If the nurse suspects a complication of a low forceps birth ...

[james0929]

If the nurse suspects a complication of a low forceps birth labor, she should immediately:
 
  a. administer a strong oral analgesic.
  b. assess the perineal and vaginal areas.
  c. assess the position of the uterine fundus.
  d. review the labor record for duration of second stage.

Question 2

Prior to ambulating the client to the bathroom whose admission hemoglobin level was 10.2 g/dL, the nurse should:
 
  a. request repeat hemoglobin and hematocrit.
  b. assess the resting pulse rate.
  c. dangle her on the side of the bed.
  d. administer the ordered oral analgesic.

[tennis14576]

Answer to Question 1

ANS: B
A low forceps birth may result in significant vaginal trauma. Assessment will provide information on the extent of trauma of the perineum and vagina. Administering an analgesic may interfere with obtaining an accurate assessment of the problem, assessing the position of the uterine fundus will not provide any information on vaginal or perineal trauma, and reviewing the labor record may support the suspicion that trauma has occurred but will not identify extent of trauma.

Answer to Question 2

ANS: C
Clients with a low hemoglobin level prior to birth will most likely have a drop in the hemoglobin level following birth. A low hemoglobin level will result in dizziness and place the client at risk for fainting when first ambulating. Dangling the client on the side of the bed prior to standing will allow for the blood pressure to stabilize and prevent fainting. Requesting additional labs will delay ambulation at a time when the client needs to empty her bladder, assessing the resting pulse rate will not provide any information about the effect of ambulation on her cardiovascular system, and administering an ordered oral analgesic may contribute to feelings of faintness.

[james0929]

Gracias!

[ttt030911]

Thanks for the timely response, appreciate it