The nurse is observing a new graduate's assessment of a ...

[Davideckstein7]

The nurse is observing a new graduate's assessment of a postpartum patient. Which action by the student nurse should prompt a corrective intervention by the preceptor nurse?
 
  1. Ask the patient to void, and don clean gloves.
  2. Discussing the effectiveness of patient comfort measures while performing the perineal assessment.
  3. Instructing the patient's visitors to leave the room prior to beginning the assessment.
  4. Requesting that the patient lie flat in bed with her head on a pillow prior to the fundal assessment.

Question 2

A Jewish patient delivers a healthy baby boy on Thursday afternoon, and she is set to be discharged on Saturday morning. Why might this present a problem for the patient?
 
  1. Jewish custom is to have the infant circumcised two days after birth.
  2. The woman will expect to be in the hospital at least seven days after delivery.
  3. Saturday is considered the Sabbath and she will not be able to leave the hospital that day.
  4. The husband cannot touch his wife while she is experiencing vaginal discharge, so he will not be able to assist his wife to and from the vehicle.

[ricroger]

Answer to Question 1

Correct Answer:
Rationale 1: Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids.
Rationale 2: The assessment provides an excellent opportunity for teaching about good healthcare practices in both the short and long term, including comfort measures.
Rationale 3: The nurse should allow the patient to choose whether visitors leave or remain in the room during the assessment.
Rationale 4: The supine position prevents a falsely high assessment of fundal height.

Answer to Question 2

Correct Answer: 3
Rationale 1: Jewish custom is to have the infant circumcised eight days after birth, not two days after birth. Jewish couples will need to return to the hospital for circumcision of the infant after discharge.
Rationale 2: The woman will expect to be cared for by her family for the first seven days after delivery. This does not need to take place in the hospital and should not interfere with discharge from the hospital.
Rationale 3: The Sabbath is sacred for Jews, and Jewish custom prohibits travel, writing, and the use of electricity on the Sabbath. Therefore, the woman will not travel home or sign any discharge forms until after the Sabbath.
Rationale 4: If the patient had a normal delivery and healthy baby, she will be able to walk on her own. Therefore, this would not interfere with the woman's discharge from the hospital.

[Davideckstein7]

TYSM

[laurnthompson]

Excellent