The charge nurse has received shift change report. Which patient requires immediate intervention?
1. Multip at 6 cm undergoing induction of labor, strong contractions every three minutes
2. Primip at 4 cm whose fetus is in a longitudinal lie with an cephalic presentation
3. Multip at 10 cm and fetus at +2 station experiencing a strong expulsion urge
4. Primip at 3 cm screaming in fear because her mother died during childbirth
4
Rationale:
1. Strong contractions every three minutes are an adequate labor pattern during induction of labor. This client is experiencing no complications.
2. Longitudinal lie with cephalic presentation is a head-down position. This is expected.
3. 10 cm is fully dilated; a +2 station is low in the pelvis. A strong expulsion urge is the urge to push, which will facilitate the birth of the child. These are expected.
4. This client is most likely fearful that she will die during labor if her mother died during childbirth. It is very rare to die during childbirth in developing countries. The extreme fear this client is experiencing could stimulate the fight-or-flight mechanism and hormone cascade, which can significantly slow the progress of her labor; screaming and muscle tension increase the body's oxygen consumption, and in extreme cases can lead to fetal hypoxia. This client requires education and a great deal of support, and is therefore the top priority.
You might also like to view...
Which of the following identified the ethical principles of respect for persons, beneficence, and justice as relevant to the conduct of research using human subjects in the United States?
a. Declaration of Helsinki b. Department of Health, Education, and Welfare regulations c. National Commission for the Protection of Human Subjects ordinance d. Nuremberg Code
When proper flexion of the ankle is lost and permanent plantar flexion of the foot develops, the condition is known as
1. Footdrop. 2. Contractures. 3. Osteoporosis. 4. Thromboembolism.
The method of community data collection that involves directed conversation with selected community members is known as:
1. Informant interview 2. Participant observation 3. Secondary analysis 4. Windshield survey
The nurse is performing a cognitive assessment on a 16 year-old client. Which behaviors demonstrated will the nurse identify as middle formal operational, according to Piaget's theory? Select all that apply
A) Reporting that he smokes marijuana occasionally. B) Wanting to make decisions about health care independently C) Being very concerned with implications of the Affordable Care Act regarding health care benefits D) Wanting their friends to visit them in the hospital more than their parents E) Difficulty understanding the implications their diagnosis might present