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Jenny Theriot room 302 You responded correctly to 5 out of 6 evaluations: C at e g or y Your response Explanation Educational Needs Increased acuity Status assessment reports leaking of fluid from vagina, possible contractions an and support for the client. Fall Risk Increased acuity Status assessment reports the client is pregnant; this changed her center of gra Health change Increased acuity Status assessment reports leaking of fluid from vagina and possible contractions Pain level Normal acuity Status assessment does not indicate report of pain. Physiological Needs Increased acuity Status assessment reports leaking of fluid from vagina, possible contractions. Sensorium Needs Increased acuity Status assessment reports no indication of changes in sensorium. You correctly diagnosed 9 out of 10 options: Physiological Your Description Response Explanat Acute Pain False Status assessment indicates unknown status of contra Anxiety True Status assessment reports woman crying, stating she Impaired mobility, riskfor Impaired patterns of elimination True No indication at this time False Status report does not indicate impaired elimination. Infection, Risk for True Status assessment reports leaking of fluid from vagina
membranes (SROM); risk for ascending infection and cNausea False Status assessment reports no indication of nausea. Safety Your Description Response Expla Deficient knowledge True Status assessment reports woman crying, uns to her. Disturbed sensory False Status assessment reports normal sensory per perception Fall, risk for True Client is pregnant and is at risk for falls relate
Scenario 2 You correctly ordered 5 out of 5 actions: Y o u r o r d e r Correct order Step 1 1 Place bed in Trendelenburg position. Assists in relieving premature cervicalcontinuing leaking 2 2 Discuss plan of care with patient; answer questions Provision of clear in honestly, especially concerning SROM and implications for preterm labor and birth. care and can allay 3 3 Assess support systems available to woman. Assistance and cari stressful events. 4 4 Apply sequential compression device (SCD) boots Prevents the forma
Your order Correct order Step and connect to machine. 5 5 Begin Intake and Output (I&O) chart and documentevery shift. Ensures adequate Scenario 3 You correctly ordered 5 out of 5 actions: Your Correct order order Step E 1 1 Inspect perineum. Possible umbilical cord prolapse with Patient states she “feels like somethin prolapsed cord is the quickest assess 2 2 Assess FHR for bradycardia. Occult prolapse of umbilical cord cuts potential fetal death. Significant chan hidden or occult prolapsed cord. 3 3 Assess vital signs, including temperature. Increasing temperature indicates infe 4 4 Assess for contractions; palpate fundus. On-going vigilance for signs of preter detected by monitor or recognized by 5 5 Assess for foul odor to amniotic fluid; perform pericare and provide fresh underpads. Indicative of infection or chrioamnioni
Your order Correct order Step woman to do Daily Fetal Movement Counts (DFMCs). ultrasound to evaluate a babys h and amniotic fluid level. The NST signs of fetal compromise 2 2 Administer Betamethasone 12 mg IM for Stimulates fetal lung maturity by two doses 24 hours apart. production or release of lung surf 3 3 Administer a broad-spectrum antibiotic Treat infection, decrease incidenc (e.g., ampicillin, erythromycin) and additional 24 hours to elapse afte continue for 7 days. 4 4 Request neonatologist to visit patient. Affords opportunity to discuss car anxiety. 5 5 Assess results of daily CBC. Increasing WBC indicative of infe Scenario 5 ou correctly ordered 5 out of 5 actions: Y o u r o r d e r Correct order Step
1 1 Encourage vocalization of fear and concerns. Can hel 2 2 Cluster nursing care activities as much as possible, such as Promote medication administration, assessments, and vital signs. interrup 3 3 Offer diversional activities: watching TV, reading, crossword Assists i puzzles, small needlecraft activities. Request family to bring mobility articles from home to “decorate” hospital room. “normal 4 4 Teach conscious relaxation and breathing techniques. Non-pha and dec 5 5 Provide comfort measures such as back rubs, position changes, Decreas and aromatherapy. feeling
