The nurse is caring for a client who underwent a total abdominal ...

[big1devin]

The nurse is caring for a client who underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy several hours ago. The highest priority for the nurse is to:
 
  1. Monitor blood pressure and pulse.
  2. Assess the client's acceptance of not being able to have children.
  3. Teach the client how to splint her abdomen while taking deep breaths.
  4. Verify that the IV pump is working correctly.

Question 2

Of all the clients who have been scheduled to have a biophysical profile, the nurse should check with the physician and clarify the order for which client?
 
  1. A gravida with intrauterine growth restriction
  2. A gravida with mild hypertension of pregnancy
  3. A gravida who is post-term
  4. A gravida who complains of decreased fetal movement for two days

[ecabral0]

Answer to Question 1

1
Rationale:
1. A post-surgical client is at risk for internal bleeding at the site of the surgery. Monitoring blood pressure and pulse is necessary to verify that the client is hemodynamically stable.
2. Although this client will not be able to become pregnant, because of the surgery, acceptance is a psychosocial issue, and a lower priority than is physiologic stability.
3. Splinting while deep-breathing is a comfort measure to facilitate oxygenation and prevent atelectasis. But hemodynamic stability is a higher priority.
4. The client needs IV fluids to replace blood loss during surgery and until oral intake is adequate. But hemodynamic stability is a higher priority.

Answer to Question 2

2
Rationale:
1. The infant who has intrauterine growth problems might be compromised due to placental insufficiency.
2. The biophysical profile is used when there is a risk of placental and/or fetal compromise. The gravida with mild hypertension will need to be monitored more closely throughout the pregnancy, but is not a candidate at present for a biophysical profile.
3. The infant who is post-term might be compromised due to placental insufficiency.
4. The gravida who is experiencing decreased fetal movement for two days needs assessment of the placenta and the fetus.

[big1devin]

Gracias!

[sultana.d]

Excellent