Author Question: A nurse has assessed a client and is now preparing for the nursing diagnosis process. Which ... (Read 36 times)

storky111 · **on:** Jul 16, 2018

A nurse has assessed a client and is now preparing for the nursing diagnosis process.
Which activity must the nurse perform as part of the nursing diagnosis process?

A) Direct nursing interventions to meet the client's high-priority needs
B) Identify the disease a person has or is believed to have
C) Study the physiologic manifestations of the illness of the client
D) Establish the cause and nature of the illness of the client

Question 2

The obstetrical nurse records the expulsion of the placenta in stage III labor as a Duncan presentation. What does this data represent?

A) The placenta is expelled with the dull side out.
B) The placenta is expelled with the shiny side out.
C) The placenta is not fully expelled.
D) The placenta contains placental fragments.

irishcancer18 · **Reply #1 on:** Jul 16, 2018

Answer to Question 1

A

Answer to Question 2

A
Feedback:
If the placenta is expelled with the dull side out, it is called a Duncan presentation (dirty Duncan). This is the maternal side, which is rough and irregular. Excessive bleeding is more likely with this type of placental presentation.
If the placenta is expelled with the shiny (membranous) side out, it is called a Schultze presentation (shiny Schultze); this is the fetal side of the placenta. Schultze presentation occurs in approximately 80 of births. The birth attendant examines the expelled placenta and membranes to determine if the placenta is intact. Retained placental fragments are a major cause of hemorrhage following delivery.