A young adolescent is transferred to the labor and delivery unit from the emergency department. The patient is in active labor but did not know that she was pregnant. The most important nursing action is to:
1. Determine who might be the father of the baby for paternity testing.
2. Ask the patient what kind of birthing experience she would like to have.
3. Assess blood pressure and check for proteinuria.
4. Obtain a Social Services referral to discuss adoption.
Correct Answer: 3
Rationale 1: Paternity testing is a lower priority than the physiologic well-being of the patient and fetus.
Rationale 2: A patient with a previously undiagnosed pregnancy is unlikely to have given any thought to childbearing preferences.
Rationale 3: Pre-eclampsia is more common among adolescents than in young adults, and it is potentially life-threatening to both the mother and fetus. This assessment is the highest priority.
Rationale 4: During labor is an inappropriate time to discuss adoption or parenting. Wait until after the birth to have this discussion when dealing with an adolescent who did not know she was pregnant prior to the onset of labor.
You might also like to view...
An unidentified motor vehicle accident victim is admitted to the critical care unit after being stabilized in the ED. Day 2, the patient is experiencing hypoxemia, edema in the extremities, and microthrombi in the vessels and in the interstitium
The nurse recognizes this as A) disseminated intravascular coagulation (DIC). B) systemic inflammatory response syndrome (SIRS). C) syndrome of inappropriate antidiuretic hormone (SIADH). D) myocardial infarction (MI).
The nurse can safely administer medications that are prepared by another nurse. __________
Indicate whether the statement is true or false.
The nurse educator trains case managers on the use of an electronic medical record when providing client care. Which participant statements indicate that training has been effective?
Select all that apply. A) "The record reduces the cost of health care." B) "The record allows trending of client progress." C) "Client education is to be documented in the system." D) "Quality metrics can be observed to reduce readmission rates." E) "Coordination of care is improved."
When considering elderly long-term care, nursing research has shown which of the following concerning facility residents MOST likely to participate in animal-assisted therapy (AAT)?
a. Those who elect to participate in AAT are less likely to have previously owned a pet. b. Those who have previously owned a pet find AAT to be a traumatic reminder of their pets. c. Prior life experiences with pets is a major factor influencing desire to participate in AAT. d. Not having prior life experience with pets motivates the elderly to try something new.