Author Question: A nurse is preparing to discharge a postpartum client. The nurse notes on her chart that she is ... (Read 77 times)

saraeharris · **on:** Jun 27, 2018

A nurse is preparing to discharge a postpartum client. The nurse notes on her chart that she is nonimmune to rubella. The nurse:

1. Administers a rubella vaccine prior to discharge.
2. Instructs the client to obtain a rubella vaccine after 1 month has elapsed.
3. Charts this information in the discharge summary notes.
4. Takes no action because none is needed.

Question 2

Nursing interventions for non-reassuring fetal heart rate patterns would include which of the following? (Select all that apply.)

a. Change the maternal position from one side to the other side
b. Oxygen therapy by non-rebreather face mask at 8 to 10 L/min.
c. Anticipate administration of a tocolytic such as terbutaline (Brethine)
d. Decrease the rate of the main intravenous (IV) fluid line
e. Increase the rate of the main intravenous (IV) fluid line (usually lactated Ringer's solution)
f. Notify the primary care provider of the time of occurrence, duration, severity, and frequency of decelerations and of nursing interventions given

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

Answer to Question 1

1
Rationale:
1. If the postpartum client is nonimmune to rubella, a rubella vaccine is administered prior to discharge.
2. The client should not be instructed to wait for 1 month to have the rubella vaccine if she is not immune to rubella.
3. Simply charting the information is not appropriate.
4. Taking no action is not appropriate.

Answer to Question 2

A, B, C, E, F
Nursing interventions for non-reassuring fetal heart rate patterns would include changing the maternal position from one side to the other side; oxygen therapy by non-rebreather face mask at 8 to 10 L/min.; increasing the rate of the main intravenous (IV) fluid line (usually lactated Ringer's solution); notifying the primary care provider of the time of occurrence, duration, severity, and frequency of decelerations and of nursing interventions given; and anticipating administration of a tocolytic such as terbutaline (Brethine). Additional nursing actions would include anticipating starting an amnioinfusion, and chart all information, including the time the primary caregiver was notified, the specific information given, and the response.