The nurse is planning care for four mothers and their newborns. After reviewing the clients’ charts, the nurse should make rounds on which of thefollowing clients first?
1. An 18-year-old G2 P2 with an uncomplicated spontaneous vaginal delivery 12 hours ago who has abdominal cramps.
2. A 35-year-old G4 P4 with an uncomplicated vaginal delivery 4 hours ago. The nurse’s notes indicated she soaked two peripads over the last 2 hours; fundus is firm.
3. A 16-year-old G1 P1 with a caesarean section 4 hours ago, diagnosed with preeclampsia and receiving magnesium sulfate at 2 g/h. Reflexes are 2+, and the nurse’s notes indicate she has a headache. Vital signs are T 99.4˚F, P 88, R 20, BP 128/86.
4. An 18-year-old G2 P2 who had a caesarian birth 2 days ago and now has severe breast pain. Vital signs are T 99.8˚F, P 96, R 22.
The criteria for hemorrhage is saturating one pad per hour. The 35- year-old who delivered 4 hours ago had saturated a peripad per hour. Even though her fundus is firm, she may have experienced a cervical laceration which would be the source of the bleeding. She needs to be evaluated first, based on the bleeding.
The 18-year-old who has abdominal cramps is within normal limits for a G2 P2 and is experiencing afterbirth pains normally seen in a multiparous client; she will need pain medication.
The 16-year-old status post cesarean section on magnesium sulfate is stable with adequate urinary output and normal reflexes. Her vital signs are within normal limits for a postpartum client. The headache is the one area of concern for this client.
The 18-year-old who is 2 days postpartum with breast pain may be experiencing her milk coming in, although it does not indicate whether she is breast- or bottle-feeding; either situation may find a mother with milk developing within her system. The vital signs for this client are slightly elevated, but this may be from the milk coming in and would require nursing evaluation but is not emergent.
CN: Management of care; CL: Synthesize
3.一名16岁的G1-P1在4小时前剖腹产，被诊断为先兆子痫，接受2克/小时的硫酸镁治疗。反射为2+，护士的记录显示她头痛。生命体征为T 99.4˚F，P 88，R 20，BP 128/86。
4.一名18岁的G2 P2，两天前剖腹产，现在有严重的乳房疼痛。生命体征为T 99.8˚F，P 96，R 22。
小编寄语：The secret of success is not merely to seek, but to wait.成功的诀窍不仅仅在于追求，更在于等待。