A nurse manager on the OB unit is auditing patient charts. One ...

[RRMR]

A nurse manager on the OB unit is auditing patient charts. One record documents the care of a patient having a seizure. The record describes the time and length of the seizure, medications given, maternal and fetal vital signs, and outcome of treatment.
 
  Which action by the manager is best?
  A.
  Compare the chart with charts of similar patients.
  B.
  Educate the staff on better documentation practices.
  C.
  Have the nurse rewrite the documentation.
  D.
  No action is needed; continue with chart audits.

Question 2

A pregnant woman who has diabetes mellitus is in the high-risk OB clinic for a checkup. The nurse notes that her hemoglobin A1C (HbAIC) is 5. Which action by the nurse is most appropriate?
 
  A.
  Arrange a referral to the diabetic nurse educator.
  B.
  Assess for factors leading to noncompliance.
  C.
  Document the findings in the patient's chart.
  D.
  Schedule another HbAIC in 4 weeks.

[Natalie4ever]

Answer to Question 1

ANS: B
The elements of complete documentation include what was charted plus associated symptoms, presence (or absence) of uterine contractions, and the presence of other obstetrical complications (e.g., rupture of membranes). The manager should educate all nurses in the unit about complete documentation needed for patients having a seizure. There is no need to compare this chart with others, and the nurse should not rewrite the documentation (although the nurse may need to use an addendum, depending on how old the record is).

Answer to Question 2

ANS: C
Control of maternal glucose levels (< 7.0 in overtly diabetic women) is an important factor in determining fetal outcome. The glycosylated hemoglobin A1c (HbA1c) level is commonly assessed to guide adjustments in the treatment plan throughout pregnancy. Because the maternal serum HbA1c reflects the degree of glycemic control during the preceding 5 to 6 weeks, the test is repeated every trimester. Good diabetic control is reflected by an HbA1c value of 2.5 to 5.9; an HbA1c value greater than 8 is indicative of poor diabetic control. Because the patient's value indicates good control, the most appropriate action is documentation. The patient may need to see the diabetic nurse educator, depending on other nursing assessments or patient desire.