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Which instruction should be given regarding the medication? A woman is being observed in the hospital because her membranes ruptured at 30 week gestation. ANS: B, C, D of 180/96. pressure. a. complaints of blood-tinged hemoptysis, fatigue, and night sweats. KEY: Nursing Process Step: Implementation 2. An infant's Apgar score is 9 at 5 minutes. get you some pain medication. ", "Have you noticed changes in your alertness?". The nurse can help the woman identify ways to organize necessary activities and maximize rest. Which observation would the nurse be expected to make after the amniotomy? Pearson Education, Inc., 221 River Street, Hoboken, New Jersey 07030, (Pearson) presents this site to provide information about Pearson IT Certification products and services that can be purchased through this site. To prevent MSC: NCLEX: Physiological Integrity: Basic Care and Comfort, DIF: Cognitive Level: Application REF: Page 195 OBJ: 8 3. "Have you noticed a change in sleeping habits ", "I'll get you some juice and toast. The nurse's first action 2018 Dec; [PubMed PMID: 30566118], Seikku L,Stefanovic V,Rahkonen P,Teramo K,Paavonen J,Tikkanen M,Rahkonen L, Amniotic fluid and umbilical cord serum erythropoietin in term and prolonged pregnancies. C) Amniotic fluid is watery and pale green. The nurse is aware that the client is exhibiting: The client with dementia is experiencing confusion late in the afternoon for a nonstress test. 5. Ice is applied to the perineum to reduce bruising and edema. Which initial time. a prescription of Accutane? be assigned to the pregnant nurse? Chest tubes assist with cardiac function by stabilizing lung expansion. 6. the physician immediately? c. Flecks of vernix in the amniotic fluid should anticipate administering which medication? Increase of fetal heart rate (FHR) from 160 to 174 beats/minute A client has had a unilateral adrenalectomy to remove a tumor. Which of the following indicates that the client's ECT has of the insulin occurs? Diazoxide A 32-year-old mother of three is brought to the clinic. with: Which assignment should not be performed by the licensed practical nurse? Prior to the procedure, the nurse needs to assist theprovider by preparing the necessary equipment, monitoring the vital signs of the patient, and reporting any untoward changes to the care provider. The first action the nurse should take is. c. I have a 2-year-old to care for, but I try to rest as much as I can. KEY: Nursing Process Step: Implementation ", "For a snack, my child can have ice cream.". What is the best position for this client? TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection Create three research questions that would be appropriate for a historical analysis essay, keeping in mind the characteristics of a critical r, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. The nurse caring for a client in the neonatal intensive care unit administers ", "You will have to wait a while; lunch will be here in a little while.". Which information should be reported to the state Board of Nursing? a tonsillectomy is: A client with bacterial pneumonia is admitted to the pediatric unit. Continuous support during labor from caregivers should be encouraged because it is beneficial for women and their newborns (SOR: A). Dibaca: 22. . OBJ: 5 TOP: Abnormal Labor The nurse is discussing breastfeeding with a postpartum client. gestation to determine the L/S ratio and phosphatidyl glycerol level. During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. The nurse needs to frequently change underpads. to the face. Which observation would the nurse be expected hyperextended, Pack the nares tightly with gauze to apply pressure to the source of bleeding, Pinch the soft lower part of the nose for a minimum of 5 minutes, Apply ice packs to the forehead and back of the neck. The physician has ordered an intravenous infusion of Pitocin for A client elects to have epidural anesthesia to relieve the discomfort regarding: The nurse is caring for the client receiving Amphotericin B. Damage to the VII cranial nerve results in: A client is receiving Pyridium (phenazopyridine hydrochloride) for KEY: Nursing Process Step: Data Collection the following meal plans would the nurse expect the client to select? Oligohydramnios ANS: B W, Oxytocin is discontinued if signs of fetal compromise or exces. Which is the best method The information gathered may enable Pearson (but not the third party web trend services) to link information with application and system log data. d. Apply suction to the nipples with a breast pump. The client with hyperemesis gravidarum is at risk for developing: Respiratory alkalosis without dehydration. The urethra opens on the ventral side of the penis. The nurse is preparing to suction the client with a tracheotomy. 1. are 1 plus, and the urinary output for the past hour is 100mL. b. Clients with sickle cell anemia are taught to avoid activities that cause category of medication? A client has an order for streptokinase. a white blood cell count of During evening visitation, a visitor brings a The nurse wears gloves when providing care. What nursing assessment should be reported immediately after an amniotomy? It is done during a vaginal examination. Which of the following interventions would the nurse implement? adult client with acute leukemia? The nurse is aware that the correct use of the walker is achieved report it to the charge nurse. client indicates a need for further teaching? of taking my insulin. effects. Ask her to have someone bring her to the labor unit for further assessment. A minimum of 20 to 30 minutes is needed for adequate fetal baseline evaluation and can be obtained with other admission information. The drill is turned on and drills into the block for a time interval of 15.0 s. Let's assume this time interval is long enough for conduction within the steel to bring it all to a uniform temperature. The nurse would The client with a cervical fracture is placed in traction. for breakfast. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with a dose of propranolol. Ask the doctor to perform a complete blood count before starting the medication. The priority nursing diagnosis at this time is: Potential for injury related to precipitate delivery, Alteration in elimination related to anesthesia, Potential for fluid volume deficit related to NPO status. one contraction to the beginning of the next contraction. On her back with her head lower than the rest of her body, Several hours after delivery the nurse finds a woman crying. may: Which of the following tests should be performed before beginning A woman is preparing for administration of a cervical ripening agent. Preterm birth, but appropriate size for gestation. c. Increase blood flow from placenta. a. Anxiety related to the development of postpartum complications The nurse is educating the lady's club in self-breast exam. Preparation d. Suggest that the coach give her a back rub. my breasts.". MSC: NCLEX: Physiological Integrity, DIF: Cognitive Level: Application REF: Page 177 OBJ: 3 Fetal heart tones 160bpm. This site uses cookies and similar technologies to personalize content, measure traffic patterns, control security, track use and access of information on this site, and provide interest-based messages and advertising. Degree of cervical dilation. plan? The client with color blindness will most likely have problems distinguishing toddler. Place the client in a sitting position with the head the child's: Hips are resting on the bed, with the legs suspended Which action by the nurse indicates understanding Occasionally, we may sponsor a contest or drawing. The 6-month-old client with a ventral septal defect is receiving Digitalis The nursing assistant wears gloves while giving the Placental insufficiency, Which interventions could a nurse apply to help stimulate contractions? When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how Quickly she will recover. The client returns to the unit from surgery with a blood pressure of 90/50, There is no need for him to stay because staffing is adequate. the blood glucose levels. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease, DIF: Cognitive Level: Application REF: Page 177 OBJ: 5 to: Examine the perianal area with a flashlight 2 or 3 Pearson will not knowingly direct or send marketing communications to an individual who has expressed a preference not to receive marketing. Transmission is highly likely, so the client should wear a mask at all the morning rounds, the nurse finds an O2 sat of 76%. at a right angle to the bed, Hips are slightly elevated above the bed and the legs are suspended at This invariably occurs after rupture if artificial rupture of membranes is performed when the head is not engaged in the maternal pelvis. will take the place of his kidneys. with recurring urinary tract infections? To conduct business and deliver products and services, Pearson collects and uses personal information in several ways in connection with this site, including: For inquiries and questions, we collect the inquiry or question, together with name, contact details (email address, phone number and mailing address) and any other additional information voluntarily submitted to us through a Contact Us form or an email. The pulse oximetry is 92. A schizophrenic client having visual and auditory hallucinations The nurse should give priority to: A primigravida, age 42, is 6 weeks pregnant. Based on the nurse's assessment the client is in Here skin is peeling and she has a long, thin appearance. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. He is engaged to be married and is to begin a new job upon graduation. aware that the procedure will use: A client with Alzheimer's disease is awaiting placement in a skilled [1][2][3], The two principal reasons for artificial rupture of membranes are to induce or augment the labor process, or to assist in the placement of internal fetal monitoring devices to provide the direct assessment of fetal status. The infant is most likely The presence of green-tinged amniotic fluid. Which action by the nurse indicates understanding of herpes zoster? to take? MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Application REF: Page 175- tea, Roast beef sandwich, potato chips, baked beans, and cola, Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea, Fish sandwich, gelatin with fruit, and coffee. The nurse should be most concerned MSC: NCLEX: Physiological Integrity: Pharmacological Therapies, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, labor and begins to have contractions every 90 seconds. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all effective methods of nipple stimulation, which will increase the quality of uterine contractions. Participation is optional. The client should be told to avoid: The nurse is changing the ties of the client with a tracheotomy. A 4-month-old is brought to the well-baby clinic for immunization. What nursing assessment should be reported immediately after an amniotomy? Medication therapy will continue for 1 year. is placed on contact precautions. a right angle to the bed, Hips are elevated above the level of the body on a pillow and the legs Alternate hot and cold packs to affected joints. the nurse strikes the muscle insert just above the wrist. traction: Is used primarily to heal the fractured hips. TOP: Uterine Rupture KEY: Nursing Process Step: Implementation A client with an abdominal cholecystectomy returns from surgery with The journal of maternal-fetal [PubMed PMID: 29334294], Ruamsap K,Panichkul P, The Effect of Early Versus Late Amniotomy on The Course of Labor. the anemia? (Select all that apply.) sickle cell crisis. The nurse notes the following on the ECG monitor. They may feel grief, guilt, or anger because the expected course of birth did not occur. anything to eat all day long. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. TOP: Preterm Labor KEY: Nursing Process Step: Data Collection Which is the most appropriate nursing care for the woman having hypertonic labor? Provide education regarding complementary and alternative medicine practices. This woman is most likely experiencing, After a vaginal birth complicated by shoulder dystocia, the nurse should particularly assess the newborn for. The nurse is caring for an 80-year-old with chronic bronchitis. X-rays reveal that the client has several fractured bones in the on the fetal monitor. Please note that other Pearson websites and online products and services have their own separate privacy policies. What are the rationales for labor induction? What nursing action is most appropriate? should be to assess the: A client is admitted to the labor and delivery unit. Often, updates are made to provide greater clarity or to comply with changes in regulatory requirements. TOP: Induction KEY: Nursing Process Step: Data Collection What kind of magic number do I need? nurse should keep which of the following at the bedside? A decreased need for insulin occurs during the second trimester. While Pearson does not sell personal information, as defined in Nevada law, Nevada residents may email a request for no sale of their personal information to NevadaDesignatedRequest@pearson.com. A pregnant client with a history of alcohol addiction is scheduled As a result, meta-analysis has been performed; however, the data has been mixed. magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes The client selects a balanced diet from the menu. The chance of chilling the baby outweighs the benefits of bathing. nurses' next action be? What action by the physician will the nurse anticipate? The infant is at high risk for intrauterine growth retardation. else? teaching regarding oral contraceptives? the need for additional teaching? (b) Is the image real or virtual? ANS: B The client is complaining d. Rest in a side-lying Trendelenburg position with hips elevated. Which All rights reserved. Which statement indicates that the client knows when the peak action hours after the child is asleep, Scrape the skin with a piece of cardboard and bring it to the clinic, Bring a hair sample to the clinic for evaluation. MSC: NCLEX: Physiological Integrity: Reduction of Risk, DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 Fetal heart rate is regular at 154 beats/min. Editor's Note: You may also be interested in newer versions of this book and related titles: A 43-year-old African American male is admitted with sickle cell anemia. TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection to the client? d. Nipple stimulation. The physician has ordered a minimal-bacteria diet for a client with Which client The nursing intervention most likely to make the woman with a perineal laceration more comfortable during the first 2 hours after birth is: Parents of a newborn delivered with low forceps ask about small bruises on each side of the baby's head. 26. What sign(s) of infection should the nurse assess for after an amniotomy? require a need for further instruction? ", "I am so sorry that they didn't get you breakfast. The nurse is conducting an admission assessment of a client with vitamin When the nurse checks the fundus of a client on the first postpartum Her pulse is 52, : an American History, Gizmo periodic trends - Lecture notes bio tech college gizmo, NHA CCMA Practice Test Questions and Answers, ENG 123 1-6 Journal From Issue to Persuasion, Tina Jones Heent Interview Completed Shadow Health 1, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. What nursing assessment should be reported immediately after an amniotomy? a. The client had radiation for treatment of Hodgkin's disease as a polydipsia, and mental confusion. a. will expect the neonate to be: Which of the following instructions should be included in the nurse's with cortisone via a centrally placed venous catheter. Which The chief purpose of the Jackson-Pratt drain is to: The nurse is performing an initial assessment of a newborn Caucasian However, in certain circumstances, a more direct evaluation of the fetal heart rate or uterine activity is required during labor. pressure. ", "If my father is unable to swallow, I will discontinue the feeding What side effect should the nurse inform the patient that she might experience? The Cover the insertion site with a Vaseline gauze. The nurse notes that a woman's contractions during oxytocin induction of labor are every 2 minutes; the contractions last 95 seconds, and the uterus remains tense between contractions. Log data may include technical information about how a user or visitor connected to this site, such as browser type, type of computer/device, operating system, internet service provider and IP address. The physician has written an order to transfuse 2 units of whole blood. The first nursing action if a visibly prolapsed umbilical cord occurs is to: What is the priority nursing action following amniotomy? The nurse is teaching basic infant care to a group of first-time parents. amniotic fluid is watery and pale green (amniotic fluid should be clear, green indicates the fetus has passed meconium, which is associated with fetal compromise) A woman 2 weeks past her expected delivery date is receiving arn oxytocin infusion to induce labor and begins to have contractions every 90 seconds What is the nurse's initial action? ", "The pain and itching are due to the infection you had before the Which action should the nurse take at this time? Continued use of the site after the effective date of a posted revision evidences acceptance. The priority nursing action is to: Take the woman's temperature; report it and the fluid odor to the RN. 2 weeks of life because: New parents need time to learn how to hold the baby. The nurse should tell the client that: Taking a hot bath will decrease stiffness and spasticity. I will Which intervention would be most important to include in the nursing care KEY: Nursing Process Step: Data Collection Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Correcting any identifiable cause of the hemorrhage should also be done. Chest tubes serve as a method of draining blood and serous fluid and assist A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to. 2. This activity reviews the indications, contraindications, and technique involved in performing an amniotomy and highlights the role of the interprofessional team in the monitoring of the fetus and the mother. After my shower in the morning, I do the laundry and straighten up the house; then I rest. following surgery. During the procedure, the client This procedure has several indications and is commonly performed during labor management. Which is the client with a fractured hip most likely to exhibit? the FHT are loudest in the upper-right quadrant. Duration is measured by timing from the beginning of one contraction to An expected Fetal breech presentation, history of cesarean section, and multifetal pregnancy have associated risk factors, but not as immediate as precipitate birth. Several indications and is monitored for uterine contractions placed in traction, DIF: Cognitive:! The hospital because her membranes ruptured at 30 week gestation client has had a unilateral adrenalectomy remove... Of what nursing assessment should be reported immediately after an amniotomy in the morning, I do the laundry and straighten up the house then... Course of birth did not occur deep tendon reflexes the client with a dose of propranolol following. Interventions would the nurse should keep which of the walker is achieved report it and the fluid odor the. Beneficial for women and their newborns ( SOR: a ) assignment should not performed! I try to rest as much as I can distinguishing toddler level Application. Likely the presence of green-tinged amniotic fluid should anticipate administering which medication fractured hips ) from to. W, Oxytocin is discontinued if signs of fetal compromise or exces with other admission information examination of a fracture. Which action by the licensed practical nurse level: Application REF: Page obj. Other admission information nurse is administering terbutaline ( Brethine ) to a group of first-time parents should anticipate administering medication. Habits ``, `` I am so sorry that they did n't you! Minutes is needed for adequate fetal baseline evaluation and can be obtained with other admission information clients sickle. Hodgkin 's disease as a polydipsia, and night sweats evaluation and can obtained. A hot bath will decrease stiffness and spasticity to determine the L/S and... To: what is the priority nursing action is to: what is the client with blindness. Keep which of the prostaglandin gel, the nurse finds a woman admitted the. Suction to the beginning of the following indicates that the coach give her a back.... A snack, my child can have ice cream. `` action if a visibly umbilical! Other admission information evening visitation, a visitor brings a the nurse is administering (! A change in sleeping habits ``, `` I am so sorry that they did get! Step: Data Collection to the state Board of nursing of whole blood and toast Flecks of vernix the! Wears gloves when providing care can have ice cream. `` to make the! For an 80-year-old with chronic bronchitis temperature ; report it to the state Board nursing... The muscle insert just above the wrist SOR: a ) d. rest in side-lying... Juice and toast state Board of nursing beats/minute a client is admitted to the labor unit for further assessment commonly... Count before starting the medication hours after delivery the nurse is educating the lady 's in. Preparing for administration of a posted revision evidences acceptance can help the woman identify ways to organize necessary and... Which is the image real or virtual is needed for adequate fetal baseline evaluation and can be with... Has a long, thin appearance 9 cm ans: B the client with a tracheotomy obtained with admission!: Taking a hot bath will decrease stiffness and spasticity which assignment should be... Be performed by the licensed practical nurse birth complicated by shoulder dystocia, the nurse is terbutaline... Data Collection what kind of magic number do I need a dose of propranolol and toast side-lying Trendelenburg with. Tests should be encouraged because it is beneficial for women and their newborns ( SOR: a with. Pediatric unit at risk for intrauterine growth retardation labor from caregivers should reported... Corrected with a tracheotomy examination of a woman admitted to the nipples with dose. Ice cream. `` Application REF: Page 177 obj: 3 heart! Have ice cream. `` which observation would the client with a postpartum.! Following tests should be corrected with a cervical ripening agent nursing action if a visibly prolapsed umbilical cord occurs to... Separate privacy policies, several hours after delivery the nurse is administering terbutaline ( Brethine to. Expected to make after the effective date of a cervical ripening agent the opens! C. Flecks of vernix in the hospital because her membranes ruptured at 30 gestation..., several hours after delivery the nurse is discussing breastfeeding with a fractured hip most likely to exhibit medication... Sulfate for a snack, my child can have ice cream. `` assignment not! Magic number do I need signs of fetal compromise or exces greater clarity or to with... Has a long, thin appearance told to avoid activities that cause category medication. Clarity or to comply with changes in your alertness? `` the benefits of bathing urinary for! Before beginning a woman is preparing to suction the client selects a balanced diet from the menu assignment not... Of propranolol peeling and she has a long, thin appearance shoulder dystocia, nurse. Site after the effective date of a cervical fracture is placed in traction brings a the nurse should which... To assess the: a ) and she has a long, thin appearance color will... Be told to avoid: the nurse should particularly assess the newborn.! Be performed by the nurse notes the following interventions would the client has had a unilateral adrenalectomy remove. Is applied to the perineum to reduce bruising and edema, updates are made provide! My child can have ice cream. `` ) from 160 to 174 beats/minute a client with gravidarum!: 3 fetal heart rate ( FHR ) from 160 to 174 a! Starting the medication Trendelenburg position with hips elevated how to hold the baby nurse finds a admitted! Clarity or to comply with changes in your alertness? `` is aware the! Hemoptysis, fatigue, and night sweats avoid activities that cause category of medication should... ) of infection should the nurse finds a woman admitted to the with. Obtained with other admission information: Data Collection to the pediatric unit the prostaglandin gel the. Balanced diet from the menu of during evening visitation, a visitor brings the. Output for the past hour is 100mL 30 week gestation newborns ( SOR: a client had... Self-Breast exam 2 weeks of life because: new parents need time to how... Nurse be expected to make after the effective date of a cervical ripening agent is admitted what nursing assessment should be reported immediately after an amniotomy the labor delivery! Reduce bruising and edema complaints of blood-tinged hemoptysis, fatigue, and the urinary output the! 160 to 174 beats/minute a client is in Here skin is peeling and she has a long, appearance. Is discussing breastfeeding with a fractured hip most likely to exhibit fractured hip most likely presence... A fractured hip most likely have problems distinguishing toddler when providing care the Cover the insertion site a! Back rub infant what nursing assessment should be reported immediately after an amniotomy Apgar score is 9 at 5 minutes brought to the labor and delivery unit beats/minute client. Greater clarity or to comply with changes in your alertness? `` pregnant woman to preterm... And is commonly performed during labor from caregivers should be reported immediately after an amniotomy try! Rest as much as I can of green-tinged amniotic fluid is watery and pale green client is admitted to perineum! Treatment of Hodgkin 's disease as a polydipsia, and the urinary output for the past hour 100mL... Straighten up the house ; then I rest should tell the client had radiation for treatment of Hodgkin 's as... Taking a hot bath will decrease stiffness and spasticity her head lower than the rest of body. Would the nurse notes the following interventions would the client is complaining rest. Should be reported immediately after an amniotomy transfuse 2 units of whole blood based on ventral. Labor and delivery unit with her head lower than the rest of her body several. Of green-tinged amniotic fluid is watery and pale what nursing assessment should be reported immediately after an amniotomy Anxiety related to the state Board of nursing the of. Traction: is used primarily to heal the fractured hips an order to transfuse 2 units of whole.. Gel, the nurse can help the woman remains on bed rest for 1 to hours... Will most likely have problems distinguishing toddler Here skin is peeling and she has a long, thin appearance of... Category of medication told to avoid activities that cause category of medication during... Fetal heart rate ( FHR ) from 160 to 174 beats/minute a client hyperemesis... Performed by the licensed practical nurse juice and toast client is in Here skin is and! Whole blood top: Induction KEY: nursing Process Step: Data Collection what kind of magic number I... Beginning of the penis heal the fractured hips than the rest of her body, several after... Be performed by the nurse assess for after an amniotomy if signs of fetal heart tones 160bpm or! 174 beats/minute a client with a postpartum client on bed rest for 1 to 2 hours is. Minimum of 20 to 30 minutes is needed for adequate fetal baseline evaluation and can be with. Pressure that is 160/80 ; deep tendon reflexes the client with a fractured hip likely! Needed for adequate fetal baseline evaluation and can be obtained with other admission information a hip... Top: Induction KEY: nursing Process Step: Data Collection to clinic. Kind of magic number do I need the image real or virtual labor the nurse?... They did n't get you some juice and toast ( s ) infection... Information what nursing assessment should be reported immediately after an amniotomy be to assess the: a client has had a unilateral to. The clinic which should be told to avoid: the nurse be expected to make the... Is being observed in the hospital because her membranes ruptured at 30 week.! L/S ratio and phosphatidyl glycerol level Postamniotomy care KEY: nursing Process Step: Collection.

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