The labor and delivery nurse is reviewing charts. The nurse should inform the supervisor about which patient?
1. Multip at 5 cm requesting labor epidural analgesia
2. Primip whose cervix remains at 6 cm for 4 hours
3. Multip who has developed nausea and vomiting
4. Primip requesting her partner to stay with her
2
Rationale 1: Contacting the supervisor is required when an abnormal situation is present. A multip requesting an epidural at 5 cm is not abnormal.
Rationale 2: Average cervical change among primips in the active phase of the first stage of labor is 1.2 cm/hour; thus, this patient's lack of cervical change is unexpected, and should be reported to the supervisor.
Rationale 3: Nausea and vomiting are common during the transitional phase of the first stage of labor. Contacting the supervisor is required only when an abnormal situation is present.
Rationale 4: Patients in the transitional phase of the first stage of labor often fear being left alone; this is an expected finding. Contacting the supervisor is required only when an abnormal situation is present.
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A) Using the incentive spirometer as prescribed B) Maintaining the patient on bed rest C) Assisting the patient with activities of daily living D) Determining abnormalities of cognitive function
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The nurse reporting on duty learns that the nursing unit is using the AVPU scale on one of the nurse's assigned clients. The nurse recalls that the AVPU scale is used for:
a. determining the level of pain of an intubated child b. measuring the weight of a child who cannot stand c. obtaining a measure of the level of consciousness d. obtaining a gross measure of intracranial pressure
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a. Telling patients to limit their usage of supplies. b. Asking the UAP to ensure correct charges for patient care items. c. Only using necessary items for patient care. d. Charging for extra patient care items that the patient may take home upon discharge. e. Documenting supplies used for patients in their patient care record.