You notice that a laboring client's blood pressure is lower when she rests on her back than when she is on her side. This is because
a. she is having back labor
b. she is in early labor
c. the fetus may compress the major vessels when she is supine
d. there is pressure on her arteries in the side-lying position
C
Because maternal hypotension can occur in the supine position from the pressure of the fetus on the descending aorta or vena cava, the lateral position often is best for the well-being of both the mother and fetus during labor. This is not a manifestation of early labor. Pressure on the major vessels is usually relieved in the lateral position.
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A patient is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met?
A) Assess for edema. B) Assess skin integrity frequently. C) Assess the patient's level of consciousness frequently. D) Closely monitor intake and output.
Which nursing documentation best meets the requirement for problem-oriented charting?
a. "Pacing and muttering to self. Sensory perceptual alteration related to internal auditory stimulation. Given fluphenazine 2.5 mg PO at 0900 and went to room to lie down. Calmer by 0930 . Returned to lounge to watch TV." b. "Agitated behavior. Patient muttering to self as though answering an unseen person. Given haloperidol 2 mg PO and went to room to lie down. Patient calmer within 30 minutes. Returned to lounge to watch TV." c. "S: States ‘I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg PO. I: Haloperidol 2 mg PO given at 0900 . E: Returned to lounge at 0930 and quietly watched TV." d. "Pacing hall and muttering to self as though answering an unseen person. Haloperidol 2 mg PO administered at 0900, with calming effect in 30 minutes. Stated ‘I'm no longer bothered by the voices.'"
Compliance with prescribed medications must be monitored frequently and safeguards put in place to prevent or reduce the risk of
1. deceit. 2. suicide. 3. homicide. 4. manipulation.
The temperature of bath water should be
A. 90°F. B. 105°F. C. 120°F. D. 140°F.