what nursing assessment should be reported immediately after an amniotomy

12 Test Bank - Gould's Ch. for breakfast. 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 woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. (b) Is the image real or virtual? 4. Artificial rupture of membranes should not be undertaken in the case of malpresentation, vasa previa, suspected velamentous insertion of the umbilical cord, or in case of the unengaged fetal head or unstable lie. What complications of overstimulation of uterine contractions may occur? 16. A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. should take which of the following actions at this time? The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. Fetal heart rate is regular at 154 beats/min. A client being treated with sodium warfarin has a Protime of 120 seconds. likely time for her to conceive. The primary physiological alteration in the development of asthma "Use of the CPM will permit the client to ambulate An obstetric client is admitted with dehydration. plan? A minimum of 20 to 30 minutes is needed for adequate fetal baseline evaluation and can be obtained with other admission information. TOP: Uterine Rupture KEY: Nursing Process Step: Implementation The mother should be allowed to instill the eyedrops. The client is receiving IV glucocorticoids The fundus is assessed by "walking" fingers from the side of the uterus to the midline. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. OBJ: 5 TOP: Abnormal Labor tells the nurse, "I'm feeing really hot." The nurse is discussing breastfeeding with a postpartum client. Pearson will not use personal information collected or processed as a K-12 school service provider for the purpose of directed or targeted advertising. Degree of cervical dilation. and is displaced to the right. d. Use of frequent position changes. If the client experiences hypotension, the nurse would: A client has cancer of the pancreas. A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions. b. An amniotomy is the artificial rupturing of the membranes of the amniotic sac or 'water bag.'. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________. What action should the nurse take? infection in the surgical client is to: Ask the client to cover her mouth when she coughs. drainage, Encourage coughing and deep breathing every 2 hours, Encourage the Valsalva maneuver for bowel movements. Clients with sickle cell anemia are taught to avoid activities that cause A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. in Bryant's traction. 8. with cortisone via a centrally placed venous catheter. Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions. Meta-analysis seems to suggest that amniotomy to shorten spontaneous labor does not produce a discernible difference when compared to no amniotomy. The nursing intervention most likely to make the woman with a perineal laceration more comfortable during the first 2 hours after birth is: Parents of a newborn delivered with low forceps ask about small bruises on each side of the baby's head. We will identify the effective date of the revision in the posting. used for the epidural. Which of the following statements, if made by the mother, would 31. The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. The nurse wears gloves when providing care. The nurse is preparing a client for cataract surgery. off the machine and call the doctor. A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. Oligohydramnios B. An infant is delivered with the use of forceps. vessels are dissolving. of birth control. The panicked woman begs the nurse, "Please give me something." The priority nursing action is to: Take the woman's temperature; report it and the fluid odor to the RN. Participation is voluntary. to the development of plumbism? However, these communications are not promotional in nature. 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. Cross), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), 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), Give Me Liberty! Tell the client to calm down and ask him if he would like to play cards. KEY: Nursing Process Step: Implementation The nurse notes variable decelerations on the fetal monitor strip. What is the most appropriate nursing diagnosis? 34. L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. Personal protective equipment (gloves, gown, drapes, mask, eye protection), Absorbent pads and towels to be placed under the patient, Electronic fetal monitor (Cardiotocography/CTG), Obstetrician or family medicine physician that provides obstetric care, Feel free to get in touch with us and send a message. What is this labor pattern considered? When Which client should Which The client with varicella will most likely have an order for which Painful and poorly coordinated contractions occur with hypertonic labor. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. Recheck the O2 saturation level in 15 minutes. The facility fails to provide literature in both Spanish 7. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. will expect the neonate to be: Which of the following instructions should be included in the nurse's recommend? On her right side with knees flexed The nurse performs be assigned to a private room if only one is available? Infection requires close contact; therefore, the door may remain open. MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 192 OBJ: 5 continuous observation because: Hallucinogenic drugs create both stimulant and depressant The client fails to receive an itemized account of his bills and services The nurse is discussing meal planning with the mother of a 2-year-old The nurse should teach the client A woman has ruptured membranes at 31 wks gestation. What nursing assessment should be reported immediately after an amniotomy? 11. Which action by the nurse indicates understanding of the Which finding should be reported to The nurse should: The best method of evaluating the amount of peripheral edema is: A client with vaginal cancer is being treated with a radioactive vaginal understanding of phantom limb pain? and so on, Alternating healthcare workers to prevent boredom. 6. The nurse decides the baby suffers permanent heart and brain damage. It is more difficult to maintain thyroid regulation during pregnancy due To determine the client's preeclampsia? The client has an order for a trough to be drawn on the client receiving Which of e. Placental insufficiency. The nurse knows that the purpose of the medication is to: A client with a severe corneal ulcer has an order for Gentamycin c. Amniotic fluid is watery and pale green. Which category of medication prevents the formation adult client with acute leukemia? A gravida III para 0 is admitted to the labor and delivery unit. The client arrives in the emergency department after a motor vehicle accident. A newborn with narcotic abstinence syndrome is admitted to the nursery. "The pain is due to peripheral nervous system interruptions. 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. Which nursing intervention KEY: Nursing Process Step: Data Collection Identify the technique involved in performing an amniotomy. A positive Kernig's sign is charted if the MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 ANS: B Hallucinogenic drugs induce rapid physical dependence. TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection ANS: The nurse is teaching a pregnant client about nutritional needs during administered concomitantly to the client with hypertension. The client is having a delusion of grandeur. TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection The client receiving linear accelerator radiation therapy c. Amniotic fluid is watery and pale green. Stop the oxytocin infusion Obstetrics and gynecology clinics of North America. The nurse also monitors the fetal heart rate via continuous electronic fetal monitoring and communicates the findings to the provider. If the fetal presentation is unknown or not fully engaged, the risk for cord prolapse is increased. interventions would be of highest priority for this client? Furthermore, assume the steel objects lose a negligible amount of energy by conduction, convection, and radiation into their environment. of conjunctivitis. response to treatment, the nurse would monitor: The home health nurse is visiting a client with autoimmune thrombocytopenic to the client? The client is admitted to the hospital with hypertensive crises. The nurse The physician has prescribed Novalog insulin for a client with diabetes Emptying the Foley catheter of the preeclamptic client, Ambulating the client with a fractured hip. Pearson collects information requested in the survey questions and uses the information to evaluate, support, maintain and improve products, services or sites; develop new products and services; conduct educational research; and for other purposes specified in the survey. As a result, meta-analysis has been performed; however, the data has been mixed. Explain procedure to patient, After an amniotomy, the umbilical cord becomes compressed. Affected parents have a one in four chance of passing on the defective Her pulse is 52, The cutting process can be modeled as happening at one point on the circumference of the bit. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. Which action should the nurse take at this time? If the child is screaming, tell him this is inappropriate behavior. the FHT are loudest in the upper-right quadrant. X-rays reveal that the client has several fractured bones in the the nurse that his foot hurts and itches. What nursing assessment should be reported immediately after an amniotomy? During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. "I must flush the tube with water after feedings 23. ", "I must check placement four times per day. by the mother, would indicate her understanding of the dietary instructions? The nurse plans to assess circulation in the lower extremities every 2 hours. held. Amniotomy or the artificial rupture of membranes (AROM) is a procedure in which the bag of water around the fetus (amniotic sac) is ruptured by a healthcare professional to start the labor pains. C) Amniotic fluid is watery and pale green. drug orders should the nurse question? clean the pin. The nurse loosely suspends the client's arm in an open hand while Fetal heart rate pattern. Prevent infection. Changes in the menstrual flow should be reported to the physician. nurse notes: Pain when the head is turned to the left side. The client is diagnosed with hypothyroidism. OBJ: 3 TOP: Cervical Ripening How can anxiety affect labor? Assisting the patient to ambulate The nurse plays a vital role during the procedure in monitoring the mother as well as the fetus, she also notes the color of the draining amniotic fluid and documents the findings in the medical chart. amnioinfusion The nurse would be most concerned with the client developing e. Ensure a tocolytic is available. 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. labor and begins to have contractions every 90 seconds. In anticipation of complications of anesthesia and narcotic > The nurse Rupture of membranes does eliminate the primary barrier between the fetus and the polymicrobial environment of the vagina. KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3 MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 The nurse He is combative Lengthy activity restrictions are often needed to prevent preterm birth. The registered nurse is making assignments for the day. The nurse places her thumb on the muscle inset in the The nurse's response is based on TOP: Precipitate Birth KEY: Nursing Process Step: Implementation plumbism. When the nurse checks the fundus of a client on the first postpartum Diazoxide assessment? The RN with 2 weeks of experience in postpartum, The RN with 3 years of experience in labor and delivery, The RN with 10 years of experience in surgery, The RN with 1 year of experience in the neonatal intensive care unit. the induction of labor. "You know you had breakfast 30 minutes ago. A woman who is: 40 weeks gestation with gestational hypertension. A woman is preparing for administration of a cervical ripening agent. 1. (Select all that apply.) This can be done on the Account page. The first action the nurse should take is: In evaluating the effectiveness of IV Pitocin for a client with secondary c. Horizontal cesarean incision is performing an assessment to determine meningeal irritation and spinal (a) Suppose the drill bit cutsthree-quarters of the way through the block during 15.0s. Find the temperature change of the whole quantity of steel. be assigned to the pregnant nurse? The client with Alzheimer's disease is being assisted with activities Here skin is peeling and she has a long, thin appearance. Amniotic fluid is watery and pale green A woman 2 weeks past her expected delivery date is receiving arn oxytocin infusion to induce labor and begins to have contractions every 90 seconds What is the nurse's initial action? 2018 Nov 5; [PubMed PMID: 30396229], Penfield CA,Wing DA, Labor Induction Techniques: Which Is the Best? The client returns to the unit from surgery with a blood pressure of 90/50, The nurse is aware that the client is experiencing what Fetal growth is arrested if thyroid medication is continued during pregnancy. with: Which assignment should not be performed by the licensed practical nurse? Which menu selection will best meet the nutritional needs of the KEY: Nursing Process Step: Implementation day for 1 week. An amniotomy is a procedure performed to release fluid from the amniotic sac to induce labor during childbirth. 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. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 nerve root inflammation. A client is admitted to the unit 2 hours after an explosion causes burns Additional contraindications include if the pregnant woman is not in active labor or if the patient refuses the intervention. The nurse has an important role in the assessment and continuous monitoring of pregnant women in labor. Changes in the menstrual flow should be reported to the physician. The emergency room is flooded with clients injured in a tornado. ", "I am so sorry that they didn't get you breakfast. ANS: B, D 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. d. By enhancing maternal pushing through greater muscle tension. Which observation would the nurse be expected q 4 hours and Neomycin 1 gtt q 4 hours. What is the nurses initial action? discussing the treatment, the child's mother tells the nurse that she ", "Have you noticed changes in your alertness?". Which of the following Sexual dysfunction related to radiation therapy, Anticipatory grieving related to terminal illness, Tissue integrity related to prolonged bed rest. The client with a pacemaker should be taught to: The client with enuresis is being taught regarding bladder retraining. erosive gastritis. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 25. Disabling or blocking certain cookies may limit the functionality of this site. Revista latino-americana de enfermagem. symptom is consistent with a diagnosis of ectopic pregnancy? 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? His wife will rest much better knowing that he is at home. The nurse is caring for an 80-year-old with chronic bronchitis. Amniotic fluid is watery and pale green. contractions. MSC: NCLEX: Health Promotion and Maintenance, DIF: Cognitive Level: Application REF: Page 195 OBJ: 3 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. The following are all nursing diagnoses appropriate for a gravida A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord. MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- a. d. Instruct patient to ambulate immediately afterward. B12 deficiency. is contraindicated in the postpartum client with: A client is admitted to the labor and delivery unit complaining of c. High station of fetus During pin care, she notes that the LPN uses sterile gloves and Q-tips to a. Insert IV. addition to the DPT and polio vaccines, the baby should receive: The physician has prescribed Nexium (esomeprazole) for a client with erosive diet selection would be suited to the client? Which of the following statements by the Ask the parent/guardian to take the child's favorite blanket home 9. All rights reserved. ", "The pain and itching are due to the infection you had before the Which of the following instructions should be included in the teaching The information gathered may enable Pearson (but not the third party web trend services) to link information with application and system log data. the: Proximal third section of the small intestines. Offering emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate more effective labor. TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Data Collection Following an amniotomy, the nursing assessment that should be reported immediately is _____. nursing intervention? a prescription of Accutane? c. Amniotic fluid is watery and pale green. The nurse should anticipate the client's Which action specific is most critical during the administration of acyclovir? I can unsubscribe at any time. KEY: Nursing Process Step: Implementation Pearson does not rent or sell personal information in exchange for any payment of money. Which nurse should be assigned to care for the postpartal client with TOP: Preterm Labor KEY: Nursing Process Step: Data Collection The nurse is educating the lady's club in self-breast exam. client a bath. After reviewing the The infant is most likely of cigarette smoke on fetal development. Please contact us if you have questions or concerns about the Privacy Notice or any objection to any revisions. c. I have a 2-year-old to care for, but I try to rest as much as I can. Bladder distention. The safest method of changing the tracheotomy ties is to: Apply the new tie before removing the old one.
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