Renee Workman Scenario 1
The nurse prepares to complete an initial assessment. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:
1Wash hands/apply gloves.Prevention of spread of infection. Wash and don gloves prior to touching client for assessment. Should be done on entering the room.
2Introduce self and explain assessments to be completed.Introduction and explanation of assessments help put client and spouse at ease, decreases anxiety.
3Apply electronic fetal monitor.Client is concerned about fetus due to decreased fetal movement. Hearing fetal heart will decrease client's anxiety prior to taking her VS. Verifies fetal wellbeing. Non-stress test will take at least 20-30 to be done so apply EFM prior to taking maternal vital signs.
4Assess maternal vital signs- temperature, pulse, BP both arms.Client's blood pressure was elevated at office. Need to fully assess by BP in both arms.
5Auscultate heart and breath sounds.Generalized edema may cause increased workload on the heart and a murmur or extra sound, S3 or S4, as well as crackles in the lungs
6Assess for peripheral edema and reflexes.Assessment progresses systematically in head to toe fashion so peripheral edema and DTRs would be assessed last. Edema develops as fluid shifts from the intravascular to extravascular spaces. Generalized edema of preeclampsia can cause significant pitting edema in lower extremities related to gravity when the client has been ambulatory. Generalized edema can also cause cerebral edema and irritability of CNS and hyperreflexia. Baseline DTRs are important to assess of admission. Hyperreflexia may occur as preeclampsia worsens