A woman who had two previous cesarean births is in active labor, when she suddenly complains of pain between her scapulae. The nurse's priority action should be to:
a. Reposition the woman with her hips slightly elevated.
b. Observe for abnormally high uterine resting tone.
c. Decrease the rate of nonadditive intravenous fluid.
d. Notify the physician promptly.
D
Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention.
Repositioning the woman with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties.
Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the woman at high risk for uterine rupture.
The woman is now at high risk for shock. Nonadditive intravenous fluids should be in-creased.
You might also like to view...
When confirming telephone orders or other communication, the LPN/LVN documents:
1. By whom the telephone order was received. 2. By whom the verbal order was received. 3. Agency protocol. 4. 100% read back.
While inspecting the pressure ulcer of a 90-year-old client, the nurse observes new tissue growth around the area, which is pinkish-red in color. The nurse should document the presence of:
1. epithelialization. 2. slough. 3. granulation. 4. eschar.
The nurse has been closely observing a client who has been displaying aggressive behaviors and notes that the client's aggressiveness is escalating. Which nursing intervention would be least helpful to this client at this time?
A. Initiating confinement measures B. Acknowledging the client's behavior C. Assisting the client to an area that is quiet D. Maintaining a safe distance with the client
Which interventions are appropriate for a burn patient newly admitted to the emergency department? (select all that apply.)
a. Cover burns with sterile saline–saturated towels. b. Carefully remove clothing adhered to burned areas. c. Carefully avoid disturbing blisters. d. Remove jewelry from injured limbs. e. Determine the causative agent of the burn.