A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged
The nurse has the woman void and massages her fundus, but her fundus remains difficult to find and the rubra lochia remains heavy. The nurse should: a. continue to massage the fundus.
b. notify the physician.
c. recheck vital signs.
d. insert a Foley catheter.
B
The uterine muscle can be overly stimulated by massage, leading to uterine atony and rebound hemorrhage. Treatment of excessive bleeding requires the collaboration of the physician and the nurses. The nurse should call the clinician while a second nurse rechecks the vital signs. Do not leave the patient alone. The woman has voided successfully so a Foley catheter is not needed at this time.
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The nurse is aware that positioning and range-of-motion (ROM) exercises most help the immobilized patient to prevent:
a. increased pain. b. contractures. c. pressure ulcers. d. compromised circulation.
The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood
What nursing action is most appropriate to institute initially? a. Notify the physician. b. Place the child in Trendelenburg position. c. Apply a new bandage with more pressure. d. Apply direct pressure above the catheterization site.
Which disorder of the chest best describes these symptoms?
A 68-year-old retired postman presents to your clinic, complaining of dull, intermittent left-sided chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed and nauseated with the pain but has had no other symptoms. He states when he sits down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years. He denies any recent alcohol use and reports no drug use. He is married and has two healthy children. His mother died of breast cancer and his father died of a stroke. His younger brother has had bypass surgery. On examination you find him healthy-appearing and breathing comfortably. His blood pressure is 140/90 and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are unremarkable. His lungs have normal breath sounds and there are no abnormalities with percussion and palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending. A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain
The nurse is identifying the difference between primary headaches to secondary headaches. Secondary headaches can occur:
1. Because of stress. 2. In relation to low blood pressure. 3. Because of concussions. 4. Because of migraines.