A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?

Decreased platelet count

Increased erythrocyte sedimentation rate (ESR)

Decreased megakaryocytes

Increased WBC

Answer and Explanation

The Correct Answer is A

The correct answer is A. Decreased platelet count.

A. Decreased platelet count: ITP is characterized by a decreased platelet count. It is an autoimmune disorder where the immune system attacks and destroys platelets, leading to a reduction in the number of circulating platelets.

B. Increased erythrocyte sedimentation rate (ESR): ITP is not typically associated with an increased ESR. ESR is a marker of inflammation, and ITP is primarily a disorder of platelet destruction rather than inflammation.

C. Decreased megakaryocytes: ITP is often associated with normal or increased numbers of megakaryocytes in the bone marrow. Megakaryocytes are the precursor cells for platelets, and their increased presence indicates that the bone marrow is trying to produce more platelets to compensate for the destruction occurring in the bloodstream.

D. Increased WBC: ITP primarily affects platelet counts and does not necessarily lead to an increased white blood cell (WBC) count. The primary concern in ITP is the risk of bleeding due to low platelet levels.

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Correct Answer is A

Explanation

The correct answer is A. Monitor the fetal heart rate (FHR) every hour.

A. Monitoring the fetal heart rate every hour is a crucial aspect of the plan of care during active labor. Continuous fetal monitoring helps assess the well-being of the baby and ensures timely identification of any signs of fetal distress.

B. Inserting an indwelling urinary catheter is not a routine intervention during active labor. The bladder can be monitored using other non-invasive methods, and catheterization is generally reserved for specific indications.

C. Keeping four side rails up while the client is in bed is not recommended. It may limit the client's mobility and is not a standard practice during labor. Ensuring the safety of the client and promoting mobility is important.

D. Checking the cervix prior to analgesic administration may be necessary, but it is not a general action for every client in active labor. The need for cervical checks should be individualized based on the client's progress, preferences, and clinical indications.

A. Apply oxygen at 10 L/min via venturi mask B. Increase the oxytocin infusion to 13 mu/min C. initiate bolus of primary IV fluids D. Perform sterile vaginal examination (SVE) E. Place the client in a side lying position

Correct Answer is ["{"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}"]

Explanation

A. Apply oxygen at 10 L/min via venturi mask:
Anticipated: Applying oxygen is an appropriate action, especially during labor, to ensure adequate oxygenation for both the mother and the fetus.

B. Increase the oxytocin infusion to 13 mu/min:
Anticipated: Adjusting the oxytocin infusion rate may be considered based on the progress of labor and the response to the current infusion rate. This action is anticipated but should be done cautiously and in accordance with established protocols.

C. Initiate a bolus of primary IV fluids:
Anticipated: Initiating a bolus of primary IV fluids is appropriate, especially if there are signs of dehydration or if additional hydration is needed during labor.

D. Perform a sterile vaginal examination (SVE):
Anticipated: Performing a sterile vaginal examination is appropriate to assess cervical dilation, effacement, and station. This information helps in monitoring the progress of labor and making decisions about interventions.

E. Place the client in a side-lying position:
Anticipated: Placing the client in a side-lying position is an appropriate action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.

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A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is caring for a client who is 42 weeks of gestation Exhibits Based on the assessment findings, which of the following actions should the nurse plan to take? (Select All that Apply)

Correct Answer is ["{"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}"]

Explanation

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