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deza01 deza01
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8 years ago Edited: 8 years ago, deza01
1. C - Uterine firmness
2. A - Risk for Injury
3. C - Apply perineal ice packs consistently for the first 24 to 48hrs
4. D - Hemorrhage
5. A - Massage the fundus
6. C - Activate the priority call light from the bedside
7. C - Assess for bladder distention
8. D - Obtain the vital signs and O2 saturation
9. 1mL
10. 240mL/hr
11. D - Firm fundus
12. C - Uterine atony
13. B - Call Mr.Wilson from the nurses' station to inform him of his wifes' status and request that he come to the hospital soon, without the children
14. B,C,E - Start an additional IV using 16 or 18 gauge angiocath. Prime a new Y-set blood tubing using a new bag of normal saline. Explain the blood transfusion process to Marie.
15. D - Explain Marie's history and request that the infant be fed with formula in the nursery
16. C - Provide a warm blanket and continue to monitor
17. C - Palpate Marie's bladder for fullness and catheterize if indicated
18. B - epidural anesthesia
19. B - Labor and delivery nurse with 12 years of experience, who was called in to work for 4 hours until 2300
20. B - Marie's nurse who has already given the shift report and is preparing to clock out
21. C - Obtain and document Marie's vital signs
22. A - Indications and mechanism of action of caffeine sodium benzoate
23. B - Allow Marie to rest during the blood transfusion, and administer the Rhogam as prescribed at a later time
24. A - Notify the security personnel and direct all staff to report to their assigned exit in the hospital
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wrote...
6 years ago
Need help pn evolve case study question "what is the sequence of nursing actions to assess maureen's 4th degree perineal laceration?(Arrange in order of priority , with the most immediate action as 1 and the least 6 )
1.Ask the client to turn on her side and flex her leg
2.Observe anus for edema which can interfere with bowel elimination
3.Put on Gloves
4.examine laceration for reeda( rednesss,ecchymosis ,edema, discharge and approximation)
5.dispose of soiled materials
6.apply clean peripad
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