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A nurse is assisting with the care of a client who presents to the labor and delivery unit.

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is ChoiceC.

Choice A rationale:Restricting fluid intake to 1 L per day is not recommended for a client with a urinary tract infection (UTI). Adequate hydration is essential for flushing out bacteria from the urinary tract and preventing further infections. Therefore, this choice is incorrect.

Choice B rationale:Taking the prescribed antibiotic until manifestations are gone is partially correct. It’s crucial for the client to complete the entire course of antibiotics, even if symptoms improve or disappear before the medication is finished. Stopping antibiotics early can lead to recurrent infections or antibiotic resistance. Therefore, this choice ispartially correct, but the instruction should be clarified to ensure the client understands the importance of completing the full course of antibiotics.

Choice C rationale:Wearing cotton underwear is recommended for clients with a UTI. Cotton is a breathable fabric that can help keep the area around the urethra dry, reducing the likelihood of bacterial growth. Therefore, this choice is correct.

Choice D rationale:Drinking orange juice daily for 3 to 4 weeks is not specifically recommended for a client with a UTI. While vitamin C can help inhibit bacterial growth, orange juice is high in sugar, which can promote bacterial growth. It’s more beneficial to drink water and other unsweetened fluids to help flush out the bacteria from the urinary tract. Therefore, this choice is incorrect.

A. "I will notify my doctor if the stoma starts to look purple.” B. "I should expect my stool to be formed.” C. "I will no longer be able to eat nuts.” D. "I will irrigate the colostomy every day.”

Correct Answer is A

Explanation

Choice A rationale:

"I will notify my doctor if the stoma starts to look purple" indicates an understanding of the importance of monitoring the colostomy site for signs of compromised blood flow or ischemia. A purple or bluish color of the stoma may suggest reduced blood supply, which is a critical concern and should be reported promptly to the healthcare provider.

Choice B rationale:

"I should expect my stool to be formed" is incorrect. In a colostomy, the type of stool output will depend on the location of the colostomy and the surgical procedure performed. Stool consistency can vary, and it may be formed or semi-formed depending on the individual and the specific situation. Expecting formed stool may not always be accurate.

Choice C rationale:

"I will no longer be able to eat nuts" is not necessarily true for all individuals with a colostomy. While some people may experience digestive difficulties with certain foods, including nuts, it is not a universal rule. Dietary restrictions should be discussed with a healthcare provider or a registered dietitian based on the individual's specific condition and needs.

Choice D rationale:

"I will irrigate the colostomy every day" is not a recommended practice for all colostomy patients. Colostomy irrigation is a procedure that may be performed by some individuals with descending or sigmoid colostomies to regulate bowel movements. However, it is not necessary or appropriate for all colostomy patients. The need for colostomy irrigation should be determined by the healthcare provider and discussed with the patient as part of their individualized care plan.

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A nurse is assisting with the care of a client who presents to the labor and delivery unit. Exhibits The nurse assisting with this client's care should expect which of the following prescriptions from the client's provider? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a urinary tract infection. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reinforcing teaching for a client who has a new ascending colostomy.Which of the following comments by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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A nurse is assisting with the care of a client who presents to the labor and delivery unit.

Exhibits

The nurse assisting with this client's care should expect which of the following prescriptions from the client's provider? Select all that apply.