Maternity HESI 1

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The nurse should encourage the laboring client to begin pushing when... the cervix is completely dilated. Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated... at 10 cm (C). If pushing begins before the cervix is completely dilated the cervix can become edematous and may never completely dilate, necessitating an operative 1 delivery. Many primigravida’s begin active labor 100% effaced and then proceed to dilate. • The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? Have the client breathe into her cupped hands Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands. • Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as... a cephalohematoma, caused by forceps trauma and may last up to 8 weeks. Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull. • When does the head return to its normal shape? 7-10 days • What did Nurse theorist Reva Rubin describe? The initial postpartum period as the "taking-in phase," which is characterized by maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and closeness to families and the newborn. [Show More]

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