A client with dysfunctional labor patterns has a nursing diagnosis of "Risk for Infection related to prolonged latent labor process." Which of the following would the nurse use as evidence to support this diagnosis?
a. Non-reassuring fetal tracing inclusive of severe variable decelerations; late decelerations
b. Maternal fever of 100.4°F or 38°C, maternal tachycardia, fetal tachycardia, or a combination of these
c. Client questions and an inability to cooperate with requested interventions
d. Frequent or persistent maternal requests for pain relief, frequent uterine contractions, poor uterine resting tone, and failure of the cervix to dilate 1 to 2 cm per hour on cervical assessment
B
The evidence that would support a diagnosis of risk for infection would include maternal fever of 100.4°F or 38°C, maternal tachycardia, fetal tachycardia, or a combination of these
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A nurse has administered an analgesic to a premature infant in pain. What assessment would indicate to the nurse that the baby's pain is improving?
A. Crunching the forehead B. Keeps eyes tightly closed C. Shallow respirations D. Sleeps after feeding
The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective?
A) "I'll make sure to limit my intake of protein." B) "I'll make sure that the bandage is wrapped tightly." C) "My foot should feel cool or cold while my leg's healing." D) "I'll eat plenty of fruits and vegetables."
An extremely anxious patient is beginning to awaken in the postanesthesia care unit. He or she states that his or her arms and legs feel like tree trunks and that they are hard to move
He or she also complains that his or her head feels "fuzzy" and that the right words will not come to his or her. What is the priority nursing intervention for this patient? A) Provide analgesic medication for the discomfort. B) Stay with patient as much as possible and provide reassurance. C) Provide fluids to increase his or her wakefulness. D) Encourage the patient to turn from side to side periodically.
Although a registered nurse has been working for several years as a staff nurse on an adult oncology unit, the nurse recently transferred to a pediatric unit in the hospital
The nurse will be in orientation for several days to learn about the different systems and will need to demonstrate proficiency in various pediatric areas such as medication administration. Which behavior is the nurse demonstrating? a. Competency b. Judgment c. Advocacy d. Utilitarianism