Answer to Question 1
Correct Answer: 2
Rationale 1: The systolic blood pressure will change by up to 35 mm Hg during the first stage of labor and can increase further in the second stage of labor.
Rationale 2: A white count of 25,00030,000 is normal at the end of labor and during the early postpartum period. This white count is abnormally high and requires further assessment and provider notification.
Rationale 3: The respiratory rate increases during labor because uterine contractions increase oxygen requirements. This patient requires no further intervention.
Rationale 4: This is a normal urine output and requires no further intervention.
Answer to Question 2
Correct Answer: 1
Rationale 1: Softening and effacement of the cervix is accompanied by expulsion of the mucous plug and a small amount of blood loss from the exposed cervical capillaries. The resulting pink-tinged secretions are called bloody show. Bloody show is considered a sign that labor will begin within 24 to 48 hours.
Rationale 2: The patient is most likely demonstrating expulsion of the mucous plug and bloody show, which is considered a sign that labor will begin within 24 to 48 hours.
Rationale 3: The patient is describing pregnancy-related changes associated with imminent onset of labor. Based upon her report, there is no indication that cesarean section will be necessary.
Rationale 4: Chorioamnionitis is associated with premature rupture of amniotic membranes (PROM). Based upon the patient's report, she is demonstrating mucus plug expulsion and bloody show.
The nurse needs to note the source of the patient health history
Patient teaching: male genetalia assessment
Example of a patient statement.
Deliver abdominal thrusts to the supine unconscious patient.
Gingival enlargement in a patient taking nifedipine.
National Patient Safety Goals for Acute-Care Hospitals