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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 A

Explanation

Choice A rationale:

The nurse should respond by offering to show the client how to swaddle and cuddle the newborn and then encourage the client to try it herself. This response promotes bonding between the mother and newborn and empowers the client to care for her baby, building her confidence and self-esteem.

Choice B rationale:

Taking the newborn back to the nursery without involving the mother does not support maternal-infant bonding and does not address the client's feelings of inadequacy. It is essential to encourage maternal involvement in infant care.

Choice C rationale:

Turning the newborn on his side without addressing the client's concerns does not provide emotional support or guidance on infant care. It is important to respond to the client's emotional needs and offer assistance in caring for the baby.

Choice D rationale:

Telling the client that babies need to cry to develop their lungs is not an appropriate response to the client's distress. It does not address the client's concerns or provide helpful guidance on caring for the newborn.

A. A client who has psychomotor retardation. B. A client who reports an inability to concentrate. C. A client who exhibits an increase in energy. D. A client who experiences persistent insomnia.

Correct Answer is C

Explanation

The correct answer is: c. A client who exhibits an increase in energy.

Choice A reason: A client with psychomotor retardation may experience a visible slowing of physical and emotional reactions. This symptom is associated with major depressive disorder and can manifest as slowed speech, decreased movement, and impaired cognitive function. While psychomotor retardation is a significant symptom of depression, it is not typically identified as the highest risk factor for suicide when compared to other symptoms such as a sudden increase in energy, which can indicate a potential for acting on suicidal thoughts.

Choice B reason: An inability to concentrate is another symptom that can be present in individuals with major depressive disorder. It refers to difficulty in focusing, making decisions, or remembering things. Although this can contribute to the overall severity of depression, it is not directly linked to an increased risk of suicide as strongly as some other symptoms like changes in sleep patterns or behavior.

Choice C reason: An increase in energy in a client with major depressive disorder, especially if it occurs suddenly, can be a warning sign of potential suicidal behavior. This change can indicate that the individual has decided about suicide and may now have the energy to act on these thoughts. It is important for healthcare providers to closely monitor such changes in energy levels, as they can be indicative of an increased risk for suicide.

Choice D reason: Persistent insomnia is a common symptom in individuals with major depressive disorder and can exacerbate other symptoms of depression. Lack of sleep can lead to irritability, cognitive impairment, and can affect overall health. While it is a concerning symptom and can affect a person’s risk for suicide, it is not considered the single highest risk factor when compared to a sudden increase in energy.

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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

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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.