The nurse has received end of shift report on the postpartum unit. Which client should she see first?
1. Multip, second day post-cesarean, moderate lochia serosa
2. Primip, day of delivery, fundus firm 2 cm above umbilicus
3. Multip, first postpartum day, 4 cm diastasis recti abdominis
4. Primip, first postpartum day, hypoactive bowel sounds all quadrants
2
Rationale:
1. This client is not experiencing any unexpected findings.
2. This client is the top priority. The fundus should not be positioned above the fundus after delivery. This high location could indicate an overdistended bladder or uterine atony and excessive bleeding.
3. This finding is normal, especially in a multiparous client.
4. Bowel sounds are often decreased after delivery.
You might also like to view...
Aware that continuing education is a must in providing a high standard of patient care, a nurse will enhance her practice by
1. Taking a cooking class. 2. Becoming computer literate. 3. Studying the history of nursing. 4. Using research to improve practice.
The nurse anticipates that a patient without comorbidities and a blood pressure of 125/75 mmHg will be most likely be treated:
A) with lifestyle modifications. B) with lifestyle modifications and one antihypertensive medication. C) with lifestyle modifications and more than one antihypertensive medication. D) with lifestyle modifications and higher doses of more than one antihypertensive medications.
When assessing a patient following an aneurysmal subarachnoid hemorrhage, the nurse should be alert for delayed cerebral ischemia during which time period?
A) In the first 2 hours B) In 3 to 5 days C) In 3 to 14 days D) After 6 weeks
The nurse is caring for a patient who is undergoing an exercise treadmill test. What interventions would be appropriate for the test? (Select all that apply.)
a. Monitor electrocardiogram before, during, and after the test. b. Remove all metal objects. c. Monitor vital signs throughout the test. d. Administer antianxiety medication as ordered. e. Ask the patient about allergies to dyes used in diagnostic procedures.