The nurse has written the nursing diagnosis Injury, Risk for for ...

[waynest]

The nurse has written the nursing diagnosis Injury, Risk for for a diabetic pregnant client. Interventions for this diagnosis include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected.
 
  Select all that apply. 1. Assessment of fetal heart tones
  2. Perform oxytocin challenge test, if ordered
  3. Refer the client to a diabetes support group
  4. Assist with the biophysical profile assessment
  5. Develop an appropriate teaching plan

Question 2

The nurse caring for a patient in labor anticipates fetal macrosomia and shoulder dystocia.
 
  Appropriate management of shoulder dystocia is essential in order to prevent which fetal complications? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Brachial plexus injury
  2. Fractured clavicle
  3. Asphyxia
  4. Neurological damage
  5. Puerperal infection

[tdewitt]

Answer to Question 1

1, 2, 4
Explanation: 1. Reassuring fetal heart rate variability and accelerations are interpreted as adequate placental oxygenation.
2. The nurse would perform oxytocin challenge test (OCT)/contraction stress test (CST) and non-stress tests as determined by physician.
4. The nurse assists the physician in performing a biophysical profile assessment.

Answer to Question 2

1,2,3,4
Rationale 1: Brachial plexus injury occurs due to improper or excessive traction applied to the fetal head.
Rationale 2: Fractured clavicles can occur as a result of the excessive traction applied to the fetal head.
Rationale 3: Asphyxia of the fetus can occur during this obstetric emergency and the possible inability to deliver the fetal body.
Rationale 4: Neurological damage can result from excessive traction applied to the fetal head and the increased incidence of vacuum and forceps birth.
Rationale 5: This is a risk for the mother, not for the fetus.

[waynest]

Gracias!

[Perkypinki]

TYSM