Two hours after delivery, a client's fundus is boggy and has risen to above the umbilicus. What is the first action the nurse would take?
1. Massage the fundus until firm
2. Express retained clots
3. Increase the intravenous solution
4. Call the physician
1
Explanation: 1. When the uterus becomes boggy, pooling of blood occurs within it, resulting in the formation of clots. Anything left in the uterus prevents it from contracting effectively. Thus if it becomes boggy or appears to rise in the abdomen, the fundus should be massaged until firm.
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Verbal communication becomes even more difficult when an interaction involves people who speak different languages. What can a nurse do to mitigate this difficulty?
1. Speak quickly so the client can understand more rapidly. 2. Speak louder, even if the client does not understand the language. 3. Avoid slang words, medical terminology, and abbreviations. 4. Do nothing; understanding is the client's problem, not the nurse's.
Why should a nurse not touch a client with schizophrenia without warning?
A) It frightens the client. C) It disorients the client. B) It generates a violent response. D) It generates anxiety in the client.
The nursing instructor is teaching the senior nursing students about the stages of crisis
The instructor uses the following example: The nurse notes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their remorse, while explaining that there was probably little they could do to prevent the injury. What stage of crisis is this family in? A) Anxiety and denial B) Remorse and guilt C) Anger D) Grief
The parents of a 2-month-old boy are concerned about spoiling their son by picking him up when he cries. What is the nurse's best response?
a. "Allow him to cry for no longer than 15 minutes and then pick him up." b. "Babies need comforting and cuddling. Meeting these needs will not spoil him." c. "Babies this young cry when they are hungry. Try feeding him when he cries." d. "If he isn't soiled or wet, leave him, and he'll cry himself to sleep."