During the initial intrapartal assessment of a client in early labor, the nurse performs a vaginal examination. The client's partner asks why this pelvic exam needs to be done
The nurse should explain that the purpose of the vaginal exam is to obtain information about which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Uterine contraction pattern
2. Fetal position
3. Presence of the mucous plug
4. Cervical dilation and effacement
5. Presenting part
4, 5
Explanation: 4. The vaginal examination of a laboring client obtains information about the station of the presenting part and the dilation and effacement of the cervix.
5. The vaginal examination of a laboring client obtains information about the fetal presenting part.
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The nurse is seeing a patient during a follow-up visit after discharge in which the patient had a nursing diagnosis of Ineffective coping. Which statement by the patient would be a cause for concern?
a. "I am sleeping better most nights." b. "I feel less anxious." c. "I do not need to do the relaxation exercises anymore." d. "I am continuing my exercises every day."
When assisting the battered woman to develop a safety plan, the nurse should
a. avoid documentation of the plan in the client's record b. give the client a list of community resources c. ask the local police department for help d. consider making contact with the spouse
Individuals receiving anticoagulant therapy with warfarin should be instructed to monitor their consumption of foods high in vitamin K because:
1. Vitamin K potentiates the action of warfarin 2. Warfarin causes hypervitaminosis K 3. The combination of the two substances is toxic to the liver 4. Excess vitamin K would decrease the effect of warfarin
The nurse should assess the infant's umbilical cord frequently during the first few hours after birth for:
a. Pallor b. Bleeding c. Herniation d. Infection