Question

The nurse prepares to complete an initial assessment. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

a. Wash 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.
b. Introduce self and explain assessments to be completed.Introduction and explanation of assessments help put client and spouse at ease, decreases anxiety.
c. Apply 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.
d. Assess 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.
e. Auscultate 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
f. Assess 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

Answer 1

The first two actions by a nurse during an initial assessment should be to wash hands/apply gloves to prevent infection, and to introduce themselves and explain the upcoming assessments to reduce patient anxiety.

Step-by-step explanation:

The first two nursing actions that should be implemented are: a. Wash hands/apply gloves. This action ensures the prevention of infection spread and should be done upon entering the room. b. Introduce self and explain assessments to be completed. This helps decrease the client's anxiety by establishing a rapport and explaining the upcoming procedures.

These steps are essential before proceeding to more specific assessments such as applying the electronic fetal monitor, assessing maternal vital signs, or auscultating heart and breath sounds. Each subsequent step in the assessment is important, but the first actions lay the groundwork for a safe and communicative interaction between the nurse and the patient.