A client was admitted to the labor area at 5 cm with ruptured ...

[RODY.ELKHALIL]

A client was admitted to the labor area at 5 cm with ruptured membranes about 14 hours ago. What assessment data would be most beneficial for the nurse to collect?
 
  1. Blood pressure
  2. Temperature
  3. Pulse
  4. Respiration

Question 2

The labor and birth nurse is admitting a patient. The nurse's assessment includes asking the patient whom she would like to have present for the labor and birth, and what the patient would prefer to wear.
 
  The patient's partner asks the nurse the reason for these questions. The nurse's best response would be: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. These questions are asked of all women. It's no big deal.
  2. I'd prefer that your partner ask me all the questions, not you.
  3. A patient's preferences for her birth are important for me to understand.
  4. Many women have beliefs about childbearing that affect these choices.
  5. I'm gathering information that the nurses will use after the birth.

[Qarqy]

Answer to Question 1

2
Explanation: 2. Rupture of membranes places the mother at risk for infection. The temperature is the primary and often the first indication of a problem.

Answer to Question 2

3,4
Rationale 1: Although this information is asked of all patients, it is purposefully gathered.
Rationale 2: It is not therapeutic communication to tell the partner not to ask questions.
Rationale 3: The nurse incorporates the family's expectations into the plan of care to be culturally appropriate and to facilitate the birth.
Rationale 4: The nurse incorporates the family's expectations into the plan of care to be culturally appropriate and to facilitate the birth.
Rationale 5: The information gathered will be used during the labor and birth, not after delivery.

[RODY.ELKHALIL]

TYSM

[EAN94]

Excellent