A woman with a history of mild heart failure has just vaginally given birth to a healthy baby. What action by the nurse is most important?
A.
Assess the woman for signs of heart failure.
B.
Facilitate an EKG.
C.
Insert a Foley catheter for hourly urine output assessments.
D.
Auscultate the woman's heart sounds.
ANS: A
Dramatic changes occur in the maternal hemodynamic system after the birth of the baby. This can lead to cardiac instability. In a woman with known heart failure, the nurse should be vigilant about assessing for signs of heart failure. Listening to heart sounds is part of the assessment, but is not sufficient. The woman may or may not need a catheter for hourly urine output assessments or an EKG.
You might also like to view...
A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help the client promote his or her own safety?
a. Encourage the client and family to be active partners. b. Have the client monitor hand hygiene in caregivers. c. Offer the family the opportunity to stay with the client. d. Tell the client to always wear his or her armband.
While working as the charge nurse on the 7 p.m. to 7 a.m. shift, the nurse overhears the UAP speaking harshly to Mr. Hernandez, who has an expressive aphasia and a left hemiparesis from a stroke
When the UAP leaves the room, the nurse decides to speak with her. Which of the following would be the most appropriate approach? A) "I have decided to change your assignment from Mr. Hernandez to Mrs. Hopkins" B) "I am concerned because it sounded to me as though you might be losing patience with Mr. Hernandez" C) "You need to watch your tone of voice as it sounded very harsh" D) "Perhaps you need to consider attending a training session on communication skills"
A client's therapeutic regimen for rheumatoid arthritis may include which of the following treatments? (Select all that apply.)
a. medications d. heat applications b. exercise e. cold applications c. rest f. stress management
The nurse is working with the parents of a newborn. The mother requires surgery and the follow-up treatment will interfere with bonding
In applying Freud's theory, the nurse recognizes that which of the following stages of the child's development will be affected? a. Oral stage b. Anal stage c. Phallic stage d. Latent stage