Sandra, 30 year old, primigravida consulted the Obstetrical Unit for a prenatal visit. She complains of abdominal pain and vaginal bleeding. She was diagnosed as Pregnancy Uterine 28 weeks AOG, Gestational Hypertension. Which of the following assessments should the nurse perform first? a. Assess strength of contractions b. Assess serum electrolytes c. Assess urinary output d. Assess fetal heart tones
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Sandra, 30 year old, primigravida consulted the Obstetrical Unit for a prenatal visit. She complains of abdominal pain and vaginal bleeding. She was diagnosed as Pregnancy Uterine 28 weeks AOG, Gestational Hypertension. Which of the following assessments should the nurse perform first?
a. Assess strength of contractions
b. Assess serum electrolytes
c. Assess urinary output
d. Assess fetal heart tones
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- SITUATION: Bella Bernardo 24 year old gravida 4 para 2 visits the prenatal clinic for her check-up. Her last LMP was August 21, 2020. Determine the age of gestation AOG] of the client on December 25, 2020. The nurse anticipates the following laboratory exams to be requested, except: a. Serum HBSAg b. Blood glucose level c. Urinalysis d. Complete blood countScenario Client, Mary Smith, DOB 4/27/1976, was admitted to your unit yesterday with a bladder infection related to neurogenic bladder. The client is part of your assignment today and she is due for her 10 a.m. medication. You go to see her to administer her medication, and she is complaining of feeling like she needs to urinate but has been unable to void since this morning at 5:30 a.m. You review the client’s chart and find these orders: If client has not voided within 4 hours, use bladder scanner to check residual amount. If residual is > 200mL then perform intermittent urinary catheterization. You use the bladder scanner and see that there is 400mL urine in the bladder. Following the provider’s orders, you perform an intermittent urinary catheterization using sterile technique. Document the procedure for the intermittent urinary catheterization for this patient?A client at 30 weeks gestation is admitted to the maternity unit with vaginal bleeding. What should be the RN’s initial nursing response? Question 31 options: a) Count and weigh peripads b) Start an intravenous infusion drip c) Assess blood pressure and pulse d) Observe for pallor, clammy skin, and perspiration
- When a patient is admitted to the unit in active labor, what is the action the nurse should take? a. Take vital signs only and check FHT b. Assess for ruptured membranes c. Perform Leopolds maneuver d. Catheterize the urine specimenA nurse is flushing a patient’s implanted port after adminis-tering medications. The nurse observes that the port flushes, but does not have a blood return. What would be the nurse’snext action based on these findings?a. Gently push down on the needle and flush it a second time.b. Stop flushing and remove the needle; notify the primarycare provider.c. Ask the patient to perform a Valsalva maneuver; changethe patient position.d. Close the clamp; wait 3 minutes, try flushing the portagain.A nurse is assessing infants in the NICU for fluid balancestatus. Which nursing action would the nurse depend on asthe most reliable indicator of a patient’s fluid balance status?a. Recording intake and outputb. Testing skin turgorc. Reviewing the complete blood countd. Measuring weight daily
- A physician has ordered hypotonic parenteral therapy for a post-operativeclient over a 24-hour period. Based on this order, what is the priority nursing action? a. Verify the order with the physician and pharmacy and hang the fluid as ordered.b. Obtain a pump for the infusion. c. Place the client on intake and output measures.d. Begin intravenous hypotonic fluids.The nurse is discussing therapy with clomiphene (Clomid) with a husband and wife who are considering trying this drug as part of treatment for infertility. It is important that they be informed of which possible effect of this drug? a) Increased menstrual flowb )Increased menstrual crampingc) Multiple pregnancy (twins or more)d )SedationThe nurse is caring for a 40-year-old client who is 2 hours postoperative following an appendectomy. The client received general anesthesia for the procedure and has opioid pain medications prescribed. The client’s vital signs are Temp 97.2°F, HR 105, RR 24 and BP 110/50. The client has had only 30 mL urine output since arriving to the postoperative area. The client is arousable and slow to respond to commands, but has become slightly restless, shifting in the bed frequently. The client states that they “hurt” and asks for something to drink. The last dose of IV pain medication was given to the client just before leaving the surgical suite. Discuss three key pieces of assessment data and why you feel they are important. Discuss nursing interventions you would implement in caring for this client.
- A client is in the first hour of her recovery after a vaginal birth. During an assessment, the lochia is moderate to heavy, bright red, and is tricking from the vagina. The nurse located the fundus at the umbilicus: it is firm and midline, with no palpable bladder. The client’s vital signs remain at their baseline. Based on the information, the nurse would implement which of the following actions? Document the findings as normal Increase IV rate Recheck the admission hematocrit and hemoglobin levels Report the findings to the healthcare providerA patient with end-stage renal disease is admitted with orders for hemodialysis. Which actions should the nurse take to prepare the client for hemodialysis? Select all that apply. 1 .Administer subcutaneous heparin to decrease clotting during dialysis 2. Administer the client's morning doses of carvedilol and lisinopril 3. Check the client's medical records to determine the last post-dialysis weight 4. Obtain a set of client vital signs and the client's current weight 5. Palpate the fistula in the client's arm for a thrill and auscultate for a bruitThe nurse is caring for a client who is 10 weeks gestation and palpates the fundus at 2 fingerbreaths above the pubic symphysis. The client reports nausea, vomiting and scant dark brown vaginal discharge. Which action should the nurse take? a. Measure vital signs b. Recommend bed rest c. Collect urine sample for urinalysis d. Obtain human chononic gonadatropin levels