NCLEX question relating to L&D - page 2

by ygmr6666

could you please help me with the order of this question? the order is different in every book:madface: thanks a lot from now on :) when evaluating an external monitor tracing of a woman in active labor, the nurse notes that... Read More


  1. 0
    Thank you for your great and detailed explanation It really helps..
  2. 0
    Thanks a lot for your detailed explanation Awesome )
  3. 0
    whoa, I am confused then. In my OB textbook (lowdermilk), it says for contractions greater than 90 secs and/or more freq. than 2 mins, you notify the physician, then stop the infusion, lay the woman on her side, insert IV/increase fluids, place oxygen, then you would document last. I also have saunders which says notify physician, stop infusion, lay woman on side, place oxygen, increase fluids, and last is document. Saunders considers ABCs yet the other one is a textbook in which many study books are derived.
  4. 1
    I wouldn't call the Dr before I did all the necessary interventions. Think of how that conversation would go.

    "Dr. Nose, I have your pt here and her CTX are over 90 mm/hg by IUPC and coming Q1min."
    "OK, what did you do?"
    "Call you."
    ::Click:: OR "Well, did you try to stop the pit?"
    "Oh, hold on a minute."




    S
    queenanneslace likes this.
  5. 1
    okay, so, looking at different sources, I firmly believe the order is stop the pit, lay the woman on her side, apply oxygen, increase/start IV fluids, notify PCP, and document. My mom is an instructor and she said the same thing sugarbee did. She said that your patient can really go south fast if you don't intervene first. Also, she had decels with me and they intervened before notifying PCP. So, if I get that question the above order is what I am putting.
    sugarbee likes this.
  6. 0
    Quote from sugarbee
    I wouldn't call the Dr before I did all the necessary interventions. Think of how that conversation would go.

    "Dr. Nose, I have your pt here and her CTX are over 90 mm/hg by IUPC and coming Q1min."
    "OK, what did you do?"
    "Call you."
    ::Click:: OR "Well, did you try to stop the pit?"
    "Oh, hold on a minute."


    S

    Could you imagine doing that? Just reading it makes me laugh....md would be very annoyed!
  7. 0
    Hello everyone,

    I finally passed NCLEX-RN examination. It is really important for me to get your opinions as I always do. I graduated from nursing school in 2009 in a foreign country and we were not taught how to do head to toe assessment. Before I start looking for a job, I wanna learn about it.
    Do you have any recommendation what i should do?
    Do you also have any advise what should i read as a nurse that keeps me updated?

    I appreciate any information you would give me
    Thank you..
  8. 0
    Quote from ygmr6666
    Hello everyone,

    I finally passed NCLEX-RN examination. It is really important for me to get your opinions as I always do. I graduated from nursing school in 2009 in a foreign country and we were not taught how to do head to toe assessment. Before I start looking for a job, I wanna learn about it.
    Do you have any recommendation what i should do?
    Do you also have any advise what should i read as a nurse that keeps me updated?

    I appreciate any information you would give me
    Thank you..
    A head to toe is just that---start at the head. What do you do "head" related? Neuro checks, nasal patency, for chemo patients, check the mouth for sores. If they have tubes, check skin for sores. Are they sweaty or dry? Pale or normal for ethnicity? Check ears, tympanic membrane shiny grey or red and angry? Next, chest. Lung sounds, heart sounds. Arms, grips and strength, pulses, color, warm/cool, clammy/dry skin, cap refill. More neuro, check for drift. Next, stomach- look at it, is it symmetrical, are there bulges? Listen to bowel sounds, are they hyper? Hypo? Percuss the stomach. What does it sound like? Palpate stomach, is it soft? Hard? Are there hard things in there? Could it be an obstruction? Keep in mind, gastric bypass patients will have a hard "grape" in there depending on the type of bypass done (lab band usually has a hard grape feeling where the band is). Now genitourinary---do they have a foley? Does it burn to pee? What color is urine? Does it smell? Now legs- pulses, feeling, clammy/dry, color, tingling? Cap refil?

    Finally we check the back for evidence of bed sores. What does the skin look like? Are they sweating? Are the sheets dry or moist? If moist, change sheets and maybe consider a bed bath (I do this more for comfort if their skin is in tact, I had feeling sweaty!)
  9. 0
    Completely forgot they were L&D...dont percus or palpate a pregnant ladies stomach. After baby though, check fundus, check for return of bowel sounds. Or are you asking in general for a head to toe?


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