Newborn delivered by repeat cesarean birth at 40 weeks of gestation.
Birth weight 3,515 g (7 lb 12 oz)
Apgar scores 8 at 1 min and 9 at 5 min
Maternal
... [Show More] history of methadone use during pregnancy.
Which should the Nurse report?
Respiratory findings
Temperature
Oxygen saturation
Central nervous system findings
Gastrointestinal findings - Gastrointestinal findings
Central nervous system findings
Client reports a small amount of bright red blood in their underwear upon awakening. Client denies contractions or abdominal pain.
External fetal monitor applied.
Potential Nursing Action
Indicated or Contraindicated
Assess cervical dilation
Weigh perineal pads.
Administer methotrexate.
Insert a large bore intravenous catheter. - Contraindicated
Assess Cervical Dilation - She's currently bleeding and not in the middle of labor, unnecessary.
Administer Methotrexate - She isn't having an ectopic pregnancy - this is used to resolve ectopic pregnancies in the first trimester.
Indicated
Weigh Perineal Pads - We need to know how much blood she's losing.
Insert a large bore IV - Third Trimester Bleeding may lead to larger hemorrhage - having IV access is critical if we need to administer fluids.
A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? - Vomiting - Also could be irritability, agitation, tremors, or diarrhea. These manifestations typically last 2 days.
A nurse in a family planning clinic is caring for a client who request an oral
contraceptive. Which of the following findings in the clients history show the nurse
recognized as a contraindication to oral contraceptives. select all that apply
Cholecystitis
Hypertension
Human papillomavirus
Migraine headaches
Anxiety disorder - Cholecystitis
Hypertension
Anxiety disorder
A nurse is caring for a newborn.Medical History
1600:Apgar Score 9 at 1 min and 9 at 5 min
Birth weight 10 lb 6 oz (4706 gm)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. - Indicated:
Educate the parents to begin ROM exercises on the affected arm after 1 week. - ROM help restore functionality. Delay 1 week to prevent additional injury to brachial plexus.
Assess for grasp reflex in the affected extremity. - With Erb's Palsy (Erb-Duchenne) only the upper arm is affected. Wrist and finger function should NOT be affected.
Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. - This will assist int he healing process. [Show Less]