Shortly after the client's health care provider evaluated her cervical dilation as being 7 centimeters, she tells you, "I think I'm about to have the baby!" Which of these actions should the nurse take immediately?
a. Instruct her to pant.
b. Leave the room to notify the health care provider.
c. Open an emergency birth pack.
d. Visualize her perineum for crowning.
D
The active phase begins when the cervix is dilated 4 cm and ends when the cervix is dilated 8 cm. The client will focus on breathing techniques and is less receptive to teaching. Nursing interventions would include frequently visualizing the perineum for crowning.
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A woman who is admitted for an induction of labor with oxytocin is questioning the need for continuous electronic fetal monitoring. The appropriate response to this woman is
A. Hospital policy requires that all patients have continuous electronic fetal monitoring. B. I would like to answer your questions about continuous monitoring and give you some information about why continuous monitoring is recommended. C. Nurses have more training with continuous electronic fetal monitoring than intermittent auscultation so it is safer for you and your baby to use this method.
The nurse's outcome for the patient is, "Patient self-administers subcutaneous heparin before discharge.". What does the nurse include in patient teaching?
a. Expect large areas of bruising around the injection site. b. Promote heparin absorption by massaging the injection site. c. Choose one large area for consistent he-parin absorption. d. Inject heparin into the abdomen but avoid the umbilical area.
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis:
no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. b. sinus tachycardia. c. ventricular fibrillation. d. ventricular tachycardia.
A client tells a nurse that she wants to know what treatments she can refuse. Which is the most appropriate response by the nurse?
A) "Clients can refuse pharmacological but not psychological treatment." B) "Clients can refuse any treatment at any time." C) "Clients can refuse only electroconvulsive therapy." D) "Clients can refuse treatment, but professionals can override this right when clients are a danger to themselves or others."