A neonate with a meningomyelocele is to have surgery in the morning. Which nursing action is appropriate for this neonate?
1. Applying a diaper to prevent contamination of sac
2. Positioning the newborn in a side-lying position
3. Encouraging the mother to hold the newborn because she will not be able to pick him up after surgery
4. Positioning the newborn in a prone position
Question 2
The charge nurse is reviewing the plan of care for maternal clients currently admitted for postpartum care. During the course of the medical record review, which intervention requires immediate consideration for revision?
1. Daily prothrombin time (PT) measurements for coagulation assessment in a client receiving heparin for treatment of thrombophlebitis.
2. Use of the REEDA (redness, edema, ecchymosis, discharge, approximation) scale for assessment every 8 hours in the care of a client diagnosed with puerperal infection.
3. Misoprostol (Cytotec) administration to a client who demonstrates uterine atony and bleeding after receiving oxytocic medications.
4. Inserting a straight catheter to drain the overdistended bladder of a client during the early postpartum period of her care.
A fixed action pattern as an example of innate behaviour.
Five step nursing process
Nursing sensitive outcome
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