The nurse is preparing to assess assigned clients on a postpartum unit. Which client should be seen first?
1. Multipara, second day postcesarean, moderate lochia serosa
2. Primipara, day of delivery, fundus firm 2 cm above umbilicus
3. Multipara, first postpartum day, 4 cm diastasis recti abdominis
4. Primipara, first postpartum day, hypoactive bowel sounds all quadrants
2
Explanation:
1. This client is not experiencing any unexpected findings.
2. This client is the top priority. The fundus should not be positioned above the umbilicus 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.
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A menopausal woman tells the nurse that she does not know when to do a breast self-exam since she does not have a period any longer. The nurse's best response is
a. "Perform your exam on the first day of every other month." b. "A breast self-exam after menopause is not necessary. Just get a mammogram annually." c. "Select the same day of every month to do your exam." d. "Do your breast exam anytime you can re-member."
Approximately 30% of preterm infants weighing less than 1500 g develop bleeding around and into the ventricles of the brain. This condition is known as _______________
Fill in the blank(s) with correct word
A nurse is explaining to parents how the central nervous system of a child differs from that of an adult. Which statement accurately describes these differences?
a. The infant has 150 milliliters of cerebrospinal fluid compared with 50 milliliters in the adult. b. Papilledema is a common manifestation of increased intracranial pressure in the very young child. c. The brain of a term infant weighs less than half of the weight of the adult brain. d. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses.
If the skin around the dressing appears red and irritated, the nurse should avoid the use of:
A. Tape B. Gauze C. Montgomery ties D. Strips of hydrocolloid dressing