A patient delivers within 3 hours of the onset of labor. Which of the potential maternal risks should the nurse consider when planning her care? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Postpartum hemorrhage
2. Macrosomic fetus
3. Oligohydramnios
4. Abruptio placentae
5. Lacerations of the cervix
1,4,5
Rationale 1: Postpartum hemorrhage can occur because the uterus often becomes hypotonic after delivery from a precipitous labor and birth.
Rationale 2: This could be the result of a postterm delivery, not precipitous labor.
Rationale 3: This can increase cord compression in postterm labor, not precipitous labor.
Rationale 4: Abnormally strong contractions in a precipitous labor and birth can cause abruptio placentae.
Rationale 5: Lacerations of the cervix, vagina, and perineum can occur with rapid cervical dilatation and fetal descent.
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The nurse is admitting a client to the psychiatric unit. Which nursing action is correct?
1. Instruct the client that all information gathered during the assessment will be shared with the mental health team. 2. Alert the client that the psychiatrist will do all the intake assessment to maximize the efficiency of the team. 3. Discuss with the client information that is to be shared with family members and the mental health team. 4. Instruct the client that the mental health team will decide what the client needs to do in treatment.
The nurse is repositioning her patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the HOB should be placed at:
a. flat. b. 90 degrees. c. 30 degrees. d. 45 degrees.
To prevent breast engorgement, the new breastfeeding mother should be instructed to:
a. apply cold packs to the breast prior to feeding. b. breastfeed frequently and for adequate lengths of time. c. limit her intake of fluids for the first few days. d. feed her infant no more than every 4 hours.
The best way to monitor agitation and effectiveness of treating it in the critically ill patient is to use a/the:
a. Confusion Assessment Method (CAM-ICU). b. FACES assessment tool. c. Glasgow Coma Scale. d. scale such as Richmond Agitation Sedation Scale.