Author Question: The nurse is observing a new graduate perform a postpartum assessment. Which action requires ... (Read 36 times)

ec501234 · **on:** Jun 27, 2018

The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse?

1. Asking the patient to void and donning clean gloves
2. Listening to bowel sounds, then asking when her last BM occurred
3. Telling visitors the assessment will be quick, then checking the fundus
4. Completing the assessment and explaining the results to the patient

Question 2

A patient at 32 weeks' gestation is admitted with painless vaginal bleeding. Placenta previa has been confirmed by ultrasound.

What should be included in the nursing plan? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. No vaginal exams
2. Encouraging activity
3. No intravenous access until labor begins
4. Evaluating fetal heart rate with an external monitor
5. Monitoring blood loss, pain, and uterine contractility

Missbam101 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

3
Rationale 1: Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids.
Rationale 2: It is appropriate to ask about a body part when assessing that part.
Rationale 3: The patient should be asked whether she wants visitors to remain in the room or leave the room prior to beginning the assessment.
Rationale 4: Informing the patient of the results and of the normalcy of the results helps reassure her.

Answer to Question 2

1,4,5
Rationale 1: Expectant management of placenta previa, when the patient is at less than 37 weeks' gestation, includes no vaginal exams.
Rationale 2: In cases of placenta previa, activity should not be encouraged.
Rationale 3: In cases of placenta previa, an intravenous access would be initiated before labor began.
Rationale 4: Expectant management of placenta previa, when the patient is at less than 37 weeks' gestation, includes evaluating FHR with an external monitor.
Rationale 5: Expectant management of placenta previa, when the patient is at less than 37 weeks' gestation, includes monitoring blood loss, pain, and uterine contractility.