During a postpartum assessment of a women who delivered just hours ago, the nurse notices a continuous trickle of blood from the vagina. The fundus is firm and the bladder is not full. The nurse's best action is to:
1. Document normal lochia.
2. Instruct the client to inform the nurse when pads are changed.
3. Notify the primary RN.
4. Instruct the client to remain in bed until lochia is checked again.
3
Rationale: This is excessive blood loss, and the nurse should notify the primary RN so the client can be further assessed.
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The nurse and a client talk about healthy ways to meet needs. The client states, "When I am looking really good, it is not asking too much for people to acknowledge me." The nurse recognizes that this experience is indicative of:
1. Affective instability. 2. Splitting. 3. Feelings of emptiness. 4. A sense of entitlement.
Which of the following is a correct statement about the empowerment of a patient?
1. The nurse tells the patient what to do. 2. The nurse treats all patients the same. 3. The patient must actively participate in his or her own care. 4. The doctor tells the patient what to do without input from the patient.
When a nurse cares for a newborn who has spina bifida occulta, which of these signs would be evident?
a. a dimple at the base of the spine on the infant's back b. a mild degree of paralysis of the lower extremities with no visible defect c. paralysis of the lower extremities, including lack of sphincter control d. progressive hydrocephalus and a protrusion of the meninges through the skin of the back
A 15-year-old girl is brought to the clinic by her mother because the girl has been experiencing irregular and sporadic menstrual periods and excessive body hair growth. Polycystic ovary syndrome is suspected. Which additional assessment finding would help to support this suspicion?
What will be an ideal response?