What assessments are important for D.H. after delivery?
What will be an ideal response?
• Take VS.
• Assess uterine function, position, and firmness. Fundus must stay firm to control bleeding.
With uterus midline, measure its position relative to the woman's umbilicus. Lay fingers flat on
abdomen under umbilicus; measure how many fingerbreadths (fb) or centimeters (cm) fit between
umbilicus and top of fundus. For example, if fundus is 2 cm above umbilicus, it is recorded as +2 cm
or +2 fb; or if below, record as −2 cm or −2 fb.
• Administer oxytocin intramuscularly or intravenously as ordered by physician
• Monitor and document lochia
• Document when the mother voids; assess for bladder distention
• Document perineal bruising or edema and status of the episiotomy, presence of hemorrhoids
• Document D.H.'s emotional state
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A registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.)
a. State Nurse Practice Act b. The facility's Policies and Procedures manual c. The LPN's level of education and experience d. The Joint Commission's goals and criterion e. Client needs and prescribed orders
A group of nurses would like to help change a workplace policy. What should these nurses consider in this desire?
1. Political action is best carried out individually. 2. Working in a group will require less individual time. 3. Group work fosters creative thinking and planning. 4. People with deep feelings about an issue often are too involved to be effective.
The patient's admitting 12-lead ECG shows wide, M-shaped P waves. Which of the following admitting diagnoses could be responsible for this finding?
a. Mitral stenosis b. Chronic pulmonary disease c. Hypotension d. Pericarditis
The nurse is planning care for a number of clients who have been victims of a tornado. Which nursing diagnosis would the nurse include in the plan of care for the victims?
1. Decreased Cardiac Output. 2. Risk for Post-Trauma Syndrome. 3. Chronic Confusion. 4. Fatigue.