The nurse receives report on four patients at the start of the shift. Which patient does the nurse visit first?

Correct

  • A 35-year-old patient who requested help with bathing prior to discharge
  • A 22-year-old patient with diabetes who needs her first insulin dose
  • A 42-year-old patient who has expelled a large amount of lochia since delivery last night
  • A 16-year-old patient who wants to breastfeed but doesn't know how

Rationale

Lochia is the normal vaginal bleeding that occurs after delivery. In most cases, this is not a threat to health, but in 5% of cases the bleeding is excessive and can compromise the cardiovascular system. As the nurse is prioritizing patients, the woman with excessive lochia should be seen first. Blood pressure, heart rate, and pulse oximetry should be assessed. A short history should be taken to assess for signs of hemorrhage (e.g. hypotension, dizziness). The patient who requires insulin, the teen mother who would like help breastfeeding, and the patient who would like help bathing can all be seen after the patient is assessed for hemorrhage.

  • Category: Management of Care
  • Difficulty: 7
  • Tags: Cardiovascular Labor and Delivery Postpartum Care Delegation, Prioritization and Leadership Hematology/Oncology Neonatal Care Nursing Interventions Sexuality and Reproduction

Question 71 of 75

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