The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the client's record?
a. Fetal heart rate
b. Pain level
c. Test results ensuring that the fluid is not urine
d. The client's understanding of the event
ANS: A
Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The client's understanding of the event would only need to be documented if it presents a problem.
You might also like to view...
Patients meeting criteria for imminent death and cardiac death are to be
a. immediately placed on life support and referred to the organ procurement organizations. b. referred to the organ procurement organizations at the time of their death. c. referred to the organ procurement organizations in a timely manner. d. referred to physician to make the decision if they are a candidate for organ donation.
The nurse cared for Senator Bill Smith while he was hospitalized last year. The nurse now wishes to send him a letter supporting a bill that will be voted on in the current legislative session
Which salutation should the nurse use in the letter? 1. Dear Senator: 2. Dear Bill: 3. Dear Sir: 4. To whom it may concern:
A researcher wants to obtain a large sample of participants for his survey with the least amount of trouble. Each participant is asked to complete the survey containing 10 likert type items. Each person completing the survey will receive a gift card for a local fast food restaurant. The researcher stands in a mall food court and ask patrons to participate in the research. Which method of sampling is this?
A nurse is using a concurrent audit to review documentation following home health visits. Which of the following statements describes why this type of audit is most appropriate in this situation?
a. It is less costly than a retrospective audit. b. It represents the total picture of care that the client receives. c. It provides more accurate data for plan-ning corrective action. d. It identifies problems at the time that care is given.