The charge nurse is reviewing the plan of care for maternal patients currently admitted for postpartum care. During the course of her chart review, which intervention requires immediate consideration for revision?
1. Daily prothrombin time (PT) measurements for coagulation assessment in a woman receiving heparin for treatment of thrombophlebitis.
2. Use of the REEDA scale for assessment every 8 hours in the care of a patient diagnosed with puerperal infection.
3. Misoprostol (Cytotec) administration to a patient who demonstrates uterine atony and bleeding after receiving oxytocic medications.
4. Inserting a straight catheter to drain the overdistended bladder of a woman during the early postpartum period of her care.
Correct Answer: 1
Rationale 1: Prothrombin time (PT) evaluates the anticoagulation effects of Coumadin; the effects of heparin are assessed by way of activated partial thromboplastin time (aPTT).
Rationale 2: The nurse should inspect the woman's perineum every 8 to 12 hours for signs of early infection. The REEDA scale helps the nurse remember to consider redness, edema, ecchymosis, discharge, and approximation.
Rationale 3: Misoprostol (Cytotec) is used to prevent and treat uterine atony after failed attempts to control bleeding with oxytocics.
Rationale 4: Overdistention in the early postpartum period is often managed by draining the bladder with a straight catheter as a one-time measure.
You might also like to view...
Mr. John is an 81-year-old man who lives alone. On a recent visit to his physician, it was noted that Mr. John had dried feces on his legs and under his fingernails. His hair was oily, and his beard was unkempt
He had lost 15 lb in the last 2 months. Mr. John is at high risk for a. Diabetes b. Nursing home placement c. Adult day care d. Tuberculosis
Rh0 immune globulin will be ordered postpartum if which situation occurs?
a. Mother Rh-negative, baby Rh-positive b. Mother Rh-negative, baby Rh-negative c. Mother Rh-positive, baby Rh-positive d. Mother Rh-positive, baby Rh-negative
A 75-year-old patient is tearful, shaky, and withdrawn. She tells you that she is "worrying herself to death" about losing her aging husband and being "all alone." Why do you recognize this reaction as Anxiety rather than Fear? Select all that apply
a. It concerns future or anticipated events. b. It concerns anticipation of danger rather than a present danger. c. There is no shakiness or tearfulness present. d. There is a psychological rather than a physical threat.
The nurse is providing care for a hospice client who is in the last stages of the dying process. The client develops a pressure ulcer on her sacrum, and family members tell the nurse that they would like a specialist consulted to treat the ulcer
When the nurse discusses this with the client, the client states that the ulcer does not bother her, that it is not causing her pain, and that she'd rather not have additional caregivers at this time. What should the hospice nurse do next? a. Tell the family the wound care specialist will be consulted and treatment will begin. b. Ask the social worker and the chaplain to talk with family members about the dying process. c. Explain the client's desires to the family, emphasizing that the client will be made as comfortable as possible. d. Ask the agency mental health nurse to speak with the client about refusing treatment.