The nurse manager observes care being provided by a graduate nurse who is caring for a client undergoing a forceps delivery. Which action requires intervention?
1. Bladder is emptied using a straight catheter.
2. The client is instructed to push between contractions.
3. Fetal heart tones are consistently between 110 and 115.
4. Regional anesthesia is administered via pudendal block.
2
Explanation:
1. The urinary bladder is emptied to prevent the full bladder from impeding descent of the fetal head.
2. The client should only push during contractions, not between contractions.
3. These are normal fetal heart tones. No intervention is needed.
4. Regional anesthesia is important to facilitate application of the forceps and cooperation with pushing efforts.
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a. "I nearly always wear comfy sweatpants and house shoes." b. "I'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d. "My hands shake when I try to do things requiring coordination."
A client is prescribed a CNS stimulant as treatment for attention deficit hyperactivity disorder. Which of the following assessments would be most important for the nurse to obtain before administering the drug? Select all that apply
A) Blood pressure B) Weight C) Respiratory rate D) Behavior pattern E) Review of recent lab work
Which action should the nurse teach to the client to prevent toxic shock syndrome?
A. "Use a barrier method of contraception." B. "Wash your hands before inserting a tampon." C. "Avoid intercourse with more than one partner." D. "Empty your bladder immediately after intercourse."
The nurse is caring for a client who has been using barbiturates at high doses for a long period of time. What does the nurse expect when assessing this client? (Select all that apply.)
Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Tremors 2. Tolerance 3. Psychological dependence 4. Physical dependence 5. Hallucinations