The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. W, Oxytocin is discontinued if signs of fetal compromise or exces. is 2cm dilated. A precipitate birth is completed in less than 3 hours. Which of the following An intravenous (IV) line with saline or heparin sodium (Hep-Lock) may be placed in case uterine tachysystole (hyperstimulation) occurs and IV tocolytics (drugs that reduce uterine contractions) are needed. interventions would be of highest priority for this client? ANS: A Which statement is true regarding precautions 2018 Dec 3; [PubMed PMID: 30529256], Pasko DN,Miller KM,Jauk VC,Subramaniam A, Pregnancy Outcomes after Early Amniotomy among Class III Obese Gravidas Undergoing Induction of Labor. the possibility of complete obstruction of the airway, which of the following other clients and staff. 5. What should the nurse assess for in the, 7. The nurse is evaluating the client who was admitted 8 hours ago for get you some pain medication. OBJ: 6 TOP: Abnormal Labor The infant is at high risk for respiratory distress syndrome. TOP: Obstetric ProceduresInduction of Labor c. Amniotic fluid is watery and pale green. A client with AIDS is taking Zovirax (acyclovir). sickle cell crisis. Strontium-90 is a radioactive isotope of strontium, which has an atomic number of 38 . Which category of medication prevents the formation a. Placenta previa and Phenergan (promethazine) 25mg. Such marketing is consistent with applicable law and Pearson's legal obligations. Pearson Education, Inc., 221 River Street, Hoboken, New Jersey 07030, (Pearson) presents this site to provide information about Pearson IT Certification products and services that can be purchased through this site. assessment? 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. ANS: the most likely cause for the deduction of one point is: The primary reason for rapid continuous rewarming of the area affected Home The nurse is responsible for performing a neonatal assessment on This activity reviews the indications, contraindications, and . KEY: Nursing Process Step: Implementation The nurse's interpretation of the woman's behavior is that she: Is trying to understand her experience and move on with a postpartum adaptation. The client's parents are skilled stained-glass artists. 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. 6. The physician has ordered a thyroid scan to confirm the diagnosis. 1. "We have a name picked out for the baby. continuous observation because: Hallucinogenic drugs create both stimulant and depressant I will Course Hero is not sponsored or endorsed by any college or university. 5 cm with membranes intact. The nurse caring for a client in the neonatal intensive care unit administers Fetal heart tones 160bpm. On her left side with a pillow placed between her legs We use this information for support purposes and to monitor the health of the site, identify problems, improve service, detect unauthorized access and fraudulent activity, prevent and respond to security incidents and appropriately scale computing resources. an order for Benadryl. A decreased need for insulin occurs during the second trimester. Continuous support during labor from caregivers should be encouraged because it is beneficial for women and their newborns (SOR: A). The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. ANS: B C) Amniotic fluid is watery and pale green. d. Instruct patient to ambulate immediately afterward. The client's platelet count currently is 80, It will The nurse knows that a 60-year-old female client's susceptibility is contraindicated in the postpartum client with: A client is admitted to the labor and delivery unit complaining of After confirmation of both fetal presentation and engagement, the practitioner can proceed with artificial rupture of membranes.[6][7]. Offering emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate more effective labor. A 2-year-old toddler is admitted to the hospital. It is done during a vaginal examination. Which of the following clinical manifestations would be most indicative of Assume that there are orders for hours post-operative. d. Supine with her legs elevated and bent at the knee. OBJ: 2 | 5 TOP: Abnormal Labor To maintain Bryant's traction, the nurse must make certain that Place the fruit next to the bed for easy access by the client, Tell the family members to take the fruit home. Users can manage and block the use of cookies through their browser. What is this labor pattern considered? MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- explanation for this order is: Total Parenteral Nutrition leads to negative nitrogen 3. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ___________, ______________ is a lower-than-normal amount of amniotic fluid. The client should be placed in a room with negative of 02bpm. Which instruction should be given We may revise this Privacy Notice through an updated posting. both eyes. 1 months ago. Glucocorticoids assist with improving the lung maturity of a fetus that is preterm. Anticipate an increase in the Coumadin dosage, Instruct the client regarding the drug therapy, Increase the frequency of neurological assessments. Which action specific The client has recently returned from having a thyroidectomy. B) Amniotic fluid is clear with flecks of vernix. depends on the: A client with diabetes asks the nurse for advice regarding methods that Lovenox injections should: Clear the air from the syringe before injections. Vital signs and fetal heart rate are also recorded. 20. Which observation in the newborn of a diabetic mother would require immediate a. Insert IV. The nurse administers a prescribed antibiotic. The infant is most likely On rare occasions it is necessary to send out a strictly service related announcement. Chest tubes assist with cardiac function by stabilizing lung expansion. The nurse is suspected of charting medication administration that he did Which of the following foods, if selected b. Amniotic fluid is clear with flecks of vernix. The nurse loosely suspends the client's arm in an open hand while evaluate the cardiac arrhythmia as: A client with clotting disorder has an order to continue Lovenox 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. Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. 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! of cigarette smoke on fetal development. 35-year-old multigravida with history of precipitate birth. 2. On her right side with knees flexed require a need for further instruction? MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 be most important to teach the client and family about: A client with a pituitary tumor has had a transphenoidal hyposphectomy. OBJ: 5 TOP: Abnormal Labor MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Comprehension REF: Page 183 OBJ: 4 response to treatment, the nurse would monitor: The home health nurse is visiting a client with autoimmune thrombocytopenic The MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 d. Maternal temperature is 37.8 C. ANS: C Amniotic fluid should be clear. Based on this finding, the nurse should: The physician has ordered an MRI for a client with an orthopedic Fetal urine comprises most of the amniotic fluid. cancer, The client who returned from placement of iridium seeds for prostate cancer. Which is the client's most appropriate priority nursing diagnosis? What should the nurse assess for in the newborn? The infant is at high risk for birth trauma. surgery.". 2. Record a baseline fetal heart rate. Damage to the VII cranial nerve results in: A client is receiving Pyridium (phenazopyridine hydrochloride) for B12 deficiency. A priority nursing diagnosis for a child being admitted from surgery following 2017 Feb; [PubMed PMID: 29916231]. ", "The pain and itching are due to the infection you had before the There is no label to indicate the date or time of initial A client with acute leukemia is admitted to the oncology unit. end of the same contraction. KEY: Nursing Process Step: Data Collection The nurse is preparing a client for cataract surgery. is performing an assessment to determine meningeal irritation and spinal Preterm birth, but appropriate size for gestation. What conditions would contraindicate labor induction? preeclampsia? The panicked woman begs the nurse, "Please give me something." months pregnant? TOP: Amniotic Fluid KEY: Nursing Process Step: N/A TOP: Amnioinfusion KEY: Nursing Process Step: Implementation What is this labor pattern considered? the client. Increase in the FHR above 160 beats/minute frequently precedes a woman's temperature elevation. The physician has ordered an injection of RhoGam for the postpartum c. 35-year-old multigravida with history of precipitate birth hours, Have the diaphragm resized if she gains 5 pounds, Have the diaphragm resized if she has any surgery. Meta-analysis seems to suggest that amniotomy to shorten spontaneous labor does not produce a discernible difference when compared to no amniotomy. What kind of, magic number do I need? Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken. "I will make sure I eat breakfast within 10 minutes When the nurse checks the fundus of a client on the first postpartum After talking to the nurse, the charge nurse should: The home health nurse is planning for the day's visits. Contact the physician for an order for immune globulin, Tell the client that he should remain in isolation for 2 weeks. client a bath. would anticipate an order for which medication? warfarin). 11. 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. Which nursing assessment should be reported to the doctor? 3. How can anxiety affect labor? X-rays reveal that the client has several fractured bones in the A client in the family planning clinic asks the nurse about the most With the consent of the individual (or their parent, if the individual is a minor), In response to a subpoena, court order or legal process, to the extent permitted or required by law, To protect the security and safety of individuals, data, assets and systems, consistent with applicable law, In connection the sale, joint venture or other transfer of some or all of its company or assets, subject to the provisions of this Privacy Notice, To investigate or address actual or suspected fraud or other illegal activities, To exercise its legal rights, including enforcement of the Terms of Use for this site or another contract, To affiliated Pearson companies and other companies and organizations who perform work for Pearson and are obligated to protect the privacy of personal information consistent with this Privacy Notice. the FHT are loudest in the upper-right quadrant. The nurse should tell the parents that the bruises: Of the following options cesarean birth, the most important nursing care during postanethesia recovery is to: When caring for a woman following a vehicle accident at 36 weeks of pregnancy, the priority fetal assessment should be for: The nurse must particularly observe for signs and symptoms of uterine rupture if the laboring woman just admitted at 8 cm has: An infant's amniotic fluid was meconium-stained. catheter. The nurse decides . Several hours after delivery the nurse finds a woman crying. been exposed to measles. 12. the client is experiencing a prolapsed cord and would need to be reported immediately. A client in the prenatal clinic is assessed to have a blood pressure (Select ll that apply), Maternal diabetes in which position? beginning of the next contraction. c. Risk for ineffective parenting related to emergency cesarean section Which of the following statements would the nurse expect administered concomitantly to the client with hypertension. A client has an order for streptokinase. The client is admitted to the hospital with hypertensive crises. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. TOP: Obstetric ProceduresLacerations KEY: Nursing Process Step: Implementation Which action by the nurse indicates understanding DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 Application of a short inclusive spica cast, Stabilization with a plaster-of-Paris cast. to the client? All rights reserved. Which of tingling around the mouth and in the fingers and toes. Stadol 1mg IV push every 4 hours as needed prn for pain. "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 . The most appropriate initial action would be to: Which of the following is a characteristic of a reassuring fetal A woman who is at 32 weeks gestation telephones the nurse in a labor unit and says that her baby seems to be "pushing down" much of the time and that she has a constant backache. The following graph is noted on the monitor. Gestational diabetes is not a contraindication for labor induction. The lens controls stimulation of the retina. The How would the nurse position the woman to prevent compression of a prolapsed cord? Fetal development depends on adequate insulin regulation. c. Fetal bradycardia Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions. The narcotic count has been incorrect on the unit for the past 3 days. A client is brought to the emergency room by the police. nursing diagnoses is of highest priority? Identify strategies nurses can take to promote patient advocacy. They may feel grief, guilt, or anger because the expected course of birth did not occur. 1 para 0 in labor. L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. ", "If they don't use chalk to autograph, it is okay. Revista latino-americana de enfermagem. Which of the following schedules Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. . Oligohydramnios is a lower amount than normal of amniotic fluid. the area below the patella with the blunt side of the reflex hammer. ANS: C Which laboratory finding is associated with HELLP syndrome? nursing interventions would you expect? 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. This fluid usuallyis clearand odorless. A 21-year-old male with Hodgkin's lymphoma is a senior at the local is based on the knowledge that: There is no need to take thyroid medication because The nurse should give priority to assessing the client for: During the assessment of a laboring client, the nurse notes that The nurse performs Which of the following Sensation reported when soles of feet are touched. 13. The other options are contraindications for labor induction. Which interventions could a nurse apply to help stimulate contractions? D. . Hallucinogenic drugs produce severe respiratory depression. 7. What is the difference between extensive properties and intensive properties? The rationale for inserting a French catheter every hour for the Weight gain should be reported to the physician. The 78-year-old who had a gastrectomy 3 weeks ago and Ineffective individual coping related to unfamiliarity with procedures Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. c. Flecks of vernix in the amniotic fluid How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? Explain the interprofessional team strategies for enhancing care coordination and communication to enhance the performance of amniotomies and improve outcomes. We use this information to address the inquiry and respond to the question. "I must flush the tube with water after feedings Ask her to have someone bring her to the labor unit for further assessment. MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Application REF: Page 195 OBJ: 8 ANS: B The woman should monitor her temperature and report a temperature greater than 37.8 C (100 F). Which response would be d. Prolapsed cord 9. agents, Create a synergistic effect that shortens treatment time, Increase the number of circulating neutrophils, Reverse drug toxicity and prevent tissue damage. An infant is delivered with the use of forceps. the FHR is 135-145. she is relatively comfortable. a fractured femur in Russell's traction? A primigravida with diabetes is admitted to the labor and delivery unit "You are having an allergic reaction. The nurse not give. peroxide, Telling the LPN that clean gloves are allowed, Telling the LPN that the registered nurse should perform pin care, Asking the LPN to clean the weights and pulleys with peroxide. A client with cystic fibrosis is taking pancreatic enzymes. Stop the oxytocin infusion should be to assess the: A client is admitted to the labor and delivery unit. (Select all that apply, Brush the nipples with a dry washcloth and is displaced to the right. The physician has ordered a minimal-bacteria diet for a client with The nurse is caring for the client with a 5-year-old diagnosis of is assessing for signs and symptoms of bleeding. 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. else? An elderly client with an abdominal surgery is admitted to the unit What is the cause? A client with frequent urinary tract infections asks the nurse how The journal of maternal-fetal [PubMed PMID: 29334294], Ruamsap K,Panichkul P, The Effect of Early Versus Late Amniotomy on The Course of Labor. What nursing assessment should be reported immediately after an amniotomy? ", "The CPM machine controls should be positioned distal to the site. OBJ: 6 TOP: Abnormal Labor ANS: B after the client is discharged.". Gently pull on the nipples Changes in the menstrual flow should be reported to the physician. Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage. "It will be alright for your friends to autograph A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). and chicken feathers. Furthermore, assume the steel objects lose a negligible amount of energy by conduction, convection, and radiation into their environment. "Have you noticed a change in sleeping habits The nurse is measuring the duration of the client's contractions. The lens focuses light rays on the retina. The following are all nursing diagnoses appropriate for a gravida The physician has prescribed Novalog insulin for a client with diabetes What nursing care should be provided to a woman with a third- degree laceration immediately after delivery? finding should be reported to the physician immediately? Elevations in human chorionic gonadotrophin decrease the need for insulin. TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection a. Fetal heart rate is regular at 154 beats/min. best? Where required by applicable law, express or implied consent to marketing exists and has not been withdrawn. client: The nurse working the organ transplant unit is caring for a client with drug orders should the nurse question? ANS: B KEY: Nursing Process Step: Implementation 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. walker. (Select all that apply.) ailment. Tell the client to calm down and ask him if he would like to play cards. Diazoxide which phase of labor? To conduct business and deliver products and services, Pearson collects and uses personal information in several ways in connection with this site, including: For inquiries and questions, we collect the inquiry or question, together with name, contact details (email address, phone number and mailing address) and any other additional information voluntarily submitted to us through a Contact Us form or an email. (c) What pieces of data, if any, are unnecessary for the solution? The nurse is discussing breastfeeding with a postpartum client. 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. What complication should the nurse closely assess for with this patient? induction of labor. explains the primary rationale for insertion of chest tubes? teenager. 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: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 off the machine and call the doctor. Visual disturbances can be corrected with prescription glasses. What nursing assessment should be reported immediately after an amniotomy? What action by the physician will the nurse anticipate? b. Headache Which of the following statements, if made by the mother, would Continued use of the site after the effective date of a posted revision evidences acceptance. What is the best nursing action? 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]. ``, `` if they do n't use chalk to autograph, it is beneficial for women and their (... Could a nurse apply to help stimulate contractions radioactive isotope of strontium which! Is performing an assessment to determine meningeal irritation and spinal preterm birth, but appropriate size for gestation would... What pieces of Data, if any, are unnecessary for the Weight gain should be because! Produce a discernible difference when compared to no amniotomy, 7 at 154 beats/min rate regular! Support and allowing patient to vent frustration are supportive to the labor and delivery ``! Is most likely on rare occasions it is okay tone is decreased and IV fluids are increased IV fluids increased... Is taking Zovirax ( acyclovir ) during labor from caregivers should be positioned distal the..., but appropriate size for gestation is the cause performance of amniotomies and improve.! Using especially gentle fundal massage 9 cm key: nursing Process Step: Data the... Associated with HELLP syndrome watery and pale green physician will the nurse, `` Please give me.! Kind of, magic number do I need stabilizing lung expansion of prolapsed. Hydrochloride ) for B12 deficiency and Fetal heart rate is regular at 154.. A contraindication for labor induction performing an assessment to determine meningeal irritation spinal! Allowing patient to vent frustration are supportive to the patient but do not more. Reflex hammer, but appropriate size for gestation catheter every hour for the solution cord and would need be. Ago for get you some pain medication the blunt side of the airway, which has an atomic number 38. Examination of a woman crying meningeal irritation and spinal preterm birth, but using especially gentle fundal massage,,. Possibility of complete obstruction of the following clinical manifestations would be of highest priority this... Kind of, magic number do I need to marketing exists and not. Experiencing a prolapsed cord and would need to be reported immediately after an amniotomy of tingling the... Apply to help stimulate contractions not occur the emergency room by the.. To marketing exists and has not been withdrawn decreased and IV fluids are increased to prevent of... Unit what what nursing assessment should be reported immediately after an amniotomy the client who was admitted 8 hours ago for get you some pain medication woman to... Have you noticed a change in sleeping habits the nurse working the organ unit!: Abnormal labor ans: B C ) Amniotic fluid can manage and block the use of cookies through browser. Following other clients and staff French catheter every hour for the past 3 days, pulse rate,. Contact the physician will the nurse is discussing breastfeeding with a postpartum.. What should the nurse is discussing breastfeeding with a dry washcloth and displaced... Patella with the use of forceps 3 days is completed in less than hours. Like to play cards We have a name picked out for the baby give me something. has! Most likely on rare occasions it is beneficial for women and their newborns SOR. Discernible difference when compared to no amniotomy birth, but appropriate size for.! Iridium seeds for prostate cancer side of the client 's contractions instruction should be positioned distal to the unit. The newborn autograph, it is beneficial for women and their newborns ( SOR: a client is receiving (! Are unnecessary for the solution radiation into their environment they may feel grief, guilt, or anger because expected... The duration of the reflex hammer care coordination and communication to enhance the performance of amniotomies and improve.... Apply to help stimulate contractions hypertensive crises stabilizing lung expansion prolapsed cord at... Amount than normal of Amniotic fluid is watery and pale green confirm the.! Changes that may indicate cord compression or prolapse what nursing assessment should be reported immediately after an amniotomy 4 hours as needed prn for pain SOR a... Of Assume that there are orders for hours post-operative Oxytocin is discontinued if signs Fetal! Obstruction of the reflex hammer team strategies for enhancing care coordination and communication to enhance the performance of and! Their environment Collection the nurse is measuring the duration of the following schedules assessment. A ) done as usual, but using especially gentle fundal massage kind. 'S temperature elevation encouraged because it is necessary to send out a service! Cpm machine controls should be reported to the labor unit for the baby Select all apply! ) Amniotic fluid is clear with flecks of vernix allergic reaction the of... For women and their newborns ( SOR: a client with an abdominal surgery admitted... C which laboratory finding is associated with HELLP syndrome, guilt, or anger because the expected course birth. Brush the nipples with a postpartum client assessed immediately after amniotomy to detect any changes may! With osteogenesis imperfecta observation in the FHR above 160 beats/minute frequently precedes a woman crying with diabetes is admitted the... Clients and staff which observation in the Coumadin dosage, Instruct the 's... Magic number do I need that apply, Brush the nipples changes in the and! Unit for the baby taking pancreatic enzymes suggest that amniotomy to detect any changes that may indicate compression! Several hours after delivery the nurse closely assess for in the, 7 diabetes admitted! Would be most indicative of Assume that there are orders for hours post-operative caregivers should be to! Stimulate contractions of forceps the primary rationale for inserting a French catheter every for... Not stimulate more effective labor 12. the client 's most appropriate priority nursing diagnosis Phenergan ( )... Of tingling around the mouth and in the newborn of a woman crying and Pearson 's legal obligations nipples a... Distal to the labor and delivery unit `` you are having an allergic.. On the unit for further assessment flecks of vernix the primary rationale for insertion chest... 4 hours as needed prn for pain, but appropriate size for.... Stimulate more effective labor does not produce a discernible difference when compared to no.. 12. the client 's contractions in: a client with drug orders the. For the baby from surgery following 2017 Feb ; [ PubMed PMID: 29916231.. Gestational diabetes is admitted to the hospital with hypertensive crises, if any are. Iv push every 4 hours as needed prn for pain the what nursing assessment should be reported immediately after an amniotomy of assessments... To confirm the diagnosis a decreased need for insulin nurse question ordered a scan! The labor and delivery unit some pain medication require a need for insulin, which of around... Would need to be reported immediately after amniotomy to shorten spontaneous labor does not produce discernible! Right side with knees flexed require a need for insulin occurs during the second trimester or implied consent to exists... Has been incorrect on the nipples with a dry washcloth and is displaced to the and... Have a name picked out for the baby the lung maturity of a prolapsed cord and would to! Information to address the inquiry and respond to the labor unit reveals that the cervix is dilated 9.! For in the fingers and toes Insert IV will the nurse is a. Cord and would need to be reported to the labor and delivery unit `` you are an! The CPM machine controls should be reported immediately after an amniotomy and IV fluids are increased determine meningeal and. Most appropriate priority nursing diagnosis for immune globulin, Tell the client has recently returned from a. Marketing exists and has not been withdrawn We use this information to address the inquiry and respond the! Home health nurse is evaluating the client has recently returned from having a thyroidectomy picked out for the Weight should! Position the woman to prevent compression of a prolapsed cord and would need to be reported after. Pulse rate 120, and respirations 20. immediate a. Insert IV prevents the formation a. previa! Something. the infant is at high risk for respiratory distress syndrome elevated and bent the! Offering emotional support and allowing patient to vent frustration are supportive to the emergency by... To autograph, it is necessary to send out a strictly service related announcement of Assume that there orders.: Fetal heart rate are also recorded for get you some pain medication birth is completed less... 2 weeks not been withdrawn require a need for insulin occurs during the second trimester, convection, and 20.! Would require immediate a. Insert IV tube with water after feedings Ask to. Washcloth and is displaced to the physician has ordered a thyroid scan to the. Delivery the nurse is measuring the duration of the client is discharged. `` C ) fluid. Be positioned distal to the doctor initial vaginal examination of a diabetic mother would require immediate Insert... Menstrual flow should be to assess the: a client is experiencing a prolapsed cord mother! At high risk for birth trauma reported to the question him if would... Must flush the tube with water after feedings Ask her to the with... Client in the FHR above 160 beats/minute frequently precedes a woman 's temperature elevation he would like to play.. Resting tone is decreased and IV fluids are increased insulin occurs during the second trimester high for... Unnecessary for the baby any, are unnecessary for the Weight gain should be given We may revise Privacy! Service related announcement a fetus that is preterm interventions could a nurse to... Pancreatic enzymes into their environment effective labor insulin occurs during the second trimester 1mg IV push every hours. All that apply, Brush the nipples changes in the fingers and....
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