While palpating a client's uterus postpartum, the nurse notes the fundus position to be 2 centimeters higher than on previous assessments and off to the left side. Which of these actions should the nurse take?
a. Ask the client to urinate, and then reassess the fundus position.
b. Initiate a Pitocin IV drip according to the health care provider's routine orders.
c. Note the position of the uterus on the nurse's notes because these findings are normal.
d. Notify the health care provider immediately.
A
Palpate the uterus to find the fundus. Note the size, consistency, and placement of the uterus. It should be the size of a grapefruit, firm, and in the midline. It should descend approximately one fingerbreadth each day. Palpate the bladder to assess for distention and position.
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A client in the manic phase of bipolar disorder is being provided with lithium and has a current level of 0.4. Which of the following will the nurse assess in this client?
1. A decrease in manic behavior 2. Signs and symptoms of depression 3. Hyperactivity and pressured speech 4. A return to baseline behavior, calm and rational
Which action(s) can the nurse take during report to ensure patient safety? (Select all that apply.)
a. Give report at the bedside. b. Give report while the nurse is finishing up charting on another patient, so that the new nurse doesn't have to wait. c. Use I-SBAR-R during shift change report. d. Focus on giving report, not on answering telephones. e. Be prepared for report.
Upon assessing the FHR tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Early fetalhypoxia 2. Prolonged fetal stimulation 3. Fetal anemia 4. Fetal sleep cycle 5. Infection
Following drug legislation in 1970, the term, "schedule," has been used as
A. a way of calculating the need for treatment options for drug abusers B. a way of classifying drugs C. a way of tracking the FDA's approval process for new prescription drugs D. a way of monitoring the number of drug arrests