A nurse assesses a G2 P1 woman who gave birth to a 4500 gram baby boy 2 hours ago. The nurse notes that the woman's labor was only 2 hours and that the infant was delivered by the labor nurse
The nurse's assessment findings are:
Fundus firm and midline at umbilicus
Lochia heavy—saturates pad within 15 minutes and bleeding is a steady stream without clots
Perineum intact, slight bruising
Ice pack on perineum
Vital signs are B/P 105/65, P 98, R 20, T 38°
Based on this information, the nurse is concerned that the woman has a __________ of the __________ or __________.
Fill in the blank with the appropriate word.
ANS: laceration; cervix; vagina
Based on the assessment data, the woman is experiencing an early postpartum hemorrhage (PPH). The hemorrhage is most likely not due to uterine atony because the fundus is firm and midline. Laceration of the cervix or vagina is the second most common cause of early PPH. This woman is displaying typical signs and symptoms of laceration of cervix or vagina—firm, midline fundus with steady stream of blood without clots.
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Amniotic fluid surrounds the growing fetus and increases in volume as the pregnancy progresses. If the pregnant woman thinks her membranes have ruptured, which assessment finding would verify that the woman's membranes have ruptured?
A) fluid in vagina would test alkaline with litmus paper B) fluid would be acidic when tested with litmus paper C) fluid would be mixed with bloody show from cervix D) fluid amount remaining in the uterus could be measured
The nurse is explaining fetus viability to a client considering terminating her pregnancy. The nurse explains that a fetus is usually considered viable and can survive with medical interventions at how many weeks' gestation?
a. 16 c. 24 b. 18 d. 28
An older patient has moved into an adult child's home after an extended stay at a rehabilitation facility. The patient complains the child is now "the boss" and the child complains about care-giving duties. What action by the nurse is best?
a. Help the older patient find another place to live. b. Suggest that it is time for assisted living. c. Mediate a family meeting to discuss roles. d. Listen empathetically but let them work it out.
A client with a history of malingering pain tells the nurse that he needs a prescription for pain medication. Which of the following should the nurse do first to assist this client?
1. Ask the physician for a pain medication prescription for the client. 2. Remind the client that he does not have pain but just wants the medication. 3. Thoroughly assess the client for pain. 4. Suggest the client seek counseling for his pain medication-seeking behavior.