Nurse Zasha in the Obstetrical Unit is monitoring Mrs. Zexy Lucero, 25 years old. G1PO. Internal examination revealed 3-4cm cervical dilatation, 50% effaced, +(BOW), Station -1, cephalic with uncoordinated uterine contractions that are erratic in their frequency, duration, and intensity. Which of the following nursing actions should not be included in the priority of Nurse Zasha? (Select all that apply) Promote ambulation every 30 minutes Encourage the client to rest. Prepare the client for an amniotomy Monitor the oxytocin infusion closely. Provide pain relief measures

Nurse Zasha in the Obstetrical Unit is monitoring Mrs. Zexy Lucero, 25 years old. G1PO. Internal examination revealed 3-4cm cervical dilatation, 50% effaced, +(BOW), Station -1, cephalic with uncoordinated uterine contractions that are erratic in their frequency, duration, and intensity. Which of the following nursing actions should not be included in the priority of Nurse Zasha? (Select all that apply) Promote ambulation every 30 minutes Encourage the client to rest. Prepare the client for an amniotomy Monitor the oxytocin infusion closely. Provide pain relief measures

3-2-1 Code It

6th Edition

ISBN:9781337660549

Author:GREEN

Publisher:GREEN

Chapter15: Cpt Surgery V

Section: Chapter Questions

Problem 3MC

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Nurse Zasha in the Obstetrical Unit is monitoring Mrs. Zexy Lucero, 25 years old. G1P0. Internal examination revealed 5cm cervical dilatation, 50% effaced, +(BOW). Station 0, cephalic with a prolongation disorder for signs of fetal or maternal compromise. Which of the following assessment findings should not alert Nurse Zasha to a compromise? (Select all that apply) Coordinated uterine contractions Persistent nonreassuring fetal heart rate Maternal fatigue Uncoordinated uterine contractions Progressive changes in the cervix
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Mrs. Perez, 48 years old, is admitted to the nursing unit 2 hours after undergoing a right surgical removal of her breast (mastectomy). The floor nurse receives a report from the post anesthesia care unit (PACU) nurse that includes the patient’s admitting diagnosis of breast cancer, latest vital signs, focused assessment, medication & intravenous (IV) orders, pain level & the time she was last medicated for pain & status of the surgical dressing. Initially, Mrs. Perez appears to be comfortable, dozing occasionally between short conversations with her husband, who is at her side. When she was fully awake 3 hours after, she complains of sharp, constant pain on the right side of her chest. She rates her pain at 8 / 10 on the pain scale. She is grimacing and appears tense. The RN took her vital signs - T = 36.5 "C; BP = 130/100 mmHg; RR = 20 bpm; PR = 80 beats/min. She inspected the surgical wound, at the right breast and reveals that the dressing is slightly soaked with blood…
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