nursing care plan for inversion of uterus
A client has had a cesarean birth. c)"Try applying warm compresses to your breasts to encourage the milk to be released.". The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. 2. The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount. b)The client feels empty since she delivered the neonate. The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse is creating a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The next day, her vaginal bleeding continues to be moderately heavy with numerous large clots. Which statement should the nurse include in the explanation? A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. 3. 2. Which response is most appropriate initially? • About 70% of immediate PPH cases are due to uterine atony. The nurse determines that the client understands the signs of true labor if she makes which statement? Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Which action should the nurse take to determine fetal heart sounds accurately? The nurse explains the purpose of effleurage to a client in early labor. Oh no! A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. What is the initial nursing action? Select all that apply. Appendix 1. The nurse in the labor room is caring for a client who is in the first stage of labor. What is the most appropriate nursing action? Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. Select all that apply. 3. Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which of the following primary conditions? Which maternal observation could indicate uterine inversion and require immediate intervention? The nurse monitors the woman closely for which of the following adverse effects? One woman asks you about mastitis. Monitoring fetal status 2. a)A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. Encourage an upright or side-lying maternal position. You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. 4. Which statement, if made by the laboring client, most likely indicates that the client is in the second stage of labor? The nurse is assessing the breast of a woman who is 1 month postpartum. Which of the following causes of the hemorrhage is most likely in this client? You medicate her per orders with no relief attained. The nurse reviews the health care provider's prescriptions and should question which prescription? 2. The health care provider has prescribed an epidural block. A client with a 38-week twin gestation is admitted to a birthing center in early labor. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when? The nurse interprets these findings as suggesting which of the following conditions? 3. It might seem impossible to you that all custom-written essays, research papers, speeches, book reviews, and other custom task completed by our writers are both of high quality and cheap. Methylergonovine is ordered for a woman experiencing postpartum hemorrhage. Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate? The nurse is assisting a client in completing the Postpartum Depression Screening Scale tool to assess for postpartum depression. Which of the following actions would be most appropriate to relieve this pain? A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which should be the nurse's priority action? The nurse recognizes this client is at risk for which of the following complications? Este banco de palabras (español-inglés) de terminología del Seguro Social contiene palabras y expresiones comunes así como terminología técnica del Seguro Social. The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. • Atony of the uterus is defined as the failure of the uterus to contract adequately after the child is born. Primary (immediate) postpartum hemorrhage is defined as excessive bleeding that occurs within the first 24 hours after delivery. She calls you to her room complaining of pain "deep inside." Various medications are available to help control hemorrhage in the postpartum client. The nurse notes a local area on one breast, red and warm to touch. The nurse is monitoring a client in labor. Which finding indicates that the rate of infusion needs to be decreased? The nurse in a maternity unit is reviewing the clients' records. The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. 4. The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. Which analgesic is contraindicated for a client who has a history of opioid dependency? As a student,…” A nurse is developing a plan of care for a client experiencing dystocia, and includes several nursing interventions in the plan. d)Temperature of 38% C or higher after the first 24 hours after childbirth. What is the initial nursing action? Which of the following instructions should the nurse offer the client as a caution when the client receives anticoagulation therapy? Which assessment findings should the nurse expect to note? Based on this finding, the nurse should prepare for which appropriate nursing action? The nurse notes that the client has difficulty in relaxing and sleeping. The client's thought process is disoriented and she frequently indulges in obsessive concerns. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. When assessing the patient for postpartum hemorrhage the nurse monitors which of the following every hour? The nurse should include which instructions in her discharge teaching? Gestational age of the fetus is determined to be 37 weeks. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" 3. When assessing a postpartum patient who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? 4. The nurse ensures that which intervention is implemented before initiating the infusion? 1. 1. What will the nurse relay to the client as the most likely outcomes of the amniotomy? One of the primary assessments you, as a postpartum nurse, make every day is for postpartum hemorrhage. Which nursing intervention should be implemented after the epidural block has been placed? Which woman should you suspect of having endometritis? Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. A nurse is assigned to care for a client with a uterine prolapse. Which should be the nurse's first action? The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which measurement best describes delayed postpartum hemorrhage? Nursing Care Plans What is the priority nursing action? … dronabinol, nabilone, or nabiximols) may be useful in alleviating a wide variety of single or co-occurring symptoms often encountered in the palliative care setting. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The health care provider prepares to perform an amniotomy. The nurse is caring for a client in labor. c)"Postpartum depression develops gradually, appearing within the first 6 weeks.". What is the appropriate nursing action? Which assessment finding should alert the nurse to a compromise? The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted? The nurse is caring for a client during the second stage of labor. 50 Likes, 2 Comments - College of Medicine & Science (@mayocliniccollege) on Instagram: “ Our Ph.D. Which of the following assessments would you make to detect this? The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? 3. We’ve made a significant effort to provide you with the most informative rationale so please be sure to read them. 3. You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition? The nurse is caring for a client during the second stage of labor. Effective nursing management involves many aspects and being aware of subtle changes in the client. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min. In this section are the practice quiz and questions for maternity nursing and newborn care nursing test banks. Author Relationships With Industry and Other Entities…e365 Appendix 2. Which areas would you need to assess before the woman ambulates? Introduction. Call the health care provider (HCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP). a)Client's temperature remains below 100.4° F or 38° C orally. Perineal inspection reveals a steady stream of bright-red blood trickling out of the vagina. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. Which of the following should alert the nurse to a potential infection in the client? The nurse should document these observations as signs of which condition? Which findings are associated with abruptio placentae? The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? All Payer Model Accountable Care Organization (ACO) is the Centers for Medicare & Medicaid Services’ (CMS) new test of an alternative payment model in which the most significant payers throughout a jurisdiction come under the same payment structure for the majority of providers throughout the jurisdiction’s care delivery … Over 75% of women who give birth experience postpartum depression. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline. Which of the following is the most frequent reason for postpartum hemorrhage? The nurse should ensure that which is implemented before the beginning of the infusion? Select all that apply. She complains of abdominal pain and a "bad smell" to her lochia. To ensure the best experience, please update your browser. The nurse is monitoring a client in labor whose membranes ruptured spontaneously. One of the fetuses is a breech presentation. Every postpartum client has the potential of hemorrhage. The nurse is preparing to care for a client in labor. A nurse using the 5T's tool will recognize which of the following as being a potential cause of postpartum hemorrhage? It is discovered that a new mother has developed a puerperal infection. Assess for signs and symptoms of labor. When reviewing the client's history, the nurse notes she has a history of asthma. Comfort measures and medication fail to eliminate the pain, her pulse is rapid, and her blood pressure, hematocrit, and hemoglobin are low. The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? b)"Postpartum depression develops gradually, appearing within the first 6 weeks.". What would you suspect? b)Her uterus is at the level of the umbilicus. Click on the image to indicate your answer. Which immediate actions should the nurse take? Document the findings and continue to monitor fetal patterns. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Place the client in Trendelenburg's position. She had a cesarean birth and received deep, general anesthesia. The nurse is caring for a patient within the first four hours of her cesarean birth. 3. A postpartal woman calls you into her room because she is having a very heavy lochia flow containing large clots. Using this information, what is the appropriate action for the nurse to take? When providing care for a postpartum patient at a 6 week check-up, which behavior would alert the nurse the patient may have postpartum psychosis? After attachment of the electronic fetal monitor, what is the next nursing action? A 27-year-old G1, P1 woman arrives in the emergency department accompanied by her husband and new infant, crying, confused, and with possible hallucinations. Your patient is showing signs and symptoms of a pulmonary embolism. An Rh-positive client vaginally delivers a 6-lb, 10-oz neonate after 17 hours of labor. The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. 1. Ce document a été rédigé par Emma Kahn et Vincent Reliquet à la demande de la Coordination Santé Libre dans le but d'éclairer l'opinion du groupe quant à la pertinence d'une vaccination anti-Covid dans les conditions actuelles, à l'aune de ce qui peut être décrit, connu et prévisible en Février… Which of the following behaviors should the nurse bring to the attention of the health care provider? When the infant's head crowns, what instruction should the nurse give the client? Postpartum hemorrhage is defined as any blood loss from the uterus of more than 500ml during or after delivery. On the basis of this finding, the nurse should take which action first? On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. The nurse recognizes that these symptoms are associated with which condition? The nurse is caring for a client who is receiving oxytocin for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. A woman arrives at the office for her 4-week postpartal visit. After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. What should you do? b)Place one hand over the symphysis pubis. Which condition puts this client at risk for infection? Select all that apply. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. The nurse documents these observations as signs of which condition? When working in a free clinic for children, the nurse observes a mother with her 2 week infant. Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? It is discovered that she received no prenatal care. When monitoring a postpartum client 2 hours after delivery, the nurse notices heavy bleeding with large clots. Which maternal observation could indicate uterine inversion and require immediate intervention? A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. ), f)• Administer a mild analgesic as prescribed. What is the priority nursing action for this client? Which action is most appropriate? Which of the following nursing interventions would be appropriate to prevent thrombophlebitis? What is the nurse's best interpretation of this client's behavior? Which type of labor dystocia should the nurse document that the client is experiencing? This documented finding indicates that the fetal presenting part is located at which area? The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. While assessing a postpartum woman, the nurse palpates a contracted uterus. Select all that apply. Jerry, who is hypertensive and who received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. An amniotomy is performed on a client in labor. Select all that apply. Which complication is most likely responsible for a late postpartum hemorrhage? On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. Ineffective thermoregulation is a nursing diagnosis associated with an infection such as urinary tract infections. Netter's atlas of human anatomy [5th Edition] Download. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. a)She should continue to breast-feed; mastitis won't infect the neonate, A nurse discovers a perineal hematoma in a woman who has recently given birth. The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. The nurse is caring for a client in active labor. The nurse plans care based on which interpretation? Select all that apply. A 17-year-old nulliparous client presents in active labor. What is one of them? When diagnosed with a deep vein thrombosis, the nurse knows the patient will be treated with which medication? The nurse plans care, knowing that this identifies which category of decelerations? The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. The woman is complaining of a painful area on one breast with a red area. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. The nurse is monitoring the client closely because concealed bleeding is suspected. Within 24 hours of delivery, Diane begins to complain of pain in the pelvic region. The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. Which is the priority nursing intervention? The nurse is preparing to care for a client with hypertonic labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. A client arrives at a birthing center in active labor. In which time period would the nurse most likely expect a client who has delivered twins to experience late postpartum hemorrhage? When observing the client's condition, the nurse notices that the client tends to speak incoherently. You suspect. Your first action would be to. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal? About 10 days following birth, a new mother visits her physician with localized symptoms of redness, swelling, warmth, and a hard inflamed vessel in one leg. Continuous electronic fetal monitoring. The nurse reviews the client's prenatal record and discovers that she has had a positive group B streptococcus (GBS) laboratory report during her prenatal course. A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. Monitoring the fetal heart rate ... nontender uterus 6. c)Blood pressure, pulse, complaints of dizziness. The client has not received prenatal care but is certain that the first day of her last menstrual period (LMP) was July 7 the previous year. You are the nurse giving an educational presentation to the local Le Leche league chapter. Risk for disuse syndrome is a nursing diagnosis associated with … The nurse recognizes that the postpartum period is a time of rapid changes for each client. d)Raise the head of the bed to at least 45 degrees. The nurse has collected the following data on a client in labor. Which nursing actions should be included in the care plan for this client? Which prescription should the nurse question? "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication.". After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. c)Ambulate the client as soon as her vital signs are stable. The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. You are conducting discharge teaching with a postpartum woman. c)Avoid over-the-counter (OTC) salicylates. After the client is transferred to the delivery room table, the nurse should place the client in which position? Which should be the nurse's initial action? Netter's atlas of human anatomy [5th Edition] b)Increased vaginal acidity leading to growth of bacteria. The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. 1. 1. After teaching a class on ways to decrease the postpartum complication of thrombotic conditions, the nurse recognizes more teaching is needed when one of the participants states: b)"At least, I don't have to give up smoking for this one.". The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. The vital signs are: T 101.2°F; HR 82; RR 18; BP 125/78. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement? Which of the following is least likely to be screened with this tool? An internal fetal heart rate monitor is in place. A prenatal client with vaginal bleeding is being admitted to the labor unit. Which assessment finding should the nurse expect to note if this condition is present? The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. Select all that apply. Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? b)Interference with the maternal-newborn attachment process. The nurse recognizes that any client may develop postpartum hemorrhage and frequent assessments are conducted to ensure this is not happening. Which finding should alert the nurse to a compromise? Evolution des crimes et délits enregistrés en France entre 2012 et 2019, statistiques détaillées au niveau national, départemental et jusqu'au service de police ou gendarmerie Associations : Subventions par mot dans les noms des associations The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. A postpartal woman with a thrombophlebitis tells you that her leg is very painful. How will the nurse interpret the vital signs? Program within @mayoclinicgradschool is currently accepting applications! 1. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. (Select all that apply.). The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. b)Absent verbalization about the birthing process. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? On the third day postpartum, which temperature is internationally defined as a postpartal infection? A pregnant 39-week-gestation gravida 1, para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which of the following conditions would the nurse identify as necessitating the cautious administration of this drug? A nurse is assigned to care for a client experiencing early postpartum hemorrhage. Quickly determining the cause of postpartum hemorrhaging enables effective treatment. She just voided 200 mL of clear yellow urine. Select all that apply. It looks like your browser needs an update. How should the nurse check for the major side effect associated with this type of regional anesthesia? The nursing diagnoses associated with postpartum laceration include ineffective tissue perfusion, risk for injury, and impaired tissue integrity. The labor room nurse assists with the administration of a lumbar epidural block. The client tells the nurse that her "water broke" before coming to the hospital. 4. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? The nurse in a delivery room is assessing a client immediately after delivery of the placenta. The nurse is caring for a client in the active stage of labor. You check her vital signs and find they are markedly different then when the CNA charted them 30 minutes ago. The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the client's primary physiological need at this time? A client in labor is transported to the delivery room and prepared for a cesarean delivery. Which intervention should the nurse prepare the client for? The nurse should perform which procedure to assess the brachioradialis reflex? Which organism would the nurse most likely expect the culture to reveal? Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Pale straw in color, with flecks of vernix. Which statement should the nurse include in her teaching? Which situation should concern the nurse treating a postpartum client within a few days of delivery? Which of the following instructions should the nurse offer a client as primary preventive measures to prevent mastitis? 1. Changing the client's position frequently 4. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative. Is my baby going to be all right?" The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). (Select all that apply.