The subject is nursing but it was no longer an option not sure why Scenario: M.K
ID: 125499 • Letter: T
Question
The subject is nursing but it was no longer an option not sure why
Scenario:
M.K. delivered a healthy female infant 2 hours ago. She had a midline episiotomy. It was her fifth pregnancy. She had an epidural block for her labor and delivery. She is now on the postpartum unit.
The nurse reviews the hospital security guidelines with M.K. The nurse points out that her baby has a special identification bracelet that matches a bracelet worn by M.K., and reviews other security procedures. Which statement by M.K. indicates a need for more teaching?
“If I have a question about someone’s identity, I can ask about it.”
“If someone comes to take my baby for an examination, that person will carry my baby to the examination room.”
“Nurses on this unit all wear the same purple uniforms.”
“Each staff member who takes my baby somewhere will have a picture identification badge.”
An hour after admission, you recheck M.K.’s perineal pad and find that there is a very small amount of drainage on the pad. What will you do next?
Ask M.K. to change her perineal pad
Check her perineal pad again in 1 hour
Check the pad underneath M.K’s buttocks
Document the findings in M.K.’s medical record
That evening, the nursing assistive personnel assesses M.K.’s vital signs. Which vital signs would be of concern at this time?
Temperature 99.9 F (37.7 C) oral
Pulse rate 120 beats/min
Blood pressure 100/50 mm HG
Respiratory rate 16 breaths/min
What will you do next?
After your prompt intervention, you need to document what happened. Write an example of a documentation entry describing this event.
Two hours later, you perform another perineal pad check and note just the middle of the pad to have drainage (about 10cm of drainage). How will you describe the amount of drainage in your note?
Scant
Light
Moderate
Heavy
M.K.’s condition is stable and you prepare to provide patient teaching. What patient teaching is vital after delivery?
M.K. tells you she must go back to work in 6 weeks and is not sure she can continue breastfeeding. What potions are available to her?
Explanation / Answer
1. M.K's statement- nurses on this unit all wear the same purple uniform indicate that she needs further teaching about the safety and identity.
2. The nurse should wait and obseve the perineal pad after an hour if she found small amount of drainage after an hour of admission .
3.The observed vtal signs shows that she is having decresed blood pressure and tachycarda which is the sign of hypovolemia. The nurse should immediately advice the ptient to take fluids, check the perineal pad for excessive bleeding, and inform physician wheather to start a fluid line.
4.Documentation example: vital signs checked and recorded. observed low blood pressure
(100/50) and tachycardia(120bpm). checked the patients condition. advised to take more fluid. checked the perineal pad for excessive bleeding. inform doctor and carry out the orders. rechecked vital signs after 15 minute.
5. 10cm drainage on the perineal pad is considered as moderate bleeding.
6. Patient teaching after delivery should include the importance and method of breast feeding, about physical excersise
7. Breast feeding is necessary for the infants but as M.K need to go back for work after 6 week, other optons should be follow. such as breast feed the baby whenever she is available ,feed the baby with expressed breast mik when she is on work.
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