You are assigned to Daisy when she is admitted to ICU. Outline the key elements of your admission assessment that relate to her midwifery care
What will be an ideal response?
Suggested response: • Palpate fundus to determine uterine tone. Uterus should be firm and central, at the height of the umbilicus immediately after birth. Check PV loss; report any clots or if the pad needs changing more than 4–6 hourly. Blood loss should be dark red immediately after birth. • Check caesarean section wound site, and monitor for signs of infection or impaired healing. • Leg assessment for DVT and VTE screening risk, with suitable prophylaxis based on clinical circumstances – depending on anticoagulation practices related to ECMO and CCRT. Consider using pneumatic compression device or anti-embolic stockings. • Ensure breast milk expression occurs every 4–6 hours to establish milk supply; milk supply can progress even on ECMO. Monitor breasts for signs of engorgement, lumps or redness. • Record details about her baby and include in the handover to the next shift. • Note the blood group of Daisy and enquire about Rh D immunoglobulin since she is Rh negative.
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A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? (Select all that apply.)
1. Encourage the client to recognize the signs of escalating anxiety. 2. Encourage the client to avoid any situation that causes stress. 3. Encourage the client to employ newly learned relaxation techniques. 4. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. 5. Encourage the client to avoid caffeinated products.
The nurse initiating IV therapy is preparing a solution to which potassium chloride has been added. After adding the medication, which action by the nurse regarding the IV label is appropriate?
1. Writing the time the IV solution needs to be changed 2. Placing it upside-down on the container 3. Putting it around the IV tubing 4. Documenting the size of the angiocatheter inserted to obtain IV access
In assisting the patient to exercise, the nurse should
a. Expect that pain will occur with exercise of unused muscle groups. b. Set the pace for the exercise class. c. Force muscles or joints to go just beyond resistance. d. Stop the exercise if pain is experienced.
A nurse needs to specifically prevent emboli that may result from IV therapy. The nurse makes sure to:
A. Use a needleless system B. Prime the tubing completely C. Check for medication compatibility D. Select a larger-gauge needle or catheter