A woman experiences shivering and her blood pressure drops from ...

[frankwu]

A woman experiences shivering and her blood pressure drops from 120/80 mm Hg to 102/68 mm Hg shortly after giving birth. The nurse immediately removes the wet drapes and applies a warm blanket.
 
  The woman's fundus is firm, and there is no excessive bleeding. The woman asks, Why can't I stop shivering? The nurse's most appropriate response is: 1. You were shivering because of the pain that you experienced. The shivering will stop soon now that the pain is gone..
  2. You were shivering because your body cooled. Some women may have shiver-ing. This is a normal response..
  3. Your doctor will be here shortly to talk about your shivering..
  4. Don't worry. Your doctor will give you some pain medication that will cause your shivering to stop..

Question 2

A major nursing intervention for an infant born with myelomeningocele is to:
 
  1. protect the sac from injury.
  2. prepare the parents for the child's paralysis from the waist down.
  3. prepare the parents for the closure of the sac at around 2 years of age.
  4. assess for cyanosis.

[cadimas]

Answer to Question 1

2
1. Incorrect. During labor and immediately after the birth, women are predisposed to hypo-thermia because of the combination of the vasodilation that normally occurs during pregnan-cy and the effects of the analgesia and anesthesia.
2. Correct. During labor and immediately after the birth, women are predisposed to hypo-thermia because of the combination of the vasodilation that normally occurs during pregnan-cy and the effects of the analgesia and anesthesia. During labor, during vaginal or cesarean birth, or immediately after birth, women may have shivering, hypotension, and respiratory distress. The hypothermia may result in cardiovascular, pulmonary, circulatory, hematologic, neurologic, or renal complications. The nurse can minimize these complications by making sure that the birthing areas are warm, wet drapes and towels are removed, women are covered with warm blankets after birth, and hypothermia is recognized early.
3. Incorrect. This is an opportunity to provide teaching for the patient. It is not necessary for the physician to be contacted at this time.
4. Incorrect. The shivering is not likely to be related to pain. Furthermore, the nurse would most likely provide pain medication if needed (with a physician's order), not the physician.

Answer to Question 2

1
1. Correct. A major preoperative nursing intervention for a neonate with a myelomeningo-cele is protection of the protruding sac from injury to prevent its rupture and resultant risk of CNS infection.
2. Incorrect. The long-term prognosis in an affected infant can be determined to a large ex-tent at birth, with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved.
3. Incorrect. A myelomeningocele should be surgically closed within 24 hours.
4. Incorrect. Although the nurse would assess for multiple potential problems in this infant, the major nursing intervention would be to protect the sac from injury.

[frankwu]

Excellent

[bimper21]

TYSM