A nurse is assisting with the care of a client who presents to the labor and delivery unit.
Nurses Notes.
1700:Client reports a sudden onset of severe abdominal pain and vaginal bleeding.
Moderate amount of dark red blood noted onperineal pad.
External fetal monitor applied.
Fetal heart rate: 125/min.
Abdomen rigid and tender to touch.
1715:Contraction frequency 1.5 to 2 min.
Duration 60 to 90 seconds, strong to palpation.
Fetal heart rate 110/min.
Minimal variability.
Late decelerations noted.
Client reports abdominal pain as 9 on a 0 to 10 scale.
1720.
Provider notified of findings.
History and Physical.
Gravida 1 para 0. 38 weeks of gestation.
Maternal history positive for chronic hypertension.
Vital Signs.
1700:Exhibit 2. Blood pressure 11O/68 mm Hg. Heart rate 112/min.
Respiratory rate 22/min.
Oxygen saturation 97% on room air.
1715:. Exhibit 3. Temperature 37°C (98.6 °F) Blood pressure 95/59 mm Hg. Heart rate 120/min.
Respiratory rate 22/min.
Oxygen saturation 95% on room air.
Temperature 37 °C (98.6 °F)
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 C
Explanation
Choice A rationale:
Inquiring about a family history of suicide is relevant but not the priority when a client is actively expressing suicidal ideations. Assessing the client's immediate risk and intent is more critical.
Choice B rationale:
Understanding the stresses in the client's life is important, but asking about a plan for self-harm takes precedence in assessing the client's immediate danger.
Choice C rationale:
This question directly addresses the client's intent and plan for self-harm. Identifying a plan is crucial in assessing the level of risk and determining the appropriate intervention.
Choice D rationale:
While having someone to discuss feelings with is important, it is not the primary concern when a client is expressing suicidal ideations. Assessing the client's immediate risk and plan for self-harm should come first.
Correct Answer is ["A","B"]
Explanation
A. Elevates the legs before applying the stockings: This is a correct action. Elevating the client's legs before applying elastic antiembolic stockings can help reduce swelling and improve blood flow. It's an appropriate step to prepare the client for the stockings.
B. Measures the client's calf circumference before selecting the stocking size: This is a correct action. Proper sizing of elastic antiembolic stockings is crucial to ensure they are effective and do not cause discomfort or complications. Measuring the client's calf circumference helps in selecting the right size.
C. Applies lotion to the client's legs before putting on the stockings: This is an incorrect action. Applying lotion to the legs before putting on stockings can make the stockings less effective and may cause them to slide down. Lotions or creams can create a barrier that interferes with the compression provided by the stockings.
D. Rolls down the stockings from the thigh to the ankle: This is an incorrect action. Elastic antiembolic stockings should be applied carefully, starting at the ankle and rolling them up to the thigh. Rolling them down from the thigh to the ankle is not the correct technique, as it can impede blood flow and be uncomfortable for the client.
So, the correct answers are A and B. These actions indicate that the AP is performing the skill correctly by preparing the client appropriately and ensuring proper sizing of the stockings.
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