Author Question: A charge nurse in a unit on the night shift is making rounds and notes that one of the older nurses ... (Read 67 times)

gbarreiro · **on:** Jul 22, 2018

A charge nurse in a unit on the night shift is making rounds and notes that one of the older nurses has multiple bruises on the arms. The best action by the charge nurse is:

1. To notify authorities regarding the abuse.
2. Ask the nurse about the source of the injuries.
3. Notify the security department.
4. To do nothing about the situation.

Question 2

The nurse is instructing a pregnant adolescent client on how the baby's condition is evaluated during labor. The nurse knows the client education was successful when the client states, During labor, the nurse will:

1. Check my cervix by doing a pelvic exam every two hours..
2. Assess the baby's heart rate with an electronic fetal monitor..
3. Look at the color and amount of bloody show that I have..
4. Verify that my contractions are strong but not too close together..

Jane · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2. Ask the nurse about the source of the injuries.

Rationale:
The charge nurse cannot assume that the nurse sustained the injuries in an accident, nor can the charge nurse assume abuse. However, older adults are subjected to abuse, and the charge nurse would want to ask about the injuries. The authorities should not be notified until some proof of abuse is noted. Security is not the appropriate department to notify unless the injuries were sustained at work. Nurses are bound to report abuse, so the charge nurse would at least question the older nurse regarding the injuries.

Answer to Question 2

2. Assess the baby's heart rate with an electronic fetal monitor..

Rationale:
During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor. This is the statement the client should make to prove that education was successful. Although cervical exams are performed on a regular basis, the pelvic exam does not assess fetal status. The client has asked specifically about assessing fetal status in labor.
Although bloody show is monitored, doing so does not assess fetal status. Although contraction strength is palpated abdominally, the client has asked about assessing fetal status in labor.