The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse?
1. Asking the patient to void and donning clean gloves
2. Listening to bowel sounds, then asking when her last BM occurred
3. Telling visitors the assessment will be quick, then checking the fundus
4. Completing the assessment and explaining the results to the patient
3
Rationale 1: Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids.
Rationale 2: It is appropriate to ask about a body part when assessing that part.
Rationale 3: The patient should be asked whether she wants visitors to remain in the room or leave the room prior to beginning the assessment.
Rationale 4: Informing the patient of the results and of the normalcy of the results helps reassure her.
You might also like to view...
A pregnant client notices that she is beginning to develop dark skin patches on her face. She denies using any different type of facial products as a cleansing solution or makeup
What would the priority nursing intervention be in response to this situation? a. Refer the client to a dermatologist for further examination. b. Ask the client if she has been eating different types of foods. c. Take a culture swab and send to the lab for culture and sensitivity (C&S). d. Let the client know that this is a common finding that occurs during pregnancy.
The doctor orders testing for glucosuria and ketones. When are these tests usually done?
a. During AM and HS care b. After meals c. 30 minutes before each meal and at bed-time d. Every time the person urinates
The nurse writes the following on the patient's chart: The patient will have complete healing of the surgical incision on the right lower quadrant of the abdomen in 3 weeks. This is a(n)
A) Nursing diagnosis B) Assessment C) Evaluation D) Outcome identification
The average U.S. resident uses an average of how much water each day?
A. 5-10 gallons B. 20-40 gallons C. 80-100 gallons D. 120-150 gallons