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- Nurse Zasha in the Obstetrical Unit is monitoring Mrs. Zexy Lucero, 25 years old. G1P0. Internal examination revealed 5cm cervical dilatation, 50% effaced, +(BOW). Station 0, cephalic with a prolongation disorder for signs of fetal or maternal compromise. Which of the following assessment findings should not alert Nurse Zasha to a compromise? (Select all that apply) Coordinated uterine contractions Persistent nonreassuring fetal heart rate Maternal fatigue Uncoordinated uterine contractions Progressive changes in the cervixMs. B was admitted at OBW - BRTTH last April 7, 2022 at 1:20 am, cervix 1 cm dilated. Her BP was 160/100 and her pain level of 0/10. IVF of D5LR 1Lwas inserted at the right hand, regulated at 20 gtts/min. Laboratories such as Complete Blood Count (CBC) with typing, Blood Urea Nitrogen (BUN), Hepatitis BSurface Antigen (HBsAg), Creatinine, Platelet count, and Urinalysis were done to the pregnant mother. The Admitting Diagnosis was Pre-eclampsia withsuperimposed chronic hypertension, and the final diagnosis was Pre-eclampsia with severe features. Monitoring of V/S and FHT q 4hrs was ordered and done. At9:45 pm, delivered to a baby boy with AS of 8, 9. Several hours after delivery, the mother was ordered to undergo laboratory tests. The findings are normal resultsin CBC with typing, platelet count, and creatinine. Non-reactive HBsAg and high levels of BUN and oliguria in urinalysis. Upon checking the mother, she exhibitededema around her hands. The V/S of the mother is BP: 140/90 mmHg, T:…Patient X, 47 years old was admitted last April 15, 2021. During admission the patient experiences dark brown to bright red vaginal blessing for the last 3 months, severe nausea and vomiting, pain on the pelvic area and notice some grapelike cyst pass on her vagina. She also mentioned feeling of dizziness and fatigue. Her admitting diagnosis is: - Gravida 7; Para 3 (6016) - Gestational Tromphoblastic NeoPlasia IV:16 High Risk - Hypertension Stage 2 Controlled -Status Post Exploratory Laparotomy for Total Abdominal Hysterectomy with bilateral salpingo-oophorectomy (10-18-20) Based on the following data, answer the following:1. As a nurse on duty, give at least two (2) priority nursing diagnoses based on the admitting diagnosis.
- Ms. B was admitted at OBW - BRTTH last April 7, 2022 at 1:20 am, cervix 1 cm dilated. Her BP was 160/100 and her pain level of 0/10. IVF of D5LR 1L was inserted at the right hand, regulated at 20 gtts/min. Laboratories such as Complete Blood Count (CBC) with typing, Blood Urea Nitrogen (BUN), Hepatitis B Surface Antigen (HBsAg), Creatinine, Platelet count, and Urinalysis were done to the pregnant mother. The Admitting Diagnosis was Pre-eclampsia with superimposed chronic hypertension, and the final diagnosis was Pre-eclampsia with severe features. Monitoring of V/S and FHT q 4hrs was ordered and done. At 9:45 pm, delivered to a baby boy with AS of 8, 9. Several hours after delivery, the mother was ordered to undergo laboratory tests. The findings are normal results in CBC with typing, platelet count, and creatinine. Non-reactive HBsAg and high levels of BUN and oliguria in urinalysis. Upon checking the mother, she exhibited edema around her hands, has severe dehydration, decreased…Ms. B was admitted at OBW - BRTTH last April 7, 2022 at 1:20 am, cervix 1 cm dilated. Her BP was 160/100 and her pain level of 0/10. IVF of D5LR 1L was inserted at the right hand, regulated at 20 gtts/min. Laboratories such as Complete Blood Count (CBC) with typing, Blood Urea Nitrogen (BUN), Hepatitis B Surface Antigen (HBsAg), Creatinine, Platelet count, and Urinalysis were done to the pregnant mother. The Admitting Diagnosis was Pre-eclampsia with superimposed chronic hypertension, and the final diagnosis was Pre-eclampsia with severe features. Monitoring of V/S and FHT q 4hrs was ordered and done. At 9:45 pm, delivered to a baby boy with AS of 8, 9. Several hours after delivery, the mother was ordered to undergo laboratory tests. The findings are normal results in CBC with typing, platelet count, and creatinine. Non-reactive HBsAg and high levels of BUN and oliguria in urinalysis. Upon checking the mother, she exhibited has distended bladder and her uterus is still boggy. The V/S…Ms. B was admitted at OBW - BRTTH last April 7, 2022 at 1:20 am, cervix 1 cm dilated. Her BP was 160/100 and her pain level of 0/10. IVF of D5LR 1L was inserted at the right hand, regulated at 20 gtts/min. Laboratories such as Complete Blood Count (CBC) with typing, Blood Urea Nitrogen (BUN), Hepatitis B Surface Antigen (HBsAg), Creatinine, Platelet count, and Urinalysis were done to the pregnant mother. The Admitting Diagnosis was Pre-eclampsia with superimposed chronic hypertension, and the final diagnosis was Pre-eclampsia with severe features. Monitoring of V/S and FHT q 4hrs was ordered and done. At 9:45 pm, delivered to a baby boy with AS of 8, 9. Several hours after delivery, the mother was ordered to undergo laboratory tests. The findings are normal results in CBC with typing, platelet count, and creatinine. Non-reactive HBsAg and high levels of BUN and oliguria in urinalysis. Upon checking the mother, she exhibited has severe dehydration, decreased urine output, and her uterus…
- Marielle, 18 year-old, Gravida 1 Para 039-40 weeks AOG, was brought to the Delivery Suite due to labor pains. On admission, BP = 110/80 ; FH = 34cm; FHT = 145 bpm. Internal examination showsCervix 3 cm, 60% effaced; intact BOW, station -2; cephalic presentation. Uterine contractions were occurring at every 5-6 minutes interval, 30 seconds durationmild to moderate contractions. Marielle in this case is already in what phase of labor?a. Latent phaseb. Acceleration phasec. Phase of maximum sloped. Deceleration testwhat are the signs and symptoms that indicate that IV catheters needs to be changedNurse Zasha is reviewing the Obstetrician-Gynecologists orders for Mrs. Zexy Lucero. 25 years old, G1P0, 37 weeks AOG admitted for watery vaginal discharge before the onset of regular uterine contractions. Internal examination revealed: cervix 3-4 cms dilated, 50% effaced, cephalic, station -1, with pooling of fluid in the vaginal canal on speculum examination. Which of the following activities are expected to be written in the doctor's orders and to be performed by Nurse Zasha? (Select all that apply) Administer an antibiotic per order and hospital protocol Monitor maternal vital signs frequently Monitor fetal heart rate continuously Perform vaginal examination every shift Perform cesarean section immediately
- Nurse Zasha in the Obstetrical Unit is monitoring Mrs. Zexy Lucero, 25 years old. G1PO. Internal examination revealed 3-4cm cervical dilatation, 50% effaced, +(BOW), Station -1, cephalic with uncoordinated uterine contractions that are erratic in their frequency, duration, and intensity. Which of the following nursing actions should not be included in the priority of Nurse Zasha? (Select all that apply) Promote ambulation every 30 minutes Encourage the client to rest. Prepare the client for an amniotomy Monitor the oxytocin infusion closely. Provide pain relief measuresMrs. Ortex has been admitted to your surgical center for a breast biopsy under local anesthesia. This is the second beast biopsy for her, having had the first one 12 months prior to today. She is accompanied by her husband of 14 years. They have three children, ages 2, 8, and 10. Both appear relaxed, joke with you as you admit her, and seem not be overly worried about the results of the upcoming biopsy. The surgeon has previously informed the patient of the procedure, risks, alternatives, desired outcomes, and possible complications. You give the surgery permit form to the patient for her signature. She readily states that she knows about the procedure and has no additional questions; she signs the form with no hesitation. Her husband now acknowledges that he is worried about the procedure itself and that something could be said during the procedure to alarm his wife. What do you do at this point? Do you alert the surgeon that informed consent has not been obtained? Do you request…The physician ordered to prepare a client suspected of ectopic pregnancy with a negative culdocentesis result. Which statement by the client indicates understanding of the management for her condition? "My hemoglobin and hematocrit will be periodically monitored." "I will not be asked to sign an informed consent." "An abdominal scrub will be performed in preparation for CS! " I will be maintained in a left lateral position."
