The parents have understood the nurse's teaching with regard to ...

[bobthebuilder]

The parents have understood the nurse's teaching with regard to colostomy stoma care for their infant if they state
 
  1. We will change the colostomy bagwith each wet diaper.
  2. We will use adhesive enhancerswhen we change the bag.
  3. We will watch for skin irritationaround the stoma.
  4. We will expect a moderate amountof bleeding after cleansing the area around the stoma.

Question 2

The patient at 30 weeks' gestation is admitted with painless late vaginal bleeding. The nurse understands that expectant management includes:
 
  1. Limiting vaginal exams to only one per 24-hour period.
  2. Evaluating the fetal heart rate with an internal monitor.
  3. Monitoring for blood loss, pain, and uterine contractibility.
  4. Assessing blood pressure every 2 hours.

[katieost]

Answer to Question 1

Answer:3
Rationale:Skin irritation around the stoma should be assessed;it may indicate leakage.Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin,and removal of the appliance can strip off the skin. Also,adhesive contains latex,and its constant use is not advised due to risk of latex allergy development.Bleedin g is usually attributable to excessive cleaning.

Answer to Question 2

3
Rationale 1: Vaginal exams are contraindicated because the exam can stimulate bleeding.
Rationale 2: Fetal heart rate monitoring will be done with an external fetal monitor. The placenta is covering the cervical os, and therefore the fetal scalp cannot be accessed to apply an internal monitor.
Rationale 3: Blood loss, pain, and uterine contractibility need to be assessed for patient comfort and safety.
Rationale 4: Blood pressure measurements every 2 hours are unnecessary. They can be done on a routine basis or p.r.n.

[bobthebuilder]

Wow, this really help

[vickybb89]

Excellent