A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which of the following? (Select all that apply.)
A) History of diabetes
B) Labor of 12 hours
C) Rupture of membranes for 16 hours
D) Hemoglobin level 10 mg/dL
E) Placenta requiring manual extraction
A, D, E
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The patient with which medical condition is least likely to have a nursing diagnosis of Ineffective Airway Clearance? The patient who has
a. hypertension c. Guillain-Barré syn-drome b. just had major abdominal surgery d. scoliosis
The mother of an infant born 32 weeks premature expresses the desire to breast-feed her child. An appropriate suggestion by the nurse would be
1. "Mothers who cannot directlybreast-feed should talk with and stroke their infants during gavage feedings as this may help facilitate milk letdown" 2. "The letdown reflex is best initiatedby having the baby suck at the breast" 3. "Pumping should be done nomore than three times daily, making sure to empty each breast completely" 4. "The mother should beginpumping by six hours postpartum to ensure adequate milk production"
A couple is allowing electronic monitoring to be applied during labor. After the nurse applies the equipment, risks for which the nurse should assess include: Note: Credit will be given only if all correct and no incorrect choices are selected
Select all that apply. 1. Supine postural hypotension. 2. Cord prolapse with ruptured membranes. 3. Monitoring the machine, not the patient. 4. Intrauterine perforation. 5. Slowing of contractions in active labor.
A client who incurred an arm injury describes his pain as "sharp and localized to the lower arm." The nurse recognizes that this type of pain would be relieved best by administration of which type of medication?
a.) Muscle relaxant b.) Acetaminophen c.) Narcotic analgesics d.) Ice packs