Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration (B). Which task performed by the UAP requires immediate intervention by the nurse?ī.Positions head of bed flat when changing sheetsĬ.Takes temperature using the axillary methodĭ.Keeps head of bed elevated at 30 degrees B TERMS IN THIS SET (100) The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Positioning for abdominal surgery necessitates a supine position however, a wedge placed under the right hip provides displacement of the uterus. The best position to prevent this would be side-lying with the uterus displaced off of abdominal vessels. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and the fetus. Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. The client is transferred to the delivery room table, and the nurse places the client in the:ġ.Trendelenburg's position with the legs in stirrupsĢ.Semi-Fowler position with a pillow under the kneesģ.Prone position with the legs separated and elevatedĤ.Supine position with a wedge under the right hip 4. A client in labor is transported to the delivery room and is prepared for a cesarean delivery.
#LOW HEMATOCRIT AND HEMOGLOBIN IN DELIVERY FULL#
By full term, a normal maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification. A normal fetal heart rate is 120-160 beats per minute. Which assessment finding would indicate a need to contact the physician?ġ.Fetal heart rate of 180 beats per minuteģ.Maternal pulse rate of 85 beats per minuteĤ.Hemoglobin of 11.0 g/dL 1. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. An intravenous pitocin infusion is discontinued when a late deceleration is noted. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava.
The supine position is avoided because it decreases uterine blood flow to the fetus. This causes hypoxemia therefore oxygen is necessary. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. The most appropriate nursing action is to:ġ.Place the mother in the supine positionĢ.Document the findings and continue to monitor the fetal patternsĤ.Increase the rate of pitocin IV infusion 3. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip.
A nurse in the labor room is caring for a client in the active phases of labor. The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted?Ī.The client begins to expel clear vaginal fluidĭ.The cervix is dilated completely 1.4. TERMS IN THIS SET (41) 1.A nurse is caring for a client in labor.
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