A woman, gravida 3, para 2, is attending her fourth prenatal visit and confides in the nurse that she is battered by her husband. She is assessed to have multiple bruises at various stages of healing
What nursing actions are appropriate for the nurse to implement? (Select all that apply.)
a.
Tell the husband that authorities will be notified immediately.
b.
Provide privacy for the assessment.
c.
Determine if children are being hurt.
d.
Communicate in a non-judgmental way.
e.
Determine factors that increase the risk of injury.
ANS: B, C, D, E
The woman being assessed for abuse is taken to a private area. The nurse determines whether there are factors that increase the risk for severe injuries or homicide, such as drug use by the abuser, a gun in the house, prior use of a weapon, or violent behavior by the abuser outside the home. The nurse also determines whether children are being hurt. It is vital that the abuser not find out that the woman has reported the abuse or that she intends to leave.
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A nurse is caring for a woman who just experienced a cesarean birth under epidural anesthesia. What interventions are important to include on this woman's care plan? (Select all that apply.)
A. Apply compression stockings or sequential compression devices. B. Encourage ankle exercises while the woman remains in bed. C. Keep the woman NPO until she is allowed out of bed into a chair. D. Maintain bedrest until sensation returns to the woman's legs. E. Only allow the woman to hold her infant with supervision while in bed.
The nurse-theorist Pender developed which of the following?
A) Adaptation Model B) Social Cognitive Theory C) Health Belief Model D) Health Promotion Model
What instructions should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications?
a. Palpate the fundus daily to ensure that it is soft. b. Notify the physician of any increase in the amount of lochia or a return to bright red bleeding. c. Report any decrease in the amount of brownish red lochia. d. The passage of clots as large as an orange can be expected.
The nurse is preparing a patient to go home. Which skill should the nurse use when preparing this patient?
A. Familiarity with adult learning principles B. Ability to follow written orders C. Ability to support patient decision making D. Ability to use critical thinking