A nurse is assisting with the care of a client who presents to the labor and delivery unit.
The nurse assisting with this client's care should expect which of the following prescriptions from the client's provider? Select all that apply.
Perform intermittent external electronic fetal monitoring.
Monitor vital signs at least every 15 min.
Place the client in a supine position.
Obtain type and crossmatch.
Measure blood loss by weighing pads.
Insert a large-bore IV catheter.
Correct Answer : B,D,E,F
Choice A rationale:
Performing intermittent external electronic fetal monitoring is not the best choice in this situation. The client’s condition, which includes severe abdominal pain, vaginal bleeding, rigid and tender abdomen, and late decelerations in the fetal heart rate, suggests a possible placental abruption. In such a case, continuous fetal monitoring is required to closely monitor the fetal heart rate and contractions.
Choice B rationale:
Monitoring vital signs at least every 15 min is necessary. The client’s blood pressure has dropped from 110/68 mm Hg to 95/59 mm Hg within 15 minutes. This could indicate hypovolemia due to blood loss. Regular monitoring can help detect changes early and initiate appropriate interventions.
Choice C rationale:
Placing the client in a supine position is not recommended. This position can exacerbate supine hypotensive syndrome, which occurs when the gravid uterus compresses the inferior vena cava, reducing venous return and cardiac output. A side-lying position would be more appropriate.
Choice D rationale:
Obtaining a type and crossmatch is crucial. The client’s symptoms suggest a possible placental abruption, which can lead to significant blood loss. Having blood available for transfusion can be lifesaving.
Choice E rationale:
Measuring blood loss by weighing pads can provide an objective assessment of blood loss. This can help guide treatment decisions, including the need for blood transfusion.
Choice F rationale:
Inserting a large-bore IV catheter is necessary in this situation. It allows for rapid fluid and blood replacement if needed. Given the client’s symptoms and the potential for significant blood loss with placental abruption, this intervention is appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
"I should use the cap during my menstrual cycle to prevent pregnancy." Rationale: This statement is incorrect. The cervical cap should be used only during sexual intercourse to prevent pregnancy, not during the menstrual cycle. It does not provide protection against sexually transmitted infections (STIs) and should be used in conjunction with a spermicide for effectiveness.
Choice B rationale:
"I should avoid using spermicide with the cervical cap." Rationale: This statement is incorrect. To enhance the effectiveness of the cervical cap, it should be used with a spermicide. Spermicide helps immobilize and kill sperm, providing an additional barrier against pregnancy.
Choice C rationale:
"I need to have my provider check the size of the cap every 6 months." Rationale: This statement is incorrect. While it's important for the healthcare provider to properly fit the cervical cap initially, it does not require routine sizing checks every six months. However, clients should periodically check the cap for any signs of damage or deterioration.
Choice D rationale:
"I need to keep the cap in place for at least 6 hours after intercourse." Rationale: This is the correct statement. To ensure the effectiveness of the cervical cap, it should be left in place for at least six hours after intercourse. It provides a barrier that prevents sperm from reaching the cervix. However, it should not be left in place for more than 48 hours to reduce the risk of toxic shock syndrome.
Correct Answer is D
Explanation
Choice A rationale:
Identification is a defense mechanism where an individual associates themselves with another person or group. It does not apply to the situation described in the question.
Choice B rationale:
Reaction formation involves expressing the opposite of one's true feelings or desires. It is not the most suitable defense mechanism for the situation where the adolescent blames the teacher for their failure.
Choice C rationale:
Regression refers to reverting to an earlier stage of development in response to stress or conflict. It does not align with the adolescent's statement about their teacher disliking athletes.
Choice D rationale:
Rationalization is the defense mechanism in which a person provides logical or socially acceptable reasons for their behavior, even if these reasons are not accurate. In this case, the adolescent is rationalizing their poor performance by blaming the teacher's bias against athletes. This choice best fits the situation described.
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