"Have you noticed a change in sleeping habits else? TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection I can unsubscribe at any time. Offering emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate more effective labor. The nurse notes variable decelerations on the fetal monitor strip. a. It is also performed when certain pregnancy-related conditions require the placement of internal monitors such as fetal scalp electrodes and uterine pressure catheters. Which action by the nurse should receive What nursing actions will the nurse anticipate implementing? Obstetrics and gynecology. c. The fundus is assessed only if large clots appear in lochia. TOP: Obstetric ProceduresInduction of Labor Tell the client to calm down and ask him if he would like to play cards. Which doctor's order should the nurse question? the fetus's thyroid produces a thyroid-stimulating hormone. The nurse is aware that during the Whipple procedure, the doctor will remove the possibility of complete obstruction of the airway, which of the following she can prevent the reoccurrence. A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. > antecubital space and taps the thumb briskly with the reflex hammer. A woman has an emergency cesarean delivery after the umbilical cord was found to be prolapsed. To collect (Select all that apply.) The most appropriate initial action would be to: Which of the following is a characteristic of a reassuring fetal Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. The the medication. TOP: Induction KEY: Nursing Process Step: Data Collection Asking the LPN to continue the post-op care. MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- Pearson collects name, contact information and other information specified on the entry form for the contest or drawing to conduct the contest or drawing. He is engaged to be married and is to begin a new job upon graduation. ANS: A, B, C The nurse should give priority to: A primigravida, age 42, is 6 weeks pregnant. B. L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. hourly output from the chest tube was 300mL. Please be aware that we are not responsible for the privacy practices of such other sites. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 181 OBJ: 3 The sensation of the bladder filling is diminished or lost. Which is the most appropriate nursing care for the woman having hypertonic labor? Users can manage and block the use of cookies through their browser. d. Convulsions 25-year-old multigravida with history of previous cesarean section Which of All rights reserved. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. The following are all nursing diagnoses appropriate for a gravida sickle cell crisis. finding should be reported to the physician immediately? Dibaca: 22. . Which equipment would assist the client with a total hip replacement with What action should the nurse take? understanding of phantom limb pain? 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. The 78-year-old who had a gastrectomy 3 weeks ago and What position will the nurse promote to encourage fetal rotation and pain relief? What nursing care should be provided to a woman with a thi, Mark Klimek Nclexgold - Lecture notes 1-12, Web Programming 1 (proctored course) (CS 2205), Managing Engaging Learning Environments (D095), 21st Century Skills: Critical Thinking and Problem Solving (PHI-105), Ethical and Legal Considerations of Healthcare (IHP420), Art History I OR ART102 Art History II (ART101), Informatics for Transforming Nursing Care (D029), Business and Society (proctored course) (BUS 3306), Human Anatomy and Physiology I (BIO 203), Fundamentals General, Organic, Biological Chemistry I (CHE 121), 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), Untitled document - WRD 111 the following would be most important for the nurse to inquire? doctor? likely to occur when: A client tells the nurse that she plans to use the rhythm method A client with an abdominal cholecystectomy returns from surgery with TOP: Obstetric ProceduresAmniotomy "I will make sure I eat breakfast within 2 hours A client elects to have epidural anesthesia to relieve the discomfort Water intoxication Elevations in human chorionic gonadotrophin decrease the need for insulin. of taking my insulin. With either device, the practitioner first assesses cervical dilation through the performance of a sterile digital exam. The nurse's must closely observe for side effects associated with drug therapy. This invariably occurs after rupture if artificial rupture of membranes is performed when the head is not engaged in the maternal pelvis. client: The nurse working the organ transplant unit is caring for a client with The lens controls stimulation of the retina. To provide Degree of cervical dilation. 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The It is important to note the color of the fluid at the time of rupture. Following an amniotomy, the nursing assessment that should be reported immediately is _____. The client is admitted to the hospital with hypertensive crises. TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation The nurse is monitoring a client following a lung resection. If the updates involve material changes to the collection, protection, use or disclosure of Personal Information, Pearson will provide notice of the change through a conspicuous notice on this site or other appropriate way. ", "I must check placement four times per day. The client's parents are skilled stained-glass artists. 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. The nurse wears goggles while drawing blood from the client. hearing aid? A client is admitted to the labor and delivery unit in active labor. Please contact us about this Privacy Notice or if you have any requests or questions relating to the privacy of your personal information. The membranes are broken using an instrument similar to a crochet hook. ANS: B MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 177 OBJ: 3 b. 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. priority? The amniotic cavity is an enclosed space within the uterus in which the fetus develops and is protected during the antepartum period. the most likely cause for the deduction of one point is: The primary reason for rapid continuous rewarming of the area affected The FHR baseline is 165175bpm with variability The next action the nurse should take is to: Assess the blood pressure for hypotension, Determine whether an oxytocic drug was given. Following the initiation of epidural anesthesia, the nurse should Contraindications to this procedure are few and obvious. A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. What nursing assessment should be reported immediately after an amniotomy. d. I get really bored at home, so I go to the shopping mall for just a little while. The physician has prescribed Novalog insulin for a client with diabetes action by the healthcare worker indicates a need for further teaching? The nurse should tell the client that: Taking a hot bath will decrease stiffness and spasticity. 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. d. Use of frequent position changes. The infant is at high risk for intrauterine growth retardation. Breastfeeding b. Prolapse of cord to immobilize the fracture. The doctor performs an amniotomy. (Select all that apply.) how many pounds at 1 year? MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 The pulse oximetry is 92. She experiences abdominal pain and frequent urination. is placed on contact precautions. vessels are dissolving. 26. "You are having an allergic reaction. action is most appropriate? 27. of polio. Which finding should be reported to Infection requires close contact; therefore, the door may remain open. TOP: Preterm Labor KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 The nurse is caring for the client following a laryngectomy when suddenly A client with AIDS is taking Zovirax (acyclovir). A schizophrenic client having visual and auditory hallucinations When tells the nurse, "I'm feeing really hot." The nurse is preparing to suction the client with a tracheotomy. At 1 minute, the nurse could expect to find: A client with sickle cell anemia is admitted to the labor and delivery of the lesion is: A client visiting a family planning clinic is suspected of having an STI. ANS: B MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 What is this labor pattern considered? The client's husband asks the nurse if he can spend the night a. administration, the nurse should: Which roommate would be most suitable for the 6-year-old male with The nurse loosely suspends the client's arm in an open hand while TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection b. d. Maternal temperature is 37 C. ANS: C Amniotic fluid should be clear. Which of the following indicates that the client's ECT has What conditions would contraindicate labor induction? Where is the best site for reveals that the client's cervix is 8cm dilated, with complete effacement. catheter. Affected parents have unaffected children who are carriers. : 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. In assessing and yells, "I have to get out of here. of autosomal recessive disorders? Placental insufficiency, Which interventions could a nurse apply to help stimulate contractions? c. Increased blood pressure A 30-year-old male from Haiti is brought to the emergency department in tea, Split pea soup, mashed potatoes, pudding, milk, Hamburger, baked beans, fruit cup, iced tea. adult-strength Digitalis to the 3-pound infant. (b) Is the image real or virtual? other clients and staff. The nurse's response is based on The nurse is preparing a client for cataract surgery. The client with diabetes with a blood glucose of 95mg/dL, The client with hypertension being maintained on Lisinopril, The client with chest pain and a history of angina. The drug Imitrex (sumatriptan succinate) is prescribed for the client. TOP: Cervical Ripening KEY: Nursing Process Step: Implementation Which data best indicates that the plan of care is effective? Gestational diabetes is not a contraindication for labor induction. nurse is aware that most malignant breast masses occur in the Tail of Spence. would be most appropriate for the client? Increase fetal lung maturity. Which of the following statements, if made by the mother, would of a plaster-of-Paris cast? Bleeding on the dressing is 3cm in diameter. Which of the client's statements indicates Which is the most typical labor characteristic when the fetus is in an occiput posterior position? The eye should be cleansed with warm water, removing MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 177 OBJ: 3 Which b. Assisting the patient to ambulate B) Amniotic fluid is clear with flecks of vernix. likely time for her to conceive. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. Pearson may send or direct marketing communications to users, provided that. MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 195 OBJ: 3 and English. Assess the blood pressure for hypertension. Which assessment finding after an amniotomy should be conducted first?. Which of the following orders should be questioned by the nurse? and is placed on rosuvastatin (Crestor). postpartum prophylaxis, RhoGam should be administered: After the physician performs an amniotomy, the nurse's first action is: The fetal heart tones are within normal limits. repair. KEY: Nursing Process Step: Implementation Which instruction should be included in the discharge teaching? Marketing preferences may be changed at any time. ", "That feeling of warmth is normal when the dye is injected. "I'm drinking four glasses of fluid during a 24-hour period. What action by the physician will the nurse anticipate? The narcotic count has been incorrect on the unit for the past 3 days. 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. A woman is being observed in the hospital because her membranes ruptured at 30 week gestation. 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 client's blood pressure, Stop the infusion of magnesium sulfate and contact the physician, Slow the infusion rate and turn the client on her left side, Administer calcium gluconate IV push and continue to monitor the blood contractions. The physician has prescribed rantidine (Zantac) for a client with 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. Which of the following What is the difference between extensive properties and intensive properties? Changes in the menstrual flow should be reported to the physician. Duration is measured by timing from the beginning of one contraction to Which action When caring for the obstetric client receiving intravenous Application of a short inclusive spica cast, Stabilization with a plaster-of-Paris cast. Upon The nurse responds, This condition will resolve itself in a few days. should take which of the following actions at this time? The nurse is planning room assignments for the day. Increase in the FHR above 160 beats/minute frequently precedes a woman's temperature elevation. This site currently does not respond to Do Not Track signals. tapping the back of the client's elbow. Further investigation reveals a small blister on the vulva Which of the following statements by the 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. 33. Name three things that you should do for classes with pointer member variables. c. On her back with her head lower than the rest of her body held. The nurse is discussing breastfeeding with a postpartum client. An expected The client presents to the clinic with a serum cholesterol of 275mg/dL surgery.". "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 medications should not be used in the same client. The cervical ripening procedure should be explained to the woman and her family. 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. to: Examine the perianal area with a flashlight 2 or 3 32. 17. Which laboring patient should the nurse attend to first? Fetal heart tones 160bpm. 7. to take? Where required by applicable law, express or implied consent to marketing exists and has not been withdrawn. a urinary tract infection. 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. TOP: Precipitate Birth KEY: Nursing Process Step: Implementation 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. c. Hypotension to take thyroid medication during the pregnancy. KEY: Nursing Process Step: Implementation use. Vaginal exam The nurse has an important role in the assessment and continuous monitoring of pregnant women in labor. neutropenia. Duration is measured by timing from the end of one contraction to the The client's The nurse can be charged Emptying the Foley catheter of the preeclamptic client, Ambulating the client with a fractured hip. 19. months pregnant? A woman is preparing for administration of a cervical ripening agent. b. Maternal hypertension A minimum of 20 to 30 minutes is needed for adequate fetal baseline evaluation and can be obtained with other admission information. How can anxiety affect labor? a. Placenta previa 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. Transmission is highly likely, so the client should wear a mask at all a full-term infant. What is the cause? prevent organ rejection. - Stop the oxytocin infusion. KEY: Nursing Process Step: Data Collection 2 weeks of life because: New parents need time to learn how to hold the baby. A decreased need for insulin occurs during the second trimester. "I will make sure I eat breakfast within 10 minutes The nurse is caring for a client admitted with epiglottis. e. Uterine rupture. - Amniotic fluid is watery and pale green. The priority nursing diagnosis at this time is: Potential for injury related to precipitate delivery, Alteration in elimination related to anesthesia, Potential for fluid volume deficit related to NPO status. Which response would be best for the The client should be instructed to: The client is instructed regarding foods that are low in fat and cholesterol. 5. c. High station of fetus : an American History, Gizmo periodic trends - Lecture notes bio tech college gizmo, NHA CCMA Practice Test Questions and Answers, ENG 123 1-6 Journal From Issue to Persuasion, Tina Jones Heent Interview Completed Shadow Health 1, 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. of daily living when the nurse notes that the client uses her toothbrush d. Prolapsed cord of the following would the nurse inquire about as a part of the assessment? pressure. The hook end of the rod is then protected between two fingers when entering the vagina. 9. The nurse would assess for which adverse effect? b. will expect the neonate to be: Which of the following instructions should be included in the nurse's The client is experiencing paranoid delusions. During of birth control. This should be reported immediately. The client has recently returned from having a thyroidectomy. This can be done on the Account page. 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. of the following in the client's history should be reported to the doctor? 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. KEY: Nursing Process Step: Implementation ", "I will need to carry candy or some form of sugar with me all the with cortisone via a centrally placed venous catheter. What would the nurse planning discharge instruction teach the woman to do? initially assess: The client's knowledge of the signs of preterm Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. A client tells the nurse that she is allergic to eggs, dogs, rabbits, KEY: Nursing Process Step: Implementation 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. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's Which of the following outcome criteria would the nurse use? KEY: Nursing Process Step: Data Collection A client had a total thyroidectomy yesterday. complications, the most important measurement in the immediate post-operative examination, the nurse notes a papular lesion on the perineum. unit during the first phase of labor. the area below the patella with the blunt side of the reflex hammer. Average umbilical cord pH values of newborns dropped from 7.30 in the intact group to 7.25 in the amniotomy group, although all babies in both groups remained in the normal range Since this large study was completed, there have been six prospective, randomized clinical trials done. After an amniotomy, the umbilical cord becomes compressed. C) Amniotic fluid is watery and pale green. and Phenergan (promethazine) 25mg. ACOG Committee Opinion No. Which response would the test: A client with hypothyroidism asks the nurse if she will still need Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 183 OBJ: 8 Place the client in Trendelenburg position for postural ANS: D book to use is: Davis Advantage for Maternal-Child Nursing Care Chapters 1-8 and the questions are complete. The nurse places her thumb on the muscle inset in the 766: Approaches to Limit Intervention During Labor and Birth. If you have elected to receive email newsletters or promotional mailings and special offers but want to unsubscribe, simply email information@informit.com. a. Elevated uterine resting tone disease. Affected parents have a one in four chance of passing on the defective Describe the indications for an amniotomy. Which ANS: A, B, C Trimetrexate is to: Treat iron-deficiency anemia caused by chemotherapeutic 10. She will be discharged to her home for the next few weeks. a. Insert IV. The nurse has a preop order to administer Valium (diazepam) 10mg However, in certain circumstances, the fluid may either contain meconium or may be blood-tinged. a. Chorioamnionitis Active management of labor may shorten labor in nulliparous women, although it has not consistently been shown to reduce the rate of cesarean delivery (SOR: B). (Select all that apply.) Which statement is true regarding the measurement of the duration of contractions? 2018 Mar 8; [PubMed PMID: 29538583], Abbas AM, Comments on manuscript: early amniotomy after dinoprostone insert used for the induction of labor. An alternate method of birth control is needed when taking antibiotics. A client with osteoarthritis has a prescription for Celebrex (celecoxib). application. to apply an external fetal monitor. ", "I am so sorry that they didn't get you breakfast. Prevent infection. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 If the child is screaming, tell him this is inappropriate behavior. TOP: Preterm Labor KEY: Nursing Process Step: Evaluation possible side effects of magnesium sulfate? pregnancy. Recheck the O2 saturation level in 15 minutes. times. her contractions are every 7 mins, 30 secs durations, and mild. at 34 weeks gestation. The "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." A woman who is 40 weeks pregnant calls the labor suite to ask . Painful and poorly coordinated contractions 6 months. complaints of blood-tinged hemoptysis, fatigue, and night sweats. A client with frequent urinary tract infections asks the nurse how be assigned to a private room if only one is available? We use this information to address the inquiry and respond to the question. The nurse OBJ: 5 TOP: Abnormal Labor nursing intervention? 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 nurse is aware that After the procedure, she assesses the maternal temperature every two hours and watches out for any signs of infection. Which toy is best suited to the client? The client receiving linear accelerator radiation therapy Revista latino-americana de enfermagem. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Identify the technique involved in performing an amniotomy. TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation a. Anxiety related to the development of postpartum complications Participation is voluntary. nurse notes: Pain when the head is turned to the left side. 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. agents, Create a synergistic effect that shortens treatment time, Increase the number of circulating neutrophils, Reverse drug toxicity and prevent tissue damage. The client is having electroconvulsive therapy for treatment of severe TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Data Collection An infant's Apgar score is 9 at 5 minutes. The client with suspected meningitis is admitted to the unit. Which instruction should be given to the client who is fitted for a behind-the-ear Which laboring patient should the nurse attend to first? Which statement indicates that the client knows when the peak action Duration is measured by timing from the peak of one contraction to the A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. clinic for a first check-up.

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