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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Related Questions
Correct Answer is A
Explanation
The correct answer is: a. The client’s date of birth.
Choice A reason: The client’s date of birth is a critical identifier in healthcare settings. It is unique to the individual and does not change, making it a reliable way to confirm a patient’s identity. This is especially important in acute care settings where accurate patient identification is crucial for safe medication administration. Using the date of birth along with another identifier, such as the patient’s name, aligns with the best practices for patient safety.
Choice B reason: While a client’s full medical diagnosis is important information for a nurse to know, it is not used as an identifier for medication administration. The diagnosis helps inform treatment decisions and care planning but does not uniquely identify a patient. Multiple patients could have the same diagnosis, which could lead to medication errors if used as an identifier.
Choice C reason: A client’s telephone number is not a standard identifier used in healthcare settings for medication administration. Telephone numbers can change and are not unique to an individual. They also do not provide immediate verification of a patient’s identity at the bedside.
Choice D reason: The room number of the client is not a primary identifier for patient identification in medication administration. Room numbers are not unique to individuals and can change if a patient is moved. It is possible for errors to occur if room numbers are used as the sole identifier, as another patient could be in that room at a different time.
Correct Answer is A
Explanation
Choice A rationale:
The nurse is demonstrating advocacy by contacting the provider to return and speak with the client when the client expresses a lack of understanding about their diagnosis. Advocacy involves promoting the client's best interests, ensuring they receive appropriate information and care, and facilitating communication between the client and the healthcare team to address their concerns and needs.
Choice B rationale:
Good manners, while important in nursing practice, do not capture the essence of the nurse's action in this scenario. The nurse's primary role is to advocate for the client's understanding and communication with the healthcare provider.
Choice C rationale:
Customer service is not the primary focus in this situation. While providing excellent customer service is important in healthcare, the nurse's primary responsibility is to ensure the client's understanding of their diagnosis and address any questions or concerns they may have.
Choice D rationale:
Kindness is a positive quality in nursing practice, but it does not fully encompass the nurse's role in this scenario. The nurse's primary responsibility is to advocate for the client's understanding and facilitate effective communication with the provider to address the client's concerns and questions.
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