The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention?
1. Woman at 7 cm, fetal heart tones auscultated every 90 minutes
2. Woman at 10 cm and pushing, external fetal monitor applied
3. Woman with meconium-stained fluid, internal fetal scalp electrode in use
4. Woman in preterm labor, external monitor in place
1
Explanation: 1. During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is not frequent enough.
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As a nurse following the conceptual framework of Madeleine Leininger, which of the following would be a particular focus of the nurse's care?
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A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take?
a. Inspect the wound for foreign bodies. b. Inspect the wound for bleeding. c. Determine the size of the wound. d. Determine the need for a tetanus antitoxin injection.
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1. Bruising 2. Hypertension 3. Muscle wasting 4. Muscle spasms