A woman who has been abused for a number of years asks the nurse ...

[altibaby]

A woman who has been abused for a number of years asks the nurse for assistance in leaving the relationship. What response by the nurse is most appropriate?
 
  1. Comment that she should have left long ago.
  2. Remind the patient that that fault was not likely all attributable to her abuser.
  3. Encourage her to be sure with her decision, as her abuser will be difficult to deal with.
  4. Assist the patient to develop a safety plan.

Question 2

A telephone triage nurse gets a call from a postpartum patient who is concerned about jaundice. The patient's newborn is 37 hours old. What data point should the nurse gather first?
 
  1. Stool characteristics
  2. Fluid intake
  3. Skin color
  4. Bilirubin level

[atrochim]

Answer to Question 1

4
Rationale 1: This is an inappropriate comment.
Rationale 2: This is an inappropriate comment. Nursing needs to assure the patient that it is not her fault.
Rationale 3: This might be true, but is an inappropriate comment.
Rationale 4: The nurse should help the patient develop a plan for safely exiting the situation.

Answer to Question 2

3
Rationale 1: The stool characteristic of green coloration indicates excretion of bilirubin.
Rationale 2: Inadequate fluid intake can predispose an infant to jaundice, and is best determined by the number of wet diapers per day.
Rationale 3: Yellow coloration of the skin and sclera is a sign of physiologic jaundice that appears after the first 24 hours postnatally. Inspection of the skin would be the first step in assessing for jaundice.
Rationale 4: Skin color begins to appear yellow once the serum levels of bilirubin are about 46 mg/dL.