During the fourth stage of labor, your client's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. You would:
1. Turn her onto her left side.
2. Place the bed in Trendelenburg position.
3. Massage the fundus.
4. Continue to monitor.
4
Rationale:
1. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90.
2. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse. Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90.
3. The uterus should be midline and firm; massage is not necessary.
4. Because this is a normal scenario for the fourth stage, monitoring is the only action necessary.
You might also like to view...
The nurse is assessing a family to determine if they have access to adequate health care. Which of the following statements accurately describes how certain families are affected by common barriers to health care?
A) After a decade of escalation, the percentage of children living in low-income families has been on the decline since 2000. B) White, non-Hispanic children overall are more likely than African American and Hispanic children to be in very good or excellent health. C) The proportion of children between the ages of 6 and 18 who are overweight is decreasing, but a large increase is occurring in African American females. D) The overall health care plan of working families may improve access to specialty care but limit access to preventive services.
Which of the following behaviors might be most indicative that Layne, a nurse, is experiencing burnout?
a. Excessive alcohol consumption b. Experiencing role stress c. Inability to fall asleep as usual d. Overeating frequently
The nurse making the following statement is demonstrating a competing style of conflict
A. "I understand you are tired. Can you explain why you are late?" B. "There is no excuse for you being late. I'm writing you up." C. "If you come in early tomorrow, I'll forget about you being late today." D. None of the above.
A client has been informed that his health care plan will be changing to a managed care model. How would the nurse best explain the goal of this model?
a. Managed care decreases consumer use of outpatient health care. b. Managed care ensures maximum value received from resources used. c. Managed care decreases patient satisfaction. d. Managed care ensures provider satisfaction.