If performed too early in the labor process, there can be an increased risk of intrapartum chorioamnionitis. should anticipate administering which medication? activities of daily living? Which instruction should be given Women who have cesarean births usually need greater support than those who have vaginal births. Which of the following What nursing actions will the nurse anticipate implementing? X-rays reveal that the client has several fractured bones in the Ask the parent/guardian to take the child's favorite blanket home The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. Users can always make an informed choice as to whether they should proceed with certain services offered by Adobe Press. Which client should What kind of magic number do I need?" with 75% effacement. The client is admitted to the hospital with hypertensive crises. What sign(s) of infection should the nurse assess for after an amniotomy? foot of the bed. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 In B12 deficiency. the most likely cause for the deduction of one point is: The primary reason for rapid continuous rewarming of the area affected d. Maternal temperature is 37 C . The two most commonly used devicesare an approximately 10-inch rod with a hook on the end of the rod or a finger cot with a hook on the end of the cot. c. The fundus is assessed only if large clots appear in lochia. The client should be taught to avoid eating: A client is discharged home with a prescription for Coumadin (sodium should place the zero of the manometer at the: The physician orders lisinopril (Zestril) and furosemide (Lasix) to be reveals that the client's cervix is 8cm dilated, with complete effacement. b. Brush the nipples with a dry washcloth. client whose blood type is A negative but whose baby is O positive. a. Insert IV. Pearson may offer opportunities to provide feedback or participate in surveys, including surveys evaluating Pearson products, services or sites. This complication should be an easily avoidable, iatrogenic cause of emergency delivery.[8]. To collect OBJ: 3 TOP: Cervical Ripening A fetal heart rate baseline is recorded. ", "I am so sorry that they didn't get you breakfast. Which symptom Furthermore, assume the steel objects lose a negligible amount of energy by conduction, convection, and radiation into their environment. a urinary tract infection. Oligohydramnios "I will make sure I eat breakfast within 10 minutes TOP: Obstetric ProceduresAmniotomy This privacy notice provides an overview of our commitment to privacy and describes how we collect, protect, use and share personal information collected through this site. How can anxiety affect labor? The nurse Gynecoid pelvis is the most favorable shape for vaginal delivery. A pulsating structure is felt during a vaginal examination of a woman in labor. What is the nurse's initial action? a right angle to the bed, Hips are elevated above the level of the body on a pillow and the legs 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. balance and elevated glucose levels. MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 177 OBJ: 3 Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions. To determine the client's An African American female comes to the outpatient clinic. 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. 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. When ANS: D Duration is measured by timing from the beginning of Hallucinogenic drugs induce rapid physical dependence. When are they going to bring breakfast?" for breakfast. pressure. Drink a glass of cranberry juice every day. The client selects a balanced diet from the menu. 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. A 32-year-old mother of three is brought to the clinic. interventions would be implemented first? Which A(n) ________ is a narrow cone inserted into the cervix to ripen" the cervix to increase uterine contractions. What would the nurse expect the admitting assessment to reveal? A client has autoimmune thrombocytopenic purpura. warfarin). 14. c. Increased blood pressure is 2cm dilated. She is embarrassed to ask for the bedpan that frequently. Obstetrics and gynecology clinics of North America. "I will drink 500mL of fluid or less each day. off the machine and call the doctor. KEY: Nursing Process Step: Implementation q 4 hours and Neomycin 1 gtt q 4 hours. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 The physician has written an order to transfuse 2 units of whole blood. MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 Which initial okay to allow his friends to autograph his cast. foot. 28. 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. ", "I will need to carry candy or some form of sugar with me all the a. Gently pull on the nipples The nurse should: Lip the bottle and use a pack of sterile 4x4 for the A client with a diagnosis of HPV is at risk for which of the following? Which instruction should be given to the client who is fitted for a behind-the-ear d. Suggest that the coach give her a back rub. The nurse performs c. Amniotic fluid is watery and pale green. are being performed. The nurse is educating the lady's club in self-breast exam. The A minimum of 20 to 30 minutes is needed for adequate fetal baseline evaluation and can be obtained with other admission information. Nevertheless, when there is a delay in labor, the meta-analysis suggests there is a modest reduction in the rate of cesarean section when the rupture of membranes in conjunctionwith the use of oxytocin is used asan early intervention. for regulation of his heart rate. The client had radiation for treatment of Hodgkin's disease as a The pulse oximetry is 92. 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. Which of ANS: B The nurse is caring for the client following a laryngectomy when suddenly Preterm birth, but appropriate size for gestation. 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. A client with acute pancreatitis is experiencing severe abdominal Which Which is the client's most appropriate priority nursing diagnosis? What is the best position for this client? TOP: Induction KEY: Nursing Process Step: Data Collection Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. a. The client fails to receive an itemized account of his bills and services Intramuscular injection: Inject 10 units after delivery of the placenta. Which of the following interventions would be appropriate for this client? beginning of the next contraction. What does the nurse explain is used to soften the cervix with a "cervical ripening" agent? Pearson may disclose personal information, as follows: This web site contains links to other sites. Vital signs and fetal heart rate are also recorded. c. Risk for ineffective parenting related to emergency cesarean section (Select all that apply), Increase of fetal heart rate (FHR) from 160 to 174 beats/minute, What are the rationales for labor induction? an order for Benadryl. 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. The elderly client is admitted to the emergency room. The nurse is aware that successful breastfeeding Ice is applied to the perineum to reduce bruising and edema. A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. The first action the nurse should take is. What complication should the nurse closely assess for with this patient? Please be aware that we are not responsible for the privacy practices of such other sites. ANS: C The emergency room is flooded with clients injured in a tornado. a. Placenta previa surgery.". drug? care based on assessment of the client. What is the nurses initial action? The nurse is caring for a client hospitalized with a facial stroke. The nursing assistant assigned to the client with hepatitis fails to feed An obstetric client is admitted with dehydration. both eyes. the disaster? 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. "Use of the CPM will permit the client to ambulate b. The nurse The nurse can expect to find the presence is displaced to the right. MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 The nurse notes that a woman's contractions during oxytocin induction of labor are every 2 minutes; the contractions last 95 seconds, and the uterus remains tense between contractions. a. Infection requires close contact; therefore, the door may remain open. Administer meperidine (Demerol) 75mg IV push. Notify the charge nurse immediately. Pearson collects name, contact information and other information specified on the entry form for the contest or drawing to conduct the contest or drawing. that Lovenox injections should: Clear the air from the syringe before injections. to take thyroid medication during the pregnancy. Affected parents have unaffected children who are carriers. ", "Autographing or writing on the cast in any form will harm the cast.". Pearson may provide personal information to a third party service provider on a restricted basis to provide marketing solely on behalf of Pearson or an affiliate or customer for whom Pearson is a service provider. This activity reviews the indications, contraindications, and . The nurse is preparing to suction the client with a tracheotomy. The client's 32. motion device) applied during the post-operative period. 24. by frostbite is to: A client recently started on hemodialysis wants to know how the dialysis He said I was a 4. The panicked woman begs the nurse, "Please give me something." after the client is discharged.". Which of the following would the nurse include in the physical ANS: B Assume that there are orders for The physician has ordered a thyroid scan to confirm the diagnosis. the FHR is 135-145. she is relatively comfortable. Pearson automatically collects log data to help ensure the delivery, availability and security of this site. The nurse is aware that a nonstress test can be ordered for this client to: Show the effect of contractions on fetal heart rate. cell crisis to eat? This procedure is common during labor management and has been performed by obstetrical providers for at least a few hundred years. A client with a history of abusing barbiturates abruptly stops taking Promote rest and provide general comfort measures, A woman gravida 4, para 3, has been 5 cm dilated for 2 hrs. Occasionally, we may sponsor a contest or drawing. Fetal heart rate pattern. 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. nerve root inflammation. Notify her obstetrician if she has a temperature above 37.8 C (100 F). regarding: The nurse is caring for the client receiving Amphotericin B. should the nurse have available? He said I was a 4. A client with leukemia is receiving Trimetrexate. finding should be reported to the physician immediately? 34. What kind of, magic number do I need? An infant is delivered with the use of forceps. What is the cause? Which doctor's order should the nurse question? MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 This can be done on the Account page. ", "While I'm in the shower, I'll allow the water to run over What complication should the nurse closely assess for with this patient? Which of the following instructions should be included in the teaching purpura (ATP). I will hearing aid? A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). The rationale for administering leucovorin calcium to a client receiving is in progress, Explain the consequences without treatment, Notify the physician of the mother's refusal. The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention. Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. nurse notes: Pain when the head is turned to the left side. The nurse would be most concerned with the client developing KEY: Nursing Process Step: Implementation is placed on contact precautions. and is displaced to the right. This chapter provides a sample NCLEX-RN exam with detailed explanations for each of the answers to help you practice. What is the most appropriate nursing diagnosis? Record a baseline fetal heart rate. client a bath. clinic for a first check-up. The nurse is assigned to care for the client with a Steinmen pin. Increase fetal lung maturity. We will identify the effective date of the revision in the posting. A schizophrenic client having visual and auditory hallucinations 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. Damage to the VII cranial nerve results in: A client is receiving Pyridium (phenazopyridine hydrochloride) for side effect of magnesium sulfate is: The client has elected to have epidural anesthesia to relieve labor pain. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 (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. initial nurse's action should be to: Increase the infusion of Dextrose in normal saline. (Select all that apply.) MSC: NCLEX: Physiological Integrity: Physiological Adaptation, DIF: Cognitive Level: Comprehension REF: Page 176, 187 a. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 about which nursing diagnosis? Would you like something for the client with rheumatoid arthritis? would anticipate an order for which medication? European journal of obstetrics, gynecology, and reproductive biology. Gestational diabetes is not a contraindication for labor induction. Which action by the nurse should receive evaluate the cardiac arrhythmia as: A client with clotting disorder has an order to continue Lovenox 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? 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. The nurse would assess for which adverse effect? client with epidural anesthesia is: The bladder fills more rapidly because of the medication require a need for further instruction? to the client? The panicked woman begs the nurse, Please give me something. is most dependent on the: The nurse is monitoring the progress of a client in labor. Maternal blood pressure. The umbilical cord needs time to separate. Ineffective individual coping related to unfamiliarity with procedures 5 cm with membranes intact. Allow 5 minutes between the two medications. The nurse notes variable decelerations on the fetal monitor strip. An infant's Apgar score is 9 at 5 minutes. at a right angle to the bed, Hips are slightly elevated above the bed and the legs are suspended at response to treatment, the nurse would monitor: The home health nurse is visiting a client with autoimmune thrombocytopenic The nurse is aware that the correct use of the walker is achieved MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Knowledge REF: Page 175 OBJ: 3 This site is not directed to children under the age of 13. 1. : 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. If the client experiences hypotension, the nurse would: A client has cancer of the pancreas. Stadol 1mg IV push every 4 hours as needed prn for pain. The client's platelet count currently is 80, It will the possibility of complete obstruction of the airway, which of the following (Select all that apply,), A woman is preparing for administration of a cervical ripening agent. The nurse caring for a client receiving intravenous magnesium sulfate The client should be told to avoid: The nurse is changing the ties of the client with a tracheotomy. D) Maternal temperature is 37.8 C. Choose question tag Discard Apply plumbism. The urethra opens on the ventral side of the penis. A client is admitted complaining of chest pain. The nurse would [1][2][3], The two principal reasons for artificial rupture of membranes are to induce or augment the labor process, or to assist in the placement of internal fetal monitoring devices to provide the direct assessment of fetal status. The nurse instructs the client to dangle her legs as the nurse strikes The nurse is teaching basic infant care to a group of first-time parents. This activity reviews the indications, contraindications, and technique involved in performing an amniotomy and highlights the role of the interprofessional team in the monitoring of the fetus and the mother. 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. Users can manage and block the use of cookies through their browser. symptoms are consistent with a diagnosis of: The client is seen in the clinic for treatment of migraine headaches. A woman has ruptured membranes at 31 wks gestation. Chaperoning the local boys club on a snow-skiing trip, A bus trip to the Museum of Natural History. ANS: A is most critical during the administration of acyclovir? What conditions would contraindicate labor induction? (Select all that apply, Brush the nipples with a dry washcloth A) Fetal heart rate is regular at 154 beats/min. Where is the best site for What conditions would contraindicate labor induction? What nursing assessment should be reported immediately after an amniotomy? MSC: NCLEX: Physiological Integrity: Reduction of Risk, TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Data Collection > The client's brother had leukemia as a child. Marketing preferences may be changed at any time. A pregnant woman's membranes ruptured prematurely at 34 weeks She will be discharged to her home for the next few weeks. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 If the client misses one or more pills, two pills should be taken per a serum alpha fetoprotein. Which client should be assigned to the pregnant nurse? made by the nurse indicates understanding of the CPM machine? plan? After the procedure, she assesses the maternal temperature every two hours and watches out for any signs of infection. assessment is most likely correct in relation to this statement? for infections spread by contact? A woman has an emergency cesarean delivery after the umbilical cord was found to be prolapsed. The The client is admitted for an open reduction internal fixation of client's chart, the physician orders Wellcovorin (leucovorin calcium). d. Prolapsed cord complications, the most important measurement in the immediate post-operative The nurse responds, This condition will resolve itself in a few days. action is most appropriate? 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. gland increases in size during pregnancy. breech presentation at 38 weeks gestation. > pressure in the right arm. The nurse is measuring the duration of the client's contractions. Which statement is true regarding the measurement of the duration of contractions? 2. the need for additional teaching? A client on the postpartum unit has a proctoepisiotomy. The client presents to the clinic with a serum cholesterol of 275mg/dL During administration, the nurse should: Place the client in Trendelenburg position. a. Asking the LPN to continue the post-op care. TOP: Obstetric ProceduresAmniotomy KEY: Nursing Process Step: Implementation An elderly client with an abdominal surgery is admitted to the unit The nurse wears gloves when providing care. A client with cystic fibrosis is taking pancreatic enzymes. The nurse plans to assess circulation in the lower extremities every 2 hours. While proving morning care, the nursing student notices that the draining fluid has a strong odor. because anything from the outside should not be brought into the hospital. (b) Is the image real or virtual? "It is okay to give my child white grape juice c. Amniotic fluid is watery and pale green. any exudate, before instilling the eyedrops. the nurse strikes the muscle insert just above the wrist. Practitioners have believed thatartificial ruptureof membranes either can assist in inducing labor or augmenting spontaneous labor. A client who delivered this morning tells the nurse that she plans Which finding should be reported to if the: When assessing a laboring client, the nurse finds a prolapsed cord. The rationale for inserting a French catheter every hour for the What is the lowest Bishop score the patient should have prior to. The nurse is aware that teaching? During a home visit, a client with AIDS tells the nurse that he has in reinflating the lungs. Utilize an incentive spirometer to improve respiratory function. The nurse should tell the client that labor has probably What is the most appropriate pain relief intervention for a woman in precipitate labor? What nursing assessment should be reported immediately after an amniotomy? All rights reserved. Report any increase in fetal activity. External version is most likely to be done in which of these situations? The safest method of changing the tracheotomy ties is to: Apply the new tie before removing the old one. of cigarette smoke on fetal development. Which Which response would Visual disturbances can be corrected with prescription glasses. MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- 3. membranes and a fetal heart tone rate of 160170bpm. the medication. following surgery. OBJ: 6 TOP: Abnormal 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.

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