A client is admitted for oxytocin induction of labor due to post-dates. The nurse sees variable decelerations on the monitor. The nurse recognizes that in a post-date pregnancy, this most likely is caused by
a. decreased amniotic fluid c. nuchal cord
b. macrosomic infant d. placental insufficiency
A
Leakage of amniotic fluid is more likely in a postterm pregnancy, resulting in decreased amniotic fluid that can result in variable fetal decelerations because of umbilical cord compression. Macrosomic infant is a fetal complication associated with diabetes. Nuchal cord, also referred to as cord around the neck, is not a condition strongly associated with postterm pregnancy. Placental insufficiency can produce fetal heart tone decelerations, but the key in this question is postterm pregnancy.
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An RN working the 11 to 7 shift on Saturday night receives the following phone call from a recently discharged client, "I had my baby last night after a very fast labor, and they let me go home from the hospital this morning
Now I have this real bad pain in my bottom and a lot of pressure in my vagina that is getting worse. I took one Darvocet pill and it doesn't help at all." What is the best response to this inquiry? a. "A hematoma may be forming; you should notify your physician about these symptoms tonight." b. "One day past delivery you should still take two pills to get adequate pain relief." c. "Place ice on the episiotomy site for at least 8 hours to see if the pain resolves." d. "You may have retained placental fragments, is your uterus firm?"
The nurse is caring for a patient with a small chronic pressure ulcer on the ankle. Which activity can the nurse delegate to nursing assistive personnel (NAP)?
a. Measure the wound for length, width, and depth. b. Reposition the patient at least every 2 hours. c. Ask the patient to rate the pain during the dressing change. d. Examine the wound bed for the type and amount of tissue.
A nurse uses the SBAR method to hand off the communication to the health care team. Which of the following might be listed under the "B" of the acronym?
A) Vital signs B) Mental status C) Client request D) Further testing
Parents of an infant express concern because the infant is touching his genitals. What should the nurse teach the parents?
A) Self-manipulation of genitals is normal behavior in an infant. B) Have the child wear clothes that prohibit touching. C) If this bad behavior continues, seek counseling. D) Make him have time out every time it happens.