Author Question: A patient is being dismissed after giving birth and having a hematoma drained in the operating room. ... (Read 43 times)

tiara099 · **on:** Jun 28, 2018

A patient is being dismissed after giving birth and having a hematoma drained in the operating room. What action by the patient best indicates to the nurse that outcomes for the diagnosis of risk for altered attachment have been met?

A.
Asks partner to hold the baby so she can sleep
B.
Holds and comforts the infant when fussy
C.
Makes eye contact with the infant
D.
States that her mother will help with infant care

Question 2

A postpartum woman has a deep vein thrombosis. The patient states, I feel anxious and have some pain in my chest. The patient's respiratory rate is 28 breaths per minute. After calling for help, which action by the perinatal nurse takes priority?

A.
Administer oxygen.
B.
Document the findings.
C.
Take a full set of vital signs.
D.
Prepare to give pain medication.

Fayaz00962 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: B
Patients are at risk for altered attachment when complications interfere with normal postpartum recovery. The best indication of resolution of this nursing diagnosis is the mother demonstrating care and concern for the baby by actively participating in the baby's care. Having resources to help with baby care is important, but does not demonstrate a lack of altered attachment. Making eye contact is a positive assessment finding, but is not as good of an indicator as actively caring for the baby.

Answer to Question 2

ANS: A
The presence of dyspnea and tachypnea may signal pulmonary embolism, and the nurse should summon help immediately to deal with this condition. After that, administer oxygen, raise the head of the bed, assess vital signs, or begin CPR immediately if needed. Documentation is only correct as the priority action when the findings are normal. Pain medication is a lower priority.