The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode is to:
a. assess fetal heart rate and maternal vital signs.
b. perform a venipuncture for hemoglobin and hematocrit levels.
c. place clean disposable pads to collect any drainage.
d. monitor uterine contractions.
A
Assessment of the fetal heart rate and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus.
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A preterm infant was born at 31 weeks and has been admitted to the NICU. The nurse notes expiratory grunting, nasal flaring, and cyanosis on room air. Which laboratory findings would correlate with this condition?
A. PaCO2: 56 mm Hg B. PaO2: 76 mm Hg C. pH: 7.30 D. SaO2: 94%
The nurse identifies the client using two forms of identification
Which methods would be acceptable? Select all that apply. 1. Ask the client, "Is your name Mr. xyz?" 2. Check the client's identification band. 3. Check the client's room number. 4. Ask the client for the birthdate. 5. Ask the client for the telephone number.
While conducting a client interview, the nurse notes the client is able to talk in a steady manner. This would be documented as being:
a. prosody. c. content. b. affect. d. fluency.
The nurse is conducting a follow-up assessment on a patient who lost a best friend several months ago. What patient statement would indicate that interventions have been effective?
1. "I just can't get over it." 2. "I think I'm sleeping better lately." 3. "I don't care about my loss anymore." 4. "I think that I am fine and don't really need treatment."