During the fourth stage of labor, the nurse assesses the client's fundal height and tone. While completing this assessment, the nurse does which of the following to prevent prolapse or inversion of the uterus?
A) Place the index and middle fingers across the muscle
B) Palpate the abdomen while feeling the uterine fundus
C) Massage the fundus carefully to expel any blood clots
D) Place a gloved hand just above the symphysis pubis
D
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The nurse is collecting data on prenatal clients at a clinic on a Native American reservation in Arizona. One client has risk factors for substance abuse. What physical sign or signs did the nurse assess that suggest substance abuse in this client?
Select all that apply. A) Dilated pupils B) Odor of alcohol on the breath C) Frequent accidents or falls D) Underweight E) Dressed in jeans and a t-shirt
Ordered: Coumadin 2.5 mg PO daily at bedtime. Available:
a. What is the primary danger of Coumadin overdose? b. Which test result needs to be monitored: aPTT or INR? c. Which antidote needs to be available: vitamin K or protamine sulfate?
Which priority nursing actions should the nurse take prior to administering penicillin G benzathine (Bicillin LA) to a client?
A. Have the client lie down and assess vital signs. B. Inquire about a history of allergies to penicillin. C. Inform the client that they will need be observed for 30 minutes after the injection. D. Inform the client that they will need someone to drive them home. E. Advise the client to rest for the remainder of the day.
An Asian-American patient diagnosed with depression explains to the nurse that eating two specific foods will restore the balance of hot and cold and she will be cured. The nurse should:
a. Explain that foods cannot cure mental disorders. b. Arrange for the patient to talk with the dietitian. c. Change the subject to focus on medication compliance. d. Accept that cultural beliefs about illness die slowly.