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A nurse is caring for a 28-year-old female client in the labor and delivery unit who is in the fourth stage of labor.A nurse is caring for a 28-year-old female client in the labor and delivery unit who is in the fourth stage of labor.

Exhibits

Complete the following sentence by using the list of options. The nurse should first monitor the client's

followed by the client's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

The nurse should prioritize monitoring the client's fundal tone followed by the client's blood pressure. Here's why:

  1. Fundal Tone: The client's fundus is boggy and not firming up with massage. This is a priority concern as it indicates uterine atony, which is a major cause of postpartum hemorrhage.
  2. Blood Pressure: Monitoring blood pressure is crucial as the client is experiencing heavy lochia, and a decrease in blood pressure can indicate hypovolemic shock due to blood loss.

So, the completed sentence would be:

  • The nurse should first monitor the client's fundal tone followed by the client's blood pressure.

Taking care of immediate risks and stabilizing the patient is key in such cases.


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Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

The nurse should identify that the client is at the greatest risk for preterm birth due to:

Response 1: B) being higher than normal (fetal fibronectin: 0.09 mcg/mL is higher than the normal level of ≤ 0.05 mcg/mL).

Response 2: B) Nitrazine and ferning tests negative

Here's the

  • Fetal Fibronectin: Fetal fibronectin is a protein found between the amniotic sac and the uterine lining. Levels greater than 0.05 mcg/mL (like 0.09 mcg/mL) indicate an increased risk of preterm labor.
  • Nitrazine and Ferning Tests: Both tests being negative indicates that there is no rupture of membranes. Even though these tests are negative, the elevated fetal fibronectin level still indicates a risk for preterm birth.

So the completed sentence would be: The nurse should identify that the client is at the greatest risk for preterm birth due to fetal fibronectin being higher than normal and Nitrazine and ferning tests negative.

This combination of findings suggests that preterm labor may be imminent despite the lack of membrane rupture. The elevated fetal fibronectin is a strong indicator of risk.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Irregular spotting is common after the placement of an IUD as the body adjusts to the device. This is a normal side effect and typically resolves within a few months.

Choice B rationale

Avoiding tampons initially after IUD placement is advised to prevent displacement or infection. Once the IUD is properly positioned and the risk of infection decreases, tampons can generally be used.

Choice C rationale

Informed consent is required prior to IUD placement to ensure the client understands the procedure, potential risks, and benefits, ensuring an informed decision.

Choice D rationale

IUDs typically need to be replaced every 3 to 10 years, depending on the type. Replacing an IUD every 2 years is not accurate and does not align with standard medical recommendations.

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