Jennie arrives at the Labor and Delivery triage area at 0600 with her sister. She has been experiencing a severe headache for the past 12 hours, which has not been relieved by acetaminophen (Tylenol). Additionally, she has noticed swelling in her hands and face over the last 2 days and describes her epigastric pain as similar to bad heartburn. Jennie’s sister informs the nurse that she had similar symptoms during her own pregnancy, which turned out to be toxemia.
The nurse’s admission assessment reveals that Jennie weighs 182 pounds today. Her body temperature is recorded as 99.1° F, pulse rate is 76, respiration rate is 22, and blood pressure is measured at 138/88. There is noticeable pitting edema graded at +4 and urine analysis shows protein levels of +3. Jennie’s heart rate is regular and lung sounds are clear.
The nurse assesses the deep tendon reflexes (DTRs) and finds them to be 3+ in the biceps and triceps muscles, and 4+ in the patellar reflex with 1 beat of ankle clonus. Additionally, the nurse applies an external fetal monitor and observes a baseline fetal heart rate of 130 bpm, absent variability, positive for accelerations, no decelerations, and no contractions. Furthermore, a vaginal examination is performed by the nurse and reveals a cervix that is 1 cm dilated and 50% effaced, with the fetal head positioned at a -2 station.
1. The nurse believes that based on Jennie’s history, she is at risk of developing a hypertensive disorder. What are the specific risk factors contributing to this conclusion?
- Age (15), molar pregnancy, history of preeclampsia in a previous pregnancy.
- Age (15), gravidity, familial history.
- Age (15), history of pounding headache, low socioeconomic status.
- Age (15), low socioeconomic status (SES), history of pedal edema.
2. The nurse should obtain the most important information from the prenatal record in order to accurately assess the client’s condition.
- Pattern and number of prenatal visits.
- Prenatal blood pressure readings.
- Prepregnancy weight.
- Jennie’s Rh factor.
Assessing Deep Tendon Reflexes
Purpose
In order to evaluate hyperreflexia or hyporeflexia, use a reflex hammer to assess the brachial and patellar reflexes. When examining the brachial reflex, hold the woman’s arm and request that she fully relax it while keeping it slightly flexed. If you have difficulty finding the correct tendon to tap, ask her to flex and extend her arm until you can feel it moving under your thumb.
After identifying the tendon, instruct the woman to completely relax her arm. Position your thumb on the tendon as illustrated, enabling both visual and tactile feedback when tapping it. Utilize the smaller end of the triangular reflex hammer to strike the thumb. A typical response will cause a slight flexion in the forearm. To evaluate the patellar reflex (also referred to as knee-jerk reflex), you may either have the woman sit or lie down. If she is sitting, let her lower legs hang freely to flex the knee and stretch the tendons.
If locating the patellar tendon proves difficult, one can instruct the woman to slightly flex and extend her lower legs until the tendon becomes palpable. To assess the patellar reflex, strike the tendon with a reflex hammer just below the patella. It is important to note that if the woman has received epidural analgesia, this may affect the reliability of the patellar reflex; therefore, upper extremity reflexes should also be evaluated. When positioning the woman in a supine position, it is crucial to provide support for her leg’s weight to facilitate flexion and extension of the knee tendons. For an accurate response, ensure that limb is relaxed and partially stretched prior to striking it just below the patella.
The expected response is a slight extension of the leg or a brief twitch of the quadriceps muscle of the thigh. To assess clonus, support the lower leg and dorsiflex the footwell to stretch the tendon. Hold the flexion. If no clonus is present, no movement will be felt. Clonus, indicating hyperreflexia, is characterized by rapid rhythmic tapping motions of the foot.
The Deep Tendon Reflex Rating Scale: 0 indicates absent reflex, +1 indicates reflex present but hypoactive, +2 indicates normal reflex, +3 indicates brisker than average reflex, and 4 indicates hyperactive reflex with possible clonus present. Some facilities may exclude plus signs from their rating scales.
Pathophysiology of Preeclampsia
Preeclampsia is a condition where arterioles become narrower, leading to inadequate blood flow to important organs like the placenta, liver, brain, and kidneys. As a result, these organs may only operate at 40 to 60% of their normal capacity. Furthermore, there is a decrease in plasma volume and an increase in hematocrit as fluid exits the blood vessels.
Preeclampsia is a condition that leads to extensive edema, impacting nearly all organs in the body. As the illness advances, both the mother and fetus become more vulnerable. It usually occurs in women who previously had normal blood pressure after 20 weeks of pregnancy. Elevated blood pressure is frequently the initial indication of preeclampsia. The client also experiences proteinuria. Although it is no longer deemed a conclusive marker of preeclampsia, general swelling of the face, hands, and abdomen that persists even after 12 hours of bed rest is often observed.
Preeclampsia can advance from mild to severe stages, including HELLP syndrome or eclampsia. A client can arrive at the labor unit at any point along this progression.
What is causing Jennie to experience a pounding headache and elevated deep tendon reflexes?
- Cerebral edema.
- Increased perfusion to the brain.
- Severe anxiety.
- Retinal arteriolar spasms. Jennie’s sister is very concerned about the swelling (edema) in her sister’s face and hands because it seems to be worsening rapidly.
She inquires with the nurse about the possibility of the healthcare provider prescribing diuretics, also known as “water pills,” to help eliminate the surplus fluid.
4. What is the correct response by the nurse?
- “That is a very good idea. I will relay it to the healthcare provider when I call. “
- “I’m sorry, but it is not the family’s place to make suggestions about medical treatment. “
- “Let me explain to you about the effect of diuretics on pregnancy. “
- “Have you by any chance given your sister water pills that belong to someone else? “
At 0630, the nurse contacts the healthcare provider to report the admission to the Labor and Delivery Unit. The healthcare provider then prescribes several actions including admitting the patient to labor and delivery, bedrest with bathroom privileges (BRP), intravenous infusion of D5LR at 125 ml/hr, a complete blood count (CBC) with platelets, clotting studies, liver enzymes, a chemistry panel, a 24-hour urine collection for protein and uric acid, intake of only ice chips by mouth, nonstress test, hourly monitoring of vital signs, and testing of deep tendon reflexes (DTRs).
5. What is the highest priority nursing intervention while waiting for the lab results?
- Teach Jennie the rationale for bedrest.
- Monitor Jennie for signs of dehydration.
- Educate the client about dietary restrictions.
- Observe Jennie for CNS changes.
6. What is the most effective technique for the nurse to assess Jennie’s blood pressure while she is on bedrest?
- Have Jennie lay supine and take the blood pressure on the left arm.
- Have Jennie lie in a lateral position and take the blood pressure on the dependent arm.
- Have the client sit in a chair at the bedside, and take the blood pressure with her left arm at waist level.
- Have Jennie stand briefly and take the blood pressure on the right arm. The nurse performs a nonstress test to evaluate fetal well-being.
7. The nurse will assess which parameters when performing a nonstress test?
- Accelerations of the fetal heart rate in response to fetal movement.
- Late decelerations of the fetal heart rate in response to fetal movement.
- Accelerations of the fetal heart rate in response to uterine contractions.
- Late decelerations of the fetal heart rate in response to uterine contractions.
At 0800, the client presents with symptoms indicative of HELLP syndrome. These symptoms include a headache and slightly reduced epigastric pain. During a physical assessment, the vital signs are measured at BP 146/94, P 75, R 18 while the client is in a left lateral position. Hyperreflexia is still present along with one beat of clonus. The fetal heart rate is recorded as 140 with average long-term variability and no decelerations following a reactive nonstress test. However, there have been no further accelerations since then. Lab results show hemoglobin levels at 13.1 g/dl, hematocrit levels at 40 g/dl, platelet count at 120,000 mm3 which is slightly elevated aspartate aminotransferase (AST), normal levels of alanine aminotransferase (ALT) for pregnancy, and no burr cells on slide. Clotting studies also indicate normalcy for pregnancy.
Based on these findings, the healthcare provider diagnoses Jennie with preeclampsia rather than HELLP syndrome which is known to be a severe variant of preeclampsia.
8. The nurse would expect Jennie to exhibit specific lab results if she had HELLP syndrome.
- Elevated hemoglobin and hematocrit (H&H) without burr cells, elevated liver enzymes, platelet count >150,000 mm3.
- Decreased hemoglobin and hematocrit (H&H) with burr cells, elevated liver enzymes, platelet count
Rhetorical Analysis On Psycho
Psycho Rhetorical Analysis There are multiple factors involved in the creation of a movie as horrifying as Alfred Hitchcock’s classic horror film Psycho, even without the typical explicit scenes that audiences expect. The 1960 American psychological thriller focuses on Marion Crane, a secretary who goes into hiding after stealing a large amount of money, and Norman Bates, the motel owner afflicted with schizophrenia. Throughout the film, both characters face the consequences of their actions—guilt and constant surveillance.
Through unconventional storytelling techniques, Hitchcock effectively delivers his message in a way that surpasses typical horror films, leaving viewers stunned by the intricacies of his mysterious and twisted plot. Not only do the close-up shots of the protagonists allow the audience to empathize with their guilt, but the surveillance aspect is also portrayed through distant lens focus. By strategically capturing these specific camera angles, Hitchcock creates an unsettling sensation of being watched, akin to the uneasiness often associated with a guilty conscience.
The repetition of motifs, such as mirrors, birds, and eyes, along with the camera’s focus and background music, aid Hitchcock in portraying the themes of voyeurism and the intertwining of surveillance and guilt. Without Marion and Norman’s constant fear of being observed, their guilt would not have such a profound impact on their psyche. Like an audience watching a film, anyone can act as a witness to a crime, intensifying their sense of conscience. Hitchcock effectively communicates his message about surveillance and guilt through the opening scene using camera techniques and on-screen text.
The film’s camerawork begins by capturing a wide view of towering skyscrapers before shifting its focus towards a particular window in an affordable high-rise hotel. As the camera enters the dimly lit room through the partially open window, it evokes a voyeuristic sensation that makes viewers feel like trespassers. Displayed on the screen, the date and time enhance both the feeling of importance and unpredictability, hinting at a significant occurrence during that specific instance. These elements establish a foundation for the film’s recurring motifs of surveillance and guilt.
Marion experiences a mixture of guilt and enjoyment while trying to have a good time, as she is aware of her neglected work. Eventually, the audience learns about the dire consequences of her decisions. Simultaneously, viewers find themselves covertly observing Marion and her husband through the hotel room window. This is merely one example of Hitchcock’s skillful use of camera angles and visual presentation to portray the convergence of surveillance and guilt. The film demonstrates that guilty consciences can lead to voyeuristic tendencies, and vice versa.
From the beginning of the movie Psycho, Marion Crane, one of the protagonists, displays her guilty conscience when she takes a lengthy lunch break, setting a precedent for the guilt complex portrayed throughout the film. Frustrated with her life, Marion decides to steal $40,000 in order to make a fresh start. The camera’s close-ups of Marion’s face, particularly while driving, effectively convey her uncertainty and guilt. Her eyes hold significant importance, symbolizing the “windows of her soul,” according to Carr. This visual cue immediately conveys to the audience that she is aware of the wrongdoing she has committed.
The tension-inducing background music intensifies as she drives, adding to her anxious portrayal. This unease is transferred to the audience, who experience her emotions non-verbally. Cassidy, the money-holder, exacerbates her discomfort by passing by and directly eyeing her, blending surveillance and guilt. Following her encounter with the police officer, the camera lingers on her face, revealing her deep fear of getting caught.
The police officer becomes suspicious of Marion because her guilt is evident. He decides to keep an eye on her and follow her car. The officer watches intently as Marion exchanges her car for another one. This exchange is captured from a distance on the camera, showing the officer’s suspicious surveillance. Marion’s guilt becomes evident again when she meets Norman and observes him running up the stairs to his house. This scene is filmed in a way that highlights the surveillance of Norman, indicating that Marion’s own guilt causes her to become a voyeur herself (Carr).
Psycho demonstrated the immense power of guilt on the human mind. Once guilt has taken hold of one’s conscience, it can create a feeling of constant surveillance and judgment from others. This is precisely what Marion experienced as she drove away with the stolen money. Voices from her acquaintances and enemies echoed in her mind, anticipating their disapproval and the questions they would ask upon discovering her deceit.
Hitchcock skillfully employed multi-narrative dialogue to portray the inner turmoil that plagued Marion (Ager). Later, he aptly paralleled Marion’s internal culpability with that of Norman. The audience discovers Norman’s schizoid personality transformation, as he begins hearing his mother’s voice in his own thoughts and assumes a new identity due to his remorse for her murder. Similar to Marion’s experience after pilfering Cassidy’s money, Norman’s mother censures him in his mind, scrutinizing his every action. Hitchcock effectively illustrates the psychological and physical toll a guilty conscience exacts on an individual, irrespective of the magnitude of their transgression.
Surveillance and guilt are intertwined throughout the film in various ways. The deliberate use of close-up or distant camera shots and the high-pitched music contribute to this theme. The motif of mirrors further reinforces this concept right from the start. Marion, while gazing at herself in the mirror, reflects on the money lying on the bed behind her, pondering the moral dilemma. These alternating camera shots between her face in the mirror and the money on the bed illustrate the convergence of her guilt and self-monitoring.
The viewers can nearly feel her hesitancy, as the camera captures Marion’s double mirrors from the perspective of the back of her head. Through this positioning, the audience is thrust into her perspective, experiencing what she sees and feels. The guilt in Marion’s conscience is represented by the back of her head, and this guilt is transmitted to the viewers. This shot demonstrates how individuals contemplate their own moral choices. Even the viewers themselves can become voyeurs, uncomfortably watching close-ups in the mirror (Johns).
Throughout the film, mirrors are used extensively in various scenes to create a sense of constant surveillance. These scenes include Marion’s rear view mirror in her car, the overhead shot of the car dealer restroom, the desk at the Bates Motel, and a series of mirrors that frighten Lila in Mrs. Bates’ room. This repeated use of mirrors implies that Norman Bates, and even the cop in some scenes, is constantly watching. Norman’s guilt about his actions and his voyeuristic tendencies are evident as he goes to great lengths to keep his secret hidden. This theme of surveillance and guilt being interconnected is showcased through these mirror moments.
In Psycho, director Alfred Hitchcock employs a bird motif as a recurring element to convey the themes of guilt and surveillance. This motif is evident throughout the entire film and holds significant importance. The character Marion’s last name, “Crane,” serves to symbolize her birdlike nature, as described by Norman Bates while observing her eating. Additionally, the picture of a bird on the motel wall collapses to the ground when Norman uncovers the murder that took place in the shower room (Old School Reviews).
The text highlights the significance of birds in the film, using Norman’s description of his mother as “as harmless as one of these stuffed birds” to symbolize their role. The birds represent Norman’s murderous nature and silently observe from his room. The dead birds serve as a spectacle, existing for others to witness like a voyeur. Additionally, the background music in certain scenes, such as the infamous shower scene, resembles bird screeching. This further emphasizes the connection between guilt and the presence of birds in the movie (Carr). Guilt is something that everyone experiences at some point in their lives, sometimes even on behalf of someone else.
Being observed and being apprehended can be extremely frightening, even for those who are not participating in any wrongdoing. Moreover, observing an immoral act can evoke feelings of guilt merely from the act of watching. In the film Psycho, both Marion and Norman Bates implicate the audience in their wrongdoings. The way the camera is used in the film gives viewers a sense that they are acting as observers. In the beginning scene, the camera plunges spectators into a dimly lit hotel room, creating an illusion of clandestine surveillance on Marion and Guy.
The audience in this movie is drawn in to everything Marion and Norman are feeling and thinking, to the point where they become voyeuristic and feel guilty for invading the characters’ privacy. Hitchcock effectively uses the audience to demonstrate that anyone can feel culpable and afraid of voyeurs, no matter how insignificant the act may seem, as someone else is always watching and experiencing guilt. Guilt and voyeurism are often intertwined in various situations, such as spying on a couple’s enjoyment or witnessing a murder.
Alfred Hitchcock’s classic horror movie Psycho from the 1960s successfully brings both sides of the crime together. The film utilizes excellent camerawork, angles, motifs of birds and mirrors, screen texts, and more to convey its message to the audience. This immersive approach allows viewers to empathize with the experiences of characters such as Norman Bates and Marion Crane, as well as experience the guilty conscience of an outsider who voyeuristically observes their actions.
The GSI’s Production Quality Control
Game Shop, Inc Why was GSI’s production quality control better than its billing performance? The GSI’s production quality control had checks that had been built into the system. There were a number of personnel in place to ensure that these controls were in place and working properly at any point in time. There were no controls in place for the billing process, the company did not have a set of written billing instructions, and the managers did not know how to use the billing instructions available to them. The billing process was handled by the GSI Project managers who had no financial background.
The mangers focused more on production and ensuring that orders were shipped. A lot of controls were missing; the billing system had several flaws. Billing paper could only be submitted once a week. Reports took a long time to down load onto a computer. The billing and IT departments were resistant to a change in the system as the employee had become too comfortable with the new system and were afraid of job losses. Why would you include billing performance among the short list of critical success factors for GSI? If so Why has it apparently not received much attention from management up until now?
If not why all the concern now. Customers had been overbilled because of double billings and incorrect calculations of rebates. Customerss were not happy and top management had to step in to correct these errors. The project managers did not track project changes and did not turn in billing paper work in a timely manner. Billing could be done more than once simply because it was not documented properly in a prior period. The project managers did not understand the importance of correct and timely billing Evaluate the billing improvement effort and each of the elements of the system that emerged.
Comment specifically on the billing score card, detention meetings, P- CARs, and any other elements that you believe are relevant. The billing improvement effort focused on strengthening the billing process. A billings performance scorecard was developed to track each business unit’s performance. The managers of business units who performed low in the score card were invited to a meeting which was intended to help these managers to understand and correct the issues in the business unit.
Another motivational tool that was used to evaluate the billing performance is the Process Corrective Action Reports. These reports were issued to managers who had made billing errors in order to identify software glitches and broken procedures. The report identified and described where a process went wrong. The Process Corrective Action Reports focused on the processes rather than individuals in order to correct the flaws in the design of the processes. The billing score card helped to ensure that the billings were done on time and the billing error rates dropped significantly.