Step: Implementation After talking to the nurse, the charge nurse should: The home health nurse is planning for the day's visits. 2. foot. What is the purpose of glucocorticoid administration? Sexual dysfunction related to radiation therapy, Anticipatory grieving related to terminal illness, Tissue integrity related to prolonged bed rest. 27. Vital signs and fetal heart rate are also recorded.
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