A client delivered twins vaginally one-half hour ago with a midline episiotomy done under local anesthesia. Immediately after delivery, what would the nurse include in her nursing care plan?
a. Massage the fundus constantly.
b. Monitor blood pressure q5min.
c. Monitor temperature q30min.
d. Palpate the uterus to check muscle tone q15min.
D
The uterus should be palpated every 15 minutes for the first 1 to 2 hours postpartum. Massage is indicated if the uterus is boggy and should be done only until the uterus becomes firm. The vital signs should be monitored every 15 minutes for the first 1 to 2 hours postpartum.
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During an evaluation conference, the nurse manager observes nonverbal messages, including nodding of the head in agreement and smiling. These behaviors are examples of:
1. Metacommunication. 2. Intrasender conflict. 3. Fogging. 4. Intersender incongruity.
The priority nursing responsibility while caring for a patient with vertigo is
a. safety. b. comfort. c. hygiene. d. quiet.
A female client is being discharged after a lengthy hospitalization. The family is from a male-dominated culture. Before discharge instructions are given, which action should the nurse take?
1. Make sure instructions are understood by the client. 2. Arrange for teaching when the spouse is available. 3. Make sure that the physician gives the instructions. 4. Ask the client when the best time for teaching would be.
The nurse determines that a patient has a normal capillary refill time. What was this patient's refill time?
a. 3 seconds b. 4 seconds c. 5 seconds d. 6 seconds