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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Ice cream. Ice cream is not typically recommended for individuals with irritable bowel syndrome (IBS) as it contains dairy, which can exacerbate gastrointestinal symptoms in some people with lactose intolerance or dairy sensitivity. It may also be high in sugar, which can worsen IBS symptoms for some individuals.
Choice B rationale:
Honey. Honey is generally well-tolerated by individuals with IBS and can be used as a natural sweetener in moderation. However, it is not specifically recommended as a dietary inclusion for managing IBS symptoms.
Choice C rationale:
Watermelon. Watermelon is a low-fiber fruit that may be well-tolerated by some individuals with IBS, especially during periods of symptom flare-ups. However, it does not provide the beneficial probiotics and digestive enzymes found in yogurt, which can be helpful for some IBS patients.
Choice D rationale:
Yogurt. Yogurt, especially varieties containing live probiotic cultures, can be beneficial for individuals with IBS. Probiotics may help improve gut health and alleviate some gastrointestinal symptoms associated with IBS. It is often recommended as a dietary inclusion for those with IBS.
Correct Answer is B
Explanation
Choice A rationale:
Soft bowel sounds at a rate of 1 per minute describe hypoactive bowel sounds, which indicate decreased motility. This choice does not describe hyperactive bowel sounds.
Choice B rationale:
High-pitched bowel sounds are characteristic of hyperactive bowel sounds. These sounds are associated with increased motility and can indicate conditions such as diarrhea or early bowel obstruction. This choice correctly describes hyperactive bowel sounds.
Choice C rationale:
The absence of bowel sounds after listening for 3 to 5 minutes is indicative of absent or hypoactive bowel sounds, not hyperactive bowel sounds.
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