A patient who has already had one successful vaginal birth after cesarean (VBAC) has elected to deliver her third child vaginally
She reports a sudden sensation of "something snapping inside," followed by chest pain. What should the nurse do?
A) Remind the patient that this stage of labor always seems longer than it really is
B) Assist the patient into the squatting or hands-and-knees position
C) Monitor the EFM tracing for nonreassuring patterns
D) Notify the health care provider for a possible ruptured uterus
Ans: D
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The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient
During the orientation phase of the interview, the nurse should: a. obtain demographic data using open-ended questions. b. establish the name by which the patient prefers to be addressed. c. gather general information using closed-ended questions. d. stand by the bedside to ask the needed questions.
The nurse is performing a skin assessment on a client diagnosed with systemic lupus erythematosus (SLE). Which assessment findings does the nurse anticipate? Select all that apply.
A) Paronychia B) Facial butterfly rash C) Discoid lesions D) Alopecia E) Contact dermatitis
The nurse reviews the chart of a child and notes that the child is prescribed methylphenidate (Ritalin). The nurse expects to see which of the following if the Ritalin is effective?
A) Ability to focus B) Insomnia C) Anxiety D) Hallucinations
Which of the following nursing statements reflects the best understanding of the importance of appropriate nursing documentation regarding risk management?
1. "If the client isn't compliant, I'm sure to put that in my notes." 2. "I'm always careful to document any changes in the client's condition." 3. "My notes are the proof that I provided the client with effective, appropriate care." 4. "When there is a lawsuit, the nursing notes are the first thing the attorney looks at."