Timing and recording length of contractions.
Preparing for an emergency cesarean birth.
Checking the perineum for bulging.
Isolate the client from other patients.
Maintain a safe environment.
Orient the client to time, place, and person
Establish a trusting relationship.
Cola with ice
Yellow noncitrus Jello
Cool cherry Kool-Aid
A glass of milk
Place the client in a private room.
Wear an N 95 respirator when caring for the client.
Put on a gown every time when entering the room.
Don a surgical mask with a face shield when entering the room.
The frequent nausea and vomiting accompanying use of miotic drug.
Loss of mobility due to severe driving restrictions.
Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
The painful and insidious progression of this type of glaucoma.
Apply pressure directly over the incision site.
Clamp the chest tube near the incision site.
Clamp the chest tube closer to the drainage system.
Reconnect the chest tube to the Pleurovac.
Umbilical cord prolapse
Protect the client against harm to others.
Provide the client with motor outlets for aggressive, hostile feelings.
Reduce interpersonal contacts.
Deemphasizing preoccupation with elimination, nourishment, and sleep.
Pick up and hold a rattle.
Hold the head up.
Ask the physician to call back after the nurse has read the hospital policy manual.
Take the telephone order.
Refuse to take the telephone order.
Ask the charge nurse or one of the other senior staff nurses to take the telephone order.
Accept the new assignment and complete an incident report describing a shortage of nursing staff.
Report the incident to the nursing supervisor and request to be floated.
Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment.
Accept the new assignment and provide the best care.
40 years of age
20 years of age.
35 years of age.
20 years of age.
The float staff nurse will be informed of the situation before the shift begins.
The staff nurse will be able to negotiate the assignments in the emergency department.
Cross training will be available for the staff nurse.
Client assignments will be equally divided among the nurses.
“Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?”
“Has he been taking diuretics at home?”
“Do any of his brothers and sisters have history of cardiac problems?”
“Has he been going to school regularly?”
Call the physician to reschedule the surgery.
Call the nearest relative to come in to sign a new form.
Cross out the error and initial the form.
Have the client sign another form.
Vigorously strip the tube to dislodge a clot.
Raise the apparatus above the chest to move fluid.
Increase wall suction above 20 cm H2O pressure.
Ask the client to cough and take a deep breath.
Determine who is responsible for the mistake and terminate his or her employment.
Record the event in an incident/variance report and notify the nursing supervisor.
Reassure both mothers, report to the charge nurse, and do not record.
Record detailed notes of the event on the mother’s medical record.
Nausea and vomiting
Slowing in the heart rate
Wear sunglasses if exposed to bright light for an extended period of time.
Take oral preparations of prednisone before meals.
Have periodic complete blood counts while on the medication.
Never stop or change the amount of the medication without medical advice.
“Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife.
“Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes.”
“Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily.”
“Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy. Increase your daily fluid intake to 3L.”
Expression of anger dissipates the energy.
Energy from anger is used to accomplish what needs to be done.
Expression intimidates others.
Degree of hostility is less than the provocation.
Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care.
Main purpose is to identify expected client, family and staff performance against the timeline for clients with the same diagnosis.
Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost.
Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems.
Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.
Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy.
Plan to give phenytoin over 30-60 minutes, using an in-line filter.
Flush the IV tubing with normal saline before starting phenytoin.
Positive radioimmunoassay test (RIA test).
Auscultation of fetal heart tones.