After performing a vaginal examination on a laboring woman, the nurse charts: 80 percent, 5 cm, -1 . Which is a correct interpretation of the data?
a. Fetal presenting part is at the ischial spines.
b. Effacement is 3 centimeters from completion.
c. Dilation is 50 percent completed.
d. Effacement and dilation of the cervix is complete.
C
Complete cervical dilation is 10 cm, so this client's dilation is 50 percent complete. When fetal presenting part is at the ischial spines, the fetus would be at 0 station, but in this case the fetus is at -1 . Effacement refers to thinning of the cervix and is recorded in percentage not centimeters. This client is only effaced by 80 percent, so effacement is incomplete.
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The student nurse observes the staff nurse providing care to a patient with a chest tube. Which of the nurse's actions should the student recognize as incorrect and report to the nursing instructor?
a. Recording drainage from chest tube as output b. Securing the chest tube to the chest tube dressing c. Checking the water seal chamber for bubbling d. Milking the chest tube to promote drainage
The nurse is planning care for a 23-year-old client who has just been diagnosed with rheumatoid arthritis (RA). Which nursing diagnosis should the nurse identify as a priority for this patient's care?
1. Risk for aspiration 2. Disturbed body image 3. Bowel incontinence 4. Acute confusion
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Having concern for a person is:
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